High risk for heart disease. What about menopausal hormone therapy?

Ask Dr. Jen

I keep seeing accounts on Instagram that say everyone who is menopausal can and should take hormones, but my doctor says I shouldn’t because of my high blood pressure? What should I believe?

-Instagram

Short Take

Menopausal hormone therapy (MHT) is not recommended for everyone in menopause, it’s recommended for certain symptoms and can be used as prevention for osteoporosis. There are also some people for whom MHT is not recommended based on their medical history. While I don’t know your specifics, people in menopause at higher risk for cardiovascular disease need to be cautious about using MHT.

Go On…

I too have seen posts recommending that every woman in menopause should be on MHT, but that is simply not the case. If it were, that would be the guidelines, but there is no medical society that recommends every person in menopause should take MHT. 

We’ll limit our discussion here to cardiovascular disease, but for anyone interested in an in depth discussion of the benefits and risks of MHT I will direct you to my book The Menopause Manifesto, where the subject is covered in detail. Also, there are many posts here on The Vajenda dedicated to different aspects of menopause and MHT. 

Currently, the data tells us that heart-wise, MHT is safe for those who are under the age of 60 or who are within ten years of their last menopausal period and that transdermal estrogen is the safest. Starting MHT after the age of 60 or more than 10 years from the final menstrual period is associated with an increased risk of cardiovascular disease and it is not recommended for this population (there is also an increased risk of dementia starting MHT at this age).

There is a big caveat, as the majority of the studies looking at MHT enrolled women at low risk for cardiovascular disease. We should not assume that what we see in the lowest risk population can also be applied to women at higher risk. As age is a risk factor for cardiovascular disease, it is right to question if those who have a higher risk of cardiovascular disease for reasons other than age, for example, those with high blood pressure, might assume even more cardiovascular risk with MHT. 

Because of this unknown, most experts recommend a more tailored approach to MHT for those at higher risk of cardiovascular disease

The North American Menopause Society is a little vague, they recommend that personal and family history of cardiovascular disease, stroke, and blood clots “should be considered” when starting MHT. The Endocrine Society takes a much more explicit approach, recommending that MHT be avoided for anyone at high risk for cardiovascular disease, which includes the following:

• History of a heart attack

• History of a stroke

• Peripheral arterial disease

• Abdominal aortic aneurysm

• Diabetes

• Chronic kidney disease

• A 10- year risk of CVD risk of 10% or greater (you can calculate risk here with this tool). 

Transdermal MHT is typically considered an option for those at moderate risk for cardiovascular disease, but oral therapy should be avoided.

None of this applies to vaginal estrogen therapies, which are safe for to start over the age of 60 and safe for those with cardiovascular disease.

So whether someone with high blood pressure is a candidate for MHT depends on a few things. For the question at hand, if high blood pressure gives someone a 10-year risk of cardiovascular disease of 10% or more, then their doctor is following recommended guidelines in not recommending MHT. If the risk of cardiovascular disease is moderate, meaning 10-year risk of 5-10%, then MHT may be an option, but of course that requires a consultation with your own medical provider. For someone with some cardiac risk factors, an opinion from a cardiologist may be helpful to better understand risk. There are other ways your doctor can assess cardiac risk, such as a coronary calcium scan to help give a more complete picture.

Some Final Thoughts

There are other therapies that can be effective for hot flashes when MHT is not an option, such as cognitive behavioral therapy, gabapentin, venlafaxine, and oxybutynin. Relizen, an over the counter option, also has some data to support its use. For someone at high risk for cardiovascular disease maximizing these options is recommended. And every person can help themselves have a healthier menopause by eating the recommended amount of fiber, trying to incorporate more plant protein, moving more, and doing resistance training. 

And remember, it’s never a bad idea to get a second opinion about your health, just get it from a qualified professional who knows your medical history and not from Instagram!

References:

1. Treatment of Symptoms of the Menopause: An Endocrine Society Clinical Practice Guideline. Cynthia A. Stuenkel, Susan R. Davis, Anne Gompel, Mary Ann Lumsden, M. Hassan Murad, JoAnn V. Pinkerton, Richard J. Santen. The Journal of Clinical Endocrinology & Metabolism, Volume 100, Issue 11, 1 November 2015, Pages 3975–4011

2. Menopausal hormone therapy: Benefits and risks. Kathryn A. Martin and Robert Barbieri. UpToDate. Accessed October 28, 2021.

3. The 2017 hormone therapy position statement of The North American Menopause Society. Menopause: The Journal of The North American Menopause Society. Vol. 24, No. 7, pp. 728-753.