Current Perspective on Menopause Hormone Therapy and Cardiovascular Risk

In past decades, there has a been a paradigm shift concerning menopause, hormone therapy (HT), and cardiovascular disease (CVD). While initial observational studies suggested hormone replacement to provide a cardioprotective benefit for all menopausal women, subsequent large randomized trials have not confirmed these benefits and furthermore brought to light the risks of HT with regard to CVD, venous thrombosis, and stroke. The goal of this review is to summarize current recommendations regarding HT as it pertains to cardiovascular risk. Menopause HT remains the most effective treatment for vasomotor symptoms. Guidelines now suggest benefits outweigh the risk for in women with bothersome vasomotor symptoms, when initiated in early menopause (within 10 years of symptom onset or age < 60 years) without contraindications. Consideration of cardiovascular risk is necessary. For women with a moderate atherosclerotic CVD risk score, or with CVD risk modifiers, a transdermal formulation is preferred. For patients with known CVD, non-hormonal alternatives should be trialed. Current evidence does not support the use of HT for primary or secondary prevention of CVD. Initiation of menopausal HT requires an individualized approach taking into account age of menopause, timing of initiation, vasomotor symptoms, and cardiovascular risk factors.