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Is Menopausal Hormone Therapy Safe for Your Heart? · Heart Health, Reimagined with Dr. Mona Shah, MD

• 0:00
  SPEAKER_00: For more than 20 years, women were warned that hormone therapy could hurt their heart.
• 0:05
  SPEAKER_00: Many women stopped taking it.
• 0:07
  SPEAKER_00: Many physicians stopped prescribing it.
• 0:10
  SPEAKER_00: And an entire generation of women became afraid of estrogen.
• 0:15
  SPEAKER_00: Now, some of these warnings have changed.
• 0:18
  SPEAKER_00: So were we wrong about hormone therapy?
• 0:21
  SPEAKER_00: Or are we now making the opposite mistake and calling estrogen heart protective?
• 0:27
  SPEAKER_00: The truth is much more nuanced.
• 0:29
  SPEAKER_00: And there's one huge piece of this story most people never hear.
• 0:35
  SPEAKER_00: We have never actually done the definitive randomized trial asking whether modern transdermal estradiol starting around menopause reduces heart attacks or cardiovascular death.
• 0:48
  SPEAKER_00: Unfortunately, that trial does not exist yet.
• 0:51
  SPEAKER_00: And trust me, I wish it did.
• 0:53
  SPEAKER_00: I'm Dr.
• 0:54
  SPEAKER_00: Mona Shaw, preventative cardiologist, board certified in holistic medicine and in cardiac CT.
• 1:00
  SPEAKER_00: And hormone therapy is one of the topics I get asked about more than almost anything else.
• 1:05
  SPEAKER_00: So today I want to answer three questions.
• 1:09
  SPEAKER_00: Why did hormone therapy become so feared?
• 1:14
  SPEAKER_00: What do we now know about timing, oral versus transdermal estrogen, progesterone, and cardiovascular risk?
• 1:22
  SPEAKER_00: And what benefits of estrogen have actually been proven versus the things we still suspect have not proven?
• 1:30
  SPEAKER_00: One clarification before we start.
• 1:33
  SPEAKER_00: I don't prescribe hormone therapy.
• 1:35
  SPEAKER_00: My role as a cardiologist is to help you sort through it from a cardiovascular lens.
• 1:41
  SPEAKER_00: Blood pressure, cholesterol, clotting risk, vascular health, and existing plaque or cardiovascular disease.
• 1:49
  SPEAKER_00: Estrogen has real benefits outside the heart too, and we will touch on those briefly since they help put this whole discussion in perspective.
• 1:59
  SPEAKER_00: And I'll just tell you upfront, even without a definitive trial, I'm a real advocate for hormone therapy for the right woman.
• 2:07
  SPEAKER_00: And by the end of this video, I want you ready to advocate for yourself too.
• 2:12
  SPEAKER_00: Here's why.
• 2:13
  SPEAKER_00: Let's start with the study that changed everything.
• 2:16
  SPEAKER_00: In 2002, results from the Women's Health Initiative, or WHI, completely changed the way women and doctors thought about hormone therapy.
• 2:27
  SPEAKER_00: The hormone trials included more than 27,000 postmenopausal women.
• 2:33
  SPEAKER_00: But here's a part every woman needs to know.
• 2:36
  SPEAKER_00: The average woman was about 63, many more than 10 years beyond menopause.
• 2:42
  SPEAKER_00: Not predominantly women who are 50 or 51, newly menopausal, and trying to decide if hormone therapy made sense for them.
• 2:51
  SPEAKER_00: And the hormones were different too.
• 2:53
  SPEAKER_00: Women with a uterus got oral conjugated equine estrogen plus medoxyprogesterone acetate, an older synthetic progestin.
• 3:03
  SPEAKER_00: Women who had a hysterectomy got the oral estrogen alone.
• 3:08
  SPEAKER_00: And one quick terminology note since bioidentical gets used constantly online, it just means structurally identical to what your body makes.
• 3:18
  SPEAKER_00: Estradiol is bioidentical estrogen, and an FDA-approved patch or gel can absolutely be bioidentical.
• 3:25
  SPEAKER_00: That does not automatically mean compounded.
• 3:28
  SPEAKER_00: The conjugated equine estrogen used in WHI is not the same thing as estradiol.
• 3:42
  SPEAKER_00: And in women taking estrogen plusy progesterone, concerns about coronary disease and breast cancer, those findings absolutely mattered.
• 3:53
  SPEAKER_00: But what happened next is where I think women really paid the price.
• 3:58
  SPEAKER_00: We took findings from a study where the average woman was 63, often more than a decade past menopause, and we applied it broadly to women who were 50, 51, 52, and just entering menopause.
• 4:13
  SPEAKER_00: Think about that.
• 4:14
  SPEAKER_00: If you went through menopause in the early 2000s, there's a good chance you were told hormone therapy was dangerous based on results from women who are nothing like you.
• 4:24
  SPEAKER_00: Prescribing plummeted.
• 4:27
  SPEAKER_00: Women stopped hormones, doctors stopped offering them, and many women who might reasonably have been candidates became frightened of estrogen.
• 4:38
  SPEAKER_00: WHI itself was not a bad study.
• 4:42
  SPEAKER_00: It was an extremely important one, actually.
• 4:44
  SPEAKER_00: The problem was applying its findings too broadly.
• 4:48
  SPEAKER_00: When researchers later looked back more carefully at age and timing, the picture changed.
• 4:55
  SPEAKER_00: Among women ages 50 to 59 who took estrogen alone, the overall balance of major health outcomes actually tipped in their favor compared to placebo.
• 5:06
  SPEAKER_00: About 19 fewer serious health problems for every 10,000 women treated for a year.
• 5:13
  SPEAKER_00: Flip to women in their 70s taking that same estrogen, and the balance tips the other way.
• 5:19
  SPEAKER_00: About 51 more serious health problems per 10,000 women a year.
• 5:24
  SPEAKER_00: Same estrogen, completely different outcome, just because of when it was started.
• 5:30
  SPEAKER_00: And that brings us to the timing hypothesis.
• 5:34
  SPEAKER_00: Starting estrogen around menopause may affect the cardiovascular system very differently than starting it 10, 15, or 20 years later.
• 5:44
  SPEAKER_00: Think about the arteries of a healthy 51-year-old just entering menopause versus a 70-year-old with potentially decades of atherosclerosis and plaque already.
• 5:55
  SPEAKER_00: Very different starting points.
• 5:57
  SPEAKER_00: If you like this kind of information, make sure you subscribe because every week I put out videos on cardiovascular prevention, advanced labs, and imaging, and how to actually understand your real risk.
• 6:10
  SPEAKER_00: And if you know a woman confused or frightened by the conflicting information out there on hormone therapy, share this video with her.
• 6:18
  SPEAKER_00: Now, let's get into what estrogen actually does.
• 6:22
  SPEAKER_00: Among the younger women in WHI who took estrogen alone, there was even a signal toward fewer heart attacks and fewer deaths.
• 6:32
  SPEAKER_00: Interesting.
• 6:33
  SPEAKER_00: But not enough events to prove estrogen itself caused it.
• 6:37
  SPEAKER_00: So I can't tell a patient, take estrogen, it's going to prevent a heart attack.
• 6:42
  SPEAKER_00: We simply do not have that evidence.
• 6:45
  SPEAKER_00: But there are several cardiovascular effects of estrogen that are genuinely favorable.
• 6:51
  SPEAKER_00: Estrogen helps blood vessels relax and widen, partly through the nitric oxide system.
• 6:59
  SPEAKER_00: It can reduce arterial stiffness and lowers LDL cholesterol.
• 7:05
  SPEAKER_00: It can also, in some people, lower lipoprotein A or LPA by roughly 20 to 30 percent.
• 7:11
  SPEAKER_00: That is the mostly genetic particle I talk about often, that usually will not budge with lifestyle alone.
• 7:18
  SPEAKER_00: Estrogen also appears to improve insulin sensitivity and reduce abdominal or visceral fat.
• 7:26
  SPEAKER_00: So biologically, it absolutely makes sense to ask whether those changes ultimately help cardiovascular health.
• 7:33
  SPEAKER_00: If you can improve blood vessel function, LDL, lipoprotein A, insulin sensitivity, and visceral fat, does that eventually translate into fewer heart attacks?
• 7:46
  SPEAKER_00: I wish we knew.
• 7:47
  SPEAKER_00: But as a physician, I have to separate what makes biological sense from what has actually been proven in an outcomes trial.
• 7:56
  SPEAKER_00: Two studies called Elite and Keeps give us additional clues.
• 8:02
  SPEAKER_00: Elite specifically tested the timing idea.
• 8:06
  SPEAKER_00: Women who started esterdiol within about six years of menopause had slower thickening of the carotid artery wall, while women who started more than 10 years after menopause did not show that same benefit.
• 8:18
  SPEAKER_00: Some of our strongest experimental evidence that timing may matter.
• 8:23
  SPEAKER_00: Keeps studied healthy women very close to menopause, both lower dose oral estrogen and transdermal estradiol, and over about four years.
• 8:35
  SPEAKER_00: Neither significantly changed carotid intima thickening or coronary calcium compared with placebo.
• 8:43
  SPEAKER_00: So Elite leaned in favor of the timing hypothesis, keeps was more neutral.
• 8:49
  SPEAKER_00: But neither was to design the biggest question.
• 8:54
  SPEAKER_00: Did fewer women actually have heart attacks or strokes?
• 8:58
  SPEAKER_00: They looked at surrogate endpoints instead, like artery thickness or coronary calcium, not real heart attacks or deaths.
• 9:07
  SPEAKER_00: That is why we still do not have the definitive trial.
• 9:11
  SPEAKER_00: It would take tens of thousands of women followed for years, many on placebo, despite having treatable symptoms.
• 9:18
  SPEAKER_00: So when I say estrogen has not been proven to prevent cardiovascular disease, that does not mean it has been proven not to.
• 9:26
  SPEAKER_00: It means that trial has not been done.
• 9:29
  SPEAKER_00: And there's another reason I think the hormone conversation sometimes gets distorted.
• 9:35
  SPEAKER_00: We spend so much time talking about what estrogen has not proven for the heart that we forget it actually has several well-established benefits elsewhere.
• 9:44
  SPEAKER_00: For hot flashes and night sweats, systemic estrogen, meaning estrogen that circulates throughout the body through a patch, a gel, a spray, or a pill, is the most effective treatment we have.
• 9:56
  SPEAKER_00: You will also hear about pellets.
• 9:58
  SPEAKER_00: Those are compounded and inserted under the skin.
• 10:02
  SPEAKER_00: And because they are compounded, dosing is not regulated the same way.
• 10:06
  SPEAKER_00: Absorption can be unpredictable and levels can run much higher than intended.
• 10:10
  SPEAKER_00: That is a delivery method I am most cautious about from a cardiovascular standpoint.
• 10:17
  SPEAKER_00: That can also improve sleep and quality of life when those symptoms are disrupting them.
• 10:23
  SPEAKER_00: For bone health, the evidence is even stronger.
• 10:26
  SPEAKER_00: Estrogen is one of the few therapies shown in randomized trials to actually reduce fractures, vertebral, hip, and others, not just improve a bone density number.
• 10:38
  SPEAKER_00: It also lowers the development of new type 2 diabetes and improves insulin sensitivity, an underappreciated benefit.
• 10:46
  SPEAKER_00: Then there's vaginal estrogen, a completely different discussion from estrogen that circulates through the body.
• 10:52
  SPEAKER_00: For vaginal dryness, painful intercourse, and genital urinary symptoms, including recurrent urinary tract infections, low-dose vaginal estrogen as a cream tablet is extremely effective, and very little of it reaches the bloodstream.
• 11:08
  SPEAKER_00: So if that is all you need, you may not need systemic estrogen at all.
• 11:13
  SPEAKER_00: And then there's the brain.
• 11:15
  SPEAKER_00: Where I would be cautious about what you hear online.
• 11:18
  SPEAKER_00: There's an intriguing signal that estrogen started close to menopause may be associated with lower dementia risk.
• 11:26
  SPEAKER_00: But randomized trials in older women showed no cognitive benefit and sometimes harm.
• 11:31
  SPEAKER_00: So I would not tell a patient or a woman to take estrogen to prevent Alzheimer's.
• 11:37
  SPEAKER_00: That has just not been proven.
• 11:38
  SPEAKER_00: Though timing may matter here too.
• 11:42
  SPEAKER_00: Now let's talk about something extremely important for cardiovascular risk.
• 11:46
  SPEAKER_00: Not all estrogen is the same, and how you take it matters.
• 11:50
  SPEAKER_00: When you swallow estrogen as a pill, it goes to the liver first.
• 11:55
  SPEAKER_00: That can affect clotting proteins, triglycerides, inflammation, and other metabolic markers.
• 12:02
  SPEAKER_00: When estradiol is absorbed through the skin, through a patch or gel or a ring, it largely bypasses that first pass through the liver.
• 12:11
  SPEAKER_00: That is what we mean by transdermal estrogen.
• 12:15
  SPEAKER_00: And transdermal estradiol is bioidentical estradiol.
• 12:20
  SPEAKER_00: So the message is not, we have no evidence for the estradiol patch.
• 12:24
  SPEAKER_00: We absolutely have real evidence, improving symptoms, bone health, insulin sensitivity, and specifically elite and keeps all studied estradiol formulations in women close to menopause.
• 12:38
  SPEAKER_00: What we do not have is a large trial proving transdermal estradiol specifically prevents heart attacks or cardiovascular deaths.
• 12:46
  SPEAKER_00: That is a much more specific question.
• 12:50
  SPEAKER_00: Personally, if an appropriate patient is considering estrogen that circulates throughout the body, I generally favor transdermal estradiol over oral estrogen from a cardiovascular perspective, because of that more favorable clotting and metabolic profile.
• 13:07
  SPEAKER_00: And let's put the clot risk into perspective.
• 13:10
  SPEAKER_00: For a healthy woman, this age, not on hormone therapy, the risk of a serious blood clot is roughly one in a thousand per year.
• 13:19
  SPEAKER_00: Oral estrogen can roughly double that or more depending on the formulation, while low-dose transdermal estradiol generally has not shown that same increase in observational studies.
• 13:33
  SPEAKER_00: Reassuring, but not zero risk.
• 13:36
  SPEAKER_00: And someone with a previous clot, known clotting disorder, stroke, heart attack, or significant cardiovascular disease needs a much more individualized conversation.
• 13:49
  SPEAKER_00: Progesterone matters too, and I don't think it gets enough credit on its own.
• 13:54
  SPEAKER_00: If you have a uterus and are using systemic estrogen, you generally need progesterone to protect the lining of the uterus.
• 14:02
  SPEAKER_00: But it's not just for that.
• 14:04
  SPEAKER_00: It has real benefits on its own.
• 14:06
  SPEAKER_00: Micronized progesterone, bioidentical, taken at night, has a mild calming, sleep-promoting effect for a lot of women and can meaningfully reduce night sweats.
• 14:18
  SPEAKER_00: And I don't think we give sleep enough credit here.
• 14:20
  SPEAKER_00: When a woman is finally sleeping through the night again, that alone tends to improve blood pressure, insulin sensitivity, mood, and weight.
• 14:30
  SPEAKER_00: The WHI use the older synthetic medoxy progesterone acetate, but from a cardiovascular standpoint, I generally prefer micronized progesterone, which is structurally identical to what the body makes and may have a more favorable clotting profile, though we don't have a large trial again proving fewer cardiovascular events with it specifically.
• 14:53
  SPEAKER_00: And since we mentioned breast cancer earlier, a quick clarification.
• 14:59
  SPEAKER_00: That signal showed up with conjugated equine estrogen plus middoxy progesterone acetate.
• 15:07
  SPEAKER_00: Not with estrogen alone after hysterectomy.
• 15:10
  SPEAKER_00: Formulation and clinical situation matter here too, though that's a topic for an own video.
• 15:17
  SPEAKER_00: One thing I would not get hung up on chasing a specific hormone blood level.
• 15:22
  SPEAKER_00: This is about symptoms, age, timing, route, formulation, and your individual risk.
• 15:30
  SPEAKER_00: And this entire conversation is changing quickly.
• 15:34
  SPEAKER_00: In February 2026, the FDA revised its hormone therapy labels, pulling the cardiovascular disease, breast cancer, and probable dementia language out of the prominent boxed warning.
• 15:48
  SPEAKER_00: That does not mean those risks disappeared.
• 15:51
  SPEAKER_00: Relevant risk information stays in the labeling.
• 15:54
  SPEAKER_00: It means the warning is finally catching up to the nuance.
• 15:59
  SPEAKER_00: And on September 16th, 2026, Congress held its first ever hearing focused specifically on menopause.
• 16:08
  SPEAKER_00: Half the population goes through it, and we just held our first hearing devoted to it.
• 16:15
  SPEAKER_00: Correcting the old fear does not mean swinging to the opposite extreme and telling everyone estrogen prevents heart disease.
• 16:23
  SPEAKER_00: It means getting the nuance right.
• 16:26
  SPEAKER_00: So where does that leave a woman today?
• 16:28
  SPEAKER_00: The question should not simply be, is estrogen safe?
• 16:32
  SPEAKER_00: That question is too broad.
• 16:34
  SPEAKER_00: The better questions are, how old are you?
• 16:38
  SPEAKER_00: How long has it been since menopause?
• 16:41
  SPEAKER_00: Why are you considering treatment?
• 16:42
  SPEAKER_00: And what formulation and route make sense?
• 16:46
  SPEAKER_00: Do you already have cardiovascular disease or significant plaque?
• 16:50
  SPEAKER_00: And what does your overall metabolic and cardiovascular risk actually look like?
• 16:56
  SPEAKER_00: Because the answer for one 51-year-old woman may be very different from the answer for another woman starting hormone therapy at the age of 70.
• 17:05
  SPEAKER_00: We spent years treating hormone therapy as though it was good or bad.
• 17:10
  SPEAKER_00: The evidence tells us neither extreme is accurate.
• 17:13
  SPEAKER_00: Age matters, timing matters, route matters, the estrogen and progesterone matter, and the individual woman in front of me matters most of all.
• 17:24
  SPEAKER_00: That's precision medicine, not a blanket rule, but working through every one of those factors for the woman actually sitting in front of me.
• 17:33
  SPEAKER_00: Estrogen has real proven benefits for symptoms, bone health, and diabetes risk, plus several favorable cardiovascular effects biologically.
• 17:44
  SPEAKER_00: But what we still don't know is whether modern transdermal estradiol starting near menopause ultimately prevents heart attacks or cardiovascular death.
• 17:53
  SPEAKER_00: And personally, I would love to see that study.
• 17:57
  SPEAKER_00: Until then, I am not going to tell you estrogen has been proven to prevent heart attacks.
• 18:02
  SPEAKER_00: But here's my honest personal take, separate from what is formally proven, even without that trial.
• 18:10
  SPEAKER_00: Eileen strongly supportive of hormone therapy for the right woman.
• 18:15
  SPEAKER_00: The symptom relief, the bone protection, the metabolic benefits, it adds up to something real in my mind, even if we cannot call it proven yet.
• 18:24
  SPEAKER_00: So if you think you might be a candidate, do not let the absence of one trial tuck you out of even having the conversation.
• 18:32
  SPEAKER_00: Advocate for yourself, especially if you are the right person for it.
• 18:38
  SPEAKER_00: And I'm also not going to take data from women who started very different hormone therapy much later in life and automatically use that to frighten a healthy 51-year-old woman away from treatment that may significantly improve her quality of life.
• 18:53
  SPEAKER_00: That is exactly the kind of oversimplification we need to move beyond.
• 18:58
  SPEAKER_00: If you find this helpful, subscribe and share it with someone who has been trying to make sense of all this conflicting information about hormone therapy.
• 19:06
  SPEAKER_00: And this is really just one half of the hormone conversation.
• 19:10
  SPEAKER_00: Next week I'm covering testosterone for both men and women and what it actually does for your heart.
• 19:16
  SPEAKER_00: So keep an eye out for that one.
• 19:18
  SPEAKER_00: And if you want to actually understand what menopause itself does to your heart, including the changes in cholesterol, visceral fat, blood pressure, insulin resistance, and vascular health, watch my menopause and heart disease video next.
• 19:34
  SPEAKER_00: It's on your screen now.