Posted On: February 14, 2023

Cardiovascular Disease Prevention and Menopause: Timing Matters–don’t wait!

Towards the end of 2020, the American Heart Association (AHA) published a statement on “Menopause Transition and Cardiovascular Disease Risk: Implications for Timing of Early Prevention.” Below are the salient take home points for patients, in order of importance.

Cardiovascular disease (CVD) is the leading cause of death in women. Around the time of menopause, CVD risk in women jumps up, in part due to menopause related changes in hormone levels. For a woman who is approaching menopause, this is an important time to visit her primary care physician (PCP) to review her CVD risk profile and to devise a personalized plan to minimize risk of developing significant CVD, and thus avoid falling victim to its CVD-related morbidity and mortality.

Things to discuss with your PCP:

1. What can I do to improve my cardiovascular health? There are 7 key risk factors known as “AHA Life’s Simple 7.” They are: good nutrition, physical activity, not smoking, and having normal BMI, blood pressure, cholesterol, and fasting blood sugar numbers. “Eating right” and “regular exercise” are easier said than done, as evidenced by following statistics: 42% of US women 40-59 years old have a BMI in the obese range; 17% eat a healthy diet; and a mere 2.3% of women > 60 years old adhere to physical activity recommendations. In other words, the majority of us have lots of room for improvement.[1] Thus a good next step is work with your PCP to set “SMART” goals and making a follow up appointment to track your progress (and troubleshoot if needed). I also recommend asking what resources are available to help you (eg. referral to a health coach).
2. Should I take hormone replacement therapy (HRT)? If you and your PCP decide that HRT is an appropriate consideration for you, ask about timing of HRT and its importance. There is a “timing hypothesis” which suggests that, especially in patients who undergo menopause prior to age 45, taking HRT has overall benefits including lowering CVD risk and improving bone health. However, as with all medications, HRT also comes with its risks. When HRT is taken for more than 5-10 years in patients beyond 60-65 years of age, we worry about increased risk for stroke, blood clots, and breast cancer. At that time, the cardiovascular and mortality benefits seen with taking HRT at a younger age also disappears. A thorough discussion with your PCP about taking HRT will help ensure that you are taking the optimal medication, dose and formulation, at the optimal time interval to maximize benefits and minimize risks. Transdermal estrogen appears to have the best benefit vs risk profile pertaining to cardiovascular health.
3. Should I take a statin? If you’ve had a heart attack or stroke in the past, you’re likely already taking cholesterol medication, and should continue it. Otherwise, every year your PCP will re-assess your CVD risk profile to help answer this question. It’s all about the risk vs benefit of taking medication for cholesterol and will require a personalized decision-making process.

While reviewing this information, consider that there are several causes for optimism. First, you are not alone if you are struggling, in fact you’re in the majority. Second, there is lots of room for improvement! Finally, mean life expectancy at birth for a US woman is still 81 years. By working toward recommended health goals, you can expect even greater longevity, and be in even better health to enjoy it. Imagine the real possibility of a scenario where at 90, you are still living independently, enjoying life to the fullest, traveling and proudly able to hoist a carry-on into the overhead compartment on the plane without help. Now there’s a goal to aspire to!

In a 2022 update and call to action from the American Heart Association, the need for more research on women’s heart health was emphasized. Their mission is to remove pervasive gaps in knowledge and care delivery which serve as barriers to equality. We already understand several key influences on heart health in a woman’s life, and now we must add hormonal influences. Women who start menses prior to age 11 or go through menopause prior to age 40 are at greater risk for heart disease. Women who have polycystic ovarian syndrome or experience many months without cycles appear to be somewhat prone. Women who experience elevated blood pressure and preeclampsia during pregnancy are more likely to develop heart disease twenty-five years down the line. Also, the characteristic hot flashes and night sweats of menopause are associated with worse levels of cardiovascular risk.   

In conclusion:

Recognizing that CVD is the leading cause of death in women and that our average lifetime risk for CVD is nearly 50%, doing everything in our power to reduce CVD risk is a major strategy in ensuring a long and healthy life. Knowing that CVD risk jumps up around menopause, this is also an important time to convene with your doctor to address modifiable risk factors and optimize your health.

References:

El Khoudary SR, Aggarwal B, Beckie TM, Hodis HN, Johnson AE, Langer RD, Limacher MC, Manson JE, Stefanick ML, Allison MA; on behalf of the American Heart Association Prevention Science Committee of the Council on Epidemiology and Prevention; and Council on Cardiovascular and Stroke Nursing. Menopause transition and cardiovascular disease risk: implications for timing of early prevention: a scientific statement from the American Heart Association. Circulation. 2020;142:e506–e532. doi: 10.1161/CIR.0000000000000912

Menopause Transition and Cardiovascular Disease Risk: Implications for Timing of Early Prevention: A Scientific Statement From the American Heart Association. Circulation: Volume 142, Issue 25, 22 December 2020; Pages e506-e532 https://doi.org/10.1161/CIR.0000000000000912

Call to Action for Cardiovascular Disease in Women: Epidemiology, Awareness, Access, and Delivery of Equitable Health Care: A Presidential Advisory From the American Heart Association. Nanette K. Wenger, Donald M. Lloyd-Jones, Mitchell S.V. Elkind,Gregg C. Fonarow, John J. Warner, Heather M. Alger,Susan Cheng,Claire Kinzy,Jennifer L. Hall, Véronique L. Roger.  Originally published 9 May 2022 https://doi.org/10.1161/CIR.0000000000001071 Circulation. 2022;145:e1059–e1071