A 20-year US cohort study found women who began hormone replacement therapy within 10 years of vasomotor symptom onset had fewer serious cardiovascular events, but causation isn't established and risks remain.
Women who began HRT within 10 years of vasomotor symptom onset were estimated to be 27% less likely to have a fatal or non-fatal cardiovascular event than non-users in the study cohort.
The protective association was weaker for women who started HRT more than 10 years after symptom onset.
Other evidence links oral HRT with small increased annual risks of venous thromboembolism (0.09%), ischaemic stroke (0.06%), and heart attack (0.03%)—so benefits must be weighed against known harms.
# What the study did
# Main finding Women who began hormone replacement therapy within 10 years of the onset of vasomotor symptoms were estimated to be 27% less likely to experience a major cardiovascular event than women who did not use HRT. The association was much weaker among women who started HRT more than 10 years after symptom onset.
# How the researchers explain a possible benefit The authors note multiple biological reasons HRT could influence cardiovascular risk: oestrogen affects cholesterol and blood sugar regulation and contributes to blood vessel flexibility. Prior work has also shown that HRT dose and formulation can influence artery structure. The perimenopause itself is described as a period of distinct vascular changes, which may be relevant to timing.
# Safety context and limitations This was an observational study, so it cannot establish causation. The lead author, Samar El Khoudary, emphasised the study does not support prescribing menopausal hormonal therapy purely to prevent cardiovascular disease. Independent commentary in the report pointed out that observational results must be interpreted cautiously.
Other research cited in the article found small absolute annual increases in risk associated with oral HRT: 0.09% higher risk of venous thromboembolism, 0.06% higher risk of ischaemic stroke, and 0.03% higher risk of heart attack per year. Those risks and possible variation by HRT formulation and dose remain important when weighing benefits versus harms.
# Who might see different effects The study reports that the association between earlier HRT initiation and lower cardiovascular events was most pronounced among Black participants, who may experience more vasomotor symptoms. The report calls for further work to understand racial differences in outcomes.
# What the authors recommend next The researchers propose randomised, placebo-controlled trials focused on starting HRT during perimenopause or early menopause to test cardiovascular outcomes directly. They highlight the need to identify optimal timing, formulations, and doses for any protective effects.
# Bottom line In this long-term observational cohort, starting HRT relatively early in the menopausal transition was associated with fewer major cardiovascular events. The finding is associative, not proof of benefit. People should not start HRT solely to prevent heart disease based on this study. Decisions about HRT should consider symptom relief, individual cardiovascular and cancer risk factors, HRT formulation, and discussions with a clinician.
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