The evidence is consistent and robust: menopause harms both the heart and the bones over time, and that effect is greater with early menopause. Hormone therapy demonstrably protects the bones, but increases the risks of heart, vascular and breast disease in women over 60. Starting therapy early (before the age of 60) appears more favourable, but has not been sufficiently tested in targeted studies. Never use HT as a preventive measure against cardiovascular disease or dementia.
The menopause lowers oestrogen levels in the blood, and this has clear long-term consequences for both the heart and the bones. After menopause, the risk of cardiovascular disease increases. Women gradually catch up with men in terms of cardiovascular risk profiles. Those who reach menopause early or very early (before the age of 40) face an even greater risk. Cardiologists now consider menopause before the age of 40 an official risk signal that should be taken into account during a cardiovascular check-up, comparable to pre-eclampsia during pregnancy.
Women who experience frequent hot flushes and night sweats more often have higher blood pressure and signs of disrupted heart-rhythm regulation. Whether this directly leads to heart disease has not yet been definitively proven, but the association is present in multiple studies and strong enough to take seriously. Anyone suffering from severe vasomotor symptoms would do well to discuss them with a doctor from a cardiovascular perspective as well.
For the bones a similar pattern applies: oestrogen protects bone, and when it disappears, bone density declines. This process is strongest in women who reach menopause early, because they spend many more years without the protective effect of oestrogen. Early menopause therefore demonstrably increases the risk of osteoporosis (bone loss) and associated fractures.
Hormone therapy (HT) is the only intervention for which a large Cochrane analysis has found solid clinical evidence that it genuinely prevents bone fractures. After 5 to 7 years of therapy, the number of fractures fell markedly. But an important caveat applies here: combined hormone therapy (oestrogen with progestogen) simultaneously increases the risk of heart attacks, stroke, breast cancer, thrombosis and gallbladder problems in women over the age of 60. The absolute increase per individual is small, but it is statistically well established. Oestrogen without progestogen, which can only be used after a hysterectomy, appears to slightly lower the rate of breast cancer, giving it a different risk profile.
There are indications that hormone therapy may have a beneficial effect on the heart when women start it early, that is, before the age of 60 or within ten years of menopause. This 'timing window' is biologically plausible, but has not yet been sufficiently tested in randomised studies specifically targeting younger postmenopausal women. What is certain is that hormone therapy is not a preventive treatment for cardiovascular disease or dementia. In women over the age of 65, combined hormone therapy even increased the risk of dementia in research. The conclusion is therefore clear: HT works well for specific symptoms and bone protection, but is not intended as a broad preventive measure for the ageing heart or brain.
The claims are based on multiple epidemiological studies and a Cochrane systematic review (PMID 28093732) on hormone therapy, supplemented by guideline-related publications on cardiovascular risk management in women (PMID 35210038, 35526556, 36367692, 38458215). The fracture and cardiovascular risk data for HT are drawn from RCT-based Cochrane data. The cardiovascular risk associated with early menopause is based on observational research.