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Estrogen and Coronary Heart Disease in Women-Reply

Elizabeth Barrett-Connor, MD; Trudy L. Bush, PhD, MHS
JAMA. 1991;266(10):1358. doi:10.1001/jama.1991.03470100050018.
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In Reply.  —Dr Sullivan chastises us for an overemphasis on the role of lipids in mediating the protective effect of estrogen. We plead not guilty as charged; in our review we wrote: "These two reports suggest that between 25% and 50% of the beneficial effect of estrogen on CHD [coronary heart disease] risk is through changes in HDL [high-density lipoprotein] and LDL [low-density lipoprotein] cholesterol. However, this further implies that 50% to 75% of the beneficial effect of estrogen is through other, nonlipid mechanisms." We listed about 10 other possible mechanisms, but made no attempt to list all possible ways in which estrogen could reduce the risk of heart disease. Sullivan suggests lower levels of iron, caused by menstrual blood loss, as a possible explanation for the sex differences in heart disease, an interesting but as yet untested hypothesis.Sullivan notes that women with hypercholesterolemia have a lower risk of


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