How do you approach hormone therapy for perimenopausal patients with cardiovascular risk factors?

Highlights

• For perimenopausal patients with cardiovascular risk, transdermal hormone therapy is considered a safe approach for managing severe vasomotor symptoms.
• Oral estrogen should be avoided, as it can increase clot risk and may worsen cardiovascular disease if initiated after age 60.
• As an alternative for higher-risk patients, consider progestin-only options like pills or implants to manage symptoms by suppressing ovarian function.
• Be cautious with Depo-Provera in patients with cardiovascular risk, as recent CDC guidelines suggest its risks may outweigh benefits.
• Alongside hormone therapy, physicians should concurrently work with patients to optimize their underlying cardiovascular risk factors for better outcomes.

Expert Insights

Navigating Hormone Therapy with Cardiovascular Risk

Managing perimenopausal symptoms in patients with underlying cardiovascular (CV) risk factors requires a nuanced, individualized approach that balances symptom relief with safety. Expert consensus leans towards careful patient selection and a preference for non-oral routes of administration, with a primary goal of mitigating risks while addressing debilitating symptoms like severe vasomotor episodes. A thorough evaluation of the patient's specific symptoms, their stage in the menopausal transition, and the nature of their CV risk is paramount to guiding therapeutic decisions.

The Case for Transdermal Estrogen

For symptomatic perimenopausal patients, even those with CV risk factors, there is a strong case for the safety of transdermal hormone therapy. Cardiologist Dr. Emily Lau states that for patients with severe vasomotor symptoms, "transdermal hormone therapy is safe," provided that clinicians also work to optimize their underlying CV risk factors. This view is shared by OBGYN Dr. Tami Rowen, who argues that for patients at high CV risk, hormone therapy does not worsen their condition.

"We're simply replacing what the ovaries were already doing." Dr. Tami Rowen

Her clinical takeaway is that by using a transdermal approach, clinicians are "simply replacing what the ovaries were already doing." This method restores a more familiar hormonal milieu without the thrombotic risks associated with the first-pass metabolism of oral estrogens. Dr. Rowen notes that a patient's CV disease was not necessarily worsened by their functioning ovaries, suggesting that restoring that state with transdermal estrogen is a reasonable approach, especially when done in consultation with a cardiologist.

Avoiding Oral Estrogen and Age-Related Risks

A clear point of agreement among experts is the need to avoid oral estrogen in this patient population due to an increased risk of venous thromboembolism.

"I would try to avoid oral estrogen because it can increase the risk of blood clots." Dr. Tami Rowen

Dr. Rowen specifically cautions against initiating oral therapy, particularly oral conjugated equine estrogen, in women over 60, as evidence suggests it can worsen cardiovascular disease. If a patient began hormone therapy before 60 and subsequently developed CV risk factors, continuing therapy becomes a collaborative decision with their cardiologist. In such cases, switching to or continuing a transdermal formulation is strongly preferred, as it is unlikely to exacerbate their cardiovascular condition.

A Progestin-Only Alternative for Higher-Risk Patients

For patients with higher CV risk profiles or contraindications to estrogen, such as a hypercoagulable state, a progestin-only strategy offers an alternative. Dr. Paru David, an internal medicine specialist, outlines a systematic approach that begins with assessing symptoms, risk factors, and the patient's position in the menopausal transition. For those in early perimenopause with significant hormonal fluctuations, or for those with high CV or thrombotic risk, she favors systemic progestin-only options to suppress ovarian function and stabilize symptoms. Her preferred methods include the etonogestrel implant and progestin-only pills. Dr. David notes that recent CDC medical eligibility criteria have raised concerns about Depo-Provera, now a category 3 for some CV conditions, prompting her to use it more cautiously. Among progestin-only pills, she highlights that drospirenone (Slynd) and norethindrone provide superior ovarian suppression compared to norgestrel, though drospirenone may face insurance barriers.

Synthesis for Clinical Practice

Ultimately, the decision to use hormone therapy in perimenopausal patients with CV risk factors hinges on a careful risk-benefit analysis. For severe vasomotor symptoms, transdermal estrogen is widely considered a safe and effective option, provided that thrombotic risk is low and other CV factors are being actively managed.

"For those who are perimenopausal with cardiovascular risk factors and severe vasomotor symptoms, transdermal hormone therapy is safe." Dr. Emily Lau

In situations where estrogen is contraindicated or the risk is deemed too high, a progestin-only regimen aimed at ovarian suppression provides a valuable therapeutic alternative. This complex decision-making process often benefits from interdisciplinary collaboration, particularly with cardiology, to ensure a comprehensive approach that prioritizes both quality of life and patient safety.