Will hormone replacement therapy hurt your heart?

Women under 60 who use hormone replacement therapy during menopause tend to live longer than those who don’t, according to robust research over the last few years.

And yet, many women -- and even doctors -- aren’t aware of this. That’s because in 2002, researchers halted a large study when it appeared that women taking a combination of estrogen and progesterone were at heightened risk of heart attacks, stroke, blood clots and breast cancer. In response, most women in the U.S. stopped using hormone therapy.

Further analysis, however, revealed that those heightened risks only applied to older women. Younger women, follow-up research has shown, actually lived longer when they took hormones during menopause. The researchers followed the women for 18 years to be sure. 

As early as 2004, there was evidence of the benefits of hormone therapy for women under 60, as a meta analysis showed that younger women had a 39 percent lower risk of death than women who didn’t take hormones. 

And treatment guidelines are coming around.  For example, in 2020, the Korean Society of Menopause issued guidelines for when to use hormone therapy. (Life expectancy for Korean women is almost 90 years.) For women under 60 years old within 10 years of menopause with no history of cardiovascular disease, the society says that hormone therapy is likely to reduce heart disease and death from other causes.

What’s not perfectly clear yet is whether hormone therapy could be used for the sole purpose of preventing heart disease … it is currently not recommended for that. Researchers suspect that the timing of the therapy plays a role in how the hormones affect heart disease.

While it makes sense that women might remember the headlines from the scares over 20 years ago and be reluctant to try hormone therapy, it does not make sense that doctors aren’t up to date. Oncologist Avrum Bluming points out that less than a quarter of OB/GYN residents receive menopause education, so many providers aren’t working with current information. (The lack of sensible medical education strikes again!)

Proper management of menopause has huge impacts, so it’s hard to believe that so many doctors are in the dark. If you’ve been through menopause, you probably know that hot flashes aren’t the only symptom. You may have experienced difficulty sleeping, mood swings, depression, headaches, racing heart, vaginal dryness or trouble focusing. For some women, these symptoms begin years before menopause.

And those symptoms don’t just impact quality of life; hot flashes and night sweats have also been linked to increased risk of cardiovascular disease.

That’s not to say hormone replacement is completely without potential down sides. Women at heightened risk of breast cancer or blood clots still need to weigh the risks and benefits – although data is starting to show that transdermal estrogen may not be as worrisome in this regard.  And given some remaining concern regarding timing of hormone supplementation, starting hormone therapy more than 10 years after onset of menopause is currently still not recommended.  Nor is unlimited use, with most menopause specialists currently dissuading continuation of therapy beyond age 65.

So what should women nearing menopause do? Talk to your doctor. If they aren’t aware of the latest research, find someone who is.  Prescribed to the right patient at the right time and in the correct dose/preparation, hormone therapy can be safe and positively affect quality of life – and maybe even heart outcomes.