Hormone Therapy and Heart Disease: Why Timing Matters

Does hormone replacement therapy increase or decrease heart disease risk? The answer is more complicated than a simple yes or no – and growing research suggests that when menopausal hormone therapy is started may be an important part of the equation.

Another recent study published in JAMA Internal Medicine (2026) also evaluated MHT use in 2,737 perimenopausal and recently postmenopausal women with hot flashes and/or night sweats for an association between MHT and cardiovascular disease risk. The researchers found women who initiated MHT had an estimated 22% lower risk of cardiovascular disease compared with those who did not start on MHT, with the association being stronger for women who started hormone therapy within 10 years of menopause.

But there is an important caveat: this was an observational study, and the findings do not prove that hormone therapy prevents heart disease.

There have been a number of questions from our customers at Village Green Apothecary regarding this study. Let's look at what the researchers found, how the timing of hormone therapy may play a role, and what you need to know about MHT and risk vs. benefit for yourself.

Hormone Therapy and Heart Disease: What Did the New Study Find?

The 2026 JAMA Internal Medicine study used data from the Study of Women's Health Across the Nation (SWAN), a large, long-running study following women through the menopause transition.

Researchers looked at 2,737 women with vasomotor symptoms, meaning hot flashes and/or night sweats. The women had no previous cardiovascular disease and had not previously used MHT. Over approximately 20 years, 755 women initiated menopausal hormone therapy.

After adjusting for a range of cardiovascular risk factors, MHT initiation was associated with an estimated 22% lower risk of fatal or nonfatal cardiovascular disease.

The cardiovascular outcomes included:

• Heart attack

• Stroke

• Heart failure

• Coronary revascularization

• Cardiovascular-related death

That's an interesting finding, particularly given the long-standing debate over HRT and heart disease. But it needs to be interpreted carefully.

As this study was observational in nature, it doesn't prove that the hormone therapy led to a decreased cardiovascular risk. The authors specifically state that "the current findings should not be taken as an indication for menopausal hormone therapy to prevent cardiovascular disease."

The Hormone Therapy Timing Hypothesis

One of the most important findings involved when women started hormone therapy after menopause. Women who initiated MHT within 10 years of menopause had a more favorable cardiovascular association. The same benefit was not observed among women who started therapy more than 10 years after menopause.

This backs up a theory researchers have long looked into called the hormone therapy timing hypothesis.

This idea is sometimes called the "timing hypothesis" because it implies that estrogen's impact on the heart might be affected by the age of the woman or how long ago she went through menopause.

In other words, starting hormone therapy during perimenopause or early postmenopause may affect the cardiovascular system differently from starting it many years later.

This does not mean every woman should start hormone therapy within 10 years of menopause. Instead, it suggests that age and timing are important factors when a woman and her healthcare provider consider the risks and benefits of menopausal hormone therapy.

Why might timing matter?

Other studies have shown that estrogen, including the types used in natural estrogen replacement therapy, may affect the heart and blood vessels by changing blood vessel function, cholesterol and lipid levels, inflammation and other processes involved in cardiovascular health.

Earlier in the menopause transition, blood vessels may be healthier and respond differently to estrogen than blood vessels affected by years of aging and atherosclerosis.

This is one possible explanation behind the timing hypothesis, and the relationship has been investigated as part of the broader research into ischemic heart disease in women and the role of hormone therapy.

A plausible mechanism doesn't necessarily translate into a cardiovascular effect. Factors like pre-existing cardiovascular risk factors, age, medical history, and the type, dose, and route of estrogen administration can modify the balance between risk and benefit.

What Did the Study Find in Black Women?

The most significant discovery pertained to Black women.

In the SWAN analysis, Black women who initiated HRT had an estimated 49% reduction in CVD risk .

Researchers did not find the same clear association among White women or women in the study's other racial and ethnic groups.

Why was there such a difference?

At this point, researchers don't know.

Black women are more likely to experience frequent and severe vasomotor symptoms, but that alone does not explain the cardiovascular findings. The researchers noted that additional studies are needed to better understand the difference.

The result is important, but it should not be interpreted to mean that hormone therapy reduces cardiovascular disease by 49% in all Black women. It is a finding from this particular study that requires further research.

What Did the Women's Health Initiative Find About HRT and Heart Disease?

Any discussion of hormone replacement therapy and heart disease inevitably leads back to the Women's Health Initiative (WHI).

The early results of the WHI were responsible for a dramatic change in thinking regarding the use of menopausal hormone therapy, as the study brought to light worries over increased cardiovascular disease, stroke and blood clots among other potential dangers.

But the story has become more nuanced as researchers have continued to analyze the data.

A 2025 secondary analysis of the WHI randomized clinical trials examined hormone therapy specifically in women with vasomotor symptoms. Among younger postmenopausal women ages 50 to 59, hormone therapy relieved moderate-to-severe hot flashes and night sweats without significantly affecting atherosclerotic cardiovascular disease risk. Cardiovascular risk was higher among women with vasomotor symptoms who were 70 and older.

This is not the same as showing that hormone therapy protects the heart.

Instead, the new results from WHI and the 2026 findings from SWAN reaffirm an important message: Age and timing are critical considerations for menopausal hormone therapy and heart disease risk.

For more background, see Rethinking Menopausal Hormone Therapy: For Whom, What, When, and How Long? and Menopausal Hormone Replacement Therapy and Reduction of All-Cause Mortality and Cardiovascular Disease: It Is About Time and Timing.

Does Hormone Therapy Prevent Heart Disease?

The answer: No, menopausal hormone therapy is not recommended for preventing heart disease at this time.

That's an important distinction.

The new SWAN study adds to our understanding of HRT and cardiovascular risk, but it does not establish hormone therapy as a heart disease prevention treatment.

Instead, these findings may provide additional reassurance when MHT is being considered for an appropriate reason – particularly treatment of bothersome menopausal symptoms such as hot flashes and night sweats – in women who are younger or closer to the onset of menopause and who do not have contraindications.

The decision should still be individualized.

Hormone Therapy Risks and Benefits: What Else Matters?

There isn't just one type of "hormone therapy."

Different hormones, doses and routes of administration, including systemic estrogen therapy, may have different effects. Whether the hormone progesterone or another progestogen is needed also depends on the individual.

When discussing menopause hormone therapy risks and benefits, your healthcare provider may consider:

• Your age

• How many years have passed since menopause

• Severity of hot flashes, night sweats and other menopausal symptoms

• Personal and family cardiovascular history

• Blood pressure

• Cholesterol and other cardiovascular risk factors

• History of stroke or blood clots

• Breast cancer risk and medical history

• Type of estrogen or hormone therapy

• Dose

• Oral versus transdermal delivery

• Whether progesterone or a progestogen is needed

Hence, two women of the same age can be given quite different advice regarding menopausal hormone therapy.

What About Compounded Hormone Therapy?

Some women also ask about compounded hormone replacement therapy or compounded menopausal hormones.

For many patients, commercially manufactured hormone therapy provides an appropriate treatment option. In some circumstances, however, a prescriber may determine that a customized preparation is appropriate for an individual patient.

At Village Green Apothecary, our compounding pharmacists can work with your prescriber when customized compounded hormone therapy is medically appropriate. Compounding can allow a prescribed strength or formulation to be prepared specifically for an individual's needs.

Compounded hormone therapy should not be assumed to be safer for the heart or more effective than FDA-approved menopausal hormone therapy. The appropriate formulation, dose and route should be determined with your healthcare provider based on your individual needs and medical history.

Menopause and Heart Health: Looking Beyond Hormones

Heart health during and after menopause involves much more than estrogen.

A woman’s risk for cardiovascular disease after menopause depends on her blood pressure, cholesterol, blood sugar, whether she smokes or not, how active she is, her diet, her sleep habits, her body composition and her family history.

This is why midlife is a good time to evaluate your cardiovascular disease risk factors rather than simply taking hormone therapy.

Depending on your individual health needs, medications, diet and laboratory results, you may also want to discuss nutritional support with your healthcare practitioner.

Village Green Apothecary offers Vitamin D3 Plus K2, Cholesterol Support, and Blood Pressure Support. You can also explore our heart and cardiovascular health collection for additional options.

Supplements should supplement, rather than substitute for, optimal medical care, a heart-healthy diet, exercise and control of existing cardiac risk factors.

Not sure where to begin? A lab review consultation provides an opportunity to review your laboratory results and discuss your individual health goals.

Hormone Therapy and Heart Palpitations

This is a common question for us here at Village Green. Some women do experience heart palpitations during the menopause transition, and there may be some connection with hormonal changes. However, there are many other possible causes of palpitations that have nothing to do with menopause or hormone therapy. So if you experience palpitations that are new or concerning, make sure to discuss them with your healthcare provider to ensure that they are appropriately investigated.

Key Takeaways: HRT, Menopause and Heart Disease

• A 2026 JAMA Internal Medicine study examined menopausal hormone therapy and cardiovascular disease risk in 2,737 perimenopausal and recently postmenopausal women with hot flashes and/or night sweats.

• We estimate that initiation of MHT was associated with a 22% lower risk of cardiovascular disease overall.

• The association was more favorable among women who started hormone therapy within 10 years of menopause.

• Among Black women in this study, MHT initiation was associated with an estimated 49% lower cardiovascular disease risk, although researchers do not yet understand why.

• However, this is an observational study, so the researchers cannot conclude that the hormone therapy caused the decrease in cardiovascular events.

• In a 2025 randomized analysis of data from the Women's Health Initiative (WHI), researchers found that hormone therapy did not influence atherosclerotic cardiovascular disease risk in younger women ages 50 to 59 with vasomotor symptoms; however, they did find that the risk was higher among women ages 70 and older.

• However, you shouldn't start hormone therapy just to prevent heart disease based on what we know right now.

• Discussion of individualized therapy should include age, time since menopause, symptoms, medical history, cardiovascular risk factors, and type of hormone, dose, and route of administration.

Frequently Asked Questions About Hormone Therapy and Heart Disease

Can hormone replacement therapy affect your heart?

Whether HRT increases or decreases your risk of heart disease may depend on factors like your age, time since menopause, existing risk for cardiovascular disease, and the type of HRT you use. A 2026 observational study reported an estimated 22% lower risk of cardiovascular disease in perimenopausal and recently postmenopausal women with vasomotor symptoms who began MHT compared with those who didn’t. But the study can’t show that HRT reduces heart disease risk.

Is HRT safe for the heart after menopause?

There is no one-size-fits-all answer. For some women, benefits outweigh risks, and vice versa. According to research, a woman’s age, time since menopause, and current cardiovascular health impact the balance of these benefits and risks. A 2025 study from WHI researchers found that women aged 50 to 59 years with vasomotor symptoms did not have a significantly higher risk of atherosclerotic cardiovascular disease compared with the placebo group, whereas the risk was greater in older women. Talk to your doctor about your own cardiovascular and medical history to help you make an informed decision.

When is the best time to start hormone therapy?

If hormone therapy is the best approach to treating your symptoms, it might make a difference when you take it. A more favorable cardiovascular association was found in women who began hormone therapy within 10 years of menopause in the SWAN study from 2026. This doesn’t mean all women should start taking hormone therapy within this timeframe, however. Treatment should be individualized.

What is the hormone therapy timing hypothesis?

According to the “timing hypothesis,” estrogen’s impact on the cardiovascular system might vary by age and time since menopause, meaning that the timing of initiation of MHT could play a role in cardiovascular risk for women. Beginning treatment during perimenopause or soon after menopause onset may carry a different risk than starting treatment 10+ years post menopause.

Can hormone therapy prevent heart disease?

Menopausal hormone therapy is not advised for the prevention of cardiovascular disease. The 2026 SWAN study found an association between starting MHT and lower cardiovascular risk in some women, but it was an observational study and thus cannot prove that hormone use was responsible for the difference.

Who can prescribe hormone replacement therapy for menopause?

Menopausal hormone therapy must be prescribed by an appropriate healthcare provider who can evaluate your symptoms, medical history and individual risks and benefits. When customized hormone therapy is medically appropriate, Village Green Apothecary's compounding pharmacists can work with your prescriber to prepare the prescribed formulation and dose.

Can hormone therapy cause heart problems?

The early results of the Women's Health Initiative raised concerns about increased cardiovascular disease, stroke and blood clots with menopausal hormone therapy, though the picture has become more nuanced over time. Risk and benefit depend on factors like your age, how many years since menopause, personal and family cardiovascular history, and the type, dose and route of hormone used. Some women also experience palpitations during the menopause transition, which should be discussed with your healthcare provider so they are appropriately investigated.

This article is for educational purposes only and does not replace individualized medical advice. Talk with your physician, pharmacist or other qualified healthcare provider about the risks and benefits of menopausal hormone therapy based on your symptoms and personal medical history.

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