Dr Rebeccah Tomlinson explains why a woman’s risk of cardiovascular disease increases around the time of menopause
Research shows twice as many women die from cardiovascular disease (CVD) than breast cancer in the UK. It is also the leading cause of death in women worldwide. Whilst breast cancer deaths have decreased dramatically since the 1970s, CVD deaths have increased – with a steep rise being seen in women under the age of 65. Coronary heart disease is a particular concern for women of perimenopause and menopause age (which typically occur from the mid 40s to 55) because prior to the menopause a woman’s hormones give some protection against CVD. However, following the decline of heart-protective oestrogen (this hormone safeguards the arteries from a build-up of fatty plaque and helps maintain healthy levels of cholesterol, amongst other things) women of menopausal age are at an increased risk – and that risk rises with age.
The risk factors of menopausal heart disease
Age and oestrogen deficiency at the time of menopause are recognised risk factors but others include (and the more risk factors you have, the higher your risk of CVD) health conditions like:
- Hypertension (raised blood pressure) – the biggest risk for women in terms of CVD
- Early menopause
- Breast cancer treatments like radiotherapy and chemotherapy
General risk factors include:
- A family history of heart disease
- Having diabetes
- Dyslipidaemia (unhealthy levels of cholesterol)
- Being overweight or obese
- Being a smoker
- Inactivity/not getting regular exercise.
Risk factors in women under 50 include:
- Gestational diabetes
- Polycystic Ovary Syndrome (PCOS)
- Taking the oral contraceptive pill
- Autoimmune conditions such as rheumatoid arthritis or lupus
- Breast cancer treatments
There is also research to show that women who start their periods younger (before the age of 10) or after the age of 17 or older, go through an early or premature menopause, have children at a young age, give birth to three or more children or have a miscarriage or stillbirth are linked to an increased risk of heart and circulatory disease.
Why menopausal women are at particular risk of cardiovascular disease
Discussions and awareness of women and the risk of cardiovascular disease have tended to be hampered by the common misconception that CVD is primarily a male problem. This lack of recognition has put women at a real disadvantage when it comes to education and treatment of heart and circulatory disease – not least because many trials, studies and potential treatments have been carried out on men only and over 8,000 female deaths are said to be attributable to ‘unequal heart attack care’. 
Men do tend to develop heart disease earlier than women – something generally attributed to the fact oestrogen provides women with heart-protective effects until they enter menopause. And whilst both men and women can share many CVD risk factors there may be subtle differences in how it affects them. Men tend to have more focal stenosis (narrowing of blood vessels in the body due to a build-up of arterial plaque – when cholesterol builds up in the walls of the artery) whilst women have more diffuse narrowing of the arteries and coronary artery spasm– a constriction of the muscles of the walls of the artery that can reduce or block blood flow to the heart.
Stress, which is a very common side effect of perimenopause and menopause, has also been shown to make women more susceptible to CVD – with one large study finding that women with stressful jobs have a 40% increased risk of cardiovascular disease. It also showed those worried about losing their jobs were more likely to have high blood pressure and high cholesterol.  Stress also triggers the release of the primary stress hormone cortisol which can not only interfere with hormone balance but also contribute to you putting on weight around your abdomen which can increase your risk of CVD. Studies also suggest that high levels of cortisol can increase cholesterol, triglycerides, blood sugar and blood pressure. The location and type of pain experienced many also be different in men and women. Plus women can present with slightly different symptoms to men which often means the symptoms can be misdiagnosed.
Signs of CVD in women include:
- Angina (chest pain) during exercise and when resting
- Radiating pain in the jaw, left or right arm and/or shoulder blades
- Nagging, tightening chest pains, also felt at night time
- Back pain
- Accelerating heart rate
- Nausea and/or vomiting
- Extreme tiredness
- Complete loss of energy
- Stress-induced symptoms
- Inability to concentrate
Heart attack symptoms in women
Chest pain remains the most common symptom of heart attack for both women and men according to research published in the Journal of the American Heart Association. A recent study published in The Lancet Digital Health has found that shortness of breath and difficulty breathing were early warning signs of an impending heart attack in women, whilst men were more likely to experience chest pain, difficulty breathing and excessive sweating. However, women are more likely than men to report feelings of nausea and vomiting, indigestion, anxiety, dizziness with pain in the arm, neck, jaw, throat, back and in between the shoulder blades during an attack. The problem is, when these types of symptoms present in women, they tend to be attributed to non-threatening life conditions like stress, anxiety, a panic attack, acid reflux and very often menopause. This can cause a delay in treatment with potential heart-damaging and life-threatening consequences. Crucially, if you are experiencing some of the warning signs mentioned (and they can occur around a month before having an actual heart attack) contact your doctor immediately. Similarly, if you, (or a female relative or friend), are experiencing symptoms of a suspected heart attack ring 999 immediately – you needed be admitted to hospital straight away.
How does menopause affect your heart?
Weight gain and visceral fat. As oestrogen levels decline and metabolism tends to slow many women find they put on weight (on average around 5lbs) around typical menopause age (51 in the UK). Whilst menopause might not be directly responsible for piling on the pounds the hormonal shifts at this time tend to affect the way the body distributes and stores fat – and it tends to accumulate around the abdomen (the so-called menopause belly). A study published in the journal Menopause found that this accumulation of visceral belly fat – even if you haven’t put on a single pound – increases the risk of atherosclerosis (narrowing of the arteries, raising the risk of heart attacks and stroke). Carrying more fat around the abdomen can also lead to insulin resistance, making it harder for your body to control blood sugar levels. Having high levels of glucose in your blood can damage the arteries and increase the risk of CVD.
High blood pressure. Losing oestrogen can significantly increase the risk of hypertension or high blood pressure – something around 30-50% of women will develop before the age of 60. It is also the biggest risk factor for women in terms of CVD.  Symptoms that might indicate hypertension (although often hypertension is asymptomatic, often giving it the term the ‘silent killer) such as palpitations, headaches, hot flushes, pain between the shoulder blades, tiredness and sleep issues are often mistakenly attributed to stress and/menopause. A woman’s reproductive and hormonal health can provide useful clues to her risk – for example, going through an early menopause and having complications during pregnancy (including pre-eclampsia and high blood pressure) can be significant signposts that she may have an increased risk of hypertension as she enters the menopause. 
High cholesterol. Menopause is associated with disturbances in the metabolism of lipids (or fats) as oestrogen is known to regulate cholesterol levels in the body. Lower levels of it during menopause can increase LDL ‘bad’ cholesterol and the build-up of fatty deposits in the walls of the blood vessels and decrease levels of HDL ‘good’ cholesterol – increasing the risk of heart and circulatory disease.
Heart palpitations. Another of the relatively common side effects of menopause is heart palpitations which often occur during hot flushes and/or periods of anxiety. These are generally benign – and are thought to affect almost half of menopausal women – but you should consult your GP if these episodes of a racing, pounding or fluttering heart become more frequent, are becoming worse and/or you have a history (or family history) of heart disease. Stress, lack of sleep and depression can all contribute to an increased risk of palpitations and a large study from 2021 shows that surviving on a low income, being a smoker now (or in the past), not taking much exercise and being of Hispanic descent can also raise the risk. Reassuringly, however, whilst menopausal palpitations are common there is evidence to show they are not associated with future CVD risk.
Mental health issues. Stress, anxiety and depression are also common side effects of menopause and research has shown that mental health issues like depression increase the risk of cardiovascular disease. In one study women with depression were shown to be more likely to develop myocardial infarction (a heart attack) or stroke.
HRT and heart health. Research suggests taking HRT has little, or no, effect on increasing your risk of cardiovascular disease. In fact, a Danish study published in the BMJ has shown that women who use it for 10 years following the menopause have a significantly reduced risk of heart failure and heart attack with no apparent risk of DVT or stroke. Taking it in tablet form (but not patches, creams, gels or pessaries) can, however, slightly raise the risk of developing a blood clot (DVT) or a stroke. A study published in the journal Hypertension has shown that taking HRT orally has also been shown to raise blood pressure by around 14 % more than when using it in patch form. If you have been diagnosed with high blood pressure you can still go on HRT, using other modes of delivery, but will need regular monitoring. A study from 2022 has also shown HRT to be the only available treatment that is an effective solution to menopausal heart palpitations. 
How to reduce the risk of CVD post menopause
Eat a good diet. New research links having a diet high in ultra-processed foods to a significantly increased risk of high blood pressure, heart attack and stroke. Eating a Mediterranean diet containing plenty of differently coloured fruit and vegetables, phyto-oestrogens like flax and sesame seeds, fibre-rich foods like pulses and wholegrains, fish, unsalted nuts, garlic, olive oil, herbs and spices, on the other hand, appears to significantly reduce the risk. Another cardiologist-approved diet is the DASH diet (short for Dietary Approaches to Stop Hypertension) – a low salt and low sugar plan designed to reduce high blood pressure. Research shows sodium sensitivity increases during the menopause which not only raises the risk of high blood pressure but can also lead to fluid retention in the body. 
Increase your Omega 3 intake– omega 3 fatty acids (found in fish and fish oils and nuts, seeds and avocados) are a type of unsaturated fat that have been shown to lower triglyceride (a type of fat in the blood) levels and increase HDL ‘good’ cholesterol in the body. Crucially, omega 3 appears beneficial for managing dyslipidaemia in post-menopausal women. If you don’t like eating oily fish, Omega+ supplements can be a convenient way to increase your intake, look for one specifically formulated for women.
Look after your microbiome with probiotics. A review of studies suggests supplementing with probiotics for 12 weeks may contribute to slight reductions in weight and body fat percentage. Recent research also suggests probiotic supplementation in post-menopausal women could be a safe and effective way to manage many menopause-related conditions including high blood pressure and blood glucose and lipid metabolism.  Look for a supplement containing an abundant and diverse range – around five billion is a helpful gauge – of live cultures.
Maintain a healthy weight. Being overweight or obese can lead to fatty substances (such as cholesterol) building up in the arteries, increasing the risk of heart attack and stroke.
Do some exercise. Being more physically active can reduce the risk of developing heart and circulatory disease by around 35 per cent according to the BHF. It can also help to keep your weight down and reduce stress.
Keep an eye on your blood pressure. Hypertension or high blood pressure is linked to half of all strokes and heart attacks and the BHF believe four million of us under the age of 65 are living with it untreated. The only way to know if yours is too high is to test it. You can have this done at your local pharmacy or by your GP or practice nurse. Alternatively, you can check it yourself – the BHF provides a list of recommended monitors.
Quit smoking. The British Heart Foundation estimate that at least 15,000 deaths in the UK from heart and circulatory disease are attributed to smoking.
Actively manage stress. Not only does chronic stress increase your risk of CVD there is also a stress-fat connection. Stress increases production of cortisol, dubbed the stress hormone, which stimulates the liver to increase production and release of blood sugar. If cortisol levels remain constantly high over time this can lead to insulin resistance (when your body doesn’t respond properly to the insulin produced in your body causing blood sugar problems). For advice on how to reduce, and manage, stress read Coping with stress and anxiety during menopause: expert advice from a GP. You can also find helpful relaxing breathing exercises on the free Health and Her Menopause app (download from the Apple App Store or Google Play).
The bottom line is that heart disease does increase with age and the decline in oestrogen for women. But understanding the risks posed by cardiovascular disease during menopause can help you to make the lifestyle changes and possible treatment options you need to reduce that risk.
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