The Heart in Menopause

Menopause does not cause cardiovascular disease. However, certain risk factors increase around the time of menopause, and this compounds the risk of heart disease.

CARDIOVASCULAR disease (CVD) is a term that describes any disease of the heart or blood vessels. It includes heart attack (myocardial infarction, MI), heart failure, high blood pressure (hypertension) and stroke. MI and strokes are usually caused by blocked arteries.

There is no shortage of focus on women’s worry about cancer, especially breast cancer. However, the reality is that there are more women who die from coronary heart disease (CHD) than from breast cancer.

Many women think that CHD is a man’s disease. It is not. CHD is the most common cause of death in women. About half of all deaths in women after the age of 50 years are due to some form of CVD.

The most common cause of death in women in Health Ministry hospitals is CVD, which comprises about 25 in 100 of all deaths as compared to that of all cancers, which comprise 11 in 100 of all deaths. More women die of CHD than stroke, with about 15 and 10 in 100 deaths respectively.

The misperception of the incidence of CVD in women has led to inadequate information and health promotion to the public; inadequate screening for risk factors; lower rates of diagnosis; and lower usage of appropriate medications and interventions for treating women with CVD.

The problem is compounded by the fact that the symptoms of CHD in women are often not typical, resulting in delay in diagnosis and treatment.

Another misperception is that CVD in women is less threatening than in men. It is not. In-hospital and early post-MI mortality in women (9%) is more than double that of men (4%). The mortality rate a year after an MI is about 32% higher in women than in men.

Likewise, after a stroke, women are more likely to die than men (16% vs 8%). Women survivors after a stroke have a poorer long term outcome and a lower quality of life.

Menopause and CVD

Women who have not reached the menopause have a much lower risk of CVD than men. The risk to a woman increases significantly after the menopause when the oestrogen levels fall so much so that the risk of MI is twice or thrice that of women of the same age who have not reached the menopause.

Within a decade after a woman reaches the menopause, her risk of CHD is the same as that of a man.

Women who reach the menopause before the age of 50 years, whether spontaneously or after removal of the ovaries, have an increased risk of CVD. The risk is mainly that of CHD, not stroke.

The extent to which lowered oestrogen levels may lead to an increase in CVD risk is still not well determined. There is on-going research into this aspect.

Risk factors

Menopause does not cause CVD. However, certain risk factors increase around the time of menopause, and conditions and habits like hypertension, diabetes and smoking increase the risks.

There are several cardiovascular risk factors. Some cannot be changed, but others can be controlled or modified to reduce the risk. The former include increasing age, family history and post-menopause, especially if the menopause is premature (below the age of 40 years).

The risk of CHD is increased if a woman’s father or brother had a heart attack before the age of 55 years; the mother or sister had a heart attack before the age of 65 years; the higher the number of family members with CHD; younger family members with CHD; or if a family member had a stroke.

The findings in the National Health and Morbidity Survey (NHMS) 2011 are worrying. Apart from the increase in cardiovascular risk factors since NHMS 2006 and 1996, many of the risk factors were undiagnosed or poorly controlled.

Excess weight, especially when it is 30% above ideal weight, increases the risk of CHD. Obesity is associated with physical inactivity and both contribute independently to an increased risk of CHD.

The NHMS 2011 reported that the prevalence of overweight and obesity was 29.4% and 15.1% respectively. Abdominal obesity (more than 80cm for women) was found in 43%. Women, Indians and people aged 50 to 69 years were at increased risk of abdominal obesity.

Hypertension increases the risk of MI and stroke. Every 7.5mmHg increase in diastolic blood pressure increases the risk of stroke by 46%. The likelihood of death from CHD, stroke and other CVDs is doubled with an increase in systolic blood pressure of 20mmHg.

Most studies have shown that before the age of 60 years, women have lower blood pressure than men. After the age of 60 years, women have a much steeper rise in systolic blood pressure.

The NHMS 2011 reported that the prevalence of hypertension in adults was 32.7%, with an increasing trend with age, ie from 8.1% in the 18-to-19 years age group to 74.1% in the 65-to-69 years age group.

There were no significant differences between males and females, and between the various ethnic groups.

Diabetes increases the risk of CVD. Women with diabetes have twice the risk of having an MI than those who are not diabetic. The risk of dying from an MI in diabetic women is two to five times that of non-diabetic women.

The NHMS 2011 reported that the prevalence of diabetes in adults was 15.2%, with an increasing trend with age, ie from 2.1% in the 18-to-19 years age group to 36.6% in the 65-to-69 years age group. There were no differences between males and females.

Women who have a family history of diabetes, diabetes when they were pregnant, are obese, or of Indian and/or Malay ethnicity, are at increased risk of diabetes.

Raised cholesterol levels (hypercholesterolaemia) increases fatty deposits on the inner walls of arteries (atherosclerosis), decreasing blood flow, and eventually blocking the artery entirely. If it affects an artery supplying the heart, an MI can occur. If it affects an artery supplying the brain, a stroke can occur.

The NHMS 2011 reported that the prevalence of hypercholesterolaemia in adults was 35%, with an increasing trend with age, ie from 11.3% in the 18-to-19 years age group to 57.2% in the 65-to-69 years age group. The prevalence was higher in females, Malays and Indians.

Bearing in mind that the prevalence of CVD is considerably less in menstruating women, this means that women after the menopause have an increased risk of CVD. This is because of the increase in total cholesterol and low density lipoproteins, which may exceed that of men of the same age, both of which increase risk.

Cigarette smokers, both males and females, have twice the risk of MI than non-smokers. This risk factor is dose-related, with consistently higher risks in women than men, and is independent of age.

Tobacco induces an unfavourable lipid profile, increases inflammation and “encourages” thrombosis. This results in menstruating women losing their “natural” protection against atherosclerosis.

The Global Tobacco Survey 2011 reported that one in four Malaysians smoke, with the vast majority being males. However, about four in 10 Malaysians are exposed to secondhand smoke at work and/or at home. The effects of secondhand smoke are not very different from smoking itself.

Physical inactivity is almost as important a risk factor as smoking because of decreased circulation and weight gain. CHD is almost twice as likely to affect the inactive, compared to those who exercise regularly.

The NHMS 2011 reported that 64.3% of Malaysian adults were active, with the most active in the 40-to-44 years age group, with a gradual decrease after that. Males were more active than females.

Reducing risks

A healthy lifestyle goes a long way in preventing and reducing the risk of CVD. The following lifestyle approaches and/or modifications may help in reducing and/or managing the various risk factors before, during and after the menopause.

The identification and management of CVD risk factors should be an integral component of the periodic health examinations of all women, in addition to their gynaecological and breast examinations.

Of all the cardiovascular risk factors, smoking cessation and avoidance of secondhand smoke has the greatest impact on saving lives.

When a woman ceases smoking, however much or long she has been smoking, her risk of CHD decreases by 50%.

Apart from that, there is a decreased risk of lung disease, including cancer, and many other conditions.

The maintenance of a healthy body weight goes a long way in decreasing the workload of the heart.

Activity and regular exercise improves heart function and reduces risk factors like hypertension and hypercholesterolaemia, maintains a healthy weight, and reduces stress.

A balanced diet that is high in grains, fish, fruits and vegetables, with adequate water, vitamins and minerals, but low in saturated and trans-fats contributes significantly to good health.

The intake of sweets and fatty food should be limited. Fat intake should be less than 30% of daily calories.

Medical conditions like hypertension, diabetes and hypercholesterolaemia have to be diagnosed, treated and controlled. As these are chronic conditions, it is essential that there is strict compliance with medical advice.

Dr Milton Lum – is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.

Disclaimer: Nothing on this blog should be considered or used as a substitute for medical advice, diagnosis or treatment. Blog visitors with personal health or medical questions should consult their health care provider.