Getting to the Heart of the Matter

The connection between menopause and heart health begins long before a woman’s last menstrual period. We know the statistics: A woman’s risk of having a heart attack is significantly lower before menopause than after menopause, with heart attack rates and cardiovascular disease risk rising sharply roughly 10 years after menopause due to the loss of protective estrogen.

Before menopause, natural estrogen produced mostly by the ovaries provides a protective effect on blood vessels and the heart, keeping blood vessels elastic and maintaining lower, healthier cholesterol levels. As estrogen and progesterone levels fluctuate in perimenopause and then permanently drop in menopause, many changes take place:

• LDL cholesterol (low-density lipoproteins, also called “bad” cholesterol) starts to rise.
• HDL cholesterol (high-density lipoproteins, also called “good” or “protective” cholesterol) starts to decrease.

These things can happen without a major change in diet or nutritional habits.

• Blood pressure starts to rise due to a “stiffening” effect on the arteries.
• There is a greater accumulation of abdominal (also called “visceral”) fat and a loss of lean muscle tissue.

The overall impact of these and other changes is that roughly one in three women dies from cardiovascular disease, with the biggest risk and incidence occurring in the postmenopausal years. The menopausal transition has been recognized as a good time to reassess your cardiovascular risk.

Estrogen may have beneficial effects on some aspects of cardiovascular health, but the relationship between estrogen and heart disease is complex. Declining estrogen is not the sole cause of increasing cardiovascular risk, nor should it be thought to be the one component that every woman must add to her menopause treatment plan to protect the heart. Aging, genetics, stress, lifestyle, and other factors matter just as much, if not more.

Perimenopause is the transition stage leading up to the final menstrual period. It can go on for many years, and evaluating your risk factors at this stage is highly recommended, as some of these risk factors will begin to shift. You can feel generally healthy while your risk factors are changing, so perimenopause provides an opportunity to establish baselines and identify any emerging risks.

Hot flashes and night sweats are usually discussed in terms of the discomfort they cause; these symptoms can have a severe impact on your quality of life. But research has linked these vasomotor symptoms—particularly if they are frequent and/or severe—with increased cardiovascular risk. Getting relief from hot flashes by treating them—hormonally or with other methods—not only affects sleep and quality of life but may ultimately help lower cardiovascular risk.

*This is not to say that hot flashes directly cause heart problems—but when looking at all risk factors that may influence cardiovascular health, there is evidence that you can lower your risk by relieving vasomotor symptoms.

Menopausal hormone therapy can be effective for treating symptoms such as night sweats and hot flashes. However, the exact benefits and risks must be individualized; these depend on age, time since menopause, formulation and route used, medical history, and whether a progestogen is needed in the plan. Hormone therapy is not considered a strategy for universal heart protection. Hormone therapy should not be prescribed solely to prevent heart attacks or strokes. The benefit may be greater for cardiovascular protection when hormones are initiated earlier (around the time of the menopausal transition or within a few years after that) and when they are used as part of a plan to treat menopausal symptoms. It is not appropriate for every woman.

Oral and transdermal (through the skin) estrogens are not identical in their effects on the body. Different routes may have different risks depending on your medical history, and they may differ in their cardiovascular benefits.

Hormone therapy can be an important treatment for menopausal symptoms, but it is in no way a substitute for managing your risk factors. There is much more evidence that managing and monitoring these cardiovascular risk factors early, before menopause, will have a much bigger impact on your future risk for cardiovascular disease:

1. Blood pressure: High blood pressure can develop without obvious symptoms, and blood pressure persistently above 120/80 may need attention.
2. Cholesterol: Lipid testing is essential; LDL (low-density lipoprotein) cholesterol is widely considered the most critical individual component for assessing heart disease risk. Persistently high LDL that cannot be lowered with diet and exercise should be lowered with medication.
3. Blood sugar: Screening for diabetes is essential. Glucose regulation can worsen during midlife.
4. Exercise: Recommendations and guidelines exist for aerobic activity and resistance training; both are essential to heart-healthy aging, and they have other benefits as well.
5. Nutrition: A heart-healthy eating pattern rich in vegetables, fruits, whole grains, legumes, and healthy fats helps manage cholesterol, blood pressure, and blood sugar.
6. Sleep: Identifying and addressing sleep issues supports overall health and helps maintain healthy routines.
7. Smoking: Avoid all tobacco products; smoking is a major cardiovascular risk factor.
8. Medical history: Know your family history to see if you may be at risk for hereditary factors for cardiovascular disease. Also consider your pregnancy history: We now know that preeclampsia, gestational hypertension, and gestational diabetes all increase future cardiovascular risk.
9. Stress and mental health: Increased stress or untreated mental health issues place additional stress on overall health, disrupting routines and increasing cardiovascular risk.

Cardiovascular disease remains the leading cause of death among women in the United States. Women have been understudied and underrepresented in research trials for decades. Much remains to be learned and studied about women’s cardiovascular disease and risk during perimenopause and menopause. The exact contribution of hormonal changes versus aging and other individual factors is still being investigated. Even when feeling relatively healthy, risk factors should be evaluated and discussed with a health care professional. There are practical steps to lower your risk, so you do not become that “one in three.”