Cardiovascular conditions and HRT

Overview

Cardiovascular disease is the leading cause of death for women in the UK.  

Prior data that linked increased rates of cardiovascular disease with HRT is no longer applicable. This data was in women starting HRT aged over 60 after a 10-year gap between menopause, using high dose equine derived oestrogen and medroxyprogesterone acetate (an androgenic progestogen with negative impact on cholesterol), which is not routinely used as part of current HRT preparations.  

Whilst cohort studies have found a 40-50% reduction in coronary heart disease with the use of HRT, it should not be used for primary prevention. 

Use of body-identical oestradiol within 10 years of menopause has been shown to reduce atherosclerosis and coronary events in observational studies and randomised controlled studies. Use of progestogens such as dydrogesterone, micronised progesterone (MP) and transdermal norethisterone appear not to attenuate the beneficial impact of oestrogen. 

Hypertension and HRT

High blood pressure is not a contraindication to HRT.  

The BNF lists hypertension as an uncommon side effect of estradiol and BP should be monitored at follow up.  

A pragmatic approach for women with raised blood pressure requesting HRT is below:  

• All modifiable risk factors should be addressed at the same time as starting HRT as per NICE guidance.  

• Stage 1 hypertension: start HRT with careful monitoring, 2-4 week follow up and treatment of blood pressure.  

• Stage 2 or 3 hypertension: wait until blood pressure is improved before starting HRT.  

Tibolone and oral HRT, should not be used for women with hypertension due to the risk of stroke. 

Stroke and HRT

NICE guidance states oral, but not transdermal HRT, increases the risk of stroke.  

The absolute risk of stroke under 60 is very low and the increase in risk conferred by HRT is thought to cause two additional strokes per 10,000 person years, under the age of 60. 

Specific groups requesting HRT  

Ensure all cardiovascular risk factors are well controlled for all groups. Tibolone should not be used in these groups. 

• Initiating HRT over 60  – see HRT in over 60s  

• Higher risk for stroke under 60 e.g. family history of stroke at a young age - offer transdermal HRT up to standard doses. Refer to specialist if higher than standard doses are needed. 

• Personal history of TIA – not on HRT. Offer transdermal HRT at least 3 months after TIA starting at very low dose e.g. half an estradiol containing 25 patch (dose = 12.5mcg), increasing every 4 weeks up to standard doses (e.g. 50mcg patch / 2 pumps of oestrogel). 

• Personal history of TIA – whilst on HRT. Switch to transdermal if using oral HRT. Consider reducing to standard dose if on high dose HRT. Consider switching to micronized progesterone (MP) if progestogen is needed. Refer to specialist if higher than standard doses are needed, do not start higher doses. If progestogen is required, offer MP. 

• Personal history of stroke – not on HRT. Ensure symptoms are not due to medications/experience of having a stroke. Offer transdermal HRT at least 3 months after stroke, at very low dose e.g. half an estradiol containing 25 patch (dose = 12.5mcg), increasing every 4 weeks up to standard doses. If progestogen is required, offer MP. Refer to specialist if higher than standard doses are needed. 

• Personal history of stroke- on HRT. Send Gynaecology Advice and Guidance request. Switch to transdermal if using oral HRT. No need to stop HRT until further advice received, unless this is patient preference.   

MI and HRT

Myocardial infarction is not a contraindication to HRT but initiation should be with the support of a menopause specialist as timing of HRT initiation, route and type of progestogen are important. Please make an appropriate referral.   

Be mindful that some medications commonly prescribed after MI can cause side effects such as flushes.   

Women who have experienced an MI whilst using oral HRT should switch to transdermal HRT, using progestogens with a neutral impact on cholesterol e.g. micronised progesterone, whilst awaiting review by a menopause specialist.  

For those at higher risk for MI:  

• Ensure all cardiovascular risk factors are well controlled 

• Consider starting a statin 

• Choose transdermal HRT and a lower risk progestogen (e.g. MP)   

Also see BMS guidance: 21-BMS-TfC-HRT-after-myocardial-infarction-MARCH2024-A.pdf (thebms.org.uk) 

Referral

Indications: 

• Women initiating HRT >60y and requiring above standard doses of HRT
• Women wishing to continue HRT with a personal history of stroke whilst using HRT 
• Women with a history of stroke or TIA requiring above standard doses of HRT 
• Women with a high risk of stroke requiring above standard doses of HRT
• Women with a personal history of myocardial infarction wishing to start HRT  

Send Gynaecology Advice and Guidance request via eRS for women who have had a stroke whilst using HRT.  

Women requiring specialist input may be reviewed by a Menopause Specialist in primary care if available and appropriate.  

Advice and Guidance and Referrals can be sent to the Complex Menopause Clinic at UHBW.  

Resources

Patient information  

Coronary heart disease (CHD) explained - a British Menopause Society video (youtube.com) 

Menopause and heart and circulatory conditions - BHF 

References and Resources 

Estradiol | Drugs | BNF | NICE 

Risk factors for CVD | Background information | CVD risk assessment and management | CKS | NICE 

21-BMS-TfC-HRT-after-myocardial-infarction-MARCH2024-A.pdf (thebms.org.uk) 

Hormone replacement therapy (HRT) | Prescribing information | Menopause | CKS | NICE 

CVD risk assessment and management | Health topics A to Z | CKS | NICE 

Risk factors | Background information | Hypertension | CKS | NICE 

Hypertension | Health topics A to Z | CKS | NICE 

Scenario: Management of menopause, perimenopause, or premature ovarian insufficiency | Management | Menopause | CKS | NICE 

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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