Cardiovascular risk and the menopause

CVD is the greatest cause of death in postmenopausal women, and risk factors should be assessed. By Dr Heather Currie

The menopause affects all women. The consequence is a low level of circulating estrogen and this deficiency often leads to early, intermediate and long-term health problems.

There is widespread awareness of common early symptoms, such as hot flushes, night sweats, insomnia and mood changes.

Intermediate symptoms of vaginal dryness, irritation and discomfort and bladder changes are also very common and are gradually being reported and treated a little more often.

However, there is a need for greater awareness of the longer term problems.

Waist circumference greater than 80cm is a cardiovascular risk factor in post-menopausal women

Long-term health problems
The long-term effect of the menopause on bones, with the lack of estrogen leading to loss of bone strength (and eventually osteoporosis) and an increased risk of fracture, is well known and frequently addressed.

However, there is currently poor appreciation of the important long-term effects of the menopause on women's cardiovascular systems.

CVD is the leading cause of death in postmenopausal women. More women die from heart disease and stroke than the next five causes of death combined, including breast cancer (see box).1

CAUSES OF DEATH IN EUROPEAN WOMEN1

Cardiovascular disease: 57 per cent
Cancers*: 17 per cent
Respiratory disease: 6 per cent
Injuries and poisoning: 4 per cent
Other causes: 16 per cent

*Breast, lung, stomach, colorectal and others

CVD is traditionally thought of as a problem of middle-aged men, but it affects just as many, if not more, women, albeit about a decade later.2

This delay is thought to be due to the protective effects of estrogen in the years before the menopause. As estrogen levels fall, often from the mid-40s onwards, this protective effect is lost and changes lead to an increased risk of CVD in the ensuing years.

Figures from 2005 show that in Europe, 54 per cent of women died from CVD, compared with 43 per cent of men.3

CVD risk factors
Being overweight is a significant risk factor for CVD and, although obesity is more common in men than women before the age of 45, the trend reverses after that age.

During the menopause, there is a shift in women's fat distribution and storage from the hips to the waist, resembling that of the abdominal visceral fat storage in men. This is often referred to as the change from 'pear' to 'apple' shape.

Waist circumference reflects this risk; women with a waist circumference >80cm have an increased risk of CVD and the risk is even greater for 88cm and above. Hypertension is also a major risk factor for CVD, with incidence greater in women than men after the age of 45 years.2

Raised cholesterol is a significant risk factor. Menopause is associated with a progressive increase in total cholesterol and particularly an increase in LDL and triglycerides and a decrease in HDL.

Tobacco use is one of the most important risk factors for CVD in men and women, but the risks associated with smoking are consistently higher in women than in men.

Type-2 diabetes is becoming increasingly common in men and women, and changes in insulin secretion and sensitivity after the menopause contribute to this increase in women. The risk of death from CVD associated with diabetes is higher in women than men.4

The increase in all of these risk factors leads to a fourfold increased risk of CVD for women in the 10 years following the menopause.5

Managing the risk
With the onset of menopausal symptoms, women and their GPs should not only discuss these symptoms, but also think long term and consider risk factors for bone and heart health.

It has been estimated by the WHO that 80 per cent of CVD can be prevented by diet and lifestyle changes.6

For women who have troublesome menopausal symptoms, these may need to be controlled before attention can be given to important diet and lifestyle changes.

Some changes, such as reducing weight, stopping smoking and increasing exercise, can help to reduce menopausal symptoms.

Women should be encouraged to maintain a healthy weight and to calculate their BMI.

Many women gain weight at the menopause. Healthy eating and increasing exercise (brisk walking provides the same benefit as vigorous exercise) should be encouraged.

It is believed that 59 per cent of deaths from CVD are due to a BMI >25 and less than 3.5 hours of exercise per week. We should aim for 30 minutes of exercise on at least five days per week.

Stopping smoking improves not only heart health, but also bone health, and should be a major consideration in menopausal women.

BP is usually checked as part of any menopause assessment, and subsequently as part of the review for women who take HRT. Increasing exercise and weight loss can help to reduce BP, but drug therapy may be needed.

Cholesterol levels increase with the changes experienced at the menopause, so cholesterol checks should also be considered as part of the menopause assessment.

It has been shown that a 10 per cent reduction in LDL can lead to a reduction in CVD risk of up to 20 per cent.7

Dietary changes
Inclusion of plant sterols and stanols (found in some margarines, milk products and yogurts) in the diet can also lower cholesterol levels by blocking its absorption from food during digestion and by blocking the reabsorption in the gut of biliary cholesterol from the liver.

Taking 2-2.5g of plant sterols per day can lower LDL levels by 10-15 per cent.8 For some women, statins may also be required.

CVD is by far the greatest cause of death in women who have undergone the menopause, yet there is still a low level of awareness among women and healthcare professionals.

The changes that occur at menopause lead to increased risk of CVD, so any discussion with patients about the menopause should include assessment of risk factors for long-term health problems, in particular osteoporosis and CVD.

  • Dr Heather Currie is associate specialist gynaecologist and obstetrician at Dumfries and Galloway Royal Infirmary and managing director of Menopause Matters
  • This is an edited version of an article originally published in MIMS Women's Health. Visit www.healthcarerepublic.com/WH

VIEW OUR ONLINE HEALTHY CHOLESTEROL LIFESTYLES RESOURCE CENTRE

References

1. WHO Statistical Information System (WHOSIS). Accessed 8 January 2009).

2. Bello N, Mosca L. Epidemiology of coronary heart disease in women. Prog Cardiovasc Dis 2004; 46: 287-95.

3. Allender S, Scarborough P, Peto V et al. European Cardiovascular Statistics 2008 edition. www.hearstats.org

4. Kannel W B, McGhee D L. Diabetes and cardiovascular disease. The Framingham study. JAMA 1979; 241: 2,035-8.

5. Kannel W B, Levy D. Menopause, hormones, and cardiovascular vulnerability in women. Arch Intern Med 2004; 164: 479-81.

6. WHO. Diet, nutrition and the prevention of chronic diseases. WHO Technical Report Series 916. WHO, Geneva, 2003.

7. Executive summary of the third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation and treatment of high blood cholesterol in adults (Adult Treatment Panel III). JAMA 2001; 285: 2,486-97.

8. Simons L A. Additive effect of plant sterol-ester margarine and cerivastatin in lowering low-density lipoprotein cholesterol in primary hypercholesterolemia. Am J Cardiol 2002; 90: 737-40.

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