Assessing Cardiovascular Risk in Menopause

A Guide to Safe Hormone Therapy

Balancing the benefits and risks of menopause hormone therapy can feel complex, and nowhere does that seem to be truer than with cardiovascular disease, which is the umbrella term used for diseases that affect the heart and/or blood vessels, specifically coronary heart disease (clogged arteries, which can cause heart attacks), stroke, heart failure, and peripheral artery disease (clogged blood vessels outside the brain and heart).

Cardiovascular disease is the number one cause of death for women. Regarding coronary heart disease (clogged arteries and heart attacks), the risk before menopause is lower for women than men. During the menopause transition, there is a shift, and the risk for women starts to accelerate. Some of the factors that drive this change are age-related, but others are menopause-related, including changes in lipids, risk of metabolic syndrome (read more about that here), and changes in blood vessels. 

Confusion about cardiovascular disease, hormones, and safety stems from what we used to believe years ago. Like many things, once a factoid enters the lexicon, its accuracy ceases to be relevant after it takes on a life of its own because repetition breeds a perception of accuracy. Sadly, this is as true in medicine as it is everywhere in life. I could write a whole book on things old doctor dudes once wrote in textbooks despite zero supporting facts that subsequently became canon due to overreaching confidence and then took decades of research to try to scrub from people’s brains. Case in point, we have older observational studies and animal studies that suggested that women who took menopause hormone therapy (MHT) were about 40-50% less likely to develop coronary heart disease. As coronary heart disease is a major killer of women, many people began recommending MHT to protect the heart. One of the purposes of the Women’s Health Initiative (WHI) was to see if this belief was true. It wasn’t.

We now have data from several randomized clinical trials, not just the WHI, that inform us that MHT is not an appropriate therapy to protect the heart. If your provider tells you that you should take MHT to protect your heart, you are getting an incorrect recommendation based on old information. 

What some of these studies did do was shed light on who might actually be at higher risk heart-health wise from MHT. For example, those who started their hormones when they were older (over 60 or more than 10 years from their final period) had an increase in cardiovascular and dementia risk (something I addressed earlier in this post, Age and Starting MHT). 

These studies also shed light on other situations where MHT might increase the risk for the heart, which is why we now recommend considering the risk for cardiovascular disease before prescribing. So let’s dive into that as well as the tests you should have to assess your heart health before starting MHT (actually, the tests aren’t just limited to starting MHT, these are tests everyone should have).

What We Learned from the Timing Hypothesis about MHT and Heart Health

The timing hypothesis is the concept that starting MHT later incurs cardiovascular risks while starting it around menopause or soon after does not. What’s up with that?