Long-term hormone replacement therapy used to be routinely prescribed for postmenopausal women to relieve hot flashes and other menopause symptoms. Hormone replacement therapy was also thought to reduce the risk of heart disease.

However, hormone replacement therapy — or menopause hormone therapy, as it’s now called — has had mixed results. Many of the hoped-for benefits failed to materialize for large numbers of women.

The largest randomized, controlled trial to date actually found a small increase in heart disease in postmenopausal women using combined (both estrogen and progestin) hormone therapy. For women in this study using estrogen alone, there was no increased risk of heart disease.

Other studies suggest that hormone therapy, especially estrogen alone, may not affect — or may even decrease — the risk of heart disease when taken early in postmenopausal years.

But clinical studies can be confusing to interpret into practice. Study outcomes can be affected by many factors, such as the ages of the study participants, the time elapsed since menopause and how long hormone therapy is used. Continued research will help doctors more clearly understand the relationship between menopause hormone therapy and heart disease.

Risks in perspective

If you are struggling with menopause symptoms but worry about the potential risks of hormone therapy, talk with your doctor to put your personal risk into perspective. Consider these points:

• The risk of heart disease to an individual taking hormone therapy is very low. If you are in early menopause, have moderate to severe hot flashes and other menopausal symptoms, and are otherwise healthy, the benefits of hormone therapy likely outweigh any potential risks of heart disease.
• Your individual risk of developing heart disease depends on many factors, including family medical history, personal medical history and lifestyle practices. Talk to your doctor about your personal risks. If you’re at low risk of heart disease, and your menopausal symptoms are significant, hormone therapy is a reasonable consideration.
• Risk differs for women with early natural menopause or primary ovarian insufficiency. If you stopped having periods before age 40 (early natural menopause) or lost normal function of your ovaries before age 40 (primary ovarian insufficiency), you have a different set of heart and blood vessel (cardiovascular) health risks compared with women who reach menopause closer to the average age of 51. This includes a higher risk of coronary heart disease. Hormone therapy in this case protects against heart disease, and your doctor may recommend that you take hormone therapy until you reach the average age that most women enter menopause, around age 51.

Menopause hormone therapy risks may vary depending on:

• Whether estrogen is given alone or with a progestin
• Your current age and age at menopause
• The dose, type of estrogen and how you take it, such as a pill, skin patch or vaginal cream
• Other health risks, such as your family medical history and cancer risks

Who should not take hormone therapy

If you’ve had a heart attack, menopause hormone therapy is not for you. If you already have heart disease or you have a history of blood clots, the risks of hormone therapy have been clearly shown to outweigh any potential benefits.

Women with a history of estrogen-sensitive breast or endometrial cancer are also not good candidates for menopause hormone therapy.

How to limit the risks

Talk with your doctor about ways you might be able to lower menopause hormone therapy risks:

• Try a form of hormone therapy that has limited whole-body (systemic) effects. Estrogen and progestin are available in many forms, including pills, skin patches, gels, vaginal creams, and slow-releasing suppositories or rings that you place in your vagina.

  Low-dose vaginal preparations of estrogen — which come in cream, tablet or ring form — can effectively treat vaginal symptoms while minimizing absorption into the body. Hormones delivered through skin patches aren’t as extensively metabolized in the body as the hormones in pills and have less potential for unwanted side effects.

• Take the amount of medication that’s right for you. The type of hormone therapy, how it’s administered and how long you should take it to best help with symptom relief varies from person to person. Talk with your doctor about your treatment goals and health risks to choose a hormone therapy regimen that best suits your individual needs.
• Make healthy lifestyle choices. Counter the risks of developing heart disease by making heart-healthy lifestyle choices. Don’t smoke or use tobacco products. Get regular physical activity. Eat a healthy diet focusing on fruits, vegetables, whole grains and low-fat protein. Maintain a healthy weight. And get regular health screenings to check your blood pressure and cholesterol levels to detect early signs of heart disease.
• Seek regular follow-up care. See your doctor regularly to ensure that the benefits of hormone therapy continue to outweigh the risks, and for cancer screenings such as mammograms and pelvic exams.

A balancing act

Women of all ages should take heart disease seriously. Among U.S. women, more than 1 in 5 deaths each year is due to heart and blood vessel (cardiovascular) disease.

But most healthy women younger than age 60, and within 10 years of the start of menopause, can safely take hormone therapy without significantly increasing heart disease risk. Younger women who are nearer to their last menstrual period have the lowest risk, and the risk increases as you get older and time since menopause elapses.

If you have hot flashes, night sweats or other menopause symptoms that bother you, talk to your doctor. You may be able to take hormone therapy to relieve your symptoms — without putting your health at risk.

Oct. 17, 2020

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