Hormone Replacement Therapy And Birth Control: What They Mean For Your Heart

Birth control and hormone therapy are used for women at different stages of life. Both can affect your heart health, and the risk is not the same for everyone. It depends on your age, your health history and how you take them.

Estrogen plays a natural protective role in women’s heart health. It helps lower bad cholesterol, raise good cholesterol and reduce inflammation in the arteries. That’s one reason women tend to develop heart disease about 10 to 15 years later than men. But estrogen levels change with medication use, a health condition or menopause. And when it does, that natural protection changes too.

Conditions like PCOS and endometriosis, as well as pregnancy complications like gestational hypertension and gestational diabetes, can also raise cardiovascular risk in ways that are often overlooked.

Caitlin Luebcke, DNP, a nurse practitioner with a special interest in women’s cardiology care at Franciscan Physician Network, helps patients navigate these decisions every day.

Key Takeaways: Hormones And Heart Health

• Combination birth control pills can raise your risk of high blood pressure, blood clots, heart attack and stroke. The level of risk to your heart and vascular system depends on your personal health history.
• Hormone replacement therapy started before age 60 is not linked to a higher risk of heart disease and may even offer some protection. Starting after age 60 raises the risk of stroke, heart attack and blood clots.
• Any decision about birth control or hormone therapy should be made through shared decision-making with your provider.

Birth Control Pills And Heart Risk

At Franciscan Health, oral contraceptives may be prescribed for reasons beyond pregnancy prevention, including polycystic ovarian syndrome (PCOS), endometriosis and hormonal imbalances.

Combination birth control pills, which contain both estrogen and progestin, are some of the most common oral contraceptives.

“Contraception that includes estrogen is associated with an increased risk of high blood pressure, stroke, heart attack and blood clots,” said Luebcke. “The risk is higher for some people than others.”

Women who smoke, have high blood pressure, migraines with aura, or a personal or family history of blood clots face a higher risk. Your provider can help you weigh those factors before choosing a method.

Does the delivery method matter?

You might assume that a patch or vaginal ring would be safer for your heart than a pill, since it is not swallowed. The research shows the opposite, at least for younger women.

“The patch and the ring are actually associated with a higher risk for adverse cardiovascular outcomes,” she said. “Oral combo pills that contain estrogen seem to be safer for younger women.”

For women being treated for PCOS or endometriosis, the oral combination pill is the safer choice compared to the patch or ring.

Who should avoid estrogen-based birth control?

For some women, estrogen-containing contraceptives are not a safe option regardless of the delivery method.

“If you have a history of stroke, heart attack or blood clots, I would not personally pursue these therapies,” Luebcke said.

If you have a history of cardiovascular disease or blood clots, talk to your provider.

Navigating Menopause Safely

“When women hit menopause, there is a huge drop in estrogen levels,” Luebcke said. “We have found it is associated with rapid cardiovascular aging. Women, unlike men, really age in this massive spurt, and risk rises over the course of that menopausal period.”  

Hormone replacement therapy (HRT) is used to manage menopause symptoms like hot flashes, night sweats and sleep disruptions. For many women, HRT is a safe and effective option, but the cardiovascular picture depends on when you start and how you take it.

Is hormone replacement therapy safe?

For most women, HRT is considered safe. In fact, the FDA recently removed the black box warnings from hormone replacement therapy — a change that reflects more than two decades of updated research on its safety and benefits.

Timing matters too.

“If we miss treating you in earlier years of your life and we want to start estrogen therapy after the age of 60, it tends to be associated with an increased risk for stroke, heart attack and blood clots — similarly to oral contraceptive pills,” Luebcke said.

The form of HRT also matters. For menopausal women, patches and creams carry less cardiovascular risk than oral HRT. This is the opposite of what is true for younger women on birth control.

“The same things that are more dangerous when we’re younger actually seem to have less risk when we are older,” she said. “Vaginal creams have less than 5 percent systemic absorption, and that’s probably why it’s a little different.”

Women with a known history of heart disease, stroke or blood clots should not use HRT and should talk with their provider about other options.

How to decide what is right for you

There is no single right answer when it comes to birth control or hormone therapy. The best choice depends on your age, your health history, your symptoms and your goals. That’s why a conversation with your provider matters so much.

“Any decision you make should be made through shared decision-making after a very thorough history, a very thorough physical exam and a comprehensive discussion with your healthcare provider about the symptoms you’re dealing with, how they affect your quality of life and balancing that with your individualized risk,” Luebcke said.

Come to your appointment prepared. Know your personal and family health history. Be honest about your symptoms and how much they affect your daily life.

“What’s right for me may not feel right for my patient, my friend or even a family member,” Luebcke said. “Healthcare should be individualized. You need to find a provider who is going to explain things to you and balance them out for you.”

A Franciscan Health provider can review your health history and help you find the safest path forward with birth control or hormone therapy. Find a specialist near you or schedule an appointment online.