important menopause information
Understanding the relationship between menopause and cardiovascular disease
Cardiovascular disease will kill more than 400,000 women this year, more than all cancer deaths combined. The good news is that mortality for deaths from coronary artery disease decreased 68% from 1979-2011. Unfortunately, there has been a larger decline for men than women. There is certainly less awareness and recognition of coronary disease in women than men, and this can be contributory. It is important to understand the gender differences when studying heart disease. For example, there is believed to be a larger burden in women of disease of the tiny blood vessels in the heart, which leads to heart failure without major coronary obstruction. Also,certain medical problems unique to women such as gestational diabetes, pre-eclampsia, recurrent early pregnancy loss, polycystic ovarian syndrome, and certain breast cancer treatments all increase the risk of heart disease in women.
Whether menopause itself or simply aging is associated with the increase in heart disease is still being debated. It is certain that surgical menopause, especially in women younger than 45, is associated with increased heart disease and all cause mortality. Because of this, it is recommended that women who undergo surgical menopause continue estrogen at least until the average age of menopause, but more importantly, it is recommended that the ovaries remain at hysterectomy unless involved in the disease progress.
Premature menopause is also associated with increased risk of cardiovascular disease, but now some researchers are considering the hypothesis that the underlying cardiovascular disease may contribute to the shortened reproductive life span.
In the 1990’s it was widely accepted, even by internal medicine doctors, that hormone replacement after menopause would decrease the risk of heart disease and HRT was offered to almost all women during the transition. Studies during this time demonstrated that markers for cardiovascular disease were favorable with HRT, including cholesterol, glucose, blood pressure, and markers of thrombosis. Another studied published in 1998, which gave women with heart disease hormones, was unable to show a definite benefit, and actually found an increase in heart attacks in the first year of treatment.
Next came the Women’s Health Initiative (WHI) which gave hormones to women who did not have heart disease. The study was abruptly terminated in 2002 when the researchers found more heart attacks, strokes, blood clots, and breast cancer in women who were taking HRT. The widely publicized results of the study was the impetus for many women stopping HRT immediately and many more in the next 15 years refusing to begin treatment. If hormones were to be used for the prevention of vasomotor symptoms, the lowest dose for the shortest period of time was recommended.
By 2007, the WHI data was further analyzed, and it was found that women in their 50’s, within the first ten years of menopause, had minimal cardiovascular risk, with risk increasing for women greater than age 60. The women who took estrogen only in the WHI had significant reductions in heart attacks while they were taking hormones, and no increase in CV mortality when followed 18 years later. The timing hypothesis was born, which said that it mattered how soon after menopause hormones were started.
Lessons learned from the WHI demonstrated that early use of HRT in menopausal women had less risks, and use of estrogen alone was even safer. The current use of transdermal estrogen and micronized progesterone may have less risks, but have not been studied to prove this.
Current practice today involves evaluating women for cardiac risks, and avoiding HRT in women at increased risk of CV disease. For women of intermediate risk, transdermal estrogen is thought to have less cardiovascular risk, and lower doses expected to be less risky. Instead of limiting use of HRT for a certain number of years, current recommendations suggest yearly evaluations and tailoring duration of use depending on symptoms and current health concerns.
Prescribing HRT today deserves a detailed discussion of symptoms, risk factors, family history, and treatment goals with a physician who is knowledgeable about the risks and benefits of hormone replacement.
Marilyn Jerome, MD
Foxhall Ob-Gyn Associates
Editorial: Deciphering the complex relationship between menopause and heart disease: 25 years and counting. Cynthia A. Stuenkel, MD
Menopause: The Journal of the North American Menopause Society, Vol. 25, No. 9, September, 2018.