Heart Health and Hormones: Menopause, Estrogen, Testosterone, and Cardiovascular Risk

Does Menopause Increase Cardiovascular Risk?

The menopause transition is an important cardiovascular checkpoint.

The American Heart Association has highlighted adverse cardiometabolic changes that can occur around menopause, including changes in cholesterol, body fat distribution, blood pressure, glucose regulation, and vascular health.

A 2026 analysis reported by the American Heart Association found that perimenopausal women were more likely to have lower overall cardiovascular-health scores than women who were still having regular menstrual cycles, driven particularly by cholesterol and blood-sugar differences.

That does not justify the old claim that women have “7 to 10 times lower” heart-attack rates before menopause or that their risk automatically “catches up to men within 10 years.” Cardiovascular risk changes continuously with age and with multiple risk factors, and menopause is one important component rather than a single switch.

How Does Estrogen Affect the Cardiovascular System?

Estrogen has biological effects on blood vessels, lipids, vascular signaling, and other cardiovascular processes. Lower estrogen during and after menopause is one plausible contributor to changes in cardiovascular risk.

However, statements such as “estrogen protects the heart” can become misleading when presented as if estrogen alone determines cardiovascular outcomes.

During midlife, several things change at the same time:

• age increases
• LDL cholesterol may rise
• body fat distribution may shift toward the abdomen
• blood pressure may rise
• insulin resistance or blood glucose may worsen
• sleep can be disrupted by menopause symptoms
• physical activity may decline

The practical message is to reassess the whole cardiovascular risk profile rather than measuring estrogen as a stand-alone heart-risk test.

Which Heart-Health Checks Matter During Perimenopause and Menopause?

Perimenopause can be a useful time to review:

• blood pressure
• lipid profile
• blood glucose or diabetes risk when indicated
• smoking or nicotine exposure
• physical activity
• sleep quality
• body weight and waist-related metabolic risk
• family history of premature cardiovascular disease
• pregnancy-related cardiovascular history, including preeclampsia or gestational diabetes

For a broader preventive-care overview, see Women’s Health Screenings and Checkups.

Menopausal Hormone Therapy and Heart Health

Menopausal hormone therapy—also called MHT or HRT—is primarily used to treat menopause symptoms such as hot flashes and night sweats, and some products are approved for prevention of postmenopausal bone loss.

ACOG says some research suggests combined hormone therapy may reduce heart-attack risk when started within 10 years of menopause and before age 60. But ACOG also states that more research is needed and hormone therapy should not be used solely to protect against heart disease.

The USPSTF likewise recommends against using estrogen alone or estrogen plus progestin specifically for the primary prevention of chronic conditions in asymptomatic postmenopausal people.

This distinction is important:

• Treating significant menopausal symptoms can be an appropriate reason to consider systemic hormone therapy.
• Preventing a first heart attack is not, by itself, a recommended reason to start systemic hormone therapy.

For someone with a uterus, systemic estrogen usually requires a progestogen to protect the endometrium from estrogen-driven overgrowth.

What Does the HRT “Timing Hypothesis” Mean?

The timing hypothesis proposes that the cardiovascular effects of menopausal hormone therapy may differ depending on a person's age and how long it has been since menopause began.

Evidence is more favorable for symptom treatment in many otherwise healthy women who are younger than 60 or within about 10 years of menopause than for women starting systemic therapy much later.

But “more favorable benefit-risk” is not the same as “HRT protects the heart.”

The decision still needs to consider:

• why hormone therapy is being used
• severity of menopause symptoms
• age and time since menopause
• history of breast or endometrial cancer
• prior stroke, heart attack, or blood clots
• liver disease
• blood pressure and other cardiovascular risks
• whether the uterus is present
• dose, formulation, and route

Is a Patch Safer for the Heart Than Oral Estrogen?

The route of estrogen administration can influence some risks.

ACOG notes that orally administered estrogen may have a stronger prothrombotic effect, while transdermal estrogen appears to have less effect on prothrombotic markers and may carry a lower venous-thromboembolism risk in some patients.

That does not mean patches or gels have zero clot risk or are automatically the safest choice for everyone.

Route selection should be individualized according to symptoms, clot risk, cardiovascular history, gallbladder risk, patient preference, and other medical factors.

What Changed in FDA Menopausal Hormone Therapy Labeling in 2026?

In February 2026, the FDA approved labeling changes for several menopausal hormone therapy products that removed cardiovascular disease, breast cancer, and probable dementia statements from the boxed warning.

This update is important, but it should not be misread as saying that hormone therapy has no cardiovascular or breast-cancer risks.

The FDA's broader labeling update retained cardiovascular and breast-cancer information elsewhere in systemic-product labeling and added consideration of starting therapy for moderate-to-severe vasomotor symptoms in women younger than 60 or within 10 years of menopause.

The practical message remains individualized decision-making for symptom treatment—not starting hormone therapy solely as a cardiovascular-prevention drug.

How Is Testosterone Related to Heart Health in Men?

Low testosterone can occur alongside obesity, reduced muscle mass, diabetes, chronic illness, opioid or corticosteroid use, pituitary disease, testicular disease, and other conditions that also influence cardiovascular risk.

This creates an important distinction between association and causation. Men with low testosterone may have higher cardiovascular risk, but that does not prove low testosterone itself is the main cause of their heart disease.

Testosterone therapy is not recommended as a general anti-aging treatment or as a heart-disease prevention strategy.

How Should Low Testosterone Be Diagnosed?

The Endocrine Society's July 2026 statement emphasizes that hypogonadism should be diagnosed only when a man has compatible symptoms and consistently low, accurately measured testosterone concentrations.

Symptoms such as fatigue, reduced libido, low mood, loss of muscle, or weight gain are not specific enough to diagnose low testosterone by themselves.

The Endocrine Society recommends confirmation with at least two early-morning fasting testosterone measurements using accurate assays, followed by evaluation for the underlying cause when levels are consistently low.

Routine population-wide testosterone screening in asymptomatic men is not recommended.

What Did the TRAVERSE Trial Show About Testosterone and Heart Risk?

The TRAVERSE trial enrolled more than 5,200 men with symptoms of hypogonadism, repeatedly low testosterone, and pre-existing or high cardiovascular risk.

Its main finding was reassuring: testosterone therapy was not associated with a higher rate of major cardiovascular events such as cardiovascular death, nonfatal heart attack, or nonfatal stroke compared with placebo over the trial follow-up.

But that does not mean testosterone therapy is risk free.

The Endocrine Society's 2026 statement notes that TRAVERSE also showed a higher incidence of pulmonary embolism and other safety signals, and that long-term safety remains incompletely established.

In 2025, the FDA removed the testosterone boxed-warning language about increased adverse cardiovascular outcomes after reviewing TRAVERSE. At the same time, the FDA required class-wide labeling to warn that testosterone products can increase blood pressure.

Therefore, testosterone should be prescribed for appropriately diagnosed hypogonadism with appropriate monitoring—not because a person wants to improve heart health, energy, or aging in the absence of a confirmed disorder.

What Actually Protects Cardiovascular Health Through Hormonal Changes?

Hormone levels matter, but proven cardiovascular prevention still centers on the major modifiable risk factors.

• know and treat high blood pressure
• check and manage cholesterol appropriately
• screen for diabetes when indicated
• avoid smoking and nicotine
• stay physically active
• include resistance exercise as appropriate
• prioritize sleep
• manage weight and metabolic health without extreme diets
• take prescribed cardiovascular medicines consistently
• review pregnancy-related risks such as prior preeclampsia or gestational diabetes

For broader guidance, visit the Heart & Cardiovascular Health Hub.