Despite our tendency to think that breast cancer is the number one threat of women, cardiovascular disease remains the leading cause of death in U.S. women. In 2019, women in the U.S. were 74% less likely to recognize cardiovascular disease (CVD) as their top mortality issue than in 2009. Even primary care physicians and cardiologists fall short when it comes to CVD and women, with only 22% of primary care doctors and 42% of cardiologists feeling adequately prepared to assess CVD risk in women. That is quite alarming. You at least have a better chance, if your cardiologist is a woman. According to a systematic research review from the American College of Cardiologists in 2021, female physicians have better patient outcomes compared with their male colleagues and female patients are less likely to receive standard of care medical care when treated by male physicians.
The menopause transition is a time of accelerated risk for CVD. The timing, mechanism, symptoms of menopause and their treatment are all associated with this risk. In 2022, the American Heart Association (AHA) identified “Life’s Essential 8”: Diet, physical activity, nicotine exposure, sleep, body mass index, lipids, blood pressure and glucose as the components of risk factors. During perimenopause, or the menopause transition, women have changes that are related to all these risk components. For example, only 7.2% of women in midlife report adequate physical activity (30 minutes, 5 days per week of aerobic activity), and less than 20% maintain a healthy diet. This does not bode well for women in the menopause transition and this critical period for cardiovascular health.
Let’s break it down even more and the changes that occur.
- Body mass index, fat distribution and weight.
Women gain approximately 1.5 pounds per year starting in perimenopause or roughly 2 years before the final menstrual period. This continues for several years. Women also have a redistribution of fat toward the belly and heart and liver, that has been directly linked to the menopause transition. In addition, while the rate of fat gain doubles, the lean muscle mass declines. All of this leads to weight gain and greater atherosclerosis.
- Lipids or cholesterol levels
The total cholesterol, low-density lipoprotein (LDL) cholesterol and apolipoprotein B increase within one year of the final menstrual period. The high-density lipoprotein (HDL) also changes, and while we think of that as the “good” cholesterol, certain subfractions of the HDL getting too high are associated with a greater risk of carotid artery atherosclerosis after menopause.
- Blood pressure and Vascular function
Blood pressures increases as we age, but in midlife, the increase in blood pressure in women takes a sharp turn upwards right after the final menstrual period. The systolic blood pressure (the top number) increases in particular and is more of an indicator of greater CVD risk in women. Our arteries get stiffer during the menopause transition and this characteristic escalates during this time frame.
- Insulin, Metabolism
The prevalence of insulin and glucose management, along with the increase in blood pressure, weight gain and increased triglycerides, increase the prevalence of metabolic syndrome with menopause and aging beyond menopause. But it’s the perimenopause years, before we have gone one year without a period, where the progression and increase in severity of the metabolic syndrome are the greatest.
- Age of Menopause
If you have become menopausal early, which is defined as between age 40 and 45 or prematurely , defined as less than age 40, the increased risk of CVD is more evident. In other words, these are independent risk factors for coronary heart disease in particular. This is why if you become menopausal early or prematurely, taking menopausal hormone therapy at least until age 51, is your friend in terms of reducing your risk of CVD. Women with premature menopause (final menstrual period < age 40), are three times more likely to develop CVD related problems if they don’t take estrogen. Women who become menopausal early (40 to 45), have a higher risk of abnormal lipids.
- Hot flashes and nightsweats
Hot flashes and/or nightsweats are called vasomotor symptoms (VMS); VMS during midlife are associated with abnormal lipid profiles, abnormal clotting markers and insulin resistance. Women with VMS are also more likely to develop hypertension with early and persistent VMS during midlife being associated with greater risk of CVD.
- Hormone levels
Women with higher estradiol levels before their final menstrual period but lower levels after, appear to develop less plaque after menopause.
- Hormone Therapy
Women who are at high risk for CVD is considered a contraindication for menopause hormone therapy (MHT), and is not considered a strategy for the sole purpose of prevention of CHD (coronary heart disease). If one needs MHT, per current recommendations for use then the timing of starting MHT is critical for safety. The initiation of MHT should be before the age of 60 years or within 10 years of menopause. This is considered the optimal and safe window for initiation of MHT when it comes to CVD. There are many decisions that go into MHT prescribing and determining the benefits and the risks. It behooves all women to find a clinician who is well trained in menopause and MHT. This generally does not include the typical primary care physician or gynecologist or naturopathic physician. Rather, one with special training and knowledge in this area.
- Assessment and Lifestyle
Assessment includes a good medical history, physical exam findings, family history, habit and lifestyle history and select laboratory testing. Assessing your individual risk with a focus on women-specific factors that are linked to higher risks of CVD, should be the approach your clinician takes.
The fabulous news is that more than 70% of CHD can be prevented with lifestyle changes alone. This includes no nicotine, Mediterranean diet, regular and sufficient aerobic exercise, low alcohol and good stress management.
I thank NAMS and their Practice Pearl on cardiovascular risk in the menopause transition for the cliff notes and essentials written about in this blog.
Resources:
Circulation 2022; 135 (Cardiovascular health in women; advisory from the American Heart Association)
Circulation 2022;146 ( Life’s Essential 8)
American Heart Association
American College of Cardiology
2022 Hormone Therapy Position Statement of the North American Menopause Society (NAMS) Advisory Panel
