Management of Menopause for Women With Cardiovascular Disease
Menopausal hormone therapy (MHT), also referred to as hormone replacement therapy (HRT), remains the most effective treatment for menopausal symptoms, reducing both the frequency and severity of vasomotor symptoms such as hot flushes and sweats.
While current guidance supports systemic HRT for healthy women younger than 60 years or within 10 years of menopause who require treatment for vasomotor symptoms, management becomes more complex in women with cardiovascular disease.
According to the British Menopause Society (BMS), systemic HRT is generally considered high risk in women with known cardiovascular disease (CVD), a 10-year CVD risk of at least 10%, or uncontrolled cardiovascular risk factors, including blood pressure of 180/110 mmHg or greater, total cholesterol above 7.8 mmol/L, or triglycerides above 4.5 mmol/L. In these women, non-hormonal therapies are recommended as first-line treatment, although they are often less effective than HRT for controlling vasomotor symptoms.
The BMS notes that estrogen has important effects on arterial health, including improving vascular function and reducing atheroma formation. While androgenic progestogens may reduce these benefits, micronized progesterone and dydrogesterone appear to have neutral effects. Consequently, the Society notes that a history of heart disease, including previous myocardial infarction (MI), may not represent an absolute contraindication to HRT. Instead, treatment decisions should involve shared discussion of the potential risks and benefits based on individual patient circumstances.
Evidence regarding HRT after myocardial infarction remains reassuring but is not definitive. In a placebo-controlled randomized trial involving more than 1,000 postmenopausal women treated for two years after their first MI, unopposed estrogen did not increase adverse cardiac or non-cardiac outcomes during 14 years of follow-up.
A subsequent systematic review of studies involving women with established cardiovascular disease similarly found no significant differences between HRT users and control groups for non-fatal myocardial infarction, cardiovascular death, stroke, angina, heart failure, or transient ischemic attack.
The review also found that oral estrogen favorably affected LDL and HDL cholesterol, whereas transdermal estrogen had neutral effects on lipid parameters. Statin therapy, however, was superior to HRT for lipid management. In addition, transdermal—but not oral—estrogen was neutral with respect to blood pressure. HRT was associated with positive effects on glucose tolerance and diabetes incidence but may also be associated with angiographic disease progression. The BMS notes that many of the available studies were limited by small sample sizes and relatively few cardiovascular events, meaning that the absence of observed harm may reflect limited statistical power rather than confirmed physiological safety.
For women with established ischemic heart disease whose vasomotor symptoms persist despite non-hormonal therapy, the BMS recommends shared decision-making. If systemic HRT is prescribed, the preferred approach is low-dose estrogen administered by a non-oral route when possible, combined with a non-androgenic progestogen when indicated. Oral HRT should be avoided because of its effects on blood pressure and thromboembolism risk. Concurrent statin therapy may also be considered, particularly because women with both cardiovascular disease and diabetes may face a greater risk of future cardiovascular events.
Among women already receiving HRT who subsequently experience myocardial infarction, current observational evidence does not support routine discontinuation of therapy. Because patients may enter a transient hypercoagulable state following MI, the BMS suggests considering a switch to low-dose, preferably non-oral estrogen together with a non-androgenic progestogen, while also considering statin therapy.
The evidence surrounding HRT following stroke is less robust. The BMS emphasizes that stroke represents a heterogeneous group of conditions with differing underlying mechanisms and recurrence risks. Factors including stroke subtype, embolic sources, hypertension, and other modifiable cardiovascular risk factors should be carefully evaluated before treatment decisions are made. While systemic HRT may be best avoided in some women who have experienced stroke, individualized risk assessment is recommended. When systemic HRT is considered appropriate, transdermal low-dose estrogen combined with micronized progesterone or another non-androgenic progestogen, when indicated, for the shortest duration in women younger than 60 years and within 10 years of menopause appears to represent the lowest-risk strategy.
The Society also discusses HRT use in other cardiovascular conditions. A systematic review concluded that HRT may reduce the prevalence or severity of palpitations during menopause and can be recommended with caution. Although estrogen alone has been associated with prolongation of the QTc interval, there is no clear contraindication to a trial of HRT in women with troublesome palpitations, including those with long QT syndrome. By contrast, observational data suggest that current HRT use may be associated with an increased risk of atrial fibrillation.
For women with congenital heart disease, the BMS recommends individualized risk-benefit discussions based on the underlying cardiac lesion, with transdermal HRT preferred if treatment is initiated. In women with spontaneous coronary artery dissection (SCAD), menopausal HRT is generally avoided because of concerns regarding reproductive hormones, although there is no clear evidence that hormone therapy increases the risk of SCAD or its recurrence. The document notes that expert consensus supports considering a trial of transdermal HRT in women with intrusive menopausal symptoms. Most women with valvular heart disease can receive HRT, although caution is advised in those with mechanical heart valves, poor ventricular function, atrial fibrillation, or a history of stroke. For women with heart failure, available evidence is limited, and treatment decisions should be individualized.
The BMS also addresses the use of levonorgestrel-releasing intrauterine devices as the progestogen component of HRT, outlines precautions for insertion in women with specific cardiovascular conditions, and recommends specialist contraceptive providers for women receiving anticoagulants.
Because systemic absorption is minimal at licensed doses, the Society states that there should be no limitation on the use of vaginal estrogen in women with cardiovascular disease.
For women who are unable or choose not to use systemic HRT, the BMS notes that several non-hormonal therapies have demonstrated efficacy in randomized placebo-controlled trials, including selective antidepressants, gabapentin, pregabalin, and clonidine. Self-help approaches, including isoflavones, soy products, herbal therapies, cognitive behavioral therapy with targeted self-hypnosis, acupuncture, and nerve block, have also been used for vasomotor symptom management. However, the Society notes that no non-hormonal treatment has been shown to be as effective as estrogen.
Overall, the BMS emphasizes individualized decision-making, shared discussion of risks and benefits, careful assessment of cardiovascular risk factors, and preference for low-dose, non-oral estrogen combined with a non-androgenic progestogen when systemic HRT is considered for women with cardiovascular disease.