Q&A: Health changes during menopause associated with increased cardiovascular risk
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Key takeaways :
- CV risk factors adversely affected during the menopause transition include LDL cholesterol, fat distribution and vascular health.
- Awareness during the menopause transition is key to decreasing CV prevalence.
During the transition to menopause many women may experience adverse changes to multiple cardiovascular risk factors, according to a North American Menopause Society Practice Pearl published in Menopause.
During menopause, women may experience adverse changes in their health and struggle to maintain optimal lifestyle behaviors. According to Samar R. El Khoudary, PhD, MPH, FAHA, professor of epidemiology and vice chair of education at the University of Pittsburgh School of Public Health, 7.2% of midlife women reported a physical activity level that meets current American Heart Association Life’s Essential 8 recommendations, which include diet, physical activity, nicotine exposure and sleep health as behavioral components and BMI, lipids, blood pressure and glucose as risk factor components. In addition, less than 20% of midlife women reported consistently maintaining a healthy diet, according to data published from the Study of Women’s Health Across the Nation (SWAN), the largest study of the menopause transition in the U.S. Since these are all factors related to CVD risk, researchers explored the menopause transition as a critical period for CV health.
Healio spoke with El Khoudary about how the transition to menopause is associated with CVD risk.
Healio: Could you give an overview on how the transition to menopause can increase CVD risk? Is increasing CV risk directly related to changing hormonal profile or is there something else about aging?
El Khoudary: Over the last 2 to 3 decades, the menopause transition has been an important topic for researchers to better understand its contribution to the increase in CV risk happening after women become postmenopausal. The research up to this point showed us that as women transition through menopause, they experience multiple changes in different cardiometabolic factors that are critical when we discuss CV health. Such changes happen collectively and put women at higher risk for developing CVD in the future.
These changes include increase in LDL cholesterol as well as total cholesterol and increase in the location where women store fat in their bodies. We see more of that fat in the abdomen area, which is considered more dangerous [for CV risk] than other fat locations. Also, changes happen to the blood vessels where these vessels become stiffer and more vulnerable to the disease. We also see that women, as they transition through menopause, have a higher risk for metabolic syndrome, which is a constellation of different risk factors for CVD.
Now are these happening independent of the aging process? It has been difficult to answer this question if you just look at one time point. Studying women over time and looking at them over multiple time points, we were able to disentangle the contribution of the menopause transition as to the aging. When we are talking about the menopause transition, we are talking about a constellation of physiological changes and symptoms development that characterize this stage of women’s lives. It is not just about hormonal changes. So that’s why we can’t just say it’s hormonally related or not. But we can say if it is more likely to be menopause driven or not. Studies so far have proven that changes in lipids, fat deposition and vascular health are more menopause driven, rather than driven by the aging process. There are factors that are only impacted by the aging process, but we couldn’t really claim that it’s menopause. For example, weight gain in general is more driven by the aging process.
Healio: Is there a relationship between types or severity of menopause symptoms and CV risk?
El Khoudary: Menopause symptoms are one way to study the menopause transition. We have found that vasomotor symptoms — hot flashes and nights sweats, 75% to 80% of women experience those — are related to the lipid profile, glucose, insulin and inflammatory markers, which supports that there is a link between the two. Most recently, we were able to show that women who reported more of these vasomotor symptoms are at higher risk for developing CV events later in life.
More research has shown that the pattern of these symptoms over time. For example, we are using data from the SWAN study. We were able to show that there are four groups of women in relation to experiencing vasomotor symptoms. So, you have those who experienced little levels of these symptoms that increase just a little bit around menopause, those who report high frequency of vasomotor symptoms early in the transition, those who experienced them later in the transition, and those who are experiencing them all the time. We found that those who are experiencing vasomotor symptoms early in the transition, as well as those who are experiencing them all the time, are at higher risk for changes in their vascular health, which put them at higher risk for CVD.
Healio: Does hormone therapy affect CV risk?
El Khoudary: This is what we call the million-dollar question. It has been in research for a very long time. And irrespective of the fact that observational studies, studies following people over time, were able to show 40% to 50% beneficial effects of hormone therapy, when we did a randomized clinical trial, which is the gold standard to study any treatment, the studies showed that hormone therapy could increase CV risk in women. Later, we learned that this could be related to when women start using hormone therapy.
The bottom line, at the moment, is that hormone therapy is not advisable to use for primary or secondary prevention of CVD. However, if initiated early in the transition, for the main reason of treating vasomotor symptoms, hormone therapy could have some beneficial effect on vascular health, but not if it is initiated later in the transition. Later means in women who are older than 60 years or more than 10 years postmenopausal.
Healio: How can physicians help menopausal women adopt a healthy lifestyle to help lower CVD risk?
El Khoudary: The big role that physicians can play is that if they are aware of the contribution of the menopause transition to CVD, they will be able to talk with women at midlife about this stage of their life. It’s not just a stage when you experience hot flashes and night sweats and changes in your bleeding. All these things could be a sign when you also experience changes in other factors that could impact your CV risk. So, awareness when it comes through a clinical provider would make women more alert. Explaining to women how adopting a healthy lifestyle, even if a woman has not done this before, it’s never too late to do it, because it could counter the worsening in risk factors that women experience as they transition through menopause. I would say awareness is No. 1.
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For more information:
Samar R. El Khoudary, PhD, MPH, FAHA, can be reached at elkhoudarys@edc.pitt.edu.