New Insights on Heart Disease Risk During Menopause

As if hot flashes, mood swings, uncomfortable sex, and a host of other symptoms weren’t enough to deal with, menopause is also a time when women’s risk of cardiovascular disease shoots up to match men her age. Although scientists have known this for some time, new research is beginning to shed light on the complex link between heart disease and menopause.

One factor is declining estrogen levels during perimenopause, which removes some of the hormone’s cardioprotective effects,  physician Ella Ishaaya M.D. says. “Estrogen downregulates inflammatory markers, prevents buildup of lipids and LDL, and a number of other things.” Once that happens, your body shifts toward a more androgenic profile—meaning it’s more like that of a man’s—and cardiovascular risks rise.

But you don’t have to just put up with these changes. New research has identified screenings and medications that may help detect and address heart disease sooner, potentially leading to better outcomes. 

About the Experts

Anurag Mehta, M.D., is director of preventive cardiology at VCU Health Pauley Heart Center and an assistant professor of internal medicine at VCU School of Medicine.

Ella Ishaaya, M.D., is a third-year resident physician at Harbor-UCLA Medical Center in Torrance, California. She’s the lead researcher of a study on women’s heart health after menopause.

Brandye Wilson-Manigat, M.D., FACOG, is a board-certified OB-GYN and founder of Brio Virtual Gynecology in Pasadena, California. She specializes in perimenopause, menopause, and sexual dysfunction.

Lipoprotein (a): A Potential Biomarker to Watch During Menopause

Most of us know high levels of triglycerides and LDL (bad) cholesterol are red flags for heart health. Recently, another lesser-known cardiovascular biomarker, lipoprotein (a) or Lp(a), has also been making headlines. It’s structurally similar to LDL but has a second protein called apolipoprotein(a) attached to it, cardiologist Anurag Mehta, M.D., explains. “It’s associated directly with the [heightened] risk of cardiovascular disease, heart attack, stroke, and a heart valve problem called aortic stenosis,” he adds.

While Lpa levels remain relatively stable throughout your life, they increase after menopause (1). It’s unclear why, Mehta says. “There’s some thought that estrogen levels [regulate] levels of Lp(a).” Genetics also play a role, making it difficult to manage Lp(a) levels through lifestyle changes alone (2). “The impact of menopause and lifestyle factors like diet and exercise tends to be small,” Mehta says. Additionally, “there are well-known race and ethnic differences in Lp(a) levels.” Black people generally have levels three times higher than white people, and South Asians twice as high (3, 4).

Fortunately, hormone replacement therapy (HRT)—also called menopause hormone therapy (MHT)—appears to help lower lipoprotein(a). Other emerging therapies may be available in the coming years, including the following medications (5, 6):

• Antisense oligonucleotides (ASOs) inhibit the production of apolipoprotein(a) and reduce Lpa by up to 80 percent or more in trials (7).
• RNAi are small, interfering RNA molecules that silence the gene that encodes Lp(a) (8). An early-stage clinical trial showed a single dose decreased Lp(a) by up to 98 percent (9).

If further testing confirms the safety and efficacy of these and other medications, FDA approval is anticipated in the next two to three years, Mehta says. Studies will have to show that these drugs can lower Lp(a) and improve cardiovascular outcomes. 

Getting a lipoprotein(a) screening

Although one in five people have high Lp(a) levels, a standard lipid panel doesn’t measure this biomarker (10). European and Canadian guidelines recommend everyone be screened once. But in the U.S., doctors typically only recommend checking your lipoprotein(a) if:

• You’re younger than 65 and have had a heart attack
• You have a family history of early cardiovascular disease
• You have high LDL that can’t be controlled by statins (11)

 If you’re interested in testing, talk to your healthcare provider about your risk factors.

MORE MENOPAUSE

8 Signs You Might Need Menopause Hormone Therapy

Why More Women Are on HRT for The Long Haul

Coronary Artery Calcium (CAC): The New Heart Test to Get

Calcifications in the coronary arteries indicate plaque buildup, or atherosclerosis, which can lead to heart disease. A coronary artery calcium (CAC) test can help assess your risk. It’s a CT scan that measures calcium in the arteries supplying blood to the heart, with a higher score indicating a greater risk of heart problems (12).

“Think of the coronary arteries as a plumbing system,” physician Ella Ishaaya, M.D. says. “If you develop some gunk in your faucet, the water will still pass.” But as the gunk forms and gets larger, it will eventually clog the faucet, and only a little water will pass through. The heart operates similarly. “The coronary arteries supply blood to the heart,” Ishaaya says. A build-up of calcium and other inflammatory cells could calcify and become hard plaque. If this plaque ruptures or erodes in the coronary artery, it can cause a blood clot to form, which blocks blood flow to your heart and causes a heart attack (13).

Coronary artery calcification accelerates after menopause, increasing these risks. In a recent study led by Ishaaya, researchers found among patients taking statins, CAC scores increase faster in postmenopausal women compared to men of the same age, showing a median rise of 31 points in a year—roughly double the rate for men (14). One possible explanation, Ishaaya says, is the decline in cardioprotective estrogen.

When to consider a CAC test

Though Ishaaya says anyone at risk for heart disease should get a CAC test, your insurance may not cover the CT scan needed to spot it. The American College of Cardiology and American Heart Association guidelines recommend a CAC test for people with an atherosclerotic cardiovascular disease (ASCVD) risk of 7.5 to 20 percent to determine if statins would be recommended (15).

Here’s how CAC scores are categorized (12):

• 0 = No disease
• 1-99 = Mild disease
• 100-399 = Moderate disease
• 400+ = Severe disease

“Anything greater than zero means you have a degree of calcium buildup in your heart, so you should make lifestyle modifications to mitigate that risk,” Ishaaya says. “Once your score is in the double digits, we think about statin therapy.” However, if you have a family history of atherosclerosis or have multiple risk factors for the condition, statins may be a great preventive measure—regardless of your CAC score. 

Hot Flashes and Heart Health: Is There a Connection?

Hot flashes aren’t just annoying—they may indicate a higher risk of heart problems. In a study published in the Journal of the American Heart Association in 2021, women whose hot flashes persisted for an average of four annual checkups had a 77 percent increased risk of cardiovascular disease (16). Researchers aren’t sure why, but women with hot flashes often have higher levels of cholesterol, LDL, triglycerides, blood pressure, and insulin resistance than women who don’t (17, 18). 

Steps to take if you have hot flashes

Using hormone replacement therapy (HRT) to reduce cardiovascular risk during menopause remains a topic of debate. The Menopause Society doesn’t recommend HRT in women who enter menopause at the average age (around 52), a position supported by several studies (19, 20, 21, 22, 23).

However, some studies suggest estrogen therapy may reduce the risk of heart disease and death in healthy women under 60 who are within 10 years of menopause (24, 25, 26, 27).

Ultimately, “we need more data,” gynecologist Brandye Wilson-Manigat, M.D., FACOG, says. “There are so many formulations of estrogen now; the dosings are different, and how you administer the medications is different. All of that may have some impact on the benefits and risks of cardiovascular disease in using them.” 

Deciding whether or not to take HRT should be a conversation between you and your physician. They will take into consideration your age, how long you’ve been in menopause, your personal and family history of heart health, other medications you’re taking, and more.

Get Ahead of Cardiovascular Disease

Although you can’t avoid menopause, you can take action to prevent cardiovascular disease. “Making lifestyle and diet changes can have a very beneficial effect [on your heart health],” Mehta says, even if you have high Lp(a) levels or a family history. Consider these expert-backed recommendations: 

Get screened regularly

In addition to the biomarkers mentioned above, get your lipid panel checked annually to stay on top of your total cholesterol, LDL, HDL, and triglycerides. Keep in mind: You can have normal cholesterol levels and a high CAC score.

Manage other conditions

Hypertension, diabetes, obesity, and high cholesterol—alone or combined—increase the risk of heart disease (27). Mehta recommends working with your medical team to manage these conditions as best you can through lifestyle changes and medication.

Stay active

Research shows that higher levels of physical activity are linked to a lower risk of cardiovascular disease (28). Aim for 150 minutes of moderate aerobic exercise or 75 minutes of vigorous aerobic exercise weekly, plus at least two days of strength training per week (29, 30). 

Eat a heart-healthy diet

The Mediterranean, DASH, and plant-based diets have the most evidence for preventing heart disease (31). Prioritize minimally processed foods such as vegetables, fruits, legumes, nuts, lean proteins, and healthy fats, including olive oil and avocados.

Talk to your doctor about treatment options

The best medication for women going through perimenopause is the one that’s unique to their symptoms and health history—meaning, it requires a conversation with your doctor. For anyone with elevated LDL cholesterol levels or a high CAC score, statins are typically recommended (32, 33). “Statin therapy is one of the mainstays of treatment that we have to lower cardiovascular risk,” Mehta says.