Guideline No. 422e: Menopause and Cardiovascular Disease

Published:November 16, 2021DOI:



      Provide strategies for improving the care of perimenopausal and postmenopausal women based on the most recent published evidence.

      Target Population

      Perimenopausal and postmenopausal women.

      Benefits, Harms, and Costs

      Target population will benefit from the most recent published scientific evidence provided via the information from their health care provider. No harms or costs are involved with this information since women will have the opportunity to choose among the different therapeutic options for the management of the symptoms and morbidities associated with menopause, including the option to choose no treatment.


      Databases consulted were PubMed, MEDLINE, and the Cochrane Library for the years 2002–2020, and MeSH search terms were specific for each topic developed through the 7 chapters.

      Validation Methods

      The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

      Intended Audience

      physicians, including gynaecologists, obstetricians, family physicians, internists, emergency medicine specialists; nurses, including registered nurses and nurse practitioners; pharmacists; medical trainees, including medical students, residents, fellows; and other providers of health care for the target population.


      • 1
        Women who initiate menopausal hormone therapy shortly after menopause are, in general, at low risk for events in the next few years (high). Evidence supports aggressive identification and modification of risk factors as the most effective means of reducing cardiovascular risk (high).
      • 2
        Women who initiate menopausal hormone therapy 10 or more years after menopause are at increased risk for adverse cardiac events (high).
      • 3
        With respect to stroke, increased risk has been identified in all age groups using standard formulations of menopausal hormone therapy; however, the incidence in young women is extremely low (low).
      • 4
        Incidence of venous thrombotic events increase with age (> 60 y) and BMI, even in otherwise healthy women; menopausal hormone therapy increases the risk (high).
      • 5
        Menopausal hormone therapy is not indicated for primary or secondary prevention of cardiovascular disease (moderate).
      • 6
        Women with premature or early-onset menopause appear to be at an increased risk of adverse cardiovascular outcomes, and this risk may be prevented by the use of menopausal hormone therapy until the average age of menopause (moderate).
      • 7
        Menopausal hormone therapy increases the risk of venous thromboembolism; oral and combined hormone therapy preparations are more closely associated with risk of venous thromboembolism than either with transdermal preparations or estrogen alone (moderate).
      • 8
        There is a lack of high-quality data to provide guidance on the impact of routes of estrogen administration on the risk of venous thrombotic events or cardiovascular disease (low).


      • 1
        Menopausal hormone therapy should be offered as the most effective treatment for the relief of menopausal symptoms (strong, high).
      • 2
        When prescribing menopausal hormone therapy, the lowest effective dose of estrogen, and, where indicated, estrogen-only therapy, should be offered to minimize the associated risk of venous thromboembolism (conditional, low).
      • 3
        The lowest effective dose of estrogen, either oral or transdermal, should be prescribed to minimize the risk of stroke (conditional, low).
      • 4
        When prescribing combined hormone therapy, choice of progestogen should favour those least likely to affect markers for cardiovascular disease. (strong, moderate).
      • 5
        A tissue selective estrogen complex may be used without a progestin to provide menopausal hormone therapy and uterine protection for relief of early menopausal symptoms (conditional, moderate). To date, these agents do not appear to be associated with cardiovascular risk.



      CVD (cardiovascular disease), DOPS (Danish Osteoporosis Prevention Study), ELITE (Early Versus Late Intervention Trial With Estradiol), KEEPS (Kronos Early Estrogen Prevention Study), MHT (menopausal hormone therapy), SERM (selective estrogen receptor modulator), SMART (Selective estrogens, Menopause and Response to Therapy), VTE (venous thromboembolism), WHI (Women's Health Initiative)
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