Cardiovascular Risk Associated with Menopause and Menopause Hormone Therapy: A Review and Contemporary Approach to Risk Assessment

Zoee D'Costa; Emily Spertus; Shipra Hingorany; Rajita Patil; Tamara Horwich; Marcella Calfon Press; Janki Shah; Karol E Watson; Lua Jafari

doi:10.1007/s11883-025-01343-6

Cardiovascular Risk Associated with Menopause and Menopause Hormone Therapy: A Review and Contemporary Approach to Risk Assessment

Curr Atheroscler Rep. 2025 Oct 9;27(1):100. doi: 10.1007/s11883-025-01343-6.

Authors

Zoee D'Costa¹, Emily Spertus², Shipra Hingorany³, Rajita Patil⁴, Tamara Horwich³, Marcella Calfon Press³, Janki Shah³, Karol E Watson³, Lua Jafari³

Affiliations

¹ David Geffen School of Medicine, Department of Medicine, University of California, Los Angeles, Los Angeles, CA, USA. zdcosta@mednet.ucla.edu.
² University of California, Berkeley, Berkeley, CA, USA.
³ Department of Medicine, Division of Cardiology, University of California, Los Angeles, Los Angeles, CA, USA.
⁴ Department of Obstetrics and Gynecology, University of California, Los Angeles, Los Angeles, CA, USA.

Abstract

Purpose of review: Discuss the effects of menopause and menopause hormone therapy (MHT) on cardiovascular risk, and propose a structured, person-centered framework for cardiovascular risk assessment when initiating MHT.

Recent findings: The risk of atherosclerotic heart disease accelerates during the menopause transition due to hormonal, metabolic, and vascular changes. Both menopause and MHT affect cardiovascular risk factors (i.e. blood pressure, lipids, insulin resistance) and cardiovascular events (i.e. myocardial infarction and stroke). Early clinical trial evidence demonstrated that oral synthetic MHT, including conjugated equine estrogen (CEE) with medroxyprogesterone acetate (MPA), is associated with increased coronary heart disease and stroke risk, particularly in older, postmenopausal women. Contemporary formulations such as low-dose transdermal estrogen and micronized progesterone have lower cardiovascular risk. A personalized assessment when initiating MHT should consider age, time since menopause, baseline cardiovascular (CV) risk, and choice of MHT formulation. Assessment of baseline CV risk should include a comprehensive review of traditional CV risk factors and consideration of risk-enhancing factors (including female-specific risk factors) and imaging for subclinical atherosclerosis (i.e. coronary artery calcium scoring) to provide a person-centered risk assessment. Menopause is an important period to implement prevention strategies to reduce future incidence CVD. A structured, individualized approach that accounts for the timing, formulation and delivery of MHT can optimize cardiovascular safety. This review provides a framework for personalized decision-making and highlights the need for further research to clarify MHT's impact on long-term CV outcomes.

Keywords: ASCVD; Algorithm; Cardiovascular risk; Hormone; Menopausal hormone therapy (MHT); Menopause.

Publication types

Review

MeSH terms

Cardiovascular Diseases* / epidemiology
Cardiovascular Diseases* / etiology
Estrogen Replacement Therapy* / adverse effects
Estrogen Replacement Therapy* / methods
Female
Heart Disease Risk Factors
Hormone Replacement Therapy* / adverse effects
Humans
Menopause*
Risk Assessment
Risk Factors