El Khoudary SR – A narrative review is done to feature gaps and limitations in the literature on endogenous estrogen and follicle stimulating hormone (FSH) as identified with cardiovascular disease (CVD) risk. In light of these outcomes, studies are needed to analyze the midlife course of endogenous estradiol, FSH and CVD risk. These studies ought to also consider other hormones, including androgens, with an eye towards helping women modify their cardiovascular risk in midlife when prevention is most likely possible.

• Future directions are addressed in light of recent findings in the field.
• When contemplating the connection of estrogen to cardiovascular risk, it is vital to separate endogenously produced estrogen from exogenously administered estrogen.
• Moreover, other reproductive hormones such as FSH ought to be evaluated, since growing evidence proposes a potential contribution of this hormone.
• Assessment of estrogen changes over time allows a separation of women based on their hormone trajectories.
• These individual trajectories associate with subclinical CVD and thus indicate that it is much more important to observe a woman over time rather than ascribe risk to a single determination at a single time point.
• As women progress through menopause and the ovary stops producing estradiol, the nature of the relationship between estrogens and subclinical CVD markers also appears to undergo a switch.
• Studies are needed to examine the midlife course of endogenous estradiol, FSH and CVD risk.