Menopausal Hormone Therapy Appropriate for Women at Low ASCVD Risk, According to Review

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Menopausal hormone therapy (HT) for lifestyle-limiting, bothersome vasomotor symptoms is safe and appropriate for most women at low atherosclerotic cardiovascular disease (ASCVD) risk, according to findings from a new review.

A nuanced approach is needed for menopausal women at intermediate ASCVD risk, added review authors writing in Circulation.

At one time, HT was almost universally recommended to women with symptoms of menopause, however, “with the publication of the HERS (Heart and Estrogen//Progestin Replacement Study) and WHI (Women’s Health Initiative) randomized trials, which reported excess cardiovascular risk, HT use declined substantially,” wrote first author Leslie Cho, MD, director of the Cleveland Clinic’s Women’s Cardiovascular Center, and colleagues.

“However, during the past 20 years, the relationship of CVD risk with timing of menopause, initiation of HT, and route of HT delivery has been better understood,” wrote Cho and colleagues.

Four major North American medical societies—the American College of Obstetricians and Gynecologists, American Association of Clinical Endocrinology, the Endocrine Society, and the North American Menopause Society—now recommend HT in appropriate patients for the management of menopausal symptoms.

Despite these recommendations, physicians, including cardiologists, are still hesitant to initiate HT because of confusion and lack of education regarding which patients are appropriate for the therapy, according to the research team.

The aim of the current review—led by the American College of Cardiology Cardiovascular Disease in Women Committee, along with leading gynecologists, women’s health internists, and endocrinologists who specialize in menopause management—was to provide guidance on the present understanding of the risks and benefits of HT.

Recommendations

According to investigators, the appropriate candidates for menopausal HT are women who are aged <60 years, or are within 10 years of menopause onset, who have a 10-year estimated ASCVD risk of <5%, and do not have an increased risk for breast cancer or history of venous thromboembolism (VTE).

A more nuanced approach for HT is recommended for women at intermediate risk, which was defined as women with diabetes, hypertension, obesity, 10-year estimated ASCVD risk of ≥5%-10%, among other risk factors.

“The presence of CVD risk factors alone does not preclude the use of HT, but a patient’s worsening cardiovascular risk profile around the menopause transition emphasizes the need to optimize primary prevention efforts, including lifestyle and pharmacological management,” wrote investigators.

Patients who are at high risk should be advised to avoid systemic HT and include women with a history of congenital heart disease, ASCVD, coronary artery disease, peripheral artery disease, VTE, and stroke with a high 10-year ASCVD risk (>10%). “For patients with these conditions, shared decision-making is advised using an individualized approach incorporating an assessment of symptom severity, evidence for safety versus harm relative to the woman’s underlying condition(s)/medical history, and collaboration with other members of her health care team,” wrote Cho and the team.

The various types of HT include systemic estrogen therapy, transdermal estrogen and progesterone, compounded HT, and vaginal estrogen therapy. Low-dose vaginal estrogen therapy is currently the most effective treatment because it is minimally absorbed.

“These past 2 decades have brought nuanced insights into HT use,” concluded Cho et al. “Going forward, we need additional data to better understand the risk-to-benefit balance of initiating HT early and continuing long term, and to more fully delineate the differences between various formulations and routes of HT with respect to CVD risk.”

Reference: Cho L, Faubion SS, Lau ES, et al. Rethinking menopausal hormone therapy: For whom, what, when, and how long? Circulation. 2023;147:597-610.