Cardiovascular Health: A Vital Focus in Menopause Care

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Why Focus on the Menopause?

Cardiovascular disease (CVD) is the leading cause of death among women, accounting for over 24% of all menopause-related deaths in the UK^1–4. Menopause significantly increases this risk through complex hormonal, metabolic, and lifestyle changes. Declining oestrogen levels during menopause contribute to shifts in blood pressure, lipid profiles, mood, sleep, and metabolic health, all compounding the risk of CVD.

Although CVD onset generally occurs 7-10 years later in women than men, the cardiovascular risks associated with menopause go beyond those of normal ageing, underscoring the need for menopause-specific risk management.

This blog explores how menopausal changes impact CVD risk and why this focus is essential for women's long-term health.

Menopause Age & Stages

Menopause is defined as the end of ovarian function, marking the transition from reproductive to non-reproductive life, with natural menopause occurring after 12 consecutive months of amenorrhea not due to other causes^2–5.

The average age of menopause is 50 years (45-55 years). Menopause before age 45 is considered early or premature and occurs in 10% of women.

• Early: 40-45 years
• Premature: <40 years (2%)

Pre- to Post-Menopause Transition

The pre- to post-menopausal transition includes several stages with varied symptoms and duration between individuals^2,3:

• Menopause Transition (MT): the time from the onset of cycle irregularity and menopausal symptoms until the time of the Final Menstrual Period (FMP).
• Perimenopause: the time from the onset of cycle irregularities (±7 days) or other menopause symptoms and continues 12 months post-FMP.
• Post-Menopause: Begins 12 months after the FMP.

Early/premature menopause often arises from medical conditions, premature ovarian insufficiency, or surgical removal of the ovaries. There is also a bidirectional relationship between CVD and early menopause⁶. Women experiencing early menopause face a significantly increased risk of developing CVD, while poor cardiovascular health during earlier reproductive years heightens the likelihood of early menopause. Furthermore, modifiable CVD risk factors, such as smoking, are also strongly linked to early onset of the menopause.

Scale of Menopause in the UK

With life expectancy for women at 83 years, adult women (>18 years) now spend over half (58%) of their adult lives in the menopause stage^7,8.

More than 18.6 million women in the UK are menopausal age (45+), representing 46% of all UK women⁸.

 

CVD in Menopausal Women

3.7 million UK women live with CVD, over half a million with coronary heart disease, the majority being menopausal age^8,9.

24% of female deaths in the UK are due to CVD, 99% of which occure after the age of 45 years^8,9.

Loss of Oestrogen: Core of Menopausal CVD Risk

Oestrogen influences vascular reactivity, blood pressure, endothelial function, and cardiac remodelling^2,4,10. The cardioprotective effects of oestrogen decline during menopause, altering immune response, increasing renin-angiotensin-aldosterone system activity, and reducing nitric oxide-dependent vasodilation. These changes diminish oestrogen’s vasodilator effects, particularly as vascular stiffness and atherosclerotic changes increase over time.

Early menopause (<45 years) heightens cardiovascular risk significantly: a 50% higher coronary heart disease risk and 33% greater heart failure risk².

Elevated Cardiometabolic Risk Factors

During the menopause hormonal changes, particularly oestrogen decline, lead to metabolic disturbances beyond normal ageing^2–4,11.

• Dyslipidaemias: Sharp increases in total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), and triglycerides, especially in late perimenopause and early post-menopause.
  • 55% of menopausal women in England have high TC vs. 21% pre-menopause age⁹.
  • HDL particles become less effective in their cardioprotective role^12–15. High HDL cholesterol (HDL-C) levels (>1.4 mmol/L) in menopausal women are not always protective against CVD due to changes in HDL functionality and composition, influenced by declines in oestradiol and increases in follicle-stimulating hormone (FSH)¹⁶. Increased HDL-C levels have been linked to greater carotid intima-media thickness and plaque formation attributed to changes in HDL particle functionality. Menopause leads to a reduction in large HDL particles and an increase in smaller, less effective HDL particles, which contribute to poorer cholesterol clearance. Therefore, assessing both the quality and quantity of HDL-C is crucial.
• Body Fat Redistribution: Although weight gain may not always be indicative of the menopause, fat redistribution is a consequence of menopausal hormonal changes.  Body fat redistributes to abdominal and visceral areas, increasing inflammation, insulin resistance, and oxidative stress, which ultimately heighten CVD risk.
  • Post-menopausal women have 36% more thoracic fat and 49% greater intra-abdominal fat compared to pre-menopausal⁴.
• Non-alcoholic Fatty Liver Disease (NAFLD): NAFLD is now recognised as an independent risk factor for atherosclerotic CVD, which remains the leading cause of mortality in NAFLD patients10. During the menopause, risk of NAFLD is significantly increased due to fat redistribution and in particular 'ectopic' fat deposition in the liver. Not surprising, NAFLD also increase other cardiometabolic risk factors including elevated LDL-C and TG levels.
  • Compared to pre-menopause, menopause results in a two-fold increased risk of NAFLD. Additionally, more than 50% of post-menopausal women with type 2 diabetes also have NAFLD⁴.
• Metabolic Syndrome: Menopausal women have a 2-3 fold increased risk, a key CVD risk factor^18,19.
• Diabetes, Insulin Sensitivity and Glucose Metabolism: Increased visceral fat leads to insulin resistance and, during the menopause, women experience a 50% rise in insulin resistance compared to before the menopause⁴. Insulin resistance ultimately increases risk of type 2 diabetes, which afflicts 9% of menopausal women⁹.

Other Menopausal Symptoms Linked to Increased CVD Risk

Vasomotor Symptoms: Hot flushes and night sweats affect nearly 75% of menopausal women. Severe vasomotor symptoms increase diabetes risk by 48% and are associated with endothelial dysfunction and subclinical atherosclerosis^2,3.

Sleep Disturbances: Insomnia and night sweats (vasomotor symptom) are common and linked to increased CVD risk². Poor sleep can lead to hypertension, stress, and weight gain, especially with sleep apnoea.

Mood Disorders: Higher rates of mood disorders, including depression, occur in menopause due to hormonal changes and can be exacerbated by the presence of obesity. Depression has been associated with higher risk of cardiovascular events².

Inequalities in Cardiovascular Care for Women CVD in women frequently presents with atypical symptoms such as fatigue, shortness of breath, and jaw or back pain, which differ from the classic chest pain typically seen in men20–22. This leads to delays in diagnosis and treatment, contributing to higher morbidity and mortality rates among women21,23,24.  Women are less likely to receive proper diagnostic tests or aggressive treatments, such as angiography or cardiac rehabilitation, due to gaps in recognising their unique symptom patterns20,24,26. Conditions like nonobstructive coronary artery disease, more common in women, are often overlooked during evaluations20,27.

Impact of Lifestyle Interventions  

Large intervention studies confirm that lifestyle changes significantly benefit cardiovascular health during the menopause.  Combination of healthy eating, cessation of smoking and increased physical activity have been found to improve overall cardiovascular outcomes and reduce CVD risk².

Dietary improvements have not only been shown to reduce overall CVD risk, but will also reduce metabolic disorders which are heighted during the menopause including dyslipidaemias, hypertension, NAFLD, and Metabolic Syndrome.

Various dietary patterns have been associated with improved cardiovascular outcomes including the Portfolio, DASH, and Mediterranean. They all advocate:

• A diet that is low in saturated fats with good sources of unsaturated fats
• High intakes of fruit, vegetables and whole grains
• Replacing meat with plant proteins such as beans and lentils and nuts
• At least two weekly servings of fish, one of which should be oily
• Reduced intakes of refined carbohydrates

Physical Activity: Few menopausal women meet the minimum recommendation of 150 minutes of moderate intensity weekly, with strength exercise twice weekly. Additionally, excercises such as Yoga and Tai Chi are also encouraged to help reduce stress and improve mobility. Physical activity is beneficial for all menopausal symptoms including cardiometabolic, sleep disturbances, mood and obesity. 

In Summary

The evidence is clear: addressing cardiovascular health during menopause is essential. Health professionals must prioritise CVD risk assessments and lifestyle interventions for menopausal women. Routine conversations about lifestyle changes, including diet, physical activity, and smoking cessation, alongside regular cardiovascular screenings, can significantly reduce long-term risks and improve quality of life.

With CVD being the leading cause of death among menopausal women, urgent action is needed to address inequalities in care. As menopausal women often present with atypical symptoms of CVD, this contributes to disparities in diagnosis and treatment. Developing sex-specific guidelines and raising awareness about these unique risks is critical to closing the gap in care.

Now is the time to make cardiovascular health an integral part of menopause care, paving the way for a future where fewer women suffer from preventable heart disease.

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References

1. Institute for Health Metrics and Evaluation (IHME). Global Burden of Disease 2021 Results. Published online 2022. https://vizhub.healthdata.org/gbd-results/

2. 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):e506-e532. doi:10.1161/CIR.0000000000000912

3. 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. doi:10.1093/eurheartj/ehaa1044

4. Anagnostis P, Lambrinoudaki I, Stevenson JC, Goulis DG. Menopause-associated risk of cardiovascular disease. Endocrine Connections. 2022;11(4):e210537. doi:10.1530/EC-21-0537

5. Kamińska MS, Schneider-Matyka D, Rachubińska K, Panczyk M, Grochans E, Cybulska AM. Menopause Predisposes Women to Increased Risk of Cardiovascular Disease. J Clin Med. 2023;12(22):7058. doi:10.3390/jcm12227058

6. Davis SR, Taylor S, Hemachandra C, et al. The 2023 Practitioner’s Toolkit for Managing Menopause. Climacteric. 2023;26(6):517-536. doi:10.1080/13697137.2023.2258783

   Office for National Statistics. National life tables – life expectancy in England and Wales: 2021 to 2023. Office for National Statistics. October 23, 2024. Accessed November 11, 2024. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/lifeexpectancies/bulletins/nationallifetablesunitedkingdom/2021to2023

7. Office for National Statistics. Population estimates for the UK, England, Wales, Scotland and Northern Ireland: Mid-2023. Office for National Statistics. October 8, 2024. Accessed November 11, 2024. https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/bulletins/annualmidyearpopulationestimates/mid2023

8. BHF. Heart & Circulatory Disease Statistics. 2024 Compendium. British Heart Foundation. 2024. Accessed August 22, 2024. https://www.bhf.org.uk/what-we-do/our-research/heart-statistics/heart-statistics-publications/cardiovascular-disease-statistics-2024

9. Duell PB, Welty FK, Miller M, et al. Nonalcoholic Fatty Liver Disease and Cardiovascular Risk: A Scientific Statement From the American Heart Association. Arteriosclerosis, Thrombosis, and Vascular Biology. 2022;42(6):e168-e185. doi:10.1161/ATV.0000000000000153