Hormone Replacement Therapy and Cardiovascular Risk in Postmenopausal Women

Abstract 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 ten 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 individualised therapy considering patient preferences and risk stratification. However, significant knowledge gaps remain regarding long-term safety, diverse populations, and optimised risk assessment tools. The development of a menopause-specific cardiovascular risk calculator could enhance patient-centred care and guide shared decision-making. This review synthesises current evidence from major randomised 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 optimising cardiovascular and overall health outcomes for postmenopausal women using HRT.