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HRT for postmenopausal women – does it help or harm the heart?

Hormone replacement therapy (HRT) does not protect post-menopausal women against cardiovascular disease, and may even cause an increased risk of stroke, according to a review of trials published recently in the Cochrane Library.1

HRT, now more commonly known as hormone therapy, is widely used for controlling menopausal symptoms. It has also been used for the prevention of cardiovascular disease in post-menopausal women. This latest evidence looked at the effects of using hormone therapy for at least six months and involved more than 40,000 women across the world.

The length of time women were on treatment, varied across the trials from seven months to just over 10 years. Overall, the results showed no evidence that HRT provides any protective effects against death from any cause, and specifically death from cardiovascular disease, non-fatal heart attacks or angina, either in healthy women or women with pre-existing heart disease. Instead the findings showed a small increased risk of stroke for post-menopausal women.

The authors also explored how much of an effect there was of starting HRT earlier. They found some evidence that women who started treatment within the first 10 years of their menopause, when menopausal symptoms are most common, seem to have a small protection against death and heart attacks, and no increased risk of stroke. But even in this group, the risk of deep vein thrombosis (DVT) increased.


Dr Henry Boardman (University of Oxford)

Speaking to BJC Arrhythmia Watch, co-author Dr Henry Boardman (Department of Cardiovascular Medicine, University of Oxford) said: “This review adds strength to the conclusions that hormone therapy is not recommended for the prevention of cardiovascular disease and is associated with increased rates of stroke and venous thromboembolism. These results refer to the randomised controlled trials (RCTs) taken as a whole including both primary and secondary prevention populations and agrees with existing guidelines. The average age of individuals was in the mid 60’s which is older than one would expect for a typical patient seeking menopausal relief.”

Dr Boardman added: “We also undertook a subgroup analysis looking at the effects of hormone therapy on those who started before the age of 60, or less than 10 years since their menopause. In this subgroup analysis we found lower rates of all-cause mortality and coronary heart disease, no statistically significant difference in rates of stroke and an increased rate of venous thromboembolism. These subgroup analysis results need to be interpreted with caution due to their post-hoc nature but I hope that further research in this area will allow us to make more confident conclusions for the associations with cardiovascular disease in this younger age group.”

“There have been two recent studies aimed at looking at hormone therapy in younger participants. Both have surrogate endpoints as their primary outcomes. One is recently completed, but not in time to include in this review, and the other is still ongoing. We plan to update this review in the future to include these two additional trials and any other which have been completed in the interim,” Dr Boardman concluded.

Dr David Tovey, Editor in Chief of the Cochrane Library commented, “This review adds a few more pieces to a complicated jigsaw of evidence relating to the use of HRT to treat symptoms of the menopause. The main analysis that the authors did, found no benefit and so we need to apply caution to the results from the subgroup analysis. However if true, this apparent benefit in preventing heart disease in younger women should be considered alongside other possible benefits and emerging evidence of harms, including the risk of breast cancer, ovarian cancer, and DVT.”


1. Boardman HMP, Hartley L, Eisinga A, et al. Hormone therapy for preventing cardiovascular disease in post-menopausal women. Cochrane Database Syst Rev 2015.

Published on: April 29, 2015

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