@pattiel

Thanks for sharing your thoughts. The key in deciding on HRT is individualized risk assessment with shared decision-making.

It’s true that oral estrogen carries different risks than transdermal forms, which is why many clinicians prefer patches nowadays.

From what I understand, there isn’t a strict guideline that prohibits starting HRT more than 10 years post-menopause - timing is a factor, but not an absolute rule. A low CAC score isn’t an automatic stop either; for example, mine was 38, but it was evaluated and deemed safe for me to use HRT. Your PFO though might be a factor that shifts your personal risk–benefit balance.

That said, clinical practice can vary widely, as many members here have seen. When in doubt, getting second opinions could help. I had additional consultations with both cardiology and gyn specialists to make sure HRT was appropriate for me 11 years after menopause. And of course, the endocrinologist managing osteoporosis also has a say in whether HRT is an appropriate option.