Not all menopausal hormone therapy carries the same cardiovascular risk

A major study published in The BMJ is reshaping how clinicians should think about menopausal hormone therapy (HT). Analyzing data from over 1 million Danish women aged 50–69, researchers found that oral HT significantly raises the risk of venous thromboembolism (VTE), ischemic stroke, and myocardial infarction (MI) — but transdermal HT does not carry the same dangers.

The findings are especially relevant given the FDA's February 2026 update to black box warnings on six menopausal HT products, which flagged cardiovascular risks. Researchers stress that HT is not a one-size-fits-all treatment — route of administration, estrogen dose, and duration all matter.

By the Numbers:

• 60% higher VTE risk for oral HT users vs. non-users (HR = 1.6)
• 30% higher ischemic stroke risk with oral HT (HR = 1.3); rises to 50% with high-dose (>1 mg/day) estradiol
• 20% higher MI risk with oral HT (HR = 1.2); rises to 40% with high-dose estradiol
• Transdermal HT: no increased risk for VTE, stroke, or MI

Why it matters: These findings give clinicians a clearer roadmap for individualizing HT prescribing. When oral therapy is necessary, experts recommend the lowest effective dose (≤1 mg estradiol/day) with regular reassessment — and transdermal formulations should be the preferred route when possible.