It is well-established within the medical community that cardiovascular disease (CVD) is the leading cause of death among women. Alarmingly, the incidence of this disease peaks in women about a decade later than in men, and research indicates it is often more fatal for women. Studies have demonstrated that women are more likely than men to die or suffer serious complications, such as stroke and heart failure, within five years of a myocardial infarction. One significant contributor to this heightened cardiovascular risk during midlife and beyond is menopause.
The Impact of Menopause on Cardiovascular Health
Menopause initiates a range of cardiometabolic changes in women, primarily due to declining levels of estradiol (E2). This drop disrupts metabolic homeostasis and alters fat distribution, leading to a loss of muscle mass and an accumulation of visceral fat, particularly around the abdomen and even the heart, known as pericardial fat. A heart burdened by excess fat is always concerning. The menopause transition (MT) creates a “perfect storm” for developing metabolic syndrome, a cluster of conditions—including insulin resistance, lipid dysregulation, and obesity—that significantly increase cardiovascular risk.
Timing and Its Implications
The age at which menopause begins has critical implications for cardiovascular health. Women who experience early menopause face a higher risk of future heart issues. Research analyzing 15 observational studies found that for every year earlier a woman enters menopause, her risk of cardiovascular disease incidents increases by 3%.
While cardiometabolic changes during menopause are influenced by more than just estradiol levels, the hormone plays a crucial role in heart health. During reproductive years, estradiol is vital for maintaining metabolic stability. Although its levels decline post-menopause, estradiol remains essential for cardiovascular well-being.
The Cardioprotective Role of Estradiol
Estradiol is believed to have a cardioprotective effect by aiding mitochondrial energy production, which is critical for heart function and overall oxygenation. Additionally, it interacts with various pathways linked to cardiovascular health, helping to reduce oxidative stress, lower inflammation, and prevent arterial endothelial dysfunction—key factors in heart failure development. Dr. Felice L. Gersh emphasized in her editorial that the widespread notion of estradiol shifting from beneficial to harmful as women transition into menopause is scientifically inaccurate, especially considering the many cardiovascular mechanisms it regulates.
Hormone Therapy: Timing Matters
Recent reviews of post-menopausal data highlight the importance of timing for hormone therapy (HT). Women under 60 who begin HT within the first 10 years after menopause may experience significantly improved cardiovascular outcomes. However, individual clinical factors must be considered when determining treatment strategies, as no two patients are the same.
Ultimately, the heart has unique requirements, and for some, hormone therapy can be a key ally in preserving cardiovascular health after menopause. As awareness of these factors grows, it is essential for women to have open discussions with their healthcare providers about cardiovascular health, menopause, and hormone therapy options. Understanding these dynamics empowers women to take proactive measures for heart health during and after menopause.
References
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- Gersh FL. Benefits of estrogen in cardiovascular diseases. Prog Cardiovasc Dis. 2020 May- Jun;63(3):392. doi: 10.1016/j.pcad.2020.03.008. Epub 2020 Mar 21. PMID: 32209375.
- Hodis HN, Mack WJ. Menopausal Hormone Replacement Therapy and Reduction of All-Cause Mortality and Cardiovascular Disease: It Is About Time and Timing. Cancer J. 2022 May-Jun
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