Heart Disease and Menopause

By Suzanne Fenske, MD, FACOG, ABOIM, MSCP

Heart Disease and Menopause

One of the most significant risk factors for heart disease in women is menopause! While the cause of heart disease is multifactorial, highly influenced by lifestyle, and takes years and decades to develop, going through menopause significantly raises the risk of heart issues over the long term.

From an integrative perspective, our goal is prevention. We don’t want just to treat heart disease when it’s diagnosable or after you’ve had a heart attack or stroke; we want to preserve heart health over the lifespan.

We can’t prevent menopause, but we can support a healthy menopausal transition, minimize symptoms, and build heart-healthy habits that help counteract the hormonal changes that contribute to heart disease. If you seek care, including hormone replacement therapy (HRT), for menopausal symptoms such as hot flashes, you may also get long-term heart health benefits.

Today’s article will dive into the connection between menopause and heart disease in women. Keep reading as we explore:

• Heart disease and menopause statistics
• The hormone-heart connection in women
• Menopausal symptoms and heart impact
• Role of blood sugar, weight, and metabolic health
• Integrative testing
• Heart disease prevention strategies, including nutrition, lifestyle, and HRT

Heart Disease and Hypertension After Menopause

Heart disease remains the number one cause of death for women, accounting for one out of every 3.2 deaths. That’s one woman who dies from heart disease about every 80 seconds.

Before menopause, women have less heart disease compared to men, but after menopause cardiovascular risk outpaces men.

Heart disease is also more serious for women. Sixty-four percent of women who die suddenly from a cardiovascular event, have no previous symptoms (compared to 50% of men). After a heart attack, more women die in one to five years, develop heart failure, or have a stroke than men. Risks are even greater with premature menopause, which occurs when the one-year mark without a period is before the age of 45.

Hypertension (high blood pressure) is a risk factor for heart disease. Women have lower rates of hypertension than men until the 5^th decade of life (hello, menopause!), and then risk increases for women more than men as they age. Black women have the highest risk.

According to 2017 data the prevalence of hypertension for women by age is as follows:

• 19% of women ages 20-44
• 44% of women ages 45-54 (menopausal transition/perimenopause)
• 63% of women ages 55-64 (post-menopause)
• 75% of women ages 65-74 (post-menopause)
• 85% of women over 75 years old (post-menopause)

Weight gain, insulin resistance, and other metabolic factors that increase heart disease risk can also accelerate after menopause (more on this below). Some risk factors you can’t control, like family history and air pollution where you live, but others can be controlled, such as nutrition, exercise, stress management, and smoking.

Hormone-Heart Health Connection for Women

Coronary artery disease is of particular concern for women. In this form of heart disease, fatty plaque builds up in the arteries through an inflammatory process called atherosclerosis, which can lead to heart attack and stroke. Many factors contribute, including insulin resistance, metabolic imbalances, and low estrogen.

Estrogen and progesterone are important for cardiovascular health. Estrogen is cardioprotective and seems to protect women from heart disease during the reproductive (premenopausal) years. Estrogen (and its binding to estrogen receptors) is anti-atherosclerotic and keeps the arteries flexible and dilated so blood can flow easily. Healthy estrogen levels are associated with better cellular and metabolic health.

Let’s not forget about the benefits of progesterone, which often declines before estrogen in perimenopause. Estrogen, particularly estradiol, and progesterone work together for cardiovascular benefits.

Still, progesterone has vascular actions independent of estrogen. Progesterone inhibits vasoconstriction (blood vessel constriction/narrowing), which supports healthy blood flow and blood pressure. HRT research suggests that treating hot flashes with progesterone only (for women who aren’t good candidates for estrogen therapy) indicates no increase in cardiovascular risk.

Vasomotor Symptoms and Heart Health

Vasomotor symptoms include hot flashes and night sweats and affect 60-80% of women through perimenopause. Fifty percent of women report hot flashing lasting four years post-menopause.

Vasomotor symptoms are associated with increased blood pressure, hypertension diagnoses, and increased cardiovascular disease risk. Experiencing sleep disturbances and mood changes in perimenopause also correlate to heart risks. In other words, the more severe your menopausal symptoms, the higher your heart disease risk over time.

We’d also argue that the more severe your menopausal symptoms, the more opportunity there is for preventative measures sooner rather than later. Symptoms are profound messages from the body, and it’s time to listen.

The good news is that treating vasomotor symptoms in perimenopause reduces heart disease risks later in life! HRT is the standard of care for vasomotor symptoms, and lifestyle changes also provide support.

Metabolic Health in Menopause

Menopausal hormone changes directly affect the cardiovascular system, but they also affect metabolism. Changes to metabolic health are also connected to heart disease and include:

• Changes in lipids – increased total cholesterol, LDL cholesterol, and triglycerides
• Body composition changes – weight gain and weight distribution to more visceral (midsection) fat
• Insulin resistance – higher blood sugar and insulin levels, which can be associated with weight gain and diabetes

If your cholesterol has shot up and you’ve gained weight seemingly overnight without changing your diet or lifestyle, menopause could be driving these changes. We can’t ignore the role of declining estrogen and progesterone in women’s long-term health.

Integrative Cardiometabolic Testing

Working with an integrative provider at TārāMD includes regular cardiometabolic screenings during the premenopausal transition. Testing helps us assess your risks and design a personalized plan for preventing heart disease and other chronic diseases as you age.

One study showed that a single measure of LDL cholesterol, lipoprotein(a) (a type of LDL), and high-sensitivity CRP (a marker of inflammation) biomarkers were predictive of cardiovascular events (such as heart attack and stroke) over a 30-year period.

In addition to hormone testing, as needed through perimenopause and menopause, we like to keep tabs on cardiometabolic health with these tests:

• Advanced lipid panel
• Lipoprotein(a)
• Apolipoprotein B
• Hs-CRP (C-reactive protein)
• Fasting insulin, glucose, hemoglobin A1C
• Coronary calcium score test (CT scan that looks for plaque in the coronary artery)

Key Heart Healthy Habits for Women

New research suggests that HRT initiated at or around menopause (before age 60 or less than 10 years after the last menstrual period) reduces all-cause mortality and cardiovascular disease in women. This data suggests that HRT can be used as a tool for the primary prevention of heart disease, along with the treatment of menopausal symptoms like hot flashes.

Menopause isn’t the only risk factor for heart disease; diet and lifestyle play a significant role. Here are some lifestyle strategies to work on now:

• Nutrition foundations
• Improve stress management and adrenal health
• Support gut health
• Maintain a healthy body composition
• Prioritize sleep

Menopause isn’t the cause of heart disease in women, but it’s a significant factor in long-term risk and one that women need to be aware of. Good preventive healthcare will monitor risks and catch early signs of dysfunction that could eventually lead to disease.

TārāMD offers comprehensive integrative care for women’s health. No matter what stage of life you’re in, we can start talking about perimenopause, menopause, and long-term health. We offer bioidentical hormone therapies, nutrition, supplements, and lifestyle support tailored to your unique needs. Don’t wait – reach out today!

References

1. Hodis, H. N., & Mack, W. J. (2022). Menopausal Hormone Replacement Therapy and Reduction of All-Cause Mortality and Cardiovascular Disease: It Is About Time and Timing. Cancer journal (Sudbury, Mass.), 28(3), 208–223.
2. Schuermans, A., Nakao, T., Uddin, M. M., Hornsby, W., Ganesh, S., Shadyab, A. H., Liu, S., Haring, B., Shufelt, C. L., Taub, M. A., Mathias, R. A., Kooperberg, C., Reiner, A. P., Bick, A. G., Manson, J. E., Natarajan, P., & Honigberg, M. C. (2023). Age at Menopause, Leukocyte Telomere Length, and Coronary Artery Disease in Postmenopausal Women. Circulation research, 133(5), 376–386.
3. Lee, E., Anselmo, M., Tahsin, C. T., Vanden Noven, M., Stokes, W., Carter, J. R., & Keller-Ross, M. L. (2022). Vasomotor symptoms of menopause, autonomic dysfunction, and cardiovascular disease. American journal of physiology. Heart and circulatory physiology, 323(6), H1270–H1280.
4. Iorga, A., Cunningham, C. M., Moazeni, S., Ruffenach, G., Umar, S., & Eghbali, M. (2017). The protective role of estrogen and estrogen receptors in cardiovascular disease and the controversial use of estrogen therapy. Biology of sex differences, 8(1), 33.
5. Aryan, L., Younessi, D., Zargari, M., Banerjee, S., Agopian, J., Rahman, S., Borna, R., Ruffenach, G., Umar, S., & Eghbali, M. (2020). The Role of Estrogen Receptors in Cardiovascular Disease. International journal of molecular sciences, 21(12), 4314.
6. Gersh, F., O'Keefe, J. H., Elagizi, A., Lavie, C. J., & Laukkanen, J. A. (2024). Estrogen and cardiovascular disease. Progress in cardiovascular diseases, 84, 60–67.
7. Barbagallo, M., Dominguez, L. J., Licata, G., Shan, J., Bing, L., Karpinski, E., Pang, P. K., & Resnick, L. M. (2001). Vascular Effects of Progesterone : Role of Cellular Calcium Regulation. Hypertension (Dallas, Tex. : 1979), 37(1), 142–147.
8. https://bcmj.org/news/progesterone-safe-cardiovascular-health
9. Hitchcock, C. L., & Prior, J. C. (2012). Oral micronized progesterone for vasomotor symptoms--a placebo-controlled randomized trial in healthy postmenopausal women. Menopause (New York, N.Y.), 19(8), 886–893.
10. Lee, E., Anselmo, M., Tahsin, C. T., Vanden Noven, M., Stokes, W., Carter, J. R., & Keller-Ross, M. L. (2022). Vasomotor symptoms of menopause, autonomic dysfunction, and cardiovascular disease. American journal of physiology. Heart and circulatory physiology, 323(6), H1270–H1280.
11. Prior, J. C., Hitchcock, C. L., Shirin, S., Hale, G., & Goshtasebi, A. (2023). Don't ignore perimenopause. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne, 195(29), E987.
12. Uddenberg, E. R., Safwan, N., Saadedine, M., Hurtado, M. D., Faubion, S. S., & Shufelt, C. L. (2024). Menopause transition and cardiovascular disease risk. Maturitas, 185, 107974.