From the Guidelines
Oral estrogen therapy should be used with caution in patients with hypertension due to its potential to increase blood pressure. When considering the effects of oral estrogen therapy on hypertension, it is essential to weigh the benefits against the potential harms. According to the U.S. Preventive Services Task Force recommendation statement 1, estrogen-only therapy is associated with important harms, such as an increased likelihood of stroke, which is a significant concern for patients with hypertension. Key points to consider when prescribing oral estrogen therapy to patients with hypertension include:
- Starting with the lowest effective dose to minimize potential increases in blood pressure
- Monitoring blood pressure closely, ideally within 2-4 weeks after starting therapy and regularly thereafter
- Encouraging patients to maintain regular blood pressure monitoring, follow a low-sodium diet, exercise regularly, and ensure their antihypertensive medications are optimized
- Considering alternative formulations, such as transdermal estrogen, which may have less impact on blood pressure compared to oral forms The potential for oral estrogen to increase blood pressure is attributed to its effect on the liver, where it increases the production of angiotensinogen, activating the renin-angiotensin-aldosterone system and potentially elevating blood pressure 1. In clinical practice, the decision to prescribe oral estrogen therapy to patients with hypertension should be based on a thorough evaluation of the individual patient's clinical situation, preferences, and values, with the goal of maximizing benefits while minimizing harms.
From the Research
Effects of Oral Estrogen Therapy on Hypertension
- The use of oral estrogen therapy has been associated with a discreet increase in blood pressure 2.
- A study found that oral estrogen therapy was associated with an increased risk of hypertension, with an adjusted HR of 1.09 (95% CI: 1.04-1.14) 3.
- However, another study found that the effect of oral therapy on blood pressure was essentially neutral in large trials conducted in normotensive women with blood pressure as primary outcome 4.
- The evidence suggests that transdermal estrogen therapy may be a safer option for women with hypertension, as it has been shown to have a neutral or beneficial effect on blood pressure 2, 4, 3.
Comparison with Transdermal Estrogen Therapy
- Transdermal estrogen therapy has been shown to have a minimal effect on hemostatic variables and may improve the benefit/risk ratio of postmenopausal hormone therapy 5.
- A study found that transdermal estrogen therapy was not associated with an increased risk of hypertension, with an adjusted HR of 1.03 (95% CI: 0.99-1.07) 3.
- Another study found that transdermal estrogen therapy had a beneficial effect on blood pressure in normotensive women and a neutral effect on hypertensive women 4.
Importance of Individualized Treatment Approach
- The decision to use hormone therapy should be individualized, and blood pressure should be monitored during the course of treatment 4.
- The use of hormone therapy should take into account the woman's overall cardiovascular risk profile, including her age, blood pressure, and other health factors 6, 2, 3.
- Alternative non-hormonal medications may be suggested as first-line treatment for women with increased baseline thromboembolic risk 6.