Heart disease risk increases with age for both men and women. “But there are heart disease risk factors especially associated with ovarian aging,” says Chrisandra Shufelt MD, associate director of the Mayo Clinic Center for Women’s Health in Jacksonville, Florida, which is the complex process marked by changes in hormone levels that occurs, ending with menopause. Aging ovaries produce less estrogen and follicle-stimulating hormone; a drop in these hormones is linked to heart disease risk. Here’s a rundown of the risks associated with heart disease in women in menopause — and what you can do to lower the risk.
When Estrogen Levels Drop, the Body Goes Haywire
High Cholesterol
Menopause drives detrimental changes in your cholesterol and blood fats, which can lead to artery-clogging atherosclerosis. According to an AHA Scientific Statement published in Circulation in December 2020 about menopause and cardiovascular disease risk, your total cholesterol and your “bad” cholesterol (LDL-C and apolipoprotein B levels) may go up and your good cholesterol (HDL) is likely to go down, which is bad news since we need HDL to move out extra cholesterol that our body doesn’t need. Having too much cholesterol in your blood can cause the formation of plaque (hardened deposits) in your arteries, and can ultimately lead to a heart attack or stroke.
Gaining Belly Fat
After age 40, women are more likely to pack on the pounds, especially around the midsection. “What changes in menopause that puts our hearts at risk is the shift of where we start to lay down fat,” Dr. Shufelt says. Fat around the midsection and vital organs, such as the liver, can increase your risk of heart disease, even if you’re at a healthy body weight, according to a study published in 2021 in Circulation. Want to know if you’re at risk? Get a tape measure. Research shows that postmenopausal women with a body mass index (BMI) — estimates body fat by weight and height — within normal range and a waist circumference of more than 35 inches are at increased risk of dying from heart disease, compared with women with a normal BMI without midsection body fat. If your waist circumference is more than 35 inches, talk to your doctor about how to optimize this number, which may include diet, exercise, or weight loss surgery, according to the AHA.
Metabolic Syndrome
In menopause, or even in late premenopause or perimenopause — when periods start to skip — women are more likely to develop metabolic syndrome, which is a combination of conditions, including excess belly fat, high cholesterol, and elevated blood sugar, according to the AHA statement. In other words, menopause is linked to an increased risk of metabolic syndrome, which puts you at a higher risk for heart disease, diabetes, and stroke.
Depression
Depression can take its toll on your heart. Stress and anxiety can reduce blood flow to the heart, causing your heart rate and blood pressure to rise, as well as increase stress hormone levels, like cortisol, which can up your risk for heart disease, according to the American Heart Association. A landmark study published in 2019 in Menopause, known as the Study of Women’s Health Across the Nation (SWAN), which enrolled 3,302 women between age 42 and 52 and followed them for 23 years, reported that depressive symptoms were higher during late peri- and postmenopause than premenopause. In a subset study, the SWAN Mental Health study, women were 2 to 4 times as likely to experience a major depressive episode in menopause or early postmenopause compared with premenopausal women. Still, women who have had a bout of depression before menopause may be more susceptible to having depression again in menopause. According to a study published in 2017 in Medicine & Science in Sports & Exercise, women with a history of depression are 5 times more likely to a have major bout of depression in menopause. “It’s important to discuss depression at the time of perimenopause and menopause,” Shufelt says. Talk to your doctor if you’re feeling persistently sad, anxious, hopeless, irritable, or fatigued. “Don’t ignore depression symptoms,” she cautions. “Many effective treatment options are available,” including medications and psychotherapy.
Disrupted Sleep
Restless sleep is often one of the first symptoms of menopause and perimenopause. Chronic disrupted sleep can be a risk factor for heart disease. When you’re sleeping, your blood pressure naturally takes a dip. If you don’t get enough sleep, your blood pressure can stay higher for a longer period, according to the Centers for Disease Control and Prevention. High blood pressure — above 130/80 mmHg — can increase your risk of heart disease and stroke. Menopause may be the reason for your disrupted sleep, or it could be sleep apnea, the risk of which also rises during menopause and is associated with heart disease risk. “If women are having high blood pressure changes, we don’t want to say, ‘Oh, this is just menopause.’ We want to also think about things like sleep apnea,” Shufelt says. While having hypertension doesn’t necessarily mean you have sleep apnea, it could be worth screening. Talk to your doctor about being evaluated for sleep apnea, especially if your blood pressure is on the rise. If you’re waking up often due to menopause symptoms, such as hot flashes, you should also talk to your doctor about hormone replacement therapy. “We don’t use estrogen replacement to prevent heart disease, but we do use it to manage bothersome symptoms,” Shufelt says. “If you can’t sleep through the night because you’re having night sweats all night, that’s also a disruptive symptom.” Estrogen patches, in which a low dose of estrogen is applied through the skin, may help ease menopausal symptoms, including disrupted sleep.
Keep Your Heart Healthy for the Long Haul
You could spend roughly 30 years of your life — or more — living with menopause, so it’s important to take hold of your heart health, notes Shufelt. Here’s what you can do: See your doctor regularly. “After 50, every woman should have an annual checkup,” Shufelt says. Yearly appointments can help you keep track of your numbers like your cholesterol, weight, blood pressure, and blood sugar, and keep those numbers within a healthy range to reduce your heart disease risk. If you’re at high risk for heart disease because of high cholesterol or weight gain, or if heart disease runs in your family, your doctor may recommend more screening tests. “People with a family history of heart disease are at higher than average risk of heart disease. For those people, we might use tools to assess their risk, such as a coronary calcium scan,” Shufelt says. In women at higher than average risk for heart disease due to family history, the coronary artery calcium (CAC) test offers a more precise assessment to help guide treatment and medication decisions. The CAC test is an X-ray that takes images of your heart and helps detect and measure calcium-containing plaque in your arteries, which can increase your risk for a heart attack. The scan is a good tool to virtually look at your heart,” Shufelt says. Consider hormone replacement therapy. “We don’t use estrogen replacement to prevent heart disease, but we do use it in low doses for bothersome menopausal symptoms, such as having night sweats that prevent you from sleeping,” Shufelt says. The latest hormone therapy guidelines from the North American Menopause Society, published in 2022 in Menopause — Shufelt was a coauthor — no longer recommend using the lowest dose of supplemental hormones for the shortest time for menopause symptom relief. “The guidelines now state ‘the appropriate amount of time,’” Shufelt says, which varies per person. “There’s a certain percentage of women who will have troublesome menopausal symptoms for years. Every woman is different,” Shufelt says. If you enter menopause before age 45 (because of chemotherapy, hysterectomy, or premature ovarian insufficiency, a type of early menopause in younger women), hormone replacement therapy is also recommended by the North American Menopause Society. Premature menopause (before age 40) or early menopause (before age 45) without hormone replacement therapy can accelerate your risk of heart disease, Shufelt says. “When you enter menopause at an earlier age, it’s important to get a dose of estrogen in an amount your body would otherwise naturally produce at this time. These are women who should have estrogen naturally in their bodies,” Shufelt says. If you’re in premature or early menopause and you’re eligible, Shufelt recommends using a dose of estrogen and progesterone through the time of natural menopause, at age 52, to replace what your body would naturally produce. Keep up the good work (-out). Exercise can lower the risk of heart disease as you age. According to the study from 2017 in Medicine & Sports Science in Sports and Exercise, the lifetime risk of heart disease in women who exercise was about 12 percent lower from age 45 to 85, compared with women in that age group who weren’t physically active. The American Heart Association recommends that men and women get moderate exercise 150 minutes or more per week in addition to not smoking, eating a healthy diet, losing weight if you need to, and managing blood pressure, cholesterol and blood sugar. “Menopause is an opportunity to know your numbers and look at your lifestyle because exercise and diet are the backbone and the cornerstone of cardiovascular disease prevention,” Shufelt says.
