The Menopause Transition and Cardiovascular Disease Risk

Midlife is an important window for intervention that may reduce cardiovascular disease (CVD) risk in women, according to a recent scientific statement from the American Heart Association.

“Menopause experts were happy to see this article, as we know that declining estrogen levels are associated with increasing cardiovascular risk factors. Perhaps now more physicians will make the most of the opportunity to maximize the second half of patients’ lives by reducing their risk of disease based on personal and family history, and assessing values and preferences,” says Holly L Thacker, MD, Professor and Director of the Center for Specialized Women’s Health and Executive Director of Speaking of Women’s Health.

The AHA report discussed changes in endogenous hormone levels, body fat distribution and lipids, emphasizing the importance of distinguishing between chronological age and hormonal age in order to monitor women and prevent morbidity and mortality related to CVD.

Characteristics of menopause related to cardiovascular disease risk

Several characteristics of menopause have been associated with cardiovascular risk, including:

• Age at menopause. Women who start the menopause transition at < 45 years of age have higher overall risk of and mortality from coronary heart disease (CHD). Additionally, women who experience early menopause (age 40−45) and women with premature menopause (under age 40) are at higher risk of heart disease.
• Type of menopause. CVD risk is increased in women whose menopause is a result of bilateral oophorectomy (BSO) with no estrogen therapy, especially for women with BSO at < 40−45 years.
• Menopause stage. Blood pressure, cholesterol and triglycerides peak during late perimenopause or early postmenopause.
• Endogenous estrogen levels. Declining estrogen levels have been associated with changes in CVD risk factors; hormone therapy (HT) may help to offset these changes.
• Vasomotor symptoms. Studies indicate that the presence of vasomotor symptoms and other menopause symptomatology are associated with increased risk of CHD, stroke or CHD.
• Sleep disturbance. The combination of hormonal fluctuations, life stressors and hot flashes all contribute to sleep disturbances in women that can begin in perimenopause and can through menopause and beyond. Persistent sleep disturbance is associated with worse cardiovascular health.
• Depression. Studies show that having symptoms of depression during the menopause transition is associated with increased CVD risk. There is some evidence that hormone replacement therapy may help improve mood, although this is not a stand-alone therapy for major depression, which should be addressed.

Other health changes that accompany the menopause transition include increases in lipid measurements (total cholesterol, LDL-C and apolipoprotein B levels), the prevalence of metabolic syndrome, increases in carotid atherosclerosis and arterial stiffness, as well as increases in weight and ectopic fat disposition.

Distinguishing between chronological and reproductive aging

One of the most important things the AHA report does, according to Dr. Thacker, is distinguish between chronological and hormonal age. “Chronological age doesn’t give us the whole picture for women. The average age of menopause is 51, but there’s a two-decade spread; 1% of women start before 40,” Dr. Thacker says. Adding variability, the length of the menopause transition is also different for every woman. This transition is marked by dynamic hormonal changes and related symptomatology, which may begin several years prior to the final menstrual period (FMP) and can persist for several years following the FMP.

“It’s important for physicians to remember that not all women will complain of symptoms during the menopause transition, and it’s easy for midlife women to fall through the cracks. When women feel fine, no one checks their hormone levels — but we get the most prevention from lifestyle and pharmaceutical interventions when women begin HT within the first 10 years of the onset of menopause. I like to check hormone levels annually in my patients, particularly those who have no menstrual bleeding pattern (that is, they have had hysterectomy with ovaries in place, endometrial ablation or a progesterone intrauterine system) so that I know when the menopause transition begins and can recommend risk-reducing interventions such as hormone replacement therapy and behavior modifications, which include standard risk reductions as well as consideration for HT,” Dr. Thacker says.

HT is not recommended for women with established CVD and may not be appropriate for every patient; it’s important to weigh the risks and benefits of this treatment on an individualized basis.