From the Guidelines
Hormone Replacement Therapy (HRT) is unsafe for a 50-year-old menopausal woman with a history of breast cancer, liver disease, myocardial infarction, known or suspected estrogen-dependent neoplasia, deep vein thrombosis, or thrombophilic disorders, as these conditions are considered contraindications to menopausal hormone therapy use. According to the 2024 guideline for the primary prevention of stroke from the American Heart Association/American Stroke Association 1, these conditions increase the risk of cardiovascular events, stroke, or breast cancer, making HRT a potentially harmful treatment option.
Cardiovascular Risks
The following cardiovascular risks make HRT unsafe:
- History of stroke
- Heart attack
- Blood clots (deep vein thrombosis or pulmonary embolism)
- Established coronary artery disease
- Uncontrolled hypertension
- Active liver disease
- Personal history of estrogen-sensitive cancers
Alternative Approaches
For women with these cardiovascular risks, alternative approaches for managing menopausal symptoms include:
- Non-hormonal medications like selective serotonin reuptake inhibitors (SSRIs), gabapentin, or clonidine
- Lifestyle modifications such as regular exercise and avoiding triggers like caffeine and alcohol
Shared Decision-Making
The decision to use HRT should be made with shared decision-making between the woman and her clinician, taking into account individual risk factors and preferences 1. The clinician should discuss the potential benefits and harms of HRT, as well as alternative treatment options, to determine the best course of treatment for the patient.
Ideal Candidate for HRT
The ideal candidate for starting menopausal hormone therapy (MHT) is a woman who is:
- Less than 60 years of age
- Within 10 years since menopause onset
- Has no elevated risk for cardiovascular disease, stroke, or breast cancer 1
From the FDA Drug Label
An increased risk of stroke and DVT has been reported with estrogen-alone therapy. An increased risk of PE, DVT, stroke, and MI has been reported with estrogen plus progestin therapy. Risk factors for arterial vascular disease (for example, hypertension, diabetes mellitus, tobacco use, hypercholesterolemia, and obesity) and/or venous thromboembolism (VTE) (for example, personal history or family history of VTE, obesity, and systemic lupus erythematosus) should be managed appropriately.
The following cardiovascular risks would make HRT unsafe for a 50-year-old menopausal female:
- Stroke
- Deep Vein Thrombosis (DVT)
- Pulmonary Embolism (PE)
- Myocardial Infarction (MI) These risks are increased with estrogen-alone therapy and estrogen plus progestin therapy, as reported in the Women's Health Initiative (WHI) study 2. Additionally, risk factors for arterial vascular disease and venous thromboembolism, such as:
- Hypertension
- Diabetes mellitus
- Tobacco use
- Hypercholesterolemia
- Obesity
- Personal or family history of VTE
- Systemic lupus erythematosus should be managed appropriately to minimize the risks associated with HRT 3 3.
From the Research
Cardiovascular Risks and HRT
The use of Hormone Replacement Therapy (HRT) in menopausal women has been a topic of discussion due to its potential effects on cardiovascular health. Several studies have investigated the relationship between HRT and cardiovascular disease risk.
Key Findings
- A study published in Circulation 4 found that the timing of HRT use, route of administration, and cardiovascular disease risk are important factors to consider when selecting patients for HRT.
- Research published in the Cancer journal (Sudbury, Mass.) 5 suggested that HRT initiated in women under 60 years old or at/near menopause can significantly reduce all-cause mortality and cardiovascular disease.
- A review in Best practice & research. Clinical obstetrics & gynaecology 6 discussed the current recommendations for HRT use in menopausal women, including the benefits of HRT in improving menopausal symptoms and its potential role in managing long-term sequelae.
- A study in Climacteric : the journal of the International Menopause Society 7 found that HRT use in postmenopausal Korean women was associated with a lower risk of myocardial infarction and stroke, particularly when initiated at a younger age.
- The Timing Hypothesis, discussed in the Journal of women's health (2002) 8, suggests that the cardiovascular effects of HRT depend on the timing of initiation in relation to menopause, with women under 60 years old or within 10 years of menopause having a lower risk of adverse cardiovascular events.
Cardiovascular Risks to Consider
- Stroke
- Myocardial infarction
- Venous thromboembolism
- Breast cancer (although rare, <10 events/10,000 women)
These risks should be taken into account when considering HRT for a 50-year-old menopausal female, and the decision to use HRT should be made on an individual basis, considering the woman's overall health and medical history 4, 5, 6, 7, 8.