In my years leading the Global PAD Association, I’ve witnessed the complex relationship between hormonal health and vascular disease firsthand. Time and again, women in our network describe how their vascular symptoms emerged or worsened after menopause—a connection supported by research but rarely addressed in clinical settings.
The Forgotten Connection: Estrogen and Vascular Protection
“We know that estrogen is so cardioprotective,” NP Deidre explained during our conversation. This simple statement encapsulates what many healthcare providers have recognized for years—estrogen offers significant protection for the cardiovascular system.
When women enter menopause, whether naturally or surgically, this protection diminishes as estrogen levels drop. The vascular consequences can be profound, with research showing increased arterial stiffness, elevated cholesterol levels, and higher rates of atherosclerosis in postmenopausal women.
For those already managing conditions like peripheral artery disease, this hormonal shift can accelerate disease progression. Many women in our PAD network report declining vascular health during this transition, yet few have been offered hormone therapy as part of their comprehensive care plan.
The reason? A twenty-year-old warning that has cast a long shadow over hormone therapy prescribing practices.
How We Got Here: The Black Box That Changed Everything
In 2002, the Women’s Health Initiative (WHI) study sent shockwaves through the medical community. Its findings led the FDA to place its most serious caution—a black box warning—on estrogen products, flagging potential increased risks of breast cancer, heart attacks, strokes, and blood clots.
The consequences were immediate and lasting. “Since 2002, it was a rapid decline in the use of estrogen,” NP Deidre noted. This decline continued for decades, despite emerging evidence questioning the study’s conclusions, particularly regarding cardiovascular risk.
What many patients don’t realize is that the WHI study primarily examined older women using synthetic estrogen formulations—a vastly different approach from today’s personalized, bioidentical options. The study was essentially “a one-size-fits-all study,” as Deidre described it, that didn’t reflect the nuanced, individualized approach modern practitioners take.
This historical context explains why so many women with vascular conditions have been denied a potentially beneficial therapy. Physicians, understandably cautious about prescribing medications with the strongest possible warning, have often excluded hormone therapy from treatment plans—even when it might have offered vascular benefits.
The Evolution of Hormone Therapy: New Options for Vascular Patients
Hormone therapy has evolved dramatically since 2002. NP Deidre offered this perfect analogy: modern estrogen treatments compare to the WHI study’s approaches like “an iPhone compared to a flip phone.”
Today’s options include bioidentical hormones that more closely mimic what the body naturally produces, delivered in lower doses through various methods. For vascular patients, the delivery method can be particularly significant.
“Estrogen through the skin bypasses the liver and has a lower clotting risk,” Deidre explained. These transdermal options—patches, gels, and creams—avoid the first-pass liver metabolism that can increase clotting factors with oral estrogen.
This advancement is particularly relevant for women with vascular conditions, who often have elevated clotting concerns. The transdermal approach offers a way to potentially gain cardiovascular benefits while minimizing clotting risks—an option that wasn’t widely available when the original warning was implemented.
Timing Matters: The Window of Opportunity for Vascular Protection
Perhaps the most important development in our understanding of hormone therapy is the recognition that timing is crucial. “Timing of when people go on HRT is really important, especially for vascular” health, Deidre emphasized.
New long-term studies reveal that for women under 60 or within 10 years of menopause, hormone therapy doesn’t increase cardiovascular risk—it may actually reduce it. This “window of opportunity” concept suggests that starting hormone therapy during the right timeframe could potentially prevent the vascular damage that leads to conditions like PAD.
For women who experience early or surgical menopause, this timing consideration becomes even more critical. “When you look at the studies and the loss of estrogen further out, that’s when we see an increase in cardiovascular and our lipid profiles worsen. You know, we get metabolically unstable,” Deidre explained.
This understanding of timing connects directly to the Global PAD Association’s mission of early intervention to prevent limb loss. By addressing hormonal factors during this critical window, we may be able to prevent or slow the progression of vascular disease before it reaches advanced stages.
Beyond Blood Vessels: How Estrogen Affects Comprehensive Vascular Care
The impact of estrogen extends beyond direct effects on blood vessels. One fascinating connection NP Deidre highlighted involves urinary tract infections—a common issue that often delays critical vascular procedures for our PAD patients.
“We know as we age, the bladder sits so close to the vaginal walls there, and urinary tract infections, especially in women who are in menopause, often can be attributed to a decrease in estrogen,” she explained. These infections can force postponement of limb-saving interventions, creating a dangerous delay in care.
Local estrogen therapies can help prevent these infections, potentially allowing more timely vascular treatments. This example illustrates how hormone therapy can support overall vascular care beyond its direct cardiovascular effects—another consideration that’s often overlooked in traditional treatment approaches.
What Removing the Black Box Warning Would Mean for Vascular Patients
The FDA panel’s reconsideration of the black box warning represents a potential watershed moment for women’s vascular health. Removing this warning would empower providers to prescribe hormone therapy without the underlying fear that has limited its use.
“I feel like removing the warning could open the floodgates in the best way possible because it’s going to empower more providers to prescribe HRT without this fear,” Deidre said. For women with PAD or other vascular conditions, this could mean expanded options for comprehensive care.
The change would shift conversations from automatic exclusion to thoughtful consideration of hormone therapy as part of a vascular protection strategy. For providers who have been hesitant to prescribe these medications despite understanding their potential benefits, the removal of the warning would provide reassurance and clinical support for their decisions.
Most importantly, it would allow for more individualized care plans that consider hormonal factors alongside traditional vascular treatments—potentially improving outcomes for women who have long been underserved by one-size-fits-all approaches.
A Global Perspective: Catching Up to International Standards
The United States has taken a notably more cautious approach to hormone therapy than many other countries. The UK, Canada, and Australia have maintained more balanced perspectives on hormone therapy, recognizing that for appropriate patients, the benefits often outweigh the risks.
If the FDA aligns its warnings with current evidence, American women will finally have access to the same hormone options that women in other countries have successfully used for years. This global alignment could significantly improve vascular outcomes for women in the United States who have been denied these treatments due to outdated warnings.
The Personal Side of Vascular Health
What gives NP Deidre’s perspective unique weight is her personal journey. Having experienced surgical menopause at 29 followed by open heart surgery at 46, she understands firsthand the cardiovascular implications of estrogen loss.
“It’s something that I feel there’s value in prevention of cardiovascular disease from this avenue,” she shared. “I feel like it’s another avenue that women can explore to help keep themselves well.”
Her story mirrors what many women in our PAD network have experienced—significant vascular events following premature loss of estrogen. These personal experiences, combined with emerging research, make a compelling case for reconsidering hormone therapy as part of comprehensive vascular care.
Moving Forward: What Women with Vascular Concerns Should Know
For women with PAD or vascular risk factors, this potential regulatory change expands your options for comprehensive care. If you’re approaching menopause, consider discussing with your vascular specialist how hormone therapy might fit into your overall cardiovascular protection plan.
If you’re currently using hormone therapy and have vascular concerns, this change might offer more flexibility in your treatment options. And if you were previously told hormone therapy was contraindicated due to vascular disease, it might be worth revisiting this conversation with your healthcare provider in light of newer evidence and delivery methods.
Most importantly, seek providers who understand both vascular health and menopause management. The ideal approach integrates knowledge from both fields to create truly personalized care plans that address all aspects of vascular health—including hormonal factors that are too often overlooked.
The Future of Integrated Vascular Care
While removing the black box warning would represent significant progress, much more is needed to optimize menopause care and vascular protection for women. A comprehensive approach would include increased research funding, better provider education, improved access to bioidentical options, and reduced stigma around menopause.
NP Deidre’s vision—“Imagine if menopause care was normalized like prenatal care”—points toward a future where hormonal transitions are treated as important health milestones rather than inconvenient symptoms to be endured. This approach would recognize that managing hormonal health is an essential component of preventing conditions like PAD.
At the Global PAD Association, we’re committed to advocating for this integrated approach. Through programs like Ask NP Deidre and partnerships with specialists who understand the hormonal dimensions of vascular health, we’re working to ensure women receive truly comprehensive care.
For those seeking personalized guidance on menopause management and its relationship to vascular health, Nurse Practitioner Deidre offers telehealth services through Aspire Wellness Integrative Health at AspireWIH.com.
After decades of separation between vascular and hormonal health management, I’m optimistic that we’re finally moving toward a more integrated, evidence-based approach. For women with PAD or at risk of developing it, this shift toward comprehensive care could be truly transformative—protecting both quality of life and vascular health for years to come.
If you have questions about peripheral artery disease or need help with questions to ask your doctor about what you’ve learned in this article, call the Global PAD Association’s Leg Saver Hotlines at 1-833-PAD-LEGS or go to PADhelp.org