Menopausal hormone therapy should not be used for the primary or secondary prevention of coronary heart disease at the present time. Evidence is insufficient to conclude that long-term estrogen therapy or hormone therapy use improves cardiovascular outcomes. Nevertheless, recent evidence suggests that women in early menopause who are in good cardiovascular health are at low risk of adverse cardiovascular outcomes and should be considered candidates for the use of estrogen therapy or conjugated equine estrogen plus a progestin for relief of menopausal symptoms. There is some evidence that lends support to the “timing hypothesis,” which posits that cardiovascular benefit may be derived when estrogen therapy or hormone therapy is used close to the onset of menopause, but the relationship of duration of therapy to cardiovascular outcomes awaits further study. Clinicians should encourage heart-healthy lifestyles and other strategies to reduce cardiovascular risk in menopausal women. Because some women aged 65 years and older may continue to need systemic hormone therapy for the management of vasomotor symptoms, the American College of Obstetricians and Gynecologists recommends against routine discontinuation of systemic estrogen at age 65 years. As with younger women, use of hormone therapy and estrogen therapy should be individualized based on each woman’s risk–benefit ratio and clinical presentation.