Cardiovascular Health and Menopause

What You Need to Know

Introduction

Menopause marks the end of a woman’s reproductive phase and is defined by the permanent cessation of menstruation. This phase is often accompanied by vasomotor symptoms, joint issues, and urogenital complaints. At the same time, it represents a critical window to address long-term health risks such as cardiovascular disease (CVD) and osteoporosis. CVD is the leading cause of death among postmenopausal women worldwide, with risk increasing significantly after menopause. Early onset of menopause and the absence of menopausal hormone therapy (MHT) are both associated with higher cardiovascular risk.

Causes and Risk Factors

Estrogen plays a crucial role in vascular health by improving endothelial function, increasing HDL ("good" cholesterol), decreasing LDL ("bad" cholesterol), enhancing nitric oxide production, and reducing atherosclerotic changes. After menopause, the drop in estrogen leads to:

• Endothelial dysfunction
• Increased vascular inflammation
• Lipid metabolism disorders (↓ HDL, ↑ LDL)
• Redistribution of body fat (android pattern)
• Increased sympathetic tone and blood pressure
• Reduced glucose tolerance and higher insulin resistance

These factors collectively contribute to a higher risk of cardiovascular disease. Additional risk factors include smoking, diabetes, hypertension, physical inactivity, obesity, family history, and ethnic background.

Clinical Impact of Menopause on Cardiovascular Health

Menopause is associated with:

• Higher prevalence of vasomotor symptoms, which correlate with elevated CVD risk
• Unfavorable changes in lipid profile
• Progression of atherosclerosis
• Increased risk of coronary heart disease (CHD), heart attack, stroke, and vascular dementia

Epidemiological studies show that women with vasomotor symptoms have a more adverse cardiovascular risk profile than asymptomatic women.

Role of Menopausal Hormone Therapy (MHT)

The evidence regarding MHT and cardiovascular risk is nuanced. Earlier analyses from the Women’s Health Initiative (WHI) indicated increased CVD risk with MHT, but these results were limited by methodological flaws (e.g., older study populations, late therapy initiation, fixed dosing).

More recent analyses and large observational studies indicate:

• Starting MHT within 10 years after menopause or before age 60 is associated with reduced CVD risk and mortality
• MHT provides vascular protection if initiated before significant atherosclerosis develops
• The type, dose, and timing of MHT are critical to its efficacy
• Natural progesterone and certain progestins (e.g., drospirenone) show neutral or beneficial cardiovascular profiles, whereas others (e.g., high-dose medroxyprogesterone acetate) may reduce estrogen's benefits

MHT is not recommended solely for primary prevention of CVD, but it can offer cardiovascular benefits when used to treat menopausal symptoms.

Strategies for Preventing Cardiovascular Disease in Menopausal Women

Lifestyle Modifications:

• Regular aerobic and resistance exercise (at least 150 minutes per week)
• Maintaining a healthy body weight
• Smoking cessation
• A balanced, low-fat diet rich in fruits, vegetables, and whole grains
• Stress reduction and support of emotional well-being

Medical Measures:

• Monitoring blood pressure, lipid levels, and glucose
• Early initiation of MHT in eligible women (< 60 years or < 10 years post-menopause)
• Comprehensive cardiovascular risk assessment as part of menopause care
• Consider MHT for women with premature ovarian insufficiency (POI) or early menopause, continuing treatment until the average age of natural menopause

Screening and Risk Stratification

Risk assessment tools (e.g., WHO risk charts) are especially helpful in resource-limited settings. Standard preventive care should include:

• Blood pressure and lipid testing
• Glucose tolerance test
• Analysis of body composition and fat distribution
• Evaluation of family history and lifestyle factors

Conclusion and Recommendations

Menopause is a natural life stage that significantly affects women’s cardiovascular risk profile. Timely implementation of preventive strategies – especially lifestyle changes and, if appropriate, MHT – offers an opportunity to effectively reduce the burden of cardiovascular disease. An individualized, risk-adapted approach, guided by patient preferences, medical history, and current scientific evidence, is essential.

• Preventive measures in midlife are critical for reducing CVD risk
• Early initiation of MHT can have cardiovascular benefits
• Lifestyle modification remains the cornerstone of CVD prevention
• Menopause is a key time for health promotion and risk assessment