Is it safe for a postmenopausal woman with a history of cardiovascular disease, who has been on Hormone Replacement Therapy (HRT) for 10 years, to continue HRT?

HRT Continuation After 10 Years: Not Recommended for Cardiovascular Disease

For a postmenopausal woman with cardiovascular disease who has been on HRT for 10 years, the therapy should be discontinued immediately—HRT is explicitly contraindicated for secondary prevention of cardiovascular disease and increases risk of adverse cardiovascular events. 1, 2

Primary Contraindication: Established Cardiovascular Disease

• The ACC/AHA guidelines provide a Class III recommendation (strongest contraindication) stating that hormone therapy with estrogen plus progestin, or estrogen alone, should not be given to postmenopausal women with unstable angina/NSTEMI or any established coronary artery disease for secondary prevention 1, 2

• The presence of coronary heart disease, myocardial infarction history, or angina represents an absolute contraindication to HRT use, regardless of any other indication 1, 2

• The American Heart Association explicitly states that HRT should not be used for secondary prevention of cardiovascular disease, and women with established CAD should not use hormone replacement therapy 1, 2

Evidence Base: Why HRT Fails in Cardiovascular Disease

• The Heart and Estrogen/progestin Replacement Study (HERS) demonstrated no reduction in cardiovascular events with HRT in women with established CAD, and found an increased risk of cardiac events in the first 1-2 years of therapy 1, 2

• Even after 6.8 years of follow-up in HERS II, there was still no cardiovascular benefit from HRT use 3

• The Women's Health Initiative found that combined estrogen-progestin resulted in a 29% increase in heart attacks and 41% increase in stroke 3

• For every 10,000 women taking combined estrogen-progestin for 1 year, there are 7 additional coronary events, 8 more strokes, and 8 more pulmonary emboli 1, 4

Specific Guidance for Women Already on HRT When CVD Develops

• The ACC/AHA recommends that postmenopausal women already taking HRT at the time of a cardiovascular event should generally not continue hormone therapy 1, 2

• HRT should not be continued while patients are on bedrest in the hospital 1, 2

• Women more than 1-2 years past HRT initiation who wish to continue for another compelling indication must weigh risks versus benefits, recognizing the greater risk of cardiovascular events 1, 2

Duration Considerations: 10 Years is Far Too Long

• Expert groups recommend that women who take HRT for menopausal symptoms use the lowest effective dose for the shortest possible time 4

• The risk-benefit profile is less favorable for women starting HRT more than 10 years past menopause 4

• Women over 60 or more than 10 years past menopause have less favorable risk-benefit profiles when taking HRT, with increased risk of coronary heart disease, stroke, and pulmonary emboli 4

• Breast cancer risk increases significantly with HRT duration beyond 5 years 4

Increased Thrombotic Risk in CVD Patients

• HRT increases venous thromboembolic events nearly 3-fold compared with placebo 1

• Risk for VTE was increased 5-fold in the first 90 days after MI, even after adjustment for hospitalization 1

• Because HRT and immobilization may be associated with hypercoagulable states, it may be prudent to discontinue HRT during hospitalization for an acute coronary event 1

Alternative Management for Menopausal Symptoms in CVD Patients

• For women with cardiovascular disease who have bothersome menopausal symptoms, non-hormonal therapies should be first-line treatment 2

• Non-hormonal pharmacological options include SSRIs, SNRIs, gabapentin, or clonidine for vasomotor symptoms 2

• Locally applied vaginal estrogen may be considered for genitourinary symptoms as systemic absorption is minimal 2

• Cognitive behavioral therapy or clinical hypnosis can reduce hot flashes 4

Optimal Cardiovascular Management Takes Priority

• Women with cardiovascular disease should be managed with evidence-based cardiovascular therapies, including beta-blockers, calcium channel blockers, long-acting nitrates, aspirin, and statins 2

• Aggressive coronary risk factor reduction is appropriate, including lipid-lowering agents, antiplatelet therapy, ACE inhibitors, and lifestyle modifications 2

• Lifestyle modifications remain cornerstone therapy: smoking cessation, regular physical activity, optimal weight management, and heart-healthy diet 2

Critical Clinical Pitfall to Avoid

Do not continue HRT in women with established cardiovascular disease simply because a gynecology specialist said it was acceptable—this directly contradicts ACC/AHA Class III recommendations and increases cardiovascular morbidity and mortality. 1, 2 The presence of cardiovascular disease fundamentally changes the risk-benefit calculation, making continuation of HRT after 10 years both unnecessary and harmful.