Cardiovascular Disease in Women: Focus on Postmenopause
Heart disease is the biggest killer of women in Australia: 22 women lose their lives to heart disease every day. Heart disease takes three times more lives than breast cancer.1
Cardiovascular disease (CVD) is understudied, underdiagnosed and undertreated in women, which has resulted in women being disproportionately affected by CVD when compared to men.2 Women have reported that doctors sometimes mistake symptoms of CVD for stress, panic disorder or even hypochondria.3 There are differences between women and men in the symptoms, pathophysiology and response to treatment, and women tend to have a lower perception of the risk which leads to delayed diagnosis.4
Generalised chest pain is the most common symptom of heart attack for men and women, but women are more likely to have some other symptoms, in addition to, or instead of chest pain. These additional, atypical symptoms include:5
- unusual fatigue;
- extreme weakness;
- shortness of breath;
- heart palpitations;
- faster heartbeat;
- dizziness;
- nausea;
- sudden sweating or sweating with no cause.
Figure 1. Women may have symptoms other than chest pain when having a heart attack.5
Even risk factors shared by both men and women may impact CVD risk differently in women. The relative risk of CVD is higher in women with diabetes and women who smoke when compared with men.2 Being obese increases the risk of coronary heart disease by 64% in women when compared with 46% in men, according to a 2020 study.1
Women develop heart disease several years later than men, with a notable increase in CHD risk during midlife and the menopause transition.4,6 A large case-controlled study published in 2004 noted that the first acute myocardial infarction occurs about 9 years later in women than in men.7 Women over the age of 65 are more likely to die from a silent heart attack (i.e. one that has no obvious symptoms) than men of a similar age.5
General Changes as a Result of Menopause
Longitudinal studies have found adverse alterations in body composition, lipids and lipoproteins, and measures of vascular health over the menopause transition, which can increase a woman's risk of developing CVD postmenopausally. For example:6
Earlier age at natural menopause is a marker of greater CVD risk.
Vasomotor symptoms are associated with worse CVD risk factor levels and measures of subclinical atherosclerosis.
Sleep disturbance, a common complaint during menopause, is linked to a greater risk of subclinical CVD and worse cardiovascular health indexes in midlife women.
Depression occurs more frequently during the perimenopausal and postmenopausal years and is related to the incidence of CVD.
Increased central adiposity, more pronounced during the menopause transition, is associated with an increased risk of mortality, even among those with normal body mass index.
Increases in lipids (low-density lipoprotein cholesterol and apolipoprotein B), metabolic syndrome risk and vascular remodelling at midlife are driven by the menopause transition more than by ageing.
Characteristics and Possible Mechanisms
The increase in CVD risk experienced by postmenopausal women is thought to be mainly due to the decline in oestradiol, although the increase in some risk factors may be due to a combination of hormonal and age-related changes.8,9 In addition, other changes that occur during the menopause transition are associated with increased risk of metabolic disease, and by extension, CVD. This includes adverse changes to insulin sensitivity, glucose tolerance, lipid profile and sleep quality. For example, weight gain may increase the risk of metabolic syndrome, and both these factors increase the likelihood of hypertension.8
The underlying adverse changes that become more prevalent after menopause and increase CVD risk include vascular dysfunction, hypertension and cardiac dysfunction.8,10
Vascular function progressively deteriorates, seen objectively as a decrease in endothelial function. This may be due to an increase in oxidative stress and low-grade inflammation as a result of lower oestradiol.
Increases in blood pressure are more rapid in women, coinciding with the menopause transition. This may be both a direct effect of hormonal changes on the blood vessels and metabolic changes with ageing.
Vascular dysfunction, in conjunction with adverse changes in body composition (such as increased abdominal fat), can contribute to cardiac dysfunction such as left ventricular hypertrophy (a known risk factor for CVD).
Lower oestradiol levels after menopause are related to:4,10
- altered vascular function;
- increased inflammation;
- upregulation of the renin-angiotensin-aldosterone system and sympathetic nervous
system;
- reduced nitric oxide-dependent vasodilation;
- increased oxidative stress;
- decreased mitochondrial function;
- increased cardiac fibrosis.
Specific Groups of Women
Some women have increased risk of future CVD: women who have experienced pregnancy-related disorders (gestational diabetes, preeclampsia, preterm delivery) and those who received certain medical treatments for breast cancer.7,11,12
Some conditions are more prevalent in women than men, such as autoimmune disorders (e.g. rheumatic arthritis, systemic lupus erythematosus) and thyroid disorders, and are associated with an increased CVD risk. Patients with these disorders also have a higher clustering of traditional risk factors.10 The microvasculature in women may play an important role in the predisposition of women with autoimmune diseases to develop accelerated CVD.13
Recent national statistics indicate that after adjusting for age, Aboriginal and Torres Strait Islander women are almost twice as likely as non-indigenous women to have CVD.14
Summary of Major Risk Factors
Figure 2. Cardiovascular risk factors in women.12
How to Reduce CVD Risk in Postmenopause
Risk of cardiovascular disease can be reduced in women through dietary and lifestyle interventions and judicious use of supplements. All women should:1,3,5
- eat a healthy diet;
- be physically active;
- aim for a healthy weight;
- don’t smoke (actively or passively);
- keep a check on blood pressure and blood levels of lipids and glucose;
- reduce stress and treat depression;
- reduce low-grade, chronic inflammation;
- be aware of family history of CVD.
In addition, because endothelial function decreases after perimenopause,8 it is advisable to support the microcirculation with appropriate diet and supplements.15
Women in higher risk groups can also talk to their doctor about additional surveillance.11,16
Conclusion
CVD is often overlooked in women, however it is very common in the postmenopausal period. Increasing awareness of CVD risks, presentation and prevention strategies in women is important to improve cardiovascular outcomes in women.
References
1 Victor Chang Cardiac Research Institute. Heart disease risk for women [Internet]. [2022 April 6; cited 2023 April 4]. Available from: https://www.victorchang.edu.au/blog/misconception-women-heart-disease
2 Gauci S, Cartledge S, Redfern J, Gallagher R, Huxley R, Lee CMY, et al. Biology, bias, or both? The contribution of sex and gender to the disparity in cardiovascular outcomes between women and men. Curr Atheroscler Rep. 2022 Sep;24(9):701-708.
3 Harvard Health Publishing, Harvard Medical School. Gender matters: heart disease risk in women [Internet]. [2017 March 25; cited 2023 April 17]. Available from: https://www.health.harvard.edu/heart-health/gender-matters-heart-disease-risk-in-women
4 Ryczkowska K, Adach W, Janikowski K, Banach M, Bielecka-Dabrowa A. Menopause and women's cardiovascular health: is it really an obvious relationship? Arch Med Sci. 2022 Dec 10;19(2):458-466.
5 Cleveland Clinic. Cardiovascular disease in women [Internet]. [2022 May 5; cited 2023 April 13]. Available from: https://my.clevelandclinic.org/health/diseases/17645-women--cardiovascular-disease
6 El Khoudary SR, Aggarwal B, Beckie TM, Hodis HN, Johnson AE, Langer RD,et al. Menopause transition and cardiovascular disease risk: implications for timing of early prevention: a scientific statement from the American Heart Association. Circulation. 2020 Dec 22;142(25):e506-32.
7 Vogel B, Acevedo M, Appelman Y, Bairey Merz CN, Chieffo A, Figtree GA, et al. The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030. Lancet. 2021 Jun 19;397(10292):2385-438.
8 Marlatt KL, Pitynski-Miller DR, Gavin KM, Moreau KL, Melanson EL, Santoro N, et al. Body composition and cardiometabolic health across the menopause transition. Obesity (Silver Spring). 2022 Jan;30(1):14-27.
9 Mattina GF, Van Lieshout RJ, Steiner M. Inflammation, depression and cardiovascular disease in women: the role of the immune system across critical reproductive events. Ther Adv Cardiovasc Dis. 2019 Jan-Dec;13:1753944719851950.
10 Maas AHEM, Rosano G, Cifkova R, Chieffo A, van Dijken D, Hamoda H, et al. Cardiovascular health after menopause transition, pregnancy disorders, and other gynaecologic conditions: a consensus document from European cardiologists, gynaecologists, and endocrinologists. Eur Heart J. 2021 Mar 7;42(10):967-984.
11 Bayoumi E, Karasik P. Cardiovascular disease in older women. Clin Geriatr Med. 2021 Nov;37(4):651-65.
12 Erlinger C. Heart Disease in Women – A Heart Attack Survivors Story [Internet]. Canberra (AU): The Heart Foundation; 2018 [cited 2023 May 25]. Available from: https://theheartfoundation.org/2018/02/22/heart-disease-in-women-a-heart-attack-survivors-story/: image.
13 den Ruijter HM, Haitjema S, Asselbergs FW, Pasterkamp G. Sex matters to the heart: A special issue dedicated to the impact of sex related differences of cardiovascular diseases. Atherosclerosis. 2015 Jul;241(1):205-7.
14 Australian Government: Australian Institute of Health and Welfare. Cardiovascular disease in women – a snapshot of national statistics [Internet]. [2022 May 13; cited 2023 April 17]. Available from: https://www.aihw.gov.au/reports/heart-stroke-vascular-diseases/cardiovascular-disease-in-women/contents/cvd-in-indigenous-women
15 Bone K. Functional herbal therapy: a modern paradigm for Western herbal clinicians. London: Aeon Books Ltd; 2021.
16 Heart Foundation. Cardiovascular disease risk factors and heart attack warning signs in women [Internet]. [2021 October 6; cited 2023 April 24]. Available from: https://www.heartfoundation.org.au/bundles/your-heart/risk-factors-for-women