Coronary heart disease (CHD), the number one killer worldwide, is commonly regarded as something that afflicts men rather than women. But it would be a mistake to assume, as a woman, that you are not susceptible to CHD, especially if you are about to enter, or already going through menopause.
CHD may occur later in women than in men on average but it remains the biggest killer of women worldwide. As with any disease, awareness of your own susceptibility is your first layer of protection.
As a gynaecologist who sees female patients at all stages of their lives, I am particularly interested in a growing body of research that indicates an increase in the risk of CHD among women after the menopause. True, age is a factor in the probability of developing CHD but numerous studies have revealed aspects of the menopause that are all linked to other proven CHD risk factors, such as blood pressure and cholesterol.
An Indian study involving 237 pre- and postmenopausal women (and 263 men) found that women who had gone through the menopause had higher blood pressure, heart rate, and cholesterol levels than men of the same age, or women who were yet to go through menopause. The inference is that it’s the hormonal changes associated with menopause that increase the risk.
This may sound frightening if this time of life is fast approaching for you, but there’s no need to panic. My interest lies in helping women reduce their risk of developing CHD, which you can do by making some simple lifestyle choices. The good news is that there’s a lot you can do to keep your heart healthy before, during and after menopause.
The links between menopause and heart disease
It’s important not to see menopause as an affliction. It’s a natural phase of every woman’s life, the time when the finite number of ovarian follicles (from which an egg is released each month) runs out, and it occurs typically around the age of 50 to 52 years old. Rather like puberty, it brings lots of hormonal changes, notably a fall in the level of estrogen – the ‘sex hormone’ that regulates the release of eggs. Let’s look at these various changes in a bit more detail.
Estrogen levels: Estrogen has another role, unrelated to reproduction. Researchers have found that estrogen causes the inner layer of artery walls (the endothelium) to relax, which in turn keeps blood vessels flexible. This is significant because thickened and stiff blood vessels are associated with many types of cardiovascular diseases (CVDs), including coronary artery disease (CAD) and heart attacks. One study found that women with low estrogen levels had a seven-fold higher risk of CAD than women with normal estrogen levels. Researchers have found that estrogen causes the inner layer of artery walls (the endothelium) to relax, which in turn keeps blood vessels flexible.
Body fat: Another consequence of the fall in estrogen is the redistribution of body fat. During menopause the classic female body fat profile – around the hips and thighs – shifts to around the abdomen. This type of fat distribution is known to increase a person’s risk of all types of CVDs because abdominal fat sits inside the body and stops vital organs from working properly. Studies specifically assessing Middle Eastern populations have shown that fat around the tummy can increase CVD risk by 16% to 21%.
Cholesterol: Blood cholesterol levels, another long known risk factor for CVD, have also been shown to change as a result of hormonal changes during menopause. High levels of ‘bad’ cholesterol can cause plaque build-up in your arteries, resulting in the dangerous thickening of blood vessel walls. In contrast, ‘good’ cholesterol helps to flush ‘bad’ cholesterol from the body and thus high levels of ‘good’ cholesterol can reduce your risk of CHD and stroke. Studies dating as far back as the 1980s have shown that menopause lowers ‘good’ cholesterol levels and raises the level of ‘bad’ cholesterol.
Glucose tolerance: Another role of estrogen is to act on the cells of the pancreas that secrete insulin in response to glucose in the blood. Falling estrogen levels mean a fall in insulin and a reduction in glucose tolerance, another known risk factor for CVD.
Blood pressure: Similarly, blood pressure levels have also been found to rise in menopausal women due to increased sympathetic tone. One landmark study, which involved close to 7,000 participants, demonstrated that such increases in blood pressure can raise the risk of CVD among women by 2.5 times. According to Dutch scientists, blood pressure rises steeply after menopause because the drop in estrogen level triggers an increase in the activity of the blood enzyme renin, which helps to control blood pressure.
How to build up your resistance to heart disease:
These are just a few examples of known CHD risk factors that have been shown to be affected by the decline in estrogen during menopause. Other chronic factors, such as poor diet and lifestyle, also contribute to your risk of declining heart health. I’m aware that this may create the impression that your life is being threatened on numerous fronts. As if going through the menopause isn’t enough. Other chronic factors, such as poor diet and lifestyle, also contribute to your risk of declining heart health.
But there is plenty you can do to fight back, so let’s get started.
Top up your estrogen levels: Firstly, you can minimize the hormonal changes by topping up your estrogen levels with hormone replacement therapy (HRT). There are two types: estrogen only and combined HRT, which contains estrogen and another hormone called progestogen. As highlighted in one report, combined HRT is recommended for most women because taking estrogen on its own can increase the risk of developing womb cancer. Adding progestogen to estrogen minimizes this risk.
Combined HRT is not without its own risks, including blood clots in the legs and breast cancer. However, the risk of these events is usually very small. Nonetheless, it is best to speak with your primary physician before starting HRT, and take the time to discuss bioidenticals – a new form of hormone replacement made with exactly the same chemical make-up as natural hormones and, therefore, in theory, more predictable with fewer side effects than traditional HRT.
A key element in making estrogen replacement safer is the evaluation of estrogen metabolism. Approximately 10% of patients should not take these estrogens as their bodies turn them into carcinogenic hormones, so a round of tests will determine your complete hormone panel and make sure your liver can safely handle the added estrogen before a treatment plan is chosen.
Eat a heart-friendly diet: With menopause bringing a rise in ‘bad’ cholesterol and fall in ‘good’ cholesterol, you can tip the scales back in your favor by adjusting your diet. Cholesterol-friendly chemicals called plant sterols and stanols are naturally found in many foods, including nuts, seeds, oily fish, fruits, and vegetables.
Adding heart-friendly foods to your diet is one side of the bargain; the other is removing those foods that encourage weight gain or an increase in cholesterol, specifically high-calorie sugary processed foods and saturated fats. Drinking alcohol and smoking are also proven contributory factors in the risk of developing CVD, so cut down on your alcohol intake and ditch the cigarettes as part of your heart healthy lifestyle. Adding heart-friendly foods to your diet is one side of the bargain; the other is removing those foods that encourage weight gain or an increase in cholesterol, specifically high-calorie sugary processed foods and saturated fats.
Break a sweat: Taking regular physical exercise is one of the best things you can do to reduce your risk of heart disease, at any age. Menopausal women can burn off abdominal fat and lower their blood pressure by exercising regularly. A typical recommended exercise regime is the American Heart Association’s ‘40 minutes of aerobic exercise of moderate to vigorous intensity three to four times a week’.
Supplement your diet: There are many minerals and vitamins the body needs to compensate for menopausal changes, but the two key supplements where heart health is concerned are vitamin D and omega 3 oils. Studies have found that supplementing with vitamin D can reduce high blood pressure, and vitamin D deficiency has also been linked to other CVD risk factors, including diabetes, and cardiovascular events, such as heart attacks and strokes. This suggests a need for supplementation if you are deficient in vitamin D – and you may well be, because recent research has demonstrated that more than 50% of UAE nationals have insufficient levels of vitamin D because of cultural dress customs and avoidance of the sun, which is needed by the body to produce the vitamin. Your doctor can recommend the best for your individual needs, based on your nutrigenomics profile (how your genes interact with nutrition).
Omega 3 supplements, meanwhile, have been found by numerous studies, including a large review involving 39,044 patients, to significantly reduce cardiovascular events and deaths. But remember to see your primary physician before starting any course of supplements.
Take charge of your own menopausal health:
The link between the menopause and heart disease is clear, due to the effects of falling estrogen, but that doesn’t mean it’s inevitable. Far from it. Exercise regularly, keep your weight down, eat a nutritious diet that’s high in unsaturated oils, fruits, and vegetables, and avoid unhealthy habits like smoking and eating junk food.
Most importantly, don’t worry! Consider stress reduction techniques like acupuncture, yoga, and meditation and use this knowledge as an opportunity to make the lifestyle changes needed to keep heart disease at bay. That way you should emerge from the menopause in better shape than you went in.