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Cardiovascular risk in menopausal women and our evolving understanding of menopausal hormone therapy: risks, benefits, and current guidelines for use

Sindhu Prabakaran 1Arielle Schwartz 1Gina Lundberg 2

Ther Adv Endocrinol Metab. 2021 Apr 30;12:20420188211013917.

 doi: 10.1177/20420188211013917. eCollection 2021

Abstract

Women are at increased risk for cardiovascular disease (CVD) compared with men. While traditional risk factors for CVD seem to disproportionately affect women and contribute to this disparity, increased prevalence of CVD at midlife calls into question the contribution of menopause. Given the potential role that declining hormone levels play in this transition, menopause hormone therapies (MHT) have been proposed as a strategy for risk factor reduction. Unfortunately, trials have not consistently shown cardiovascular benefit with use, and several describe significant risks. Notably, the timing of hormone administration seems to play a role in its relative risks and benefits. At present, MHT is not recommended for primary or secondary prevention of CVD. For women who may benefit from the associated vasomotor, genitourinary, and/or bone health properties of MHT, CVD risks should be taken into account prior to administration. Further research is needed to assess routes, dosing, and formulations of MHT in order to elucidate appropriate timing for administration. Here, we aim to review both traditional and sex-specific risk factors contributing to increased CVD risk in women with a focus on menopause, understand cardiovascular effects of MHT through a review of several landmark clinical trials, summarize guidelines for appropriate MHT use, and discuss a comprehensive strategy for reducing CV risk in women.

Conclusion

CV risk in women increases at the time of menopause, likely related to a combination of aging and the menopausal transition. Proper CVD risk assessment is imperative for improving long term CVD outcomes, guiding risk reduction therapy, and determining safety of MHT if needed. A thorough history of adverse pregnancy outcomes and complications is required in all perimenopausal women. Assessment of family history of CVD in addition to any personal history of autoimmune or rheumatologic disorders and human immunodeficiency virus (HIV) is essential. All traditional risk factors should be assessed as well as current lipid cholesterol levels, blood glucose levels, and blood pressure. All women should receive education on ideal body weight, a plant-based heart healthy diet, and optimal exercise routines.

MHT is not recommended for primary or secondary prevention of CVD or in women with known ASCVD or high risk for CVD events. In select populations of women who may benefit from its vasomotor, genitourinary, and bone health effects, women at low CVD risk may be prescribed MHT safely until age 65. The principles underlying safe use of MHT include using low dose MHT for the shortest possible duration and employing transdermal, SERM, and topical formulations where appropriate, often as an initial strategy. Lastly, it is imperative that both patients and providers are aware of the appropriate indications for MHT and individual risks, especially from a CV standpoint. Several calculators are available to further risk-stratify these patients and enable safe shared-decision making, such as the ASCVD pooled-cohort risk calculator and the NAMS MenoPro app. Quality of life for postmenopausal women is an important consideration, and in addition to early risk assessment and CVD risk reduction, decisions regarding MHT should be made individually and reassessed over time.