Hormone replacement therapy (HRT) is associated with an increased risk of cardiovascular disease in some women. Doctors may advise people with certain forms of heart disease against using hormone therapy, but they consider some forms safe to help treat menopausal symptoms.

Healthcare professionals may prescribe hormone therapy to manage symptoms of menopause in women and treat hormone imbalances in both men and women.

While it offers benefits like reducing hot flashes and improving mood, some people are concerned about its potential effects on heart health. Certain types of hormone therapy may increase the risk of cardiovascular problems, especially when used later in life.

Let’s explore the research to help you determine whether hormone therapy is a safe option for you.

Hormone therapy is generally not considered safe for individuals with certain forms of heart disease, particularly those with a history of heart attack or peripheral artery disease. This is due to increased cardiovascular risks associated with systemic hormone therapy.

Systemic hormone therapy, which affects the entire body, can elevate the risk of cardiovascular events in these groups. However, local vaginal formulations of hormone therapy, which are not absorbed into the bloodstream at significant levels, can help treat menopausal symptoms such as vaginal dryness without these systemic risks.

For people experiencing bothersome menopause symptoms, it is crucial to talk with their healthcare professional to weigh the risks and benefits of hormone therapy based on their health status and cardiovascular risk.

Women in menopause

Hormone therapy can be safe for menopausal women without heart disease when they start the treatment early.

Several medical societies recommend hormone therapy for women who have symptoms, even those with cardiovascular risk, as long as healthcare professionals tailor it to their individual health needs. Additionally, if a woman has cardiovascular risk factors, these should be managed by monitoring blood pressure and cholesterol levels.

Research suggests hormone therapy can reduce cardiovascular risk in women under 60 or within 10 years of menopause. The body’s cardiovascular system is more responsive to the positive effects of estrogen during this period, including improved cholesterol levels and endothelial function (the lining of blood vessels).

However, starting hormone therapy after age 60 or more than 10 years postmenopause is generally higher risk, particularly for those who have preexisting heart conditions or other risk factors like obesity. In these cases, estrogen may not provide the same protective cardiovascular benefits and may even increase the risk of heart disease in some cases.

In general, women with preexisting heart disease or high cardiovascular risk factors should have an evaluation before starting hormone therapy. The decision should include factors such as age, family history, current health, and heart disease.

Testosterone therapy in men

In men with heart disease, including coronary artery disease (CAD) and congestive heart failure (CHF), some evidence suggests that testosterone therapy may be beneficial.

Testosterone therapy has been shown to improve heart-related issues such as exercise capacity in people with CHF and reduce symptoms like myocardial ischemia (reduced blood flow to the heart) in CAD. Additionally, testosterone therapy can improve other health markers, such as blood sugar and insulin resistance, which are important for managing heart disease.

Research on the cardiovascular risks of testosterone therapy has been conflicting. Early studies suggested that testosterone therapy might increase the risk of cardiovascular disease. However, more recent evidence indicates that testosterone therapy is not only safe but potentially beneficial for men with heart disease.

For instance, a 2023 randomized study found that testosterone therapy in men with hypogonadism and either cardiovascular disease or elevated cardiovascular risk did not lead to an increased risk of cardiovascular events.

This suggests that, when carefully managed, testosterone therapy may have a neutral or even positive effect on heart health in these individuals.

The safety of hormone therapy with regard to cardiovascular risk depends on when it started, a woman’s age, and how long it has been since menopause.

While early studies suggested an increased risk of cardiovascular disease, more recent studies have identified that hormone therapy is safe and may even lower cardiovascular risk in women who are younger than 60 years or close to menopause.

Evidence suggests that when initiated in women under 60 years or close to menopause, hormone therapy is considered safe, particularly in those without cardiovascular disease or cardiovascular risk factors. For those with preexisting heart disease or risk factors, a risks versus benefits discussion is essential.

A 2017 study found that women who used hormone therapy had lower levels of atherosclerosis (plaque buildup in the arteries) and a lower risk of death compared to those who didn’t use hormone therapy.

Researchers analyzed health data from over 4,200 women and found that those using hormone therapy:

  • had a 30% lower risk of death
  • were 20% more likely to have healthy arteries
  • were 37% less likely to have significant plaque buildup that could increase the risk of heart attack

What are the potential risks of using HRT?

Hormone therapy has potential risks that vary depending on factors such as the timing of initiation, type of hormones used, and individual health conditions.

Some of the primary risks include:

Breast cancer

Hormone therapy slightly increases the risk of breast cancer, particularly with long-term use.

A large U.K. study compared over 98,000 women with breast cancer to 457,000 controls, finding that estrogen-progestin therapy was associated with a higher risk than estrogen-only therapy.

The risk also grew with age and duration of hormone therapy but declined after stopping the treatment.

Blood clots

The Women’s Health Initiative (WHI) trial initially linked hormone therapy, especially oral estrogen, to an increased risk of blood clots, such as pulmonary embolism and deep vein thrombosis.

Current research shows that clot risk depends on the type and method of hormone therapy. Transdermal options like patches and gels are associated with little to no increased risk for healthy women.

However, the safety of hormone therapy for women with thrombophilia or a history of blood clots is still unclear.

Endometrial cancer

Estrogen-only therapy in women with a uterus may increase the risk of endometrial cancer. However, combining estrogen with progestin (CEE plus MPA) lowers this risk, as progestin helps protect the uterine lining from the effects of estrogen.

Ovarian cancer

A study of 75,606 postmenopausal women in France linked combined estrogen/progesterone therapy to a higher risk of ovarian cancer, but other forms of progestagens are being investigated as having a potentially lower risk.

In contrast, estrogen combined with other progestagens showed a potentially lower risk. Estrogen-only therapy didn’t have a significant association with ovarian cancer, but further research is needed.

Gallbladder disease

A 2024 review suggests that prolonged estrogen therapy during menopause may increase the risk of gallstones by raising biliary cholesterol levels.

However, estrogen therapy for conditions like surgical menopause or hypogonadism doesn’t appear to carry this risk.

Cardiovascular risk

When initiated after age 60 or 10+ years postmenopause, hormone therapy can increase the risk of heart disease and stroke.

When discussing hormone therapy and heart disease with your healthcare professional, consider these points:

  • Personal risk factors: Ask how your health history, such as age, family history of heart disease, cholesterol levels, blood pressure, smoking, and diabetes, may affect your risk with hormone therapy.
  • Type of HRT: Discuss whether you’re considering estrogen-only or combined estrogen and progestin therapy, as their effects on heart health can vary by type, timing, and method (oral or transdermal).
  • Timing of initiation: Ask about the best time to start hormone therapy, as starting closer to menopause may have different effects on heart health than starting later.
  • Alternative treatments: If you’re concerned about risks, ask about nonhormonal options for managing menopause symptoms and protecting heart health.

What factors do healthcare professionals consider when prescribing HRT?

When prescribing hormone therapy, healthcare professionals consider several factors:

  • Age and menopause timing: Evaluate how soon you are into menopause, as starting hormone therapy earlier may have different effects than starting later.
  • Health history: Consider your health history, including risk factors for heart disease, blood clots, breast cancer, or liver problems.
  • Menopausal symptoms: Assess the severity of your symptoms, like hot flashes or vaginal dryness, to determine whether menopausal hormone therapy is appropriate.
  • Family history: Consider whether your family has a history of conditions like heart disease or cancer, which may influence the choice of therapy.
  • Type of HRT: Decide between estrogen-only therapy or a combination with progestin, depending on whether you have a uterus.
  • Method of administration: Consider whether oral, patch, gel, or other forms of hormone therapy would be best for you.

Here are a few alternatives to hormone therapy for managing menopausal symptoms:

  • Lifestyle changes: Regular exercise, a balanced diet, and stress management techniques like yoga or meditation can help reduce symptoms.
  • Nonhormonal medications: Antidepressants, antiseizure medications (gabapentin), or blood pressure medications may help with hot flashes and mood changes.
  • Herbal supplements: Sometimes, people use phytoestrogens like soy, black cohosh, and evening primrose oil, though their effectiveness is still debated.
  • Vaginal treatments: Moisturizers and lubricants can help with vaginal dryness.
  • Acupuncture: Some women find relief from hot flashes and other symptoms through acupuncture.

If you have heart disease, it’s important to discuss the risks and benefits of hormone therapy with your healthcare professional.

Hormone therapy can affect heart health differently depending on your medical history, age, and the type of therapy.

Your doctor can help determine whether hormone therapy is safe for you or suggest alternatives to manage menopausal symptoms while protecting your heart health.