Life expectancies are growing longer worldwide, making it more than likely that you’ll live almost 40 percent of your life after achieving menopause. And when you’re empowered by the wisdom that comes with a few extra years, there’s no reason that those postmenopausal years can’t be some of the best you’ve ever had.
But taking care of your body looks a little different after your period stops. Your risk of cardiovascular disease — the root cause of heart attack, stroke, and heart failure — begins to increase after menopause. Hormone replacement therapy (HRT), a common treatment for the symptoms of menopause, may offer some protection against developing heart disease, or at least lower your risk. Here’s what you need to know about heart health and HRT.
The risk factors for coronary heart disease after menopause
Cardiovascular disease is the leading cause of premature death for American women, so prevention is essential. But many women assume their risk for cardiovascular disease is lower than that of their male counterparts.
They aren’t totally wrong: A 55-year-old man would be at greater risk of heart disease than a woman of the same age. There are a host of intersecting reasons for this, including lifestyle factors. But the biggest reason that we know about has to do with ovarian function.
Lizellen La Follette, a board-certified OB-GYN in Marin County, California, explains that even after your ovaries stop releasing eggs they still have some level of hormonal function. And these hormones, especially estrogen, appear to improve your heart health when they are present.
Estrogen has a wide range of effects on cardiovascular cells. Having the hormone regularly released into your bloodstream can decrease inflammation, act as an antioxidant, bring your blood pressure down, and a host of other benefits.
But somewhere between ten to 15 years after menopause, the remaining hormonal function in your ovaries tapers off. And after that, a woman’s risk of heart disease will look similar to a man’s. “Once the ovarian function starts to decrease, the new risks start to slowly rear their ugly head,” La Follette says. After age 65, a woman’s risk of heart disease becomes roughly the same as a man of the same age.
How can HRT help manage the risk of cardiovascular disease?
Hormone replacement therapy is sometimes offered as a treatment for menopause symptoms like sleep disturbances and hot flashes, and to prevent osteoporosis. HRT can help keep the estrogen (and progesterone) going in your body even as your ovaries wind down — theoretically maintaining the protective effects of estrogen on your heart, even after menopause.
So it’s not a big surprise that some clinical trials indicate that women who used hormone therapy to treat other symptoms of menopause seemed to be at a lower risk of developing cardiovascular disease. A 2009 meta-analysis of 19 randomized trials, representing a total of 16,000 female participants with the median age of 55, found a statistically significant reduction in mortality among those women.
But some of the other research results on how beneficial HRT is in reducing heart disease risk have been, well, pretty mixed, and that’s made the use of HRT controversial for this purpose. The American Congress of Obstetricians and Gynecologists (ACOG) even reaffirmed as recently as 2020 that it does not currently recommend the use of hormone therapy for this purpose.
ACOG also stated that there is evidence that lends support to something called the “timing hypothesis.” Basically, it’s possible that the women who participated in studies where HRT didn’t have an effect on their heart disease risk might have been too old.
Women who start HRT soon after menopause are able to keep up the momentum, as it were, from their body’s natural estrogen production. That keeps important receptors in the body alive and can use any estrogen it receives, whether it’s natural or synthetic.
Once too much time has elapsed since your last period, it might not matter if you take HRT or not, at least where your heart is concerned. Women who started on HRT within ten years of reaching menopause see the most prominent results. “This idea of the sweet spot of hormone replacement therapy being within ten years of menopause clearly makes sense physiologically,” says La Follette.
In 2022, the American Heart Association published a scientific statement in Circulation calling attention to this. If all parties agree on one thing, it’s that more research is needed.
How do you decide if HRT is right for you?
If you are considering taking hormone replacement therapy to reduce your risk of heart disease, you don’t have infinite time to figure it out. In fact, the sooner you start HRT after menopause, the more effective it may be in reducing your risk of heart disease.
Hormone replacement therapy is not without side effects, though. It may increase your risk of uterine cancer, breast cancer, deep vein thrombosis, and blood clotting disorder. People who have migraines or liver disease are also advised against taking hormone replacement therapy.
Breast cancer risk in particular weighs heavily into the equation. An older study from 2002 conducted by the Women’s Health Initiative (WHI) was meant to be a long-term randomized controlled trial to identify the risks and benefits of the most commonly used HRT. This particular study had a staggering effect on how patients and doctors approached HRT due to inflated and ultimately incorrect concerns and assertions about breast cancer risk.
“Now, 18 years later, the conclusion about the risk of HRT, namely breast cancer, has been shown to be completely wrong,” said La Follette. “One out of two women die of heart disease or stroke in this country. Your risk of dying of breast cancer is, at worst, one in eight."
Heart attacks and strokes are far more lethal and far more common, said La Follette. Breast cancer is often survivable, but half of women who have a stroke survive for less than five years afterward.
It would be wrong to gloss over the danger of invasive breast cancer, but we also have to keep things in perspective according to our personal health history and the prevalence of heart disease. An honest conversation with your doctor is the best way to evaluate your individual risks.
There are plenty of other things you can do to protect your heart health, even without HRT. La Follette says that being active, keeping an eye on your blood pressure, and remaining within a healthy weight range are all critical to reducing the risk of cardiovascular disease.
These lifestyle changes can become more challenging to manage as you grow older — nobody wants to spend an hour on the elliptical with aching joints — so again, the sooner you start, the better — for your health right now and decades down the road.
By Kathryn Watson