The heart and menopause

What impact does peri-menopause have on women's hearts and why are they at greater risk of heart disease / heart attack post menopause? What can women do to protect their hearts? Mr Vikram Talaulikar, Consultant, specialist in reproductive medicine at UCLH, Senior Clinical Lecturer at UCL, Certified Menopause expert and one of our Clinical Partners, answers!

Oestrogen, the key female hormone, offers protection to women against coronary artery disease and therefore reduces the risk of a heart attack. It helps to control the blood cholesterol levels and reduces the risk of fatty plaques building up inside the artery walls.

During and after the menopausal transition, a woman's body gradually produces less oestrogen than it used to. This increases the risk of the coronary arteries narrowing, whereas it previously protected the lining of the artery walls, reducing the build-up of plaque. This in turn increases the risk of developing coronary heart disease or stroke.

Approximately 24,000 women die from coronary heart disease each year in the UK. Cardiovascular disease is a leading cause of death in women after the menopause and, in fact, more women die from heart disease and stroke than the next five causes of death combined, including breast cancer.

Heart disease is traditionally thought of as being a problem of middle-aged men. It affects just as many, if not more, women than men, albeit at, on average, a decade later.

Oestrogen replacement as part of menopausal hormone replacement therapy (HRT) is associated with a significant reduction in the incidence of cardiovascular disease. Early reports from a large clinical trial (WHI study) which included women from all age groups (50-79 years), suggested an increase in the risk of cardiovascular disease in women receiving combined HRT (oestrogen + progesterone). However, the long-term follow-up data have shown no evidence for a detrimental effect with combined HRT.

In women initiating HRT below 60 years of age, oestrogen alone resulted in a significant decrease in coronary events. Evidence from more recent studies suggests that combined HRT, started before the age of 60 or within 10 years of the menopause, is associated with a reduction in atherosclerosis and fatty plaque progression, coronary heart disease and death from cardiovascular causes, as well as all-cause mortality. Such benefits of HRT should be considered when making decisions about whether to use HRT or not.

Also, long-term follow-up data from the WHI study have shown no increase in cardiovascular events, cardiovascular mortality or all-cause mortality in women who initiated HRT more than 10 years after the menopause.

HRT is very important for women who have experienced premature menopause (before the age of 40), as they can otherwise remain at higher risk of premature coronary heart disease.

Women who have gone through the menopause are at even greater risk of heart disease if they also have any of the following health and lifestyle conditions: diabetes; smoking; high blood pressure; high LDL (low density lipoproteins) or 'bad' cholesterol; low HDL (high density lipoproteins) or 'good' cholesterol; obesity; inactive lifestyle; and family history of heart disease.

Maintaining a healthy lifestyle can go a long way to preventing heart disease in women. Incorporating the following into your everyday life can help reduce the risk of heart disease during the menopausal transition:

• Avoid or quit smoking. Smokers have twice (or higher) the risk of heart attack than non-smokers


• Maintain a healthy body weight


• Exercise regularly (ideally, at least 150 minutes total each week). Exercise also helps lower high blood pressure and cholesterol, reduces stress, helps keep weight off and improves blood sugar levels


• Eat healthily. Follow a diet low in trans-fats / sugars and high in fibre, whole grains, legumes (such as beans and peas), fruits, vegetables, fish, folate-rich foods and soy


• Treat and control diabetes, high cholesterol and high blood pressure.