Symptoms of menopause: Not just unpleasant, also a marker for heart disease
Think of them as a check engine light
When most people think of symptoms of menopause, they think of discomfort. For example, being unpredictably hot or waking up at night soaked in sweat (night sweats are hot flushes a.k.a. hot flashes at night). Or both. In my opinion, night sweats are even worse because waking up in what feels like a puddle of water is disgusting. And of course if you kick the sheets off and fall back asleep without changing, you then wake up freezing cold.
While symptoms matter because quality of life matters, it is important when we discuss symptoms of menopause that we look beyond their “bother” factor, as some symptoms can be markers for other health concerns. Meaning, they should also be treated like a check engine light.
There has been some data that has linked what are called vasomotor symptoms (hot flushes and night sweats) with an increased risk of heart disease, but new research takes that concept even further evaluating more symptoms. Last year researchers published yet another look at some of the data collected in the Women’s Health Initiative (WHI, you can find the study here). They looked at the arm of the WHI that randomized women to take calcium and vitamin D, versus no supplement, to see if calcium and vitamin D might affect health outcomes. This is as good a place as any to remind people that while the WHI is the big study that threw a wrench in menopausal hormone therapy (or MHT), the study didn’t just evaluate hormones. And while there were a lot of issues with the study (I cover that in detail in The Menopause Manifesto), researchers keep analyzing the data, and the result is we continue to learn even more about menopause.
To evaluate the link between symptoms of menopause and cardiovascular disease, such as stroke and heart attack, researchers went back and looked at the WHI data. The following symptoms experienced during menopause were tracked and also graded by severity:
Hot flushes
Night sweats
Dizziness
Heart racing/skipping beats
Tremors
Feeling restless or tired
Difficulty concentrating
Forgetfulness
Mood swings
Vaginal dryness
Breast tenderness
Migraines
Waking at night
What the researchers found was women with 2 or more moderate to severe symptoms were 40% more likely to have a stroke and 35% more likely to have cardiovascular disease of any kind. Interestingly, the severity of the symptoms wasn’t a cofactor, but the number of symptoms were. This isn’t the only paper to find this association. A study from Taiwan found a 30% increased risk of coronary heart disease associated with menopausal symptoms. Another paper found the risk was greatest for those who had symptoms that started at or after their final menstrual period and women who had severe symptoms earlier actually had a reduced risk of cardiovascular disease. Clearly there is a lot more for us to learn.
Before we go any further, just a reminder that a 40% increased risk doesn’t mean 40% of women will have a stroke. For example, in the study from Taiwan I just mentioned above the 30% increased risk of coronary heart disease translated to 5 extra women per 1,000 per year. If the incidence of stroke is approximately 1.5-4 per 1,000 people per year for women ages 44-64, a 40% increased risk means approximately an additional 0.5-2 strokes per 1,000 people per year. Medically that is significant, but perspective for an individual is needed.
Why does this connection between symptoms and cardiovascular disease exist? That is something researchers are trying to sort out. I suspect we don’t have the answer yet because it’s very complicated biology. Some possible hypotheses are there is no connection, it’s correlation not causation. Perhaps people with symptoms have less access to healthcare and so symptoms are a marker and there is no cause and effect. As the WHI was a randomized trial this seems unlikely to be a major factor if it is at all. One popular hypothesis is that for some women menopause triggers an instability in the autonomic nervous system. This autonomic instability could increase the risk of cardiovascular disease as the heart and blood vessels are innervated by the autonomic nervous system as well as contribute to a wide range of menopause related symptoms. It’s possible it could be directly related to hormones, meaning lower levels of estrogen or higher levels of follicle stimulating hormone (FSH, a hormone from the brain that increases during menopause) could trigger symptoms as well as impact blood vessels and/or the heart. We are learning more about FSH, and it appears to be a driver of symptoms and conditions, not a passive response to changes in estrogen levels. Or it’s possible there is a common causative link such as adverse childhood experiences (read more about adverse childhood experiences and menopause here).
“Ugh,” you may be thinking. “Great, I have hot flushes and brain fog, so now I am going to have a heart attack as well?”
The increased risk of cardiovascular disease for women with 2 or more moderate or severe menopausal symptoms shouldn’t make you panic, but it should make you think. It should make you check your engine light. This is a marker, not a crystal ball. Knowing you are at higher risk for a serious medical condition means that you can take steps to lower that risk! This is information to act on, because there are real things that you can do to lower your risk of cardiovascular disease.
The first step is to tell your provider you have symptoms and that you know that puts you at a higher risk of cardiovascular disease and that you want to be proactive. Make sure your cardiac screening is up to date, meaning a blood pressure check, and blood tests to screen for diabetes as well as cholesterol and lipids. Know your numbers and when to act on them! Some good information can be found here at the American Heart Association. Other factors that can lower your risk of heart disease include physical activity, a heart healthy diet, and not smoking. Weight loss may also help some people.
It’s important to acknowledge that all of these things that lower the risk of cardiac disease are not necessarily easy to accomplish. Revamping your diet takes a lot of effort and if exercise were effortless we’d all be doing it. Just remember, the more of these things a person can do, the greater the benefit, and that any effort is worthwhile, so try not to succumb to all or nothing thinking. Even seemingly small things such as adding 1,000 steps a day or eating more vegetables and legumes, is a great place to start. Getting your cholesterol checked and taking statins if indicated, also a big thing. A very big thing.
We often talk of “bother” with menopausal symptoms, meaning if you are not bothered you don’t need them treated. And while that is true, if you have 2 or more menopausal symptoms even if they are not bothersome to you, they should be brought to your provider’s attention so you can make sure all your cardiac screening is up to date and then armed with that information about your health you may be able to see what changes you can make to lower your risk of cardiovascular disease.
It takes information to be empowered. The caveat here is the information we get isn’t always what we want to hear. Reading about the link between cardiovascular disease and symptoms of menopause while writing The Menopause Manifesto, well, I admit, initially I was bummed. But after some teeth gnashing I decided to make some dietary changes (more vegetables and legumes) and get back into a regular exercise routine as well as moving more throughout the day. And now I feel like I am being proactive by considering my cardiac health as part of my day to day living and that helped me reframe the situation.