For years, clinical guidance materials have acknowledged sex-based differences in cardiac risk and care, but at times, they have not assessed a key topic affecting women: menopause and heart disease risk.1
This blind spot causes many people to miss out on essential care. Not only is cardiovascular disease a top cause of death among women (and men), but our aging population is on track to yield more menopausal and postmenopausal patients in the future.2,3 With improvements in life expectancy, women stand to spend nearly half their lives in the postmenopausal phase.1
Fortunately, data has emerged to provide more context. The American Heart Association (AHA) reviewed and compiled that data in a 2020 scientific statement.1 Similarly, the European Society of Cardiology (ESC) provided a consensus paper in 2007 that was updated in 2021.4 These and other guidelines indicate that even though menopause may not directly cause heart disease, it can drive cardiac risk factors, such as increased LDL and poor sleep.1,4,5 Risk may be especially pronounced in certain populations of female patients, such as smokers.1
These insights emphasize the need for monitoring of women at middle age and beyond to identify and address cardiac concerns. Alongside blood pressure screenings and routine lab work, ECG can be a critical tool for tracking cardiovascular health and risk in these patient populations.
Understanding Perimenopause and Menopause
Cardiovascular disease, if it develops, does not typically happen until years after menopause (which typically occurs around age 50).1 Even so, many hormonal changes can occur years before this stage that may increase cardiac risk.
These changes can start during perimenopause, the potentially multi-year process of estrogen and progesterone reduction that concludes in a final menses. During these years, patients tend to experience cycle irregularity as one of the most prominent side effects of perimenopause, including changes in period frequency, duration, or flow.6
More undetected symptoms of perimenopause include effects of hormonal changes that can have cardiovascular consequences. One such effect is unhealthy lipid levels, which can involve up to 15% higher LDL and triglyceride levels during menopause transition.4 Variability in sleep quality, heart rate, and mental health may also play a role.1, 4
However, diagnostic diligence is encouraged, as even though some symptoms may be common in menopausal patients, it doesn't mean they're not serious. For example, high blood pressure is often seen in middle-aged women, but it sometimes gets misdiagnosed as menopausal hot flashes or palpitations.7
Similarly, undetermined chest pain, which may link to endothelial declines of menopause, can sometimes be misattributed to stress, even though women who report this symptom have a higher risk of developing ischemic heart disease within five to seven years.4 This is similar to cases of STEMI going misdiagnosed as angina among women.
Factors Driving Cardiovascular Risk in Perimenopausal and Menopausal Patients
The 2020 AHA statement described a range of factors that indicate connections between menopause and heart disease risk:1
Undergoing menopause earlier, particularly before the age of 46, tends to increase a patient's risk of being diagnosed with, and dying from, coronary heart disease.
Surgical menopause caused by the removal of both ovaries during a patient's reproductive years can increase heart disease risk.
Vasomotor symptoms like hot flashes may be associated with risk factors such as hypertension, insulin resistance, and poor cholesterol.
Poor sleep experienced during menopause has been associated with metabolic syndrome risks, carotid intima-media thickness, carotid plaque, aortic calcification, and arterial stiffness. These incidences have generally not been found in premenopausal patients.
Depression can be associated with higher coronary artery calcification scores and cardiovascular disease mortality, comporting with what is known about the general population with mental health disorders.8 Women of middle age may be more vulnerable to depression due to the physical, sleep, and life changes that correlate with menopause.9
Menopause, Hormone Replacement Therapy, and Cardiac Risk
Patients commonly undergo hormone replacement therapy (HRT) to lessen some of the discomforts of menopause, including hot flashes and vaginal dryness. While HRT can greatly improve quality of life for these patients, cardiovascular scrutiny is warranted. This is due to insights regarding certain populations of patients that indicate cardiac risks of HRT, such as blood clots and stroke.10 This data upends observational evidence dating back to the 1980s and 1990s, which initially showed a cardiovascular benefit of HRT.11
These findings do not negate the need for HRT, but they do reverse prior assumptions about the cardiac benefits of hormone therapy after menopause. Starting HRT requires a risk-based approach that considers cardiovascular history, lifestyle, and risk factors. This will often require partnership between gynecologic and cardiovascular teams.
Stratifying this approach into red, yellow, and green light scenarios, risk categories include:
- Red light (avoid): Having known cardiac incidences in the medical history, such as coronary artery disease, clotting disorders, or venous thrombosis, can drive the 10-year risk of atherosclerotic cardiovascular disease to 7.5% or more.
- Yellow light (caution): Having certain comorbidities or lifestyle factors, such as diabetes, obesity, or smoking, is associated with a 10-year risk of atherosclerotic cardiovascular disease between 5% and 7.4%.
- Green light (acceptable): Ideal conditions for HRT include having menopause recently (generally within 10 years) and maintaining normal weight, blood pressure, and physical activity levels. These factors are associated with the lowest 10-year risk of atherosclerotic cardiovascular disease, under 5%.
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Managing Risk During Perimenopause, Menopause, and Postmenopause
The best tools for managing cardiac risk during midlife years are the same resources available to patients of all ages and sexes: healthy lifestyles and routine care, including cardiovascular monitoring when indicated.
However, adopting healthy habits can only provide so much benefit for patients predisposed to the hormonal changes of the menopause transition. One large-scale cohort study among women ages 47 to 55, published in Frontiers in Endocrinology, found that regular physical activity helped, but did not entirely counterbalance, cholesterol changes tied to menopause.12
Insights like these underscore the importance of heart monitoring for middle-aged female patients and collaboration between gynecologic and cardiovascular care teams. Recommended tests in the primary care setting include blood pressure monitoring, glucose assays, and cholesterol screening.4
In addition to diagnostic equipment such as echocardiography, ECG can also be a critical tool for evaluating waveform abnormalities and heart rate variabilities predictive of cardiovascular concerns. ECG can be deployed portably or at the bedside as a convenient and quick way to check symptoms that might otherwise go unexplored due to bias or other gendered disparities.
Diligence Is Necessary in Treating Middle-Aged Women
Women face increased cardiovascular risks at a later age than men, and that age often comes after menopause. But with more insights and data emerging about the associations between the menopausal transition and cardiac risks, clinicians now have more information to help them detect and monitor for potential concerns.13
Fortunately, diagnostic tools—in combination with routine care and healthy lifestyles—can help patients manage risk factors and achieve better quality of life, despite the discomforts of this final stage in reproductive health. As part of the broader resource set for cardiac surveillance in this vulnerable patient population, ECG is a crucial asset to have in the exam room.
- El Khoudary SR, Aggarwal B, Beckie TM, et al. Menopause transition and cardiovascular disease risk: implications for timing of early prevention: a scientific statement from the American Heart Association. Circulation. 2020;142(25). https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000912.
- Centers for Disease Control and Prevention. Heart disease facts. CDC.gov. https://www.cdc.gov/heartdisease/facts.htm. Accessed February 23, 2022.
- Haya El Nasser. The U.S. joins other countries with large aging populations. Census.gov. https://www.census.gov/library/stories/2018/03/graying-america.html. Accessed February 23, 2022.
- Maas AHEM, Rosano G, Cifkova R, et al. Cardiovascular health after menopause transition, pregnancy disorders, and other gynaecologic conditions: a consensus document from European cardiologists, gynaecologists, and endocrinologists. European Heart Journal. 2021;42(10):967-984. https://academic.oup.com/eurheartj/article/42/10/967/6120040
- The National Council on Aging. Why menopause matters. NCOA.org. https://www.ncoa.org/article/why-menopause-matters. Accessed February 23, 2022.
- MedlinePlus. Aging changes in the female reproductive system. Medlineplus.gov. https://medlineplus.gov/ency/article/004016.htm. Accessed February 23, 2022.
- Antipolis S. Hypertension symptoms in women often mistaken for menopause. Escardio.org. https://www.escardio.org/The-ESC/Press-Office/Press-releases/Hypertension-symptoms-in-women-often-mistaken-for-menopause. Accessed February 23, 2022.
- Centers for Disease Control and Prevention. Heart disease and mental health disorders. CDC.gov. https://www.cdc.gov/heartdisease/mentalhealth.htm. Accessed February 23, 2022.
- Johns Hopkins Medicine. Can menopause cause depression? HopkinsMedicine.org. https://www.hopkinsmedicine.org/health/wellness-and-prevention/can-menopause-cause-depression. Accessed February 23, 2022.
- Johns Hopkins Medicine. Menopause and the cardiovascular system. HopkinsMedicine.org. https://www.hopkinsmedicine.org/health/conditions-and-diseases/menopause-and-the-cardiovascular-system. Accessed February 23, 2022.
- Lundberg GP, Wenger NK. Menopause hormone therapy: what a cardiologist needs to know. American College of Cardiology. https://www.acc.org/latest-in-cardiology/articles/2019/07/17/11/56/menopause-hormone-therapy. Accessed February 23, 2022.
- Karvinen S, Jergenson MJ, Hyvärinen M, et al. Menopausal status and physical activity are independently associated with cardiovascular risk factors of healthy middle-aged women: cross-sectional and longitudinal evidence. Frontiers in Endocrinology. 2019;10. https://www.frontiersin.org/articles/10.3389/fendo.2019.00589/full
- The North American Menopause Society. Keeping your heart healthy at menopause. Menopause.org. https://www.menopause.org/for-women/menopauseflashes/bone-health-and-heart-health/keeping-your-heart-healthy-at-menopause. Accessed February 23, 2022.