New AHA Scientific Statement on Menopause and CVD Risk

Megan Brooks

December 02, 2020

Changes in hormones, body composition, lipids, and vascular health during the menopause transition can increase a woman's chance of developing cardiovascular disease (CVD) after menopause, the American Heart Association (AHA) said in a scientific statement.

"This statement aims to raise awareness of both healthcare providers and women about the menopause transition as a time of increasing heart disease risk," Samar R. El Khoudary, PhD, MPH, who chaired the writing group, told Medscape Medical News.

"As such, it emphasizes the importance of monitoring women's health during midlife and targeting this stage as a critical window for applying early intervention strategies that aim to maintain a heathy heart and reduce the risk of heart disease," said El Khoudary, of the Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania.

The statement was published online November 30 in Circulation.

Evolution in Knowledge

During the past 20 years, knowledge of how menopause might contribute to CVD has evolved "dramatically," El Khoudary noted. The accumulated data consistently point to the menopause transition as a time of change in heart health.

"Importantly," she said, the latest AHA guidelines for CVD prevention in women, published in 2011, do not include data now available on the menopause transition as a time of increased CVD risk.

"As such, there is a compelling need to discuss the implications of the accumulating body of literature on this topic," said El Khoudary.

The statement provides a contemporary synthesis of the existing data on menopause and how it relates to CVD, the leading cause of death of US women.

Earlier age at natural menopause has generally been found to be a marker of greater CVD risk. Iatrogenically induced menopause (bilateral oophorectomy) during the premenopausal period is also associated with higher CVD risk, the data suggest.

Vasomotor symptoms are associated with worse levels of CVD risk factors and measures of subclinical atherosclerosis. Sleep disturbance has also been linked to greater risk for subclinical CVD and worse CV health indexes in women during midlife.

Increases in central/visceral fat and decreases in lean muscle mass are more pronounced during the menopause transition. This increased central adiposity is associated with increased risk for mortality, even among those with normal body mass index, the writing group found.

Increases in lipid levels (low-density lipoprotein cholesterol and apolipoprotein B), metabolic syndrome risk, and vascular remodeling at midlife are driven by the menopause transition more than aging, whereas increases in blood pressure, insulin level, and glucose level are likely more influenced by chronologic aging, they report.

Lifestyle Interventions

The writing group notes that because of the increase in overall life expectancy in the United States, a significant proportion of women will spend up to 40% of their lives after menopause.

Yet data suggest that only 7.2% of women transitioning to menopause are meeting physical activity guidelines and that fewer than 20% of those women are consistently maintaining a healthy diet.

Limited data from randomized controlled trials suggest that a multidimensional lifestyle intervention during the menopause transition can prevent weight gain and reduce blood pressure and levels of triglycerides, blood glucose, and insulin and reduce the incidence of subclinical carotid atherosclerosis, they point out.

"Novel data" indicate a reversal in the associations of high-density lipoprotein cholesterol (HDL-C) with CVD risk over the menopause transition, suggesting that higher HDL-C levels may not consistently reflect good cardiovascular health in middle-aged women, the group notes.

There are also data suggesting that starting menopause hormone therapy (MHT) when younger than 60 years or within 10 years of menopause is associated with reduced CVD risk.

The group says further research is needed into the cardiometabolic effects of MHT, including effects associated with form, route, and duration of administration, in women traversing menopause.

They also note that data for the primary and secondary prevention of atherosclerotic CVD and improved survival with lipid-lowering interventions "remain elusive" for women and that further study is needed to develop evidence-based recommendations tailored specifically to women.

The research had no commercial funding. El Khoudary has disclosed no relevant financial relationships.

Circulation. Published online November 30, 2020. Abstract

For more from the | Medscape Cardiology, follow us on Twitter and Facebook.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.