Hormone replacement therapy and cardiovascular risk in postmenopausal women

Menopause hormone replacement therapy (HRT) remains the main strategy for managing menopausal symptoms and preventing osteoporosis in postmenopausal women. However, its cardiovascular effects are complex and influenced by multiple factors. Early initiation of HRT within 10 years of menopause onset consistently demonstrates cardiovascular benefits, whereas delayed initiation may increase risks such as stroke and venous thromboembolism. Transdermal and bioidentical hormones generally show a safer cardiovascular profile compared to oral synthetic preparations. Current guidelines advocate for individualized therapy considering patient preferences and risk stratification. However, significant knowledge gaps remain regarding long-term safety, diverse populations, and optimized risk assessment tools. The development of a menopause-specific cardiovascular risk calculator could enhance patient-centred care and guide shared decision-making. This review synthesizes current evidence from major randomized trials, observational studies, and meta-analyses, highlighting the critical role of timing, hormone formulation, administration route, and baseline cardiovascular risk in determining HRT's cardiovascular outcomes. It also underscores the importance of precision medicine in optimizing cardiovascular and overall health outcomes for postmenopausal women using HRT.