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.
Before menopause, women have a lower risk of heart disease than men do. But as women age, and their estrogen levels decline after menopause, their risk of heart disease increases. In the 1980s and 1990s, experts advised older women to take estrogen and other hormones to keep their hearts healthy.
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 in 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. However, these studies can be confusing to interpret into practice, since study outcomes can be affected by many factors, such as the ages of the study participants, the time elapsed since menopause and the duration of hormone therapy use. Continued research will help doctors more clearly understand the relationship between menopause hormone therapy and heart disease.
Risks in perspective
If you're having a tough time with symptoms of menopause but worry about how hormone therapy will affect your heart, talk with your doctor to put your personal risk into perspective. Consider these points:
- The risk of heart disease to an individual woman 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 premature menopause or premature ovarian failure. If you stopped having periods before age 40 (premature menopause) or lost normal function of your ovaries before age 40 (premature ovarian failure), you have a different set of heart and blood vessel (cardiovascular) health risks compared with women who reach menopause near the average age of about 50. This includes a higher risk of coronary heart disease. If you have premature ovarian failure, you'll likely be given hormone therapy to protect against heart disease.
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 route, or how you take it (oral, transdermal, transvaginal)
- Other health risks, such as your family medical history and cancer risks
Who should not take hormone therapy
If you've already 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.
How to limit the risks
Talk with your doctor about these strategies to reduce the risks of menopause hormone therapy:
- Try a form of hormone therapy that has limited 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. Similarly, hormones delivered through skin patches aren't as extensively metabolized in the body and have less potential for unwanted side effects.
- Minimize the amount of medication you take. Use the lowest effective dose for the shortest amount of time needed to treat symptoms, unless you're younger than age 45 — in that case, you need enough estrogen for protection against long-term health effects of estrogen deficiency. If you have lasting menopausal symptoms that significantly impair your quality of life, your doctor may recommend longer term treatment.
- 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 health care provider 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, nearly 1 in 3 deaths each year is due to heart and blood vessel (cardiovascular) disease.
Most healthy women who are within five years of menopause can safely take short-term hormone therapy for menopausal symptoms without significantly increasing the risk of heart disease. If you experience classic menopausal symptoms, including intolerable hot flashes, vaginal dryness or insomnia, talk to your doctor about how you can relieve troublesome symptoms without putting your health at risk.