IPM Take
Menopause is being pulled into a noisy public debate about hormone therapy. That debate matters, but it is too narrow. The bigger failure is that health systems still lack routine menopause-linked cardiovascular prevention pathways. Women reach midlife with changing blood pressure, cholesterol, insulin resistance, visceral fat and kidney-metabolic risk, yet many are offered fragmented symptom care rather than structured cardiometabolic assessment. Hormone therapy may be appropriate for selected symptomatic women after shared decision-making. It is not a substitute for cardiovascular prevention.
Executive Summary
A Healio report from the Heart in Diabetes CME Conference highlights remarks by Martha Gulati, director of the Davis Women’s Heart Center at Houston Methodist DeBakey Heart & Vascular Center, on menopause and cardio-kidney-metabolic health. Gulati argued that menopause is an important time to prioritise cardiovascular prevention and improve clinician competencies around the menopausal transition.
The clinical message is nuanced. Menopause is associated with changes in cardiovascular and metabolic risk, including blood pressure, cholesterol, lipoprotein(a), insulin resistance, visceral adiposity, inflammation and vascular function. But the role of estrogen is not simple, and available evidence does not support menopausal hormone therapy for primary prevention of cardiovascular disease.
This matters because policy and practice are moving at different speeds. The FDA has recently acted to revise long-standing warnings on menopausal hormone therapy products, while the USPSTF still recommends against systemic hormone therapy for the primary prevention of chronic conditions in postmenopausal persons. The Menopause Society states that hormone therapy remains the most effective treatment for vasomotor symptoms and genitourinary syndrome of menopause, but risks vary by type, dose, duration, route, timing and individual risk profile.
The global policy question is not whether every woman should receive hormone therapy. It is whether menopause should become a routine checkpoint for cardiometabolic risk assessment, prevention and referral.
Why it matters
- Policymakers and public authorities: Menopause should be embedded in women’s cardiovascular health strategies, not left to fragmented gynaecology, primary care and cardiology silos.
- Clinicians and providers: Midlife visits should include blood pressure, lipids, glucose or HbA1c, weight distribution, kidney risk, smoking status, sleep, physical activity, mental health and reproductive history.
- Payers and HTA bodies: Reimbursement should support prevention visits, risk assessment, counselling, follow-up and multidisciplinary menopause-heart care, not only treatment after disease is established.
- Regulators: Label changes for hormone therapy must not be misread as cardiovascular prevention endorsement. Communication should support nuanced, risk-based prescribing.
- Patients and advocates: Women need clear information: menopause can raise cardiometabolic risk, hormone therapy can help symptoms for selected women, but heart prevention still depends on screening, risk control and long-term follow-up.
Menopause is having a policy moment.
Patients are asking about hormone therapy. Regulators are revisiting old warnings. Clinicians are trying to interpret decades of conflicting evidence. Social media is turning menopause into a wellness market. And cardiology is finally being forced to admit what women have known for years: midlife is not a neutral transition.
At the Heart in Diabetes CME Conference, Martha Gulati made the point clearly. Menopause is an important time for cardiovascular prevention, and clinicians need better competencies around the menopausal transition.
That should not be controversial.
Women often spend roughly one third of their lives after menopause. During that period, cardiovascular and cardiometabolic risk can shift meaningfully. Blood pressure rises. Lipids change. Insulin resistance can worsen. Visceral adiposity can increase. Inflammation, vascular function, renal-metabolic pathways and body composition can all move in the wrong direction.
Yet health systems still treat menopause too narrowly.
For many women, menopause care is framed around hot flashes, sleep disturbance, genitourinary symptoms and hormone therapy. Those are important. But menopause is also a cardiovascular and cardio-kidney-metabolic checkpoint. If the system only asks whether symptoms need treatment, it misses the prevention window.
The danger now is that the hormone therapy debate swallows the whole conversation.
The evidence is not simple enough for slogans. Menopausal hormone therapy is effective for vasomotor symptoms and genitourinary syndrome of menopause. It may be appropriate for many symptomatic women, particularly when started in the right patient, at the right time, using the right formulation and route. But it is not recommended as a primary prevention strategy for cardiovascular disease.
The USPSTF recommends against combined estrogen and progestin for primary prevention of chronic conditions in postmenopausal persons, and against estrogen alone for primary prevention in postmenopausal persons who have had a hysterectomy. The Menopause Society’s 2022 position statement is also careful: hormone therapy benefits and risks differ by type, dose, duration, route, timing of initiation and whether a progestogen is used.
That nuance matters.
In February 2026, the FDA approved labeling changes for an initial group of menopausal hormone therapy products, following its November 2025 announcement that it would initiate removal of certain long-standing boxed warnings. This may help correct overgeneralised fear around hormone therapy. But it should not create a new misconception that hormone therapy is a cardiovascular prevention drug.
That is the line policy must hold.
The problem is not that women are asking about hormones. The problem is that many health systems have no structured answer when women ask: what does menopause mean for my heart?
The answer should start with risk assessment.
Menopause visits should routinely include cardiovascular history, reproductive history, pregnancy complications, premature or early menopause, smoking status, family history, blood pressure, lipids, glucose or HbA1c, weight and waist measures, kidney function where appropriate, sleep, physical activity and mental health. This is not exotic precision medicine. It is basic prevention, applied at the right life stage.
The 2025 JACC: Advances expert panel on improving cardiovascular clinical competencies for the menopausal transition argued for a stronger focus on cardiometabolic health in midlife. That is exactly where policy should go. Menopause should not be managed only as a symptom episode. It should be a structured care pathway.
Global signals are moving in the same direction.
Global Heart Hub’s 2026 Women’s Heart Health Action Agenda identifies perimenopause and menopause as key cardiovascular windows that remain largely absent from routine care pathways. The European Society of Cardiology has also highlighted women-specific cardiovascular risk management, including the increased risk associated with early menopause. And in 2026, European experts called for dedicated women’s heart centres to tackle inequality in cardiovascular diagnosis and care.
The pattern is clear. Women’s cardiovascular risk has been under-recognised, under-diagnosed and under-treated. Menopause is one of the moments where this failure becomes visible.
But visibility is not enough.
Health systems need operational change. That means training clinicians to ask about menopause and reproductive history. It means building referral pathways between primary care, gynaecology, endocrinology, nephrology and cardiology. It means ensuring women with elevated blood pressure, dyslipidaemia, diabetes risk, chronic kidney disease, premature menopause or severe vasomotor symptoms are not left to navigate fragmented care alone.
It also means separating symptom treatment from cardiovascular prevention without pretending they are unrelated.
A woman seeking treatment for hot flashes should not be told that hormones will prevent heart disease. But she also should not leave without cardiovascular risk assessment. A woman with worsening cholesterol during perimenopause should not be told this is just ageing. A woman with early menopause should not wait until her first cardiac event to be considered higher risk.
The biggest policy failure is not confusion about estrogen. It is the absence of a midlife women’s heart-health pathway.
That pathway should include:
- routine cardiometabolic screening during perimenopause and menopause;
- explicit documentation of menopause timing and premature or early menopause;
- inclusion of pregnancy history and adverse pregnancy outcomes;
- shared decision-making for hormone therapy based on symptoms, age, time since menopause, route, dose and individual risk;
- nonhormonal treatment options for women who cannot or choose not to use hormone therapy;
- lifestyle, blood pressure, lipid, diabetes and kidney risk management;
- referral criteria for cardiology or women’s heart centres;
- follow-up systems that do not rely on women repeatedly re-explaining their risk.
This is especially important for equity. Women with fewer resources, poor access to primary care, language barriers, rural residence or previous dismissal by clinicians are less likely to receive nuanced menopause counselling and more likely to present later with uncontrolled risk.
Digital tools could help, but only if designed carefully. EHR prompts could flag early menopause, severe menopausal symptoms, adverse pregnancy outcomes or rising cardiometabolic risk. Remote blood pressure monitoring and digital lifestyle support could improve follow-up. AI could eventually help identify risk trajectories across the menopausal transition. But technology should support care, not replace clinical judgement or widen access gaps.
The research gap remains serious.
As Gulati noted, large contemporary randomised trials with hard cardiovascular endpoints are still lacking for modern menopausal hormone therapy in current populations. Much of the debate still carries the legacy of older trials, older formulations, older routes of administration and populations that do not fully reflect women seeking treatment today.
That uncertainty should not paralyse care. But it should make policy honest.
Menopause is not a disease. It is also not a wellness niche. It is a biological transition with major implications for cardiovascular, kidney and metabolic health.
The health system should stop treating it as an awkward conversation between gynaecology and lifestyle advice.
Menopause should be a prevention checkpoint.
Not because every woman needs hormones.
Because every woman deserves a serious cardiovascular risk conversation before the disease arrives.
