Heart health, menopause and HRT FAQ

Menopause can throw up a lot of questions – here we get to the truth behind heart health and HRT

Q Does menopause cause high blood pressure?

A Blood pressure tends to rise with age – around two thirds of adults over 60 have high blood pressure. The drop in oestrogen that occurs during the menopause doesn’t directly raise your blood pressure, but it is linked to a much higher risk of heart disease and heart attacks.

The change in hormones that happens with the menopause can sometimes make you feel tired and fed up, so you feel less like doing healthy things such as exercising and eating healthy foods, which can impact blood pressure.

Q I’ve always had low cholesterol but now it’s high. I’ve not changed my diet – is menopause to blame?

A It can certainly be a factor – oestrogen has heart protective qualities, including reducing the levels of ‘bad’ cholesterol in your blood. During the perimenopause, oestrogen levels fluctuate and during the menopause, levels fall. The cholesterol in your blood often rises during menopause and this continues into old age.

Other causes of high cholesterol include eating fatty food, not exercising enough, being overweight, smoking and drinking alcohol, so it’s worth discussing it with your healthcare professional to determine the cause and action to take to lower your cholesterol level.

Q I’m menopausal – should I be worried about my risk of heart disease?

A When oestrogen levels fall, the protective effects of oestrogen can be lost. Studies have shown that women who are at a younger age when they are menopausal have a greater risk of developing heart disease as they have longer without their hormones (unless they take HRT) [1, 2].

Menopause-related symptoms such as reduced stamina, fatigue and reduced motivation can lead to a reduction in exercise, and unhealthy eating habits, which can impact heart health.

So the menopause is a good chance to take a holistic look at your lifestyle to see if you can make any adjustments that will benefit your heart. For instance, evidence shows that if you start taking HRT during your perimenopause, or within 10 years of your menopause, you have a lower risk of developing heart disease and a lower risk of death from heart disease than those who don’t take HRT [3].

Q I’ve been experiencing a fluttering feeling in my heart. Could I be menopausal?

A An increasing awareness of your heart beating – whether it feels faster than usual or irregular ­– is a common symptom of the perimenopause and menopause [4]. During this time, levels of oestrogen change, which can affect the pathways in your heart through which electrical impulses travel. Lower oestrogen levels can overstimulate your heart ­­– it can beat 8-16 times more per minute.

It’s worth seeing a healthcare professional to rule out any other causes and to get advice on potential treatment.

Q Can I take HRT with high blood pressure?

A For most women, it’s perfectly safe to take HRT if you have high blood pressure or you’re taking medicines to lower your blood pressure. Your doctor will simply need to keep an eye on your blood pressure and adjust your medicines if needed.

Oestrogen taken as a tablet has the potential to raise blood pressure but taking oestrogen through the skin as a patch, gel or spray allows your blood vessels to widen – so it can lower your blood pressure rather than raise it.

While some progestogens could raise blood pressure, the newer type, micronised progesterone, appears to have no effect or even lowers blood pressure.

Q Can I take HRT if I have high cholesterol?

A Yes. Taking body-identical HRT usually lowers cholesterol – oestrogen can decrease LDL cholesterol and increase ‘good’ HDL cholesterol. By correcting the hormone deficiency and replacing the missing hormones, HRT helps to lower your risk of heart disease in future.

Q Can I take HRT if I have heart disease?

A You’ll need individualised advice, so your cardiologist and menopause specialist may need to work together. But in general, oestrogen taken through the skin in a patch, gel or spray does not have an increased risk of clot or stroke. If you need to take a progesterone as part of your HRT, micronised progesterone (Utrogestan) is recommended and this does not increase your risk of clot either.  Synthetic oestrogen taken in tablet form can slightly increase the risk of blood clots, deep vein thrombosis and stroke, but the overall risk of stroke in women under 60 is low and the increased risk is greater if you are overweight and don’t exercise.

Q Can I go back on HRT or start it after a heart attack?

A Taking HRT can help protect the health of your heart – reviews of evidence have shown that the risk of dying from heart disease in women taking HRT is reduced by about 30% [5]. Your doctor will weigh up your individual benefits and risks of taking HRT according to your circumstances, but it is possible.

Q Is there a minimum or maximum dose of HRT that will protect my heart?

A The literature is fairly sparse in terms of quoting figures however we tend to advise blood oestradiol levels ideally over 250pmol/l, with levels over 350pmol/l being quoted in some earlier studies as being the minimum required, and most women actually feel better at these levels in terms of symptom reduction. As the oestradiol levels can vary hourly, a good way to think about it is that some oestrogen is better than none, and titrate the dose according to your symptoms rather than necessarily chasing the numbers.

Q I’m 62 and 10-years post-menopause and have been advised to stop taking HRT as there is a high risk of heart disease? Is this right?

A There is a slightly increased risk of cardiovascular disease and a stroke for women over 60 who take HRT. This is more likely if you’ve started HRT late into the menopause and use combined HRT.

The risk can depend on the amount (dose) of HRT and how you take it. The risk is lower if the dose of HRT is smaller, or if you are use an HRT gel or patch.

Q I’m over 60 – if I start taking HRT now, will it affect my heart health?

A When starting HRT over the age of 60, lower doses are given, preferably with a transdermal route for oestradiol.  The evidence has shown no increase in cardiovascular events, cardiovascular mortality or all-cause mortality in women who initiate HRT more than 10 years after the menopause [6].

Q Why does the leaflet on my HRT list heart disease as a possible side effect yet I’ve read that HRT can help reduce heart disease?

A  Oestrogen taken through the skin in a patch, gel or spray, and micronised progesterone (Utrogestan) do not have an increased risk of clot. Unfortunately, the risk information detailed in the information inserts that come inside the boxes of oestrogen patches, oestrogen gels, vaginal hormones and micronised progesterone is not accurate and is therefore very misleading. It incorrectly states risks of clot, heart disease, stroke and breast cancer which really needs to change.

The leaflet was originally written as the insert for the oral synthetic oestrogen, which does carry a small increased risk of blood clot and can raise blood pressure. Ideally an up-to-date leaflet would be inserted that is relevant to the medication it accompanies.

Q I’m on HRT and my cholesterol has shot up – is HRT to blame?

A There’s no evidence that HRT increases cholesterol – in fact research states the opposite, that HRT can help to lower cholesterol levels. However, cholesterol in your blood often rises during menopause – in women aged 45 to 64, 77% of women have raised cholesterol – and this continues into old age. Talk to your healthcare professional to learn more about possible causes of your high cholesterol and treatments and lifestyle changes that can help reduce it.

Q I was told by my GP that it is wrong to prescribe HRT for preventative reasons, to help protect my heart and brain health, and that as my symptoms were manageable, I would be better off without HRT. Is this correct?

A The Medicines and Healthcare products Regulatory Agency (MHRA) advises that HRT should only be prescribed to relieve menopausal symptoms that are adversely affecting quality of life and it should not be prescribed to prevent coronary heart disease. However, some clinicians disagree and believe the evidence suggests HRT could be of great benefit for proactive reasons.

If you are experiencing menopausal symptoms, you have a right to request HRT and your doctor should listen to your reasoning. No one should have to endure symptoms if help is available and the benefits outweigh the risks.

References

1. Honigberg, M.C. et al. ‘Association of Premature Natural and Surgical Menopause With Incident Cardiovascular Disease.’ JAMA vol. 322,24 (2019): 2411-21. doi:10.1001/jama.2019.19191

2. Honigberg, M.C. et al. (2021), ‘Premature menopause, clonal hematopoiesis, and coronary artery disease in postmenopausal women’, Circulation vol. 143,5 (2021): 410-23. doi:10.1161/CIRCULATIONAHA.120.051775

3. Hodis H.N., Mack W.J. (2022), ‘Menopausal hormone replacement therapy and reduction of all-cause mortality and cardiovascular disease: it is about time and timing’, Cancer, 28(3):208-23. doi: 10.1097/PPO.0000000000000591

 4. Carpenter J.S., Sheng Y., Elomba C., et al. (2021), ‘A systematic review of palpitations prevalence by menopausal status’, Curr Obstet Gynecol Rep; 10: 7–13. DOI: 10.1007/s13669-020-00302-z

5. Boardman, H. et al. (2015), ‘Hormone therapy for preventing cardiovascular disease in post-menopausal women’, The Cochrane database of systematic reviews, doi:10.1002/14651858.CD002229.pub4

6. https://thebms.org.uk/publications/consensus-statements/bms-whcs-2020-recommendations-on-hormone-replacement-therapy-in-menopausal-women/