Fewer Hot Flashes. A Healthier Heart?
By The Functional Medicine Report™
Originally published September 18, 2026 in Issue #010 of The Functional Medicine Report™
Menopause relief and cardiovascular prevention belong in the same visit. They are not the same treatment promise.
Key Takeaways
The association is real. The indication is not. In an observational analysis of 2,737 participants in the Study of Women’s Health Across the Nation, using methods designed to emulate a sequence of clinical trials, women who initiated menopausal hormone therapy had an estimated 22% lower relative hazard of cardiovascular events — an adjusted hazard ratio of 0.78. Treatment was not randomly assigned. The researchers did not establish hormone therapy as a treatment for cardiovascular prevention.
Age and timing change the answer. A 2025 secondary analysis of the Women’s Health Initiative trials of oral conjugated equine estrogens, with or without medroxyprogesterone acetate, found that among symptomatic women aged 50 to 59, hormone therapy improved symptoms without a statistically significant increase in atherosclerotic cardiovascular disease. Among symptomatic women aged 70 and older, cardiovascular risks were higher.
Symptom relief is a legitimate outcome on its own. The Menopause Society identifies hormone therapy as the most effective treatment for menopausal hot flashes. The U.S. Preventive Services Task Force recommendation against systemic hormone therapy applies to the primary prevention of chronic disease in asymptomatic postmenopausal people — not to the treatment of menopausal symptoms, and not to premature or surgical menopause.
The boxed warning changed. The prescribing decision did not disappear. On February 12, 2026, the FDA announced approved labeling changes for six menopausal hormone products, removing cardiovascular disease, breast cancer and probable dementia language from their boxed warnings. Product-specific requirements remain: Bijuva still lists contraindications including histories of breast cancer, deep-vein thrombosis, pulmonary embolism, stroke and myocardial infarction, and Divigel still carries a boxed warning about endometrial cancer risk.
The menopause visit holds two jobs. The American Heart Association has highlighted changes in LDL cholesterol, abdominal visceral fat, vascular health and lean body mass that can accompany the menopause transition. A successful hormone prescription does not address that risk profile. Someone has to be watching both.
An encouraging finding arrived with an important qualification.
In a study published September 8 in JAMA Internal Medicine, starting menopausal hormone therapy was associated with a lower estimated risk of cardiovascular disease. Yet the researchers were careful not to turn that association into a prescribing recommendation. Their results did not establish hormone therapy as a treatment for cardiovascular prevention.
That tension is where the story becomes useful.
The study focused on women reporting hot flashes or night sweats during and after the menopause transition and asked a practical question: when women begin hormone therapy during this stage of life, what happens to their cardiovascular risk over time?
For practitioners, this is not simply another entry in the decades-long debate over whether hormones are good or bad for the heart. It is a reminder that two different clinical decisions often sit inside the same menopause visit.
One is about how a woman feels now.
The other is about what may affect her health years from now.
Both deserve attention. Neither should be asked to stand in for the other.
Functional medicine is well suited to hold those questions together. A menopause visit can address symptoms that are disrupting a woman’s life while also looking carefully at the cardiovascular changes that often emerge during midlife. The goal is not to make a hormone prescription carry the weight of an entire prevention plan. It is to make sure the prevention plan is not forgotten because the hot flashes improved.
The Woman Behind the Average
Researchers used observational data from 2,737 participants in the Study of Women’s Health Across the Nation and applied methods designed to emulate a sequence of clinical trials.
Women who initiated hormone therapy had an estimated 22% lower relative hazard of cardiovascular events than those who did not, with an adjusted hazard ratio of 0.78.
That finding is encouraging. It is not the same as proving that hormone therapy prevents cardiovascular disease.
Treatment was not randomly assigned, and women who chose to start therapy may have differed in important ways from women who did not. Even sophisticated statistical methods cannot remove every possible difference between those groups.
The study therefore gives researchers a reason to look more closely rather than giving practitioners a universal answer.
Randomized evidence also shows why the woman in front of us matters more than the average result.
A 2025 secondary analysis revisited data from the Women’s Health Initiative trials of oral conjugated equine estrogens, with or without medroxyprogesterone acetate. Among women ages 50 to 59 with moderate or severe hot flashes or night sweats, hormone therapy improved symptoms without a statistically significant increase in atherosclerotic cardiovascular disease. Among symptomatic women age 70 and older, cardiovascular risks were higher.
These were not new trials. Researchers were taking another look at existing randomized data through a more specific clinical lens.
That distinction matters because “Does hormone therapy help or hurt the heart?” is too broad a question to guide an individual decision.
A better set of questions is more specific.
Who was studied? How old were they? How long had they been in menopause? What symptoms did they have? What hormone formulation did they receive? By what route? And what outcome actually changed?
Those details are not fine print. They are the difference between evidence that applies to the patient in front of you and evidence that may not.
Relief Is a Real Outcome
The uncertainty around cardiovascular prevention should not make us lose sight of what hormone therapy can already do well.
The Menopause Society identifies hormone therapy as the most effective treatment for menopausal hot flashes. It can also reduce night sweats and the sleep disruption that often accompanies them.
Those are meaningful outcomes.
A woman who is waking repeatedly soaked in sweat, unable to sleep, struggling to think clearly and trying to function through her day does not need evidence that treatment will prevent a heart attack twenty years from now before her symptoms deserve treatment.
Women do not need a promise of heart protection to deserve effective menopause care.
For functional medicine, looking beyond symptoms and treating symptoms should never be treated as opposites. We can ask why the patient is experiencing what she is experiencing and still relieve what is making her life miserable now.
Prevention guidance makes the same distinction.
The U.S. Preventive Services Task Force recommends against using systemic hormone therapy for the primary prevention of chronic disease in asymptomatic postmenopausal people. That recommendation does not apply to the treatment of menopausal symptoms. It also does not address premature or surgical menopause, where the clinical considerations are different.
Both mistakes matter.
A recommendation against hormone therapy for broad disease prevention should not be interpreted as a reason to leave significant menopausal symptoms untreated. At the same time, feeling better on hormone therapy does not mean every future health risk has been addressed.
A Changed Warning Is Not a Complete Answer
The regulatory conversation around menopause treatment is changing as well.
On February 12, the FDA announced approved labeling changes for six menopausal hormone products. Language concerning cardiovascular disease, breast cancer and probable dementia was removed from their boxed warnings.
That was a significant change.
It was not an announcement that menopausal hormone therapy has become risk-free.
The details still matter.
Bijuva, an oral estradiol-and-progesterone product, no longer carries the previous boxed warning, but its prescribing information continues to list important contraindications, including histories of breast cancer, deep-vein thrombosis, pulmonary embolism, stroke and myocardial infarction. The label also states that its safety and efficacy for cardiovascular prevention have not been established.
Divigel, a systemic estradiol gel, continues to carry a boxed warning about endometrial cancer risk when systemic estrogen is used without adequate endometrial protection in a woman with a uterus.
The lesson is not complicated.
Read the current information for the product being considered.
A changed boxed warning should lead to a more accurate conversation, not a shorter one.
Personalization Starts Before the Prescription
The Menopause Society describes the benefit-risk balance of hormone therapy as generally favorable for treating bothersome symptoms and preventing bone loss in women younger than 60 or within 10 years of menopause onset who do not have contraindications.
That is useful guidance.
It is not an automatic prescription based on age.
Two women can be the same age and have very different risk profiles, symptom burdens, family histories and treatment priorities. Personalization begins before choosing a patch, pill or gel.
It begins with deciding what problem is being treated and whether hormone therapy is an appropriate way to treat it.
Starting therapy and continuing therapy are also different decisions. Professional guidance does not recommend automatically stopping hormone therapy because a woman reaches 60 or 65. Continued use requires periodic reassessment of what the treatment is doing, why it is still being used and whether the benefit-risk balance has changed.
The formulation matters too.
Systemic hormone therapy used for hot flashes is different from low-dose vaginal estrogen used primarily for local genitourinary symptoms. Women with a uterus who use systemic estrogen generally require appropriate endometrial protection, while low-dose vaginal estrogen usually does not require a progestogen.
Route may also change part of the risk discussion. Evidence summarized by the American College of Cardiology suggests that transdermal estrogen may carry a lower observed risk of venous thrombosis than oral estrogen, although comparative evidence has limitations.
A patch is therefore not simply a pill in another form.
But choosing a patch instead of a pill does not prove cardiovascular protection either.
Good personalization is not about finding the formulation with the most favorable reputation. It is about being able to explain why this treatment fits this woman, what outcome you are trying to improve and what would make you reconsider the plan later.
The Prevention Opportunity Inside the Menopause Visit
The cardiovascular conversation matters whether a woman chooses hormone therapy, cannot use it or never needs it.
The menopause transition itself is a period of meaningful cardiometabolic change.
The American Heart Association has highlighted changes in LDL cholesterol, abdominal visceral fat, vascular health and lean body mass that can accompany menopause. Its scientific guidance argues for paying attention to cardiovascular prevention during midlife rather than waiting until disease appears.
That gives the menopause visit a larger purpose.
One part of the conversation asks what is disrupting the woman’s life right now. Are hot flashes waking her at night? Is sleep deteriorating? Are genitourinary symptoms affecting comfort or sexual function? What treatment options fit her goals and history?
The other part asks what is happening to her long-term risk.
What is her blood pressure? What do her lipids look like? Is glucose regulation changing? Does she smoke? Has physical activity changed? What is happening with muscle mass, weight distribution, sleep and the rest of her cardiovascular risk profile?
These are not competing conversations.
They are two parts of caring for the same woman.
For a functional medicine practitioner, that is where the opportunity becomes especially important. Midlife is often when several small changes begin appearing at once. LDL rises. Blood pressure edges up. Sleep becomes less reliable. Muscle mass declines. Insulin sensitivity may shift. Body composition changes.
None of those findings alone has to become the whole visit.
But neither should they disappear behind a successful hormone prescription.
A useful follow-up should therefore ask more than whether the hot flashes are gone.
Did the patient sleep better? Is the original treatment goal being met? Are there side effects? Does the dose still make sense?
And alongside that: Has the blood-pressure issue been addressed? Were the lipid results reviewed? Is there a clear plan for the cardiovascular risks that actually need attention?
No one practitioner has to do all of it.
What matters is that someone is paying attention to both.
For clinicians who do not prescribe hormone therapy, the same opportunity remains. They can recognize symptoms, assess broader health patterns, support appropriate evaluation and coordinate with the clinician managing hormone treatment.
The care does not become less personalized because more than one practitioner is involved.
It becomes fragmented only when no one is connecting the pieces.
Two Questions Worth Keeping Together
Menopause care becomes clearer when we stop trying to make one decision answer every question.
Hormone therapy may be an excellent treatment for bothersome menopausal symptoms in an appropriately selected woman. That does not require us to promise that it will prevent cardiovascular disease.
And the fact that hormone therapy should not be prescribed solely for cardiovascular prevention does not diminish the value of treating the symptoms it is known to improve.
The menopause visit gives us an opportunity to do both jobs well.
Help the woman feel better now.
Look carefully at what may affect her health later.
Sometimes those plans will overlap. Sometimes they will not. Either way, they should be visible.
The most useful question is no longer whether hormone therapy is simply “good” or “bad.”
It is whether the treatment fits this woman, at this stage of her life, for the reason she is taking it.
And beside that question should be another:
What are we doing about her long-term cardiovascular health?
A good hormone decision belongs inside that conversation.
It should not be where the conversation ends.
Dr. Z’s Take
I think we have spent far too many years asking the wrong question about hormone therapy.
Is it good for women or bad for women?
That is not a useful clinical question.
The better question is: Is it appropriate for this woman, at this point in her life, for what we are trying to accomplish?
I have been in practice long enough to watch the pendulum swing hard in both directions. Hormones were prescribed liberally, then the Women’s Health Initiative frightened an entire generation of women and practitioners, and hormone therapy became something many women were afraid to even discuss. Now the pendulum is moving again, and I don’t want us to make the opposite mistake and turn hormones into the answer for everything that happens in midlife.
They don’t need to be.
If a woman is having hot flashes, waking up drenched at night, not sleeping and struggling to function the next day, helping her feel better is a legitimate treatment goal. We don’t need to prove that her hormone therapy will prevent a heart attack twenty years from now to justify treating symptoms that are affecting her life today.
At the same time, I think menopause gives us an incredible opportunity to look at what is changing underneath those symptoms.
Estrogen affects far more than hot flashes. As estrogen changes, we may see changes in insulin sensitivity, body composition, visceral fat, lipids, vascular function, bone and muscle. Sleep may change. Stress tolerance may change. A woman who had beautiful blood pressure, glucose and lipid numbers at 42 may have a very different picture at 52.
That is where functional medicine should shine.
I don’t want to see a woman for menopause, recommend hormones and call the job finished. I want to know what her blood pressure is doing. I want to see her glucose and insulin picture. I want to understand her lipids—not just total cholesterol. I want to know what is happening to muscle, visceral fat, sleep, movement and the other pieces that will influence how healthy she is ten or twenty years from now.
And I want to treat the woman in front of me, not the average woman in a study.
Her age matters. The timing of menopause matters. Her symptoms matter. Her uterus matters. Her personal and family history matter. The formulation and route matter. What she wants matters.
That is what personalization actually means.
The new cardiovascular research is encouraging. I am glad we are asking these questions again, and I am glad the conversation around menopausal hormone therapy has become more nuanced.
But I don’t need hormone therapy to be a cardiovascular drug to believe it can be incredibly valuable.
And I don’t want a woman taking hormones to assume her heart is handled.
Those are two different jobs.
Help her feel better now. Pay attention to what will help keep her healthy later.
Menopause gives us the opportunity to do both. We shouldn’t waste it.
Frequently Asked Questions
Does hormone therapy prevent heart disease?
No. A September 2026 analysis in JAMA Internal Medicine found that women who started menopausal hormone therapy during the menopause transition had an estimated 22% lower relative hazard of cardiovascular events. Treatment was not randomly assigned, and the researchers were careful not to turn that association into a prescribing recommendation. Hormone therapy is not established as a treatment for cardiovascular prevention.
What did the 2026 JAMA Internal Medicine study actually find?
Researchers used observational data from 2,737 participants in the Study of Women’s Health Across the Nation and applied methods designed to emulate a sequence of clinical trials. Women who initiated hormone therapy had an adjusted hazard ratio of 0.78 for cardiovascular events. Because women who chose to start therapy may have differed in important ways from those who did not, even sophisticated statistical methods cannot remove every possible difference between the groups.
Is hormone therapy safe for the heart at any age?
The evidence separates by age and time since menopause. A 2025 secondary analysis of the Women’s Health Initiative trials found that among symptomatic women aged 50 to 59, hormone therapy improved symptoms without a statistically significant increase in atherosclerotic cardiovascular disease. Among symptomatic women aged 70 and older, cardiovascular risks were higher. The Menopause Society describes the benefit-risk balance as generally favorable for treating bothersome symptoms and preventing bone loss in women younger than 60 or within 10 years of menopause onset who have no contraindications.
Did the FDA remove the boxed warning from hormone therapy?
Partly. On February 12, 2026, the FDA announced approved labeling changes for six menopausal hormone products, removing language on cardiovascular disease, breast cancer and probable dementia from their boxed warnings. That is not an announcement that menopausal hormone therapy has become risk-free. Bijuva’s prescribing information continues to list contraindications including histories of breast cancer, deep-vein thrombosis, pulmonary embolism, stroke and myocardial infarction, and states that safety and efficacy for cardiovascular prevention have not been established. Divigel continues to carry a boxed warning about endometrial cancer risk when systemic estrogen is used without adequate endometrial protection in a woman with a uterus.
Is an estrogen patch safer than a pill?
Route may change part of the risk discussion. Evidence summarized by the American College of Cardiology suggests that transdermal estrogen may carry a lower observed risk of venous thrombosis than oral estrogen, although comparative evidence has limitations. A patch is not simply a pill in another form. Choosing a patch instead of a pill does not prove cardiovascular protection either.
Does the USPSTF recommendation mean women should not take hormone therapy?
No. The U.S. Preventive Services Task Force recommends against using systemic hormone therapy for the primary prevention of chronic disease in asymptomatic postmenopausal people. That recommendation does not apply to the treatment of menopausal symptoms, and it does not address premature or surgical menopause, where the clinical considerations are different. A recommendation against hormone therapy for broad disease prevention is not a reason to leave significant menopausal symptoms untreated.
Should hormone therapy be stopped at 60 or 65?
Not automatically. Professional guidance does not recommend stopping hormone therapy simply because a woman reaches 60 or 65. Starting therapy and continuing therapy are different decisions. Continued use requires periodic reassessment of what the treatment is doing, why it is still being used and whether the benefit-risk balance has changed.
Does vaginal estrogen require a progestogen?
Usually not. Systemic hormone therapy used for hot flashes is different from low-dose vaginal estrogen used primarily for local genitourinary symptoms. Women with a uterus who use systemic estrogen generally require appropriate endometrial protection, while low-dose vaginal estrogen usually does not require a progestogen.
What else should a menopause visit cover besides symptoms?
The cardiovascular picture, whether or not a woman chooses hormone therapy. The American Heart Association has highlighted changes in LDL cholesterol, abdominal visceral fat, vascular health and lean body mass that can accompany the menopause transition. A useful visit asks what is disrupting the woman’s life now — hot flashes, night sweats, sleep, genitourinary symptoms — and separately asks about blood pressure, lipids, glucose regulation, smoking, physical activity, body composition and muscle mass. No one practitioner has to do all of it. What matters is that someone is paying attention to both.
Sources
Wang Z, et al. Menopausal Hormone Therapy and Cardiovascular Risk in Midlife Women With Vasomotor Symptoms. JAMA Internal Medicine. Published online 8 September 2026. doi:10.1001/jamainternmed.2026.2922
Menopausal Hormone Therapy and Cardiovascular — Laying the Foundation for Future Trials. Invited commentary. JAMA Internal Medicine. 8 September 2026
Menopausal Hormone Therapy and Cardiovascular Diseases in Women With Vasomotor Symptoms: A Secondary Analysis of the Women’s Health Initiative Randomized Clinical Trials. JAMA Internal Medicine. 2025
The 2022 Hormone Therapy Position Statement of The North American Menopause Society. Menopause. 2022. doi:10.1097/GME.0000000000002028
U.S. Preventive Services Task Force. Hormone Therapy in Postmenopausal Persons: Primary Prevention of Chronic Conditions. Final Recommendation Statement, 1 November 2022
U.S. Food and Drug Administration. FDA Approves Labeling Changes to Menopausal Hormone Therapy Products. News release, 12 February 2026
U.S. Food and Drug Administration. Menopausal Hormone Therapies With Updated Prescribing Information (Bijuva, Divigel and others)
El Khoudary SR, et al. Menopause Transition and Cardiovascular Disease Risk: Implications for Timing of Early Prevention. A Scientific Statement From the American Heart Association. Circulation. 2020;142:e506–e532. doi:10.1161/CIR.0000000000000912
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