Q&A: Multimorbidity in postmenopausal women ‘a new health challenge’
Click Here to Manage Email Alerts
Key takeaways:
- Premature, early and surgical menopause predispose women to enhanced risk for multimorbidity.
- Greater duration of estrogen exposure may reduce risk for multimorbidity conditions for postmenopausal women.
Women are living, on average, 5 years longer than men with an improved overall quality of life, but with an increased lifespan comes greater risk for multimorbidity, particularly after the menopause transition.
As women go through menopause and levels of estrogen and progesterone fall, risk for chronic conditions ranging from obesity and osteoporosis to heart disease rise, according to James H. Liu MD, former chair and professor emeritus in the department of reproductive biology at Case Western Reserve School of Medicine and former chair of the department of obstetrics and gynecology at University Hospitals Cleveland Medical Center.
“Compared to single diseases, individuals with multimorbidity experience higher mortality, increased life stresses, higher health costs, and a lower quality of life,” Liu wrote in an editorial published in Menopause. “Known factors for multimorbidity include aging, female gender, and social-economic status. Unfortunately, our health systems are slow to transform their approach(s) in planning to address challenges of multimorbidity.”
Lui, who called the greater risk for multimorbidity in women “a new health challenge,” noted that postmenopausal women are a “key group” to examine the gender-specific aspects that may play a role in developing multimorbidity.
Healio spoke with Liu, also a past-president of The Menopause Society, about the connection between reproductive lifespan and multimorbidity, how hormone therapy can reduce risk, and the importance of individualized risk assessments.
Healio: What inspired this editorial?
Liu: Women live longer than men and chronic diseases do increase with aging. The hormonal environment for women changes quite drastically as they age. In contrast with men, who experience a gradual decline in sex hormones, women experience a more sudden “switching off” of the estrogen/progesterone produced by the ovaries during menopause.
I was asked to review an article, published in the October issue of Menopause, which assessed the incidence of multimorbidity in postmenopausal Chinese women and the relationship with their reproductive lifespan. The researchers demonstrated that postmenopausal women with a longer reproductive lifespan — more than 38 years — had much lower incidence for multimorbidity than women with a reproductive lifespan of less than 32 years.
Healio: In that study, researchers did show that longer exposure to reproductive hormones, specifically estrogen and progesterone, seem to be associated with lower risk for multimorbidity. Why might that be?
Liu: There is a lot of what I will call ancillary data that suggest that changes in the physiology of the menopausal woman are linked to the loss of estrogen and progesterone hormones. Let us pick one symptom that is more commonly known: bone thinning or osteoporosis. We know that there is an acceleration of calcium loss and loss of bone strength with the loss of estrogen at menopause. It accelerates rapidly for the first 3 to 4 years after menopause, and then slows down. Hence, the increased risk for hip fracture and other types of fractures for women in the menopausal age range. There are other examples, such as increased cardiovascular risk. The cholesterol profile becomes more atherogenic with the loss of estrogen at menopause, with increases in “bad” LDL cholesterol.
Healio: What are some of the increased burdens for postmenopausal women with multiple chronic conditions compared with women with just one chronic condition?
Liu: Targeting each of those chronic conditions can be challenging. A woman, for example, may have hypertension and is prescribed a medication for that, also has obesity and perhaps insulin resistance or type 2 diabetes and is prescribed medications for those conditions, such as a GLP-1 receptor agonist. Multiple drugs can interact. Some physicians or patients may not know the adverse effects of these medications. These multiple chronic conditions stress the health care system as we try managing this growing population of aging baby boomers. This will only get more difficult, due to the sheer volume of needs.
Healio: How can women going through menopause reduce their risk for multimorbidity? What should clinicians be on the lookout for?
Liu: Physicians must screen patients for early menopause — that is, before age 46 years. Early menopause is one factor when looking at a person’s individual risk profile. If the person does have early menopause or has had their ovaries removed for a variety of medical reasons, replacement with estrogen would be appropriate, at least up until time of natural menopause, which would be around age 51 years. Based on our current knowledge of estrogen replacement, perhaps maintaining hormone therapy until age 60 years is appropriate. Hormone therapy is safe for most women, as long as they are monitored regularly. The big concern for many women with hormone therapy is breast cancer. This is a real issue in that it does slightly increase breast cancer risk, but no more than obesity, alcohol, risk factors that we can control. Our perception of risk vs. reality are sometimes very disparate.
Observational studies like Nurses’ Health Study do pinpoint some benefits of longer-term estrogen exposure.
Healio: In addition to considering hormone therapy, what are some other ways physicians should be counseling women?
Liu: Let us address weight gain. Most women begin to notice weight gain around the time of menopause, despite not changing their physical activity or daily habits. Generally, it is weight gain in the middle. That happens and we do not fully understand the physiology, but some modification of diet and exercise can help women maintain their weight. Activity and diet are key. It is tough because we do tend to become more sedentary as we get older.
Reference:
For more information:
James H. Liu MD, can be reached at jamesliucle@gmail.com