Women Who Don't Speak Up at Risk for Heart Disease

Tara Haelle

September 30, 2019

CHICAGO —The more women hold back instead of speaking up, the more likely they are to have plaque in the carotid artery, an indicator of subclinical cardiovascular disease, said Karen Jakubowski, MS, from the University of Pittsburgh.

"Our study results suggest that emotional expression within intimate relationships may be important for midlife women's cardiovascular health," she told attendees here at the North American Menopause Society 2019 Annual Meeting.

"Clinicians may be in a role to support women toward greater self-expression and assertion in their relationships, and perhaps to help them identify and choose relationships that are healthy and allow for that important self-expression," Jakubowski added.

But she also suggested caution in interpreting the findings.

"There are many reasons women engage in self-silencing, and we are not intending to indicate that women are deficient in their communication or to blame them for doing something that might not be in their best interests," said Jakubowski. "Really, it's to think about the many reasons that one could engage in self-silencing in a relationship."

Previous research has shown a link between self-silencing — defined as inhibiting one's self-expression to avoid conflict or relationship loss — and poor mental and self-reported physical health, including irritable bowel syndrome and disordered eating, she reported.

In their current study, Jakubowski and her colleagues assessed 304 late perimenopausal and postmenopausal women, 40 to 60 years of age, who did not smoke or have clinical evidence of cardiovascular disease. The cohort was 72.5% white, 22% black, and 5.4% another ethnicity.


All participants completed the 12-item Silencing the Self Scale, which assesses how much women express themselves and their needs in intimate relationships. Women rated, on a 5-point Likert scale, statements such as "Caring means putting the other person's needs in front of my own," "I rarely express my anger at those close to me," and "In order for my partner to love me, I cannot reveal certain things about myself."

The women also completed the Center for Epidemiologic Studies Depression Scale (CES-D), and reported their medical history, including history of depression. Although none of the women were taking antidepressants or hormone therapy, 13.9% of the cohort reported depressive symptoms.

The researchers measured blood pressure, height, weight, and cholesterol level in all participants. Each woman was assigned a plaque index score — 0, 1, or 2 or more — after ultrasound imaging of the carotid artery.

Evidence of plaque was seen in 46% of the women, and 24% had a plaque index score greater than 2.

The researchers compared the presence of plaque with scores on the self-silencing scale, adjusting for age, race, educational level, blood pressure, body mass index, low-density-lipoprotein cholesterol, depression, and medications use for blood pressure, cholesterol, and diabetes.

Women with high scores on the self-silencing subscale were more likely to have a plaque score of 2 or more than women with low self-silencing scores (odds ratio, 1.14; = .02).

"This association persisted beyond adjustment for demographics, cardiovascular risk factors, and depressive symptoms," Jakubowski reported. However, the association could be related to any of the various reasons that women do not express their feelings or needs.

There were no associations between carotid atherosclerosis and scores on the subscales of externalized self-perception, care as self-sacrifice, and divided self.

The decision to self-silence "could be because of emotional and power dynamics in the relationship" or "related to early experiences around communication in the family of origin," Jakubowski explained. "There could be individual differences in self-expression that are at play."

Voicing Concern

But perhaps most important, women might be using self-silencing because they are in unhealthy or abusive relationships, she added.

During the presentation, James Simon, MD, from George Washington University in Washington, DC, asked whether women's sex lives or orgasmic function reflect their self-silencing. "There's nothing more bio-psychosocial than sexual interactions," he said.

But the researchers did not collect data on sexual function, Jakubowski explained.

"The whole presentation on self-silencing struck a chord because women who tend not to express their needs and desires in the bedroom tend not to have them satisfied," Simon told Medscape Medical News.

He said he's spent his career working with women and couples to "help women find their voice to express their needs to their intimate partners in the bedroom," and noted that "physical sexual function is largely vascular."

"So we have women not getting what they need because they self-silence having more cardiovascular disease. And even if they get what they need, they have more vascular disease and are less likely to be able to respond properly," he said.

The entire presentation — which ties together the biological, the psychological, the social, and intimacy — is "fantastic," said Simon.

Robert Wild, MD, PhD, from the University of Oklahoma in Oklahoma City, called the presentation intriguing, but wondered about a different factor that could be influencing the way women do or do not express themselves: religion.

Putting psychosocial characteristics into "a measure of the potential effect of internal stress that leads to a real atherosclerotic burden is really neat and novel," he said, but it is very difficult to pull off because so many social and cultural factors can be involved.

"It's complicated and there are other stressors in the home," he said. And "carotids are a poor surrogate for outcome," so additional end points will be needed in future studies.

But, Wild added, this hypothesis-generating study has provided an important lead, and he is interested in what might come of additional research with stronger design.

The research was funded by the National Institutes of Health. Jakubowski has disclosed no relevant financial relationships. Simon reports financial relationships with AbbVie, Allergan plc, Agile Therapeutics, AMAG, Amgen, Ascend Therapeutics, Bayer Healthcare, CEEK Enterprises, Covance, Dare Bioscience, Endoceutics, Duchesnay, GTx, Hologic, Ipsen, KaNDy/NeRRe Therapeutics, Mitsubishi Tanabe, Myovant Sciences, New England Research Institute, Novo Nordisk, ObsEva SA, Palatin Technologies, Sanofi SA, Sermonix Pharmaceuticals, Shionogi, Sprout, Symbio Research, TherapeuticsMD, and Viveve Medical. Wild reports being a consultant for AblaCare on a grant for polycystic ovary syndrome and is on the Amgen pregnancy registry.

North American Menopause Society (NAMS) 2019 Annual Meeting: Abstract S-5. Presented September 26, 2019.

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