Primary prevention of heart disease in the menopause– is HRT enough?

Meet Rebecca. At 46 years old she is consulting you about her cardiovascular risk – her mother had a stroke in her 60s and father an MI in his late 50s. She wants to prevent the same happening to her. Like many of our patients, she is overweight, has untreated hypertension, and pre-diabetes. Plus, she is in the perimenopause.

“I want to go on HRT. I saw on Insta its good for stopping heart attacks.”

A BJGP Editorial in 2024 discussing management of the menopause acknowledges that cardiovascular disease is the most common cause of death for mid-life women. But is her influencer correct and HRT is the solution for Rebecca? Is it even safe for her given her cardiovascular risk factors?

To answer this, we can work through a few important questions.

First, is HRT indicated in our patient? 

Yes. She has developed changes in her menstrual cycle over the past year and may be having some hot flushes. At the age of 46 year old NICE guidance recommends we can make a clinical diagnosis of perimenopause without the need for further investigations. While NICE suggests HRT would be indicated for managing troubling symptoms, the British Menopause Society takes a slightly different view recommending HRT should be considered ‘in the context of overall benefits’ including symptom control, quality of life and potentially bone and CVD health.

Second, is HRT safe to use in our patient? 

Yes. Our patient has raised blood pressure and BMI at 142/86 and 32 respectively. Thankfully, despite this and her family history, driven by her ‘young’ age (as in, not far off mine…) her QRisk is just 3%. The good news for our patient is these risk factors are not contra-indications for HRT – no, we wouldn’t be prescribing the COCP to Rebecca, but this is a very different scenario to hormonal contraceptives. HRT doses are much lower, simply replacing the natural levels that decline with the menopause, and safe in the context of hypertension. Indeed, HRT may still be prescribed to women after MI. 

Third, does HRT actually prevent cardiovascular disease?

Yes, but ‘may reduce the risk’ is probably a more accurate phrase. 

The British Menopause Society notes: “observational studies have consistently shown oestrogen to help prevent CHD in postmenopausal women” with improvements in vascular function and reduction of atheroma formation. But NICE have produced a decision aid which suggests no improvement in coronary heart disease or stroke with combined HRT. 

So what’s going on? The devil is in the detail: the timing of initiation and the medications used all influence the potential benefit.

The type of HRT used matters. Oestrogen is the CV protective hormone here, whether used via transdermal or oral routes, but the majority of women will also need endometrial protection with progestogen. Older progestogens such as medroxyprogesterone acetate may negate the beneficial effects of oestrogen, but modern micronized progestogens, such as Utrogestan, and the levonorgestrel intra-uterine system (e.g. Mirena, etc.), while having limited data in this area, are thought to not interfere.

Age and/or timing of initiation is important too. The BMS suggests oestrogen may be protective when initiated up to the age 60y or within 10 years of the onset of menopause. Women with premature ovarian insufficiency or early menopause are particularly likely to benefit from starting HRT promptly and continuing until at least the typical age of menopause.

Finally, does this mean HRT is all women need for CVD protection?

No. The key message is that, while the right HRT may well reduce cardiovascular risk in women when started at the right age, as the BJGP editorial points out, and especially given some of the uncertainties in the existing data, HRT can’t do all the heavy lifting. We need to take a holistic view and not ignore other risk factors.

Lifestyle measures to help tackle overweight and obesity, poor diet, sedentary behaviour, excess alcohol and smoking remain paramount. Drug treatment of hypertension, consideration of a statin (while there was initially uncertainty that statins reduced mortality and CVD events in post-menopausal women, data now confirms that there are reductions similar to those seen in men), and prevention or treatment of diabetes (indeed HRT may reduce the risk of diabetes in post-menopausal women) are all recommended where indicated. 

Back to Rebecca then. HRT may improve her symptoms and dramatically improve her quality of life. This alone is a good enough reason to start treatment. And it may well help reduce her future cardiovascular risk, but let’s think beyond hormone therapy alone and help her with all those other risk factors too. 

If you interested in knowing more about menopause management and many other women’s health topics, and would like the opportunity to ask the NB team any burning questions about it, then why not join us for our live Hot Topics Women’s Health for Primary care webinar on Saturday 11^th October. Find all the details on the NB Medical website here.