Estrogen’s role in cardiovascular health is one piece in a very complex system of factors. Women seem to have a lower risk for cardiovascular disease, and are less likely to die from it, up until menopause. From that point on, the risk for cardiovascular disease and heart attack rises dramatically.
Prior to menopause, estrogen provides protection for the heart. The estrogen naturally produced (or given as a supplement for those who have had hysterectomies, or their ovaries removed) offers these benefits:
- It helps tissues throughout the body stay supple and flexible, including blood vessels, which helps increase blood flow to avoid plaque build-up in coronary arteries.
- It helps keep blood pressure low.
- It helps keep blood triglycerides low, increases the good HDL cholesterol and lowers the bad LDL cholesterol levels.
- It promotes blood clotting.
- It absorbs free radicals, particles that can cause damage.
As women approach menopause, however, estrogen levels decline and risk factors for heart disease rise. Large-scale studies like the Study of Women’s Health Across the Nation (SWAN) show that during the menopause transition there are significant changes to cardiovascular health, including:
- Increase in cholesterol
- Increase in blood lipids (fats) that don’t flow easily through arteries
- Changes in blood vessels that can increase risk for clots and plaque build-up
- Increase in fibrinogen, a protein linked to stoke and heart disease
In addition, women transitioning through menopause find metabolic differences that can profoundly affect their health. Body fat is often distributed differently, with more deposited around the abdomen and heart, which increases risk for disease. Blood pressure can increase along with cholesterol and lead to obesity and/or diabetes, both of which are known to impact heart health.
Hormone replacement therapy (HRT) combines estrogen and progesterone to help women cope with uncomfortable symptoms associated with menopause such as hot flashes, depression and vaginal dryness. But HRT can also mitigate some of the risk factors for heart disease brought on by a lack of estrogen when prescribed correctly and consistently monitored by a physician.
It’s important for women to work with a primary care provider and gynecologist to evaluate whether taking HRT will fit into their care plan around the peri-, pre- and post-menopausal years. Risks and benefits along with medical goals should be discussed and monitored in conjunction with other commonly known approaches to reducing your risk for heart disease: healthy eating, exercising, quitting smoking, maintaining a good weight and adequate sleep. HRT has no time limit as long as the patient remains in otherwise good health.
In 2020, the American Heart Association issued an update to its guidance for menopausal patients. Describing menopause as a “physiological process that severely affects cardiovascular health and cardiovascular (CVD) outcomes in half of the human population,” the AHA acknowledged that this transition has been overlooked. It’s vital that we acknowledge it as a critical period in women’s lives and embrace treatments that will reduce risks of cardiovascular disease while improving the general health and wellbeing of women everywhere.
Overall, it's essential for women to be proactive about their cardiovascular health but particularly during the menopausal transition. A comprehensive approach that includes lifestyle modifications, medical interventions like HRT when appropriate and regular monitoring by health care teams will help ensure good outcomes later in life.
Shawna Ruple, M.D. practices at MidMichigan Obstetrics & Gynecology in Midland. As an obstetrician/gynecologist, she provides care for women of all ages that encompasses overall wellness, pregnancy, childbirth, breastfeeding, postpartum, adolescent care, contraception options, prevention of female reproductive cancers, incontinence and menopausal transitions.
