Women's heart during menopause: what changes for your heart and blood vessels?

Women generally experience cardiovascular diseases seven to ten years later than men. However, this pattern shifts during menopause. The ovaries produce less oestrogen, which leads to changes in metabolism and blood vessels. As a result, menopause becomes a significant turning point for cardiovascular health, independent of the changes typically associated with normal ageing.

Oestradiol, the most important form of oestrogen, plays a key role in maintaining the health of blood vessels. The inner lining of blood vessels is known as the endothelium. Oestradiol stimulates the production of nitric oxide within this layer. Nitric oxide helps relax and widen blood vessels, supporting blood pressure regulation and the proper functioning of blood vessels.

When oestrogen levels decline during menopause, this protective effect on blood vessels is reduced. This can lead to several consequences: 

• Less elastic blood vessels: Blood vessels may become stiffer and less capable of dilating. 

• Shifting body fat: Fat is more likely to accumulate around the abdomen and heart, which can contribute to inflammatory processes in the body. 

• Unfavourable cholesterol levels: Cholesterol levels may become less optimal during menopause. LDL cholesterol may increase, while HDL cholesterol may lose some of its protective qualities.

• Higher blood pressure: Blood pressure may rise following menopause. Reduced oestrogen levels and increased sensitivity to salt are contributing factors. Research suggests that this rise often occurs within 5 to 20 years after menopause.

• Reduced insulin sensitivity: Cells may become less responsive to insulin, increasing the risk of developing type 2 diabetes.

Research identifies two indicators associated with the risk of cardiovascular disease:

1. Severe hot flushes and night sweats: These well-known symptoms are more than just a nuisance. Women who experience severe hot flushes or night sweats tend to have, on average, a less favourable cardiovascular risk profile. Furthermore, the severity of these symptoms is particularly associated with a higher risk of cardiovascular disease. In a large analysis, the risk linked to severe vasomotor symptoms was found to be more than twice as high.

2. Early or premature menopause: If menopause occurs before the age of 45, it is referred to as early menopause. Before the age of 40, it is classified as premature ovarian insufficiency (POI). Research indicates that an earlier onset of menopause is associated with a higher risk of cardiovascular disease, with the risk increasing the earlier menopause occurs. The earlier menopause begins, the longer the body is exposed to lower oestrogen levels. This may contribute to the increased risk of cardiovascular disease.

The transition itself cannot be avoided, but you can influence several risk factors for cardiovascular diseases. Leading a healthy lifestyle plays a crucial role in this. The large Australian 45 and Up Study highlights that a healthy lifestyle is linked to a reduced risk of cardiovascular diseases. This association was also observed in women who experienced premature menopause before the age of 40. 

You can take steps with these four key points:

• Eat heart-healthy: choose a Mediterranean or DASH diet more often, which emphasises plenty of vegetables, fruits, whole grains, fish, and olive oil, while limiting red meat and sugar. The DASH diet is specifically designed to lower blood pressure. As you may become more sensitive to salt during and after menopause, reducing your salt intake can also help in managing blood pressure.

• Exercise regularly: aim for at least 150 minutes of moderate-intensity activity per week, such as brisk walking or cycling. Regular physical activity helps, among other benefits, to maintain healthy blood pressure. Additionally, incorporate strength training twice a week to keep your muscles strong.

• Quit smoking: smoking is linked to an earlier onset of menopause, can exacerbate hot flushes, and significantly increases the risk of a heart attack. Research among middle-aged women indicates that smokers are approximately three times more likely to experience a heart attack compared to women who have never smoked. 

• Prioritise sleep and relaxation: insufficient sleep and prolonged stress can keep your nervous system overactive, which may raise your blood pressure. Poor sleep and chronic stress are also associated with an increased risk of cardiovascular diseases. Therefore, make quality sleep and relaxation a priority.

Hormone replacement therapy (HRT) is the most effective treatment for hot flushes and night sweats. However, HRT is not used as a preventative measure for cardiovascular diseases. Recent research, however, lends support to the timing hypothesis. This hypothesis suggests that the timing of when HRT is initiated can influence its effects on the heart and blood vessels. In healthy women who begin HRT early—within 10 years of their last menstrual period or before the age of 60—cardiovascular outcomes tend to be more favourable compared to women who start later. Studies within this group have shown, among other findings, fewer cardiovascular issues and lower overall mortality rates. Further research is required to determine precisely which women and which forms of HRT provide these benefits.

This contrasts sharply with the findings of the well-known WHI study from 2002, which identified certain risks. However, the women in that study were, on average, 63 years old and approximately 12 years post-menopause when they began HRT, a scenario that differs significantly from current practices.

The method of administration and the type of hormone used also play a significant role today:

• Oestrogen via the skin (patch or gel): This bypasses the liver and therefore has less impact on blood clotting compared to oral oestrogen. Research suggests that transdermal oestrogen has a more favourable profile in terms of thrombosis risk. The dosage is also an important factor in this.

• Micronised progesterone: This is natural progesterone that has been processed to improve its absorption by the body. Micronised progesterone and dydrogesterone appear to have a more favourable effect on cardiovascular health factors compared to some older synthetic progestogens. Certain older variants can reduce some of oestrogen’s beneficial effects on cholesterol levels.

During menopause, changes may occur that increase the vulnerability of your heart and blood vessels. Do not regard this stage of life as a time of unavoidable decline, but rather as an important opportunity to prioritise your cardiovascular health. By adopting a healthy lifestyle and, if necessary, consulting your doctor about a suitable hormone treatment, you can address various risk factors for cardiovascular diseases.