@lynn59
You might want to revisit the information which you have received and speak again with your doctor.

BHRT does not carry the risks of pulmonary embolisms which were enumerated in the old WHI study. Indeed, the problem seems to be older HRT, progestins and oral BRHT or HRT, not topical, vaginal or non oral drugs.

Oral drugs carry the problem of first pass problems in the liver of which VTE is associated. When you swallow a hormone pill, it is absorbed through the digestive tract and sent immediately to the liver before entering general circulation. This concentrated exposure triggers several specific biological changes in the liver that increase embolism risk.
Creams, topical or non oral do not have this problem.

The research shows over and over again that topical , vaginal non oral BHRT is the safest method of HRT and indeed confers benefits which make it more than worth a second look and possible use.

The BMJ (2019) Nested Case-Control Study: This massive study of over 80,000 women is the most cited for comparing different therapy types. It found that transdermal estradiol (a common bioidentical form) was not associated with an increased risk of VTE, whereas oral preparations (including bioidentical estradiol) significantly increased the risk.
Read the full BMJ study here. https://www.bmj.com/content/364/bmj.k4810

The ESTHER Study (2003/2007): One of the first major trials to demonstrate that transdermal estradiol does not increase clotting risk, even in women with high-risk factors like obesity or prothrombotic mutations. It also noted that micronized progesterone (the bioidentical form) appears safer for VTE risk than synthetic progestins like MPA.
Read the ESTHER Study findings.https://pmc.ncbi.nlm.nih.gov/articles/PMC9399360/

Arbitary cut off .....there is no longer an arbitary cut off of BHRT/HRT 10 years post menopausal or at 60 years.
BHRT/HRT is driven by individual needs and a good doctor's knowledge of the best way to prescribe...which is ...topical, non oral or vaginal.
The menopause societies' recommendations now are that : "CLEVELAND, Ohio (Sept 10, 2024)—The Menopause Society’s 2022 Hormone Therapy Position Statement advises that women aged older than 65 years can continue using hormone therapy (HT) with appropriate counseling and risk assessment. A new retrospective analysis demonstrates that it’s not unusual for women aged as old as 80 years to still benefit from HT. Results of the analysis will be presented at the 2024 Annual Meeting of The Menopause Society in Chicago September 10-14." https://menopause.org/press-releases/ongoing-individualized-hormone-therapy-appears-to-have-no-age-limit

@lynn59
You’ve really nailed the key difference here: I’m at the proximity to that 10-year postmenopausal line and you are a bit further past it - as the window of opportunity shifts, the risk profile naturally shifts too. Even if all our other baseline factors were the same, that gap puts you on slightly shakier ground regarding cardiovascular risk.

Your cardiologist’s concern about Pulmonary Embolism (PE) is likely based on the WHI study, which is the biggest randomized clinical trial (RCT) we have. However, that study used oral CEE (Conjugated Equine Estrogen or Premarin), which we know spikes clotting factors in the liver. While some observational studies show that transdermal estradiol (the patch many physicians prefer nowadays) doesn't seem to increase clot risk in the general population, it’s not 100% conclusive. The Cleveland Clinic website notes that the data quality being "average".

As for the "plaque destabilization" your hormone doctor mentioned, that also stems from the oral estrogen data in the WHI where CEE was used. For the patch specifically, the ELITE trial is the most relevant study. Essentially, for women in our cohort (more than 10 years out), it showed no heart benefit and even a potential hint of harm, though again, it wasn't definitive.

One thing to keep in mind, the dose (Premarin 0.625mg oral) used in the WHI that showed a real bone protective effect was roughly equivalent to a 0.05mg/day estradiol patch. The Menostar (brand name, transdermal patch also) you mentioned is an "ultra-low' dose at 0.014mg/day.

In case you decide to seek a second opinion for a more detailed cardiovascular risk assessment, there are a few labs and tests you might want to request. Having these data can make your decision easier: ApoB and Lp(a); carotid ultrasound (could include abdominal aorta and lower extremity as well); genetic clotting panel. Bone turnover marker CTX in case you need to figure out estradiol patch dosing.

Hope this info helps somewhat. I’m still learning and keeping up with the latest data myself, but I thought these details might help you weigh the possibilities.