Cardiovascular disease (CVD) is the leading cause of death among women, accounting for about one in three female deaths each year. However, the positive news is that 80% of heart-related events and strokes can be prevented through lifestyle changes and medical interventions.
As women approach menopause, maintaining heart health becomes especially important, as hormonal changes can influence cardiovascular function. Hormone replacement therapy (HRT) has shown promise as a potential option to help reduce cardiovascular risks in menopausal women when started within a certain time frame.(1)(2)(3)(4)
Cardiovascular Disease in Women
Cardiovascular disease refers to a variety of conditions affecting the heart and blood vessels, including heart attacks, strokes, and hypertension. While both men and women are affected, women may experience CVD differently, with their symptoms often going undiagnosed or misinterpreted. For instance, women tend to develop heart disease later in life than men, but their risk increases notably after menopause.(1)(2)(5)
As awareness of cardiovascular health grows, it's important to recognize that research in this area has traditionally focused more on men. Women’s cardiovascular health remains under-researched, with gender-specific differences in symptoms and risk factors often overlooked. For example, women may experience heart attack symptoms differently, sometimes presenting with nausea, shortness of breath, and fatigue, rather than the chest pain commonly reported in men. Many women may not fully recognize their own risk, often prioritizing concerns like breast cancer over heart health — despite CVD being the leading cause of mortality among women.(2)(5)
How Aging and Menopause Impact the Heart
Aging and hormonal shifts have a significant impact on women’s cardiovascular health. During the transition to menopause, typically occurring in the late 40s to early 50s, declining sex hormone levels affect several biological systems that regulate heart function. These changes are often subtle and may not be noticeable immediately, making them easy to dismiss. Estrogen, in particular, has a protective impact on the heart and blood vessels, and its decline during menopause can disrupt these processes, increasing the risk of CVD.(1)(3)Hormones play a crucial role in heart function. Changes in hormone levels during menopause may negatively impact the following areas:
1. Blood Vessel Health
Reduced Vasodilation: Estrogen stimulates the production of nitric oxide, a molecule that relaxes blood vessels and improves blood flow. With less estrogen, blood vessels become stiffer and less flexible, increasing blood pressure and strain on the heart.(1)(3)
Increased Arterial Stiffness: The loss of estrogen contributes to the thickening and hardening of arterial walls, reducing their elasticity and increasing the heart's workload.(1)(3)
2. Lipid Profiles
Higher LDL Cholesterol: Estrogen helps regulate cholesterol by lowering low-density lipoprotein (LDL, "bad" cholesterol) levels. Declining estrogen can lead to higher LDL levels, increasing the risk of plaque buildup in the arteries (atherosclerosis).(1)(3)(6)
Lower HDL Cholesterol: Estrogen boosts high-density lipoprotein (HDL, "good" cholesterol), which helps remove bad cholesterol from the bloodstream. Reduced HDL levels may decrease this protective effect.(1)(3)(6)
3. Inflammation and Oxidative Stress
Estrogen has anti-inflammatory properties that help protect the cardiovascular system. As estrogen levels drop, inflammation and oxidative stress can increase, potentially causing damage to the heart tissue and blood vessels over time. Maintaining a proper balance between progesterone and estrogen can also help minimize inflammation.(7)
4. Blood Pressure
Estrogen supports blood pressure regulation by promoting vascular relaxation and reducing sodium retention. Its decline can lead to elevated blood pressure, increasing the risk of hypertension — a major factor in heart disease.(1)(3)(6)
5. Heart Rhythm
Estrogen influences the electrical activity of the heart, helping to maintain a steady rhythm. Declining estrogen levels may contribute to an increased risk of arrhythmias, such as atrial fibrillation, especially in postmenopausal women.(8)
HRT and Cardiovascular Disease
HRT has been shown to have a significant impact on cardiovascular health, particularly when started soon after menopause. The therapy has the potential to reduce the risk of heart disease, stroke, and related complications, but its effectiveness is closely tied to the timing of initiation.(3)(6)(9)What does the research show on HRT’s cardiovascular risk?
The relationship between HRT and CVD has been
the subject of extensive study. While earlier studies, such as the 1993–2002 Women’s Health Initiative (WHI), raised concerns about HRT's potential cardiovascular risks, recent research has provided a clearer understanding. For instance, a follow-up study found that women who started HRT within 10 years of menopause experienced significant cardiovascular benefits, including a 50% reduction in heart disease and mortality rates. Modern formulations of HRT contain bioidentical hormones and lower, more consistent doses of estrogen and progesterone. They are also more easily absorbed, making them safer and more effective than those used in earlier studies.(1)(3)(6)(9)
Does HRT reduce the risk of heart disease?
When started within 10 years of menopause, HRT can significantly reduce the risk of CVD. Studies have demonstrated that early intervention with HRT lowers the incidence of heart disease and even reduces overall mortality rates. Research indicates that menopausal women who begin HRT early may experience a reduction in heart disease risk by as much as half.(1)(3)(9)
How does HRT help prevent heart disease?
HRT works by replenishing hormones that decrease during menopause, primarily estrogen. Estrogen's beneficial effects on the cardiovascular system improve arterial function and reduce harmful cholesterol levels. Additionally, HRT may help lower blood pressure, increase blood vessel elasticity, and reduce inflammation — all of which contribute to heart health. For women in the early stages of menopause, transdermal estrogen, in particular, is associated with a lower cardiovascular risk compared to other forms of therapy, as it avoids passing through the liver, which can raise certain risks.(3)(6)
The use of progesterone alongside estrogen helps balance the effects on the uterus while maintaining the protective benefits on the cardiovascular system. This combination has been shown to reduce the risk of heart attacks, strokes, and other cardiovascular events in women who begin treatment within the recommended time frame.(3)(6)
Does HRT cause blood clots?
HRT has been associated with a slightly increased risk of blood clots, which can lead to conditions like deep vein thrombosis (DVT) or pulmonary embolism (PE). This concern comes from how estrogen affects the blood, making it more likely to form clots. The potential risk is higher in women who start HRT late or take oral forms of estrogen, as it is metabolized through the liver, which can further impact clotting mechanisms. The risk of blood clots is also influenced by other factors that include the following:(2)(6)(9)
Age
Smoking
Obesity
Overall health
A personal or family history of clotting disorders
However, new evidence suggests that the cardiovascular protective effects of HRT may outweigh the potential risk of blood clots for many women, particularly when HRT is started early in the menopause transition and candidates are screened for preexisting clotting susceptibility.
Research has shown that the benefits of HRT, including improved cholesterol levels, reduced arterial stiffness, and a potential reduction in heart disease risk, can be significant. Additionally, transdermal estrogen (patch or cream) has been linked to a lower risk of blood clots compared to oral estrogen, as it bypasses the liver and does not affect clotting factors in the same way.(3)(6)
As with any treatment, the decision to use HRT should be individualized. Healthcare providers consider a woman’s overall health, family history, and risk factors to determine whether the potential cardiovascular benefits of HRT outweigh the associated risks, including the risk of blood clots.
Can women with heart disease try HRT?
For women with existing heart disease, the safety of HRT remains a common concern. However, current research suggests that women with cardiovascular conditions can benefit from HRT if started at the right time and under careful medical supervision. The key is to begin treatment within a decade of the onset of menopause symptoms, as the protective effects on the heart are most pronounced during this period.(9)
Alternative Approaches to Cardiovascular Disease Prevention
In addition to HRT, the following lifestyle changes can help women reduce their risk of CVD:(2)(3)(4)
Quitting smoking and avoiding exposure to secondhand smoke
Maintaining a healthy weight through regular exercise and a balanced diet
Exercising regularly, aiming for at least 30 minutes of aerobic activity most days of the week
Monitoring blood pressure, cholesterol levels, and blood sugar levels
Following a heart-healthy diet, rich in fruits, vegetables, and whole grains, while limiting saturated fats
Women should also be aware of other risk factors for coronary artery disease, such as a family history, diabetes, and a sedentary lifestyle.
Preventing CVD with HRT
Heart disease remains a leading health concern for women, affecting one in three each year. As menopause approaches, hormonal changes significantly impact heart health, increasing the risk of CVD. Women in their 30s to 60s should be proactive in assessing their cardiovascular health. Research suggests that starting HRT before the age of 60 may offer benefits for heart health.(1)(9)
While HRT has faced scrutiny due to dated studies, recent evidence supports its role in cardiovascular protection when appropriately prescribed and taken. Choosing HRT during menopause is a personal decision that depends on various factors, including an individual’s health, preferences, and understanding of what’s involved. It’s important to carefully weigh the potential benefits of HRT against the risks, especially for women with preexisting cardiovascular conditions.
The best approach to heart health during menopause is individualized, considering not only HRT but also other options like diet and lifestyle modifications. Women should discuss their options with their healthcare provider to make the most informed decision based on their unique situation.
