Navigating Menopausal Hormone Therapy Safety in VMS

In this episode, "Navigating Menopausal Hormone Therapy Safety in VMS," the experts explore the nuances of menopausal hormone therapy (MHT) safety, addressing persistent misconceptions that have affected both clinical practice and patient decision-making since the FDA's black box warning.

Dr. Erin Michos opens by noting that while the black box warning served an important protective function, it has also had unintended consequences — discouraging appropriate use of hormone therapy in lower-risk women and, more recently, prompting inquiries from older, higher-risk patients who misinterpreted updated guidance as a blanket endorsement of MHT safety. The experts stress that hormone therapy is not appropriate for all women and that continued clinician education is essential.

A deeper review of Women's Health Initiative data is presented, distinguishing outcomes by age group and formulation. In the estrogen-alone arm, women aged 50–59 showed a trend toward decreased cardiovascular risk, those aged 60–69 were largely neutral, and women over 70 faced increased risk. In the combined estrogen-progestin arm, elevated cardiovascular hazard ratios were observed across all age groups, though absolute event rates were substantially lower in younger women. The timing of initiation relative to menopause is also highlighted, with women within 10 years of menopause showing a more favorable risk-benefit profile compared to those 20 or more years post-menopause.

Both panelists affirm that transdermal estradiol is generally considered safer than oral formulations due to its avoidance of first-pass hepatic metabolism, which is associated with increased thrombotic and inflammatory markers. The Menopause Society's position that MHT should not be used primarily for cardiovascular prevention is reiterated, with its indicated uses remaining symptomatic VMS relief and bone health.

Coronary artery calcium scoring is revisited as a practical tool for ongoing risk reassessment in women who wish to continue MHT beyond age 65. Both experts converge on the principle that dose, formulation, duration, and timing must be continuously individualized — mirroring the approach taken with other long-term therapies such as statins or antihypertensives.

The next episode in this series, "Novel Non-Hormonal Therapies for VMS: Mechanisms and Clinical Evidence," features the panelists discussing the neuroscience behind vasomotor symptoms and the mechanisms, efficacy, and clinical applications of two newly approved non-hormonal treatments — fezolinetant and elinzanetant — for women who cannot or choose not to use menopausal hormone therapy.