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More than one million women in Russia enter menopause each year. The severe estrogen deficiency associated with this transition causes symptoms that significantly impair quality of life and contribute to an increased risk of cardiovascular and metabolic diseases. Menopausal hormone therapy (MHT) is the established standard of care for menopausal symptoms. On the initiative of several professional societies (the Russian Society of Obstetricians and Gynecologists, the Russian Society of Cardiology, the Russian Association of Endocrinologists, the Eurasian Association of Therapists, the Russian Society of Gynecological Endocrinology and Menopause, the Russian Association of Gerontologists and Geriatricians, the Association of Phlebologists of Russia), a Delphi panel was convened to develop a multidisciplinary expert consensus on MHT for patients with cardiovascular and metabolic diseases. The goal was to enhance research and clinical approaches to managing menopausal women. A consensus was reached at the end of the first Delphi round. The experts agreed that initiating MHT requires a thorough assessment of individual risks, including cardiovascular health and comorbidities. MHT can offset metabolic and cardiovascular risk factors in peri- and postmenopausal women by normalizing the lipid profile, improving carbohydrate metabolism, and reducing insulin resistance. An interdisciplinary approach allows for personalized MHT, minimizes potential complications, improves the quality of life for peri- and postmenopausal women, and promotes active longevity.