Menopause and Heart Health

 

For many American women, the period in midlife known as the “the change” is a foreboding notion—a time that can signify old age and increased risk of heart problems. There is a reason for this concern, according to multiple statistics.  One in three American women will die of heart disease, and more women will die of heart disease than men.  (5) Women develop heart disease ten years after men, but by age 65, their risk is equal to that of men. (6) There is an overall increase in heart attacks ten years after menopause. (6) Also, at least 41% of post-menopausal women and more than 75% of American women older than 60 have high blood pressure. (6)

Yet menopause is another milestone in the life of most women and a natural phase of life; instead of dreading the inevitable, grasp education on the topic to improve wellness when the time comes.  Women can spend forty percent of their lives post-menopausal, which is more reason to be informed.  (4) 

Menopause is preceded by perimenopause or menopause transition, typically four years (for 8 out of 10 women) but up to 12 years. These are the most symptomatic years when women in their forties or fifties may experience hot flashes, night sweats, sleep disturbances, irregular periods, mood changes, loss of concentration/focus, headaches, joint and muscle stiffness, vaginal dryness, and decreased interest in sex. (7) The length of this period depends on lifestyle factors such as smoking, race and ethnicity, and the age at which the transition began. (8) During this time, complex hormonal changes affect cardiovascular health.  Menopause is a point in time defined by a lack of a period for twelve consecutive months. (2) 

 

 

 

Some of these changes involve lipids (LDL, HDL, triglycerides) , vascular health (arteries and veins), metabolic syndrome, and fat deposits in the stomach area. Vascular health refers to the ability of an artery to expand and contract and maintain a smooth lining against which blood flows. Stiff arteries were found after menopause transition. During the menopause transition, the production of estrogen by the ovaries declines. Estrogen increases HDL (good cholesterol) and decreases LDL (bad cholesterol). It relaxes, smooths, and dilates blood vessels which lowers blood pressure. It also soaks up particles in the blood that can damage the arteries and other tissues. (2) 

The menopause transition is associated with the accumulation of fat deposits around the viscera ( stomach) and heart.  Fat deposits in the stomach and around the heart are significant because fat cells produce inflammatory markers that damage the vascular system and (due to proximity) the myocardium, which is the heart’s muscle. (5) Adipose tissue (fatty tissue) creates an inflammatory state in the body, damaging the vascular system.  

The combination of these factors places women at increased risk of metabolic syndrome, raising the risk of coronary heart disease. There is an increased prevalence of metabolic syndrome with menopause. Metabolic syndrome is diagnosed if a person has 3 of the following: high blood pressure, high blood sugar, large waistline, high blood triglycerides (which raise LDL levels), and low HDL levels. (9) 

 

 

 

The menopause transition is also a pivotal time for women to reduce their risk of cardiovascular disease. (4)

Multiple lifestyle changes can reduce the detrimental effects of menopause. 

1. Stop Smoking. Women who smoke are 2-6 times more likely to have a heart attack than a non-smoker. The good news is once a person stops smoking, no matter how long or how much she has smoked, her risk of heart disease drops quickly. (10) 
2. Control blood pressure. Regular blood pressure testing is essential because high blood pressure rarely causes noticeable symptoms. (1) Weight control, limiting the intake of salt and alcohol, and exercising regularly can contribute to blood pressure control. Sometimes prescription medication is needed. (10) 
3. Control cholesterol levels. Cholesterol levels can be managed through a heart-healthy diet, regular exercise, and controlling weight. For those at increased risk of cardiovascular disease (previous cardiac event, diabetes, or elevated cholesterol), the American Heart Association recommends talking with a physician about the need for statins. (10) 
4. Exercise. Midlife women who exercise regularly have lower weight, blood pressure, lower glucose levels, and more normal cholesterol levels. (10) 
5. Control weight. A healthy body weight is essential for cardiovascular health. (10) 
6. Eat a healthy diet. A healthy diet consists of fruits and vegetables, whole grains and high fiber, fish (especially oily fish) twice a week, and sources of protein that are low in cholesterol, saturated fat, and trans-fatty acids. (10) 
7. Limit Sodium, (10) 
8. Limit alcohol consumption. No more than one drink per day. (10) 

 

Communicating with your provider: 

Menopause transition should be a time of hypervigilance of monitoring symptoms and communication with providers, including gynecologists and cardiologists.  

A provider needs to know if vasomotor changes are occurring. Vasomotor changes are associated with a high risk of coronary disease, cardiovascular disease, and stroke. Vasomotor changes are hot flashes and night sweats. (5) 

A woman should convey the presence of feelings of depression and sleep disturbance. Both of these also are linked to a greater risk of cardiovascular disease. (5) 

In the past, cardiovascular care for women has been poorly managed. Cardiovascular disease has been regarded as a man’s disease. Few women recognize their increased cardiac risk during the menopause transition, and women have atypical signs of unrecognized heart disease. Women tend to have diffuse coronary artery disease, which involves smaller vessels.  These factors interfere with prompt diagnosis and treatment. Finally, there was the perception that menopause did not cause cardiovascular disease, but research has shown that the correlation is undeniable. 

A word about hormone therapy: 

Hormone therapy is not recommended for cardiovascular protection at any age. Age and time since menopause are critical factors in the effect of hormone therapy on cardiovascular risk. Women aged 50-59 years and starting hormone therapy at treatment initiation within ten years of menopause showed favorable outcomes. Studies show that some hormone therapy may increase the risk of heart disease, blood clots, and stroke. (10) Hormone replacement therapy may be used short-term to manage symptoms. (2) 

 Resources:

1. Singh A, Kaur S, Walia I. A historical perspective on menopause and menopausal age. Bull Indian Inst Hist Med Hyderabad. 2002 Jul-Dec;32(2):121-35. PMID: 15981376.
2. Cleveland Clinic. https://my.clevelandclinic.org/health/articles/16979-estrogen–hormones#:~:text=Estrogen%20helps%20a%20younger%20woman’s,helps%20the%20blood%20to%20clot).
3. The Merck Manual. https://www.merckmanuals.com/professional/gynecology-and-obstetrics/menopause/menopause
4. Menopause and Heart Health Infographic. CDC. 2021. https://www.goredforwomen.org/en/know-your-risk/menopause/menopause-and-heart-health-infographic
5. El Khoudary et. Al. Circulation. December 2020. Menopause Transition and Cardiovascular Disease Risk: Implications for Timing of Early Prevention: A Scientific Statement From the American Heart Association 

https://www.ahajournals.org/doi/10.1161/CIR.0000000000000912?utm_campaign=sciencenews20-21&utm_source=science-  news&utm_medium=phd-     link&utm_content=phd-11-30-20 

       6. AHA. Report on latest Menopause Science. Looks at Heart Risks. Nov. 30, 2020, Riskthttps://www.heart.org/en/news/2020/11/30/report-on-latest-menopause-science-looks-at-heart-risks

        7.https://www.ncbi.nlm.nih.gov/books/NBK552590/

        8. NIH

        9. https://www.nhlbi.nih.gov/health/metabolic-syndrome

     10. Keeping your heart healthy in Menopause. 2022. The North American Menopause Society.  

https://www.menopause.org/for-women/menopauseflashes/bone-health-and-heart-health/keeping-your-heart-healthy-at-menopause#:~:text=Exercise,well%20as%20healthier%20cholesterol%20levels.