Background. Hormonal replacement therapy (HRT) after menopause can affect cardiovascular system in a positive and negative way. Positive effects are exerted through estrogenic action on metabolic risk factors, such as lipids, glucose and insulin metabolism, as well as direct arterial effects, reducing atherogenesis. Negative effects are dose-dependent transient increase in coagulation activation and adverse vascular remodelling. Observational studies suggested that HRT might have a beneficial effect on the incidence of coronary heart disease, which is not in line with later randomized clinical trials. The main difference between both types of the studies is that participants in observational trials were in their fifties and in average ten years younger compared to randomized trials. Post-hoc analysis of the Women’s Health Initiative trial found a trend toward cardioprotective HRT in younger patients. Conclusions. HRT is currently not recommended for the primary coronary prevention. But in women with menopausal symptoms, which are at the initiation of HRT younger than 60 years and are less than 10 years after menopause, HRT does seem not to increase cardiovascular events. Initiation of HRT early after menopause may reduce cardiovascular risk.