How prevalent is heart disease among women?

Cardiovascular disease is NOT just a man’s disease. Cardiovascular disease is the Number 1 killer of women over age 25 in the United States, regardless of race or ethnicity. Once a woman reaches the age of 50, (about the age of natural menopause), the risk for heart disease increases. In young women who have undergone early or surgical menopause, the risk for heart disease is also higher, especially when combined with other risk factors such as:

• Diabetes
• Smoking
• High blood pressure
• Elevated LDL (low density lipoproteins) cholesterol
• Low HDL (high density lipoproteins) cholesterol, sometimes called "good" cholesterol
• Obesity
• Sedentary lifestyle
• Family history of heart disease

What is menopause

female reproductive organs

Menopause is a normal stage in a woman’s life. The term menopause is commonly used to describe any of the changes a woman experiences either before or after she stops menstruating. As menopause nears, the ovaries gradually produce less estrogen (a female hormone), causing changes in the menstrual cycle and other physical changes. The most common symptoms of menopause are hot flashes, night sweats, emotional changes and changes in the vagina (dryness and atrophy or thinning of the vaginal walls).

Technically, menopause is the end of a woman’s reproductive cycle, when the ovaries no longer produce eggs and she has her last menstrual cycle. The diagnosis of menopause is not confirmed until a woman has not had her period for six to twelve consecutive months.

Menopause usually occurs naturally in women between ages 45 and 55 . However, loss of estrogen can also occur if the ovaries are removed during surgery or if a woman goes through early menopause.

How is heart disease associated with menopause?

• Estrogen helps a younger woman’s body protect her against heart disease.
• Changes in the walls of the blood vessels, making it more likely for plaque and blood clots to form
• Changes in the level of lipids (fats) in the blood occur
• An increase in fibrinogen (a substance in the blood that helps the blood to clot). Increased levels of blood fibrinogen are related to heart disease and stroke

What can be done to reduce the risk of heart disease for menopausal women?

First and foremost, "traditional" risk factors should be addressed. Women with the lowest risk of heart disease are those who:

• Avoid or quit smoking
• Lose weight and/or maintain their ideal body weight
• Participate in aerobic exercise for 30-40 minutes, three to five times per week
• Follow a diet low in saturated fat (<7% daily amount); low in trans-fat (partially hydrogenated fats such as margarine or shortening); and high in: fiber, whole grains, legumes (such as beans and peas), fruits, vegetables, fish and folate-rich foods
• Treat and control medical conditions such as diabetes, high cholesterol and high blood pressure that are known risk factors for heart disease

For many years, preliminary observational research showed that HRT could possibly reduce the risk of heart disease in women. It appears that the reason why the observational studies showed women on hormone replacement therapy had less heart disease was likely due to the lifestyles of women who take hormone replacement therapy rather than the medical benefits.

More recent studies of women, such as the Heart and Estrogen/progestin Replacement Study (HERS) and the Women's Health Initiative (WHI) concluded overall health risks exceeded the benefits provided by HRT. Women who participated in the WHI showed an increased risk for breast cancer, coronary heart disease (including nonfatal heart attacks), stroke, blood clots and gall bladder disease. Based on the results of these studies, HRT is not indicated for cardiovascular risk reduction. It should be noted that while one arm of the WHI study concluded (estrogen-progestin), other arms (such as estrogen alone) are ongoing. The American Heart Association states, "The loss of natural estrogen as women age may contribute to the higher risk of heart disease after menopause. However, in light of recent results from clinical trials, the American Heart Association does not advise women to take postmenopausal hormone therapy (PHT, formerly called hormone replacement therapy or HRT) to reduce the risk of coronary heart disease or stroke¹."

There are other risks and benefits that come from HRT. It is important to discuss the risks and benefits of HRT with your own doctor before making a decision.

What exactly is HRT?

Hormone replacement therapy (HRT) is a treatment program in which a woman takes estrogen with or without progestin (a synthetic form of progesterone). To decrease the risk of uterine cancer in women who have a uterus, progestin is usually prescribed with estrogen.

What are the benefits of HRT?

Benefits of hormone replacement therapy for post-menopausal women, include:

• Increased elasticity of the blood vessels, allowing them to dilate (widen) and let the blood flow more freely throughout the body
• Improved short-term symptoms of menopause such as hot flashes and mood swings, as well as vaginal dryness, dry skin, sleeplessness and irritable bladder symptoms
• Decreased risk of osteoporosis and fractures (broken bones)
• Decreased incidence of colon cancer
• Possible decreased incidence of Alzheimer’s disease
• Possible improvement of glucose levels

Is HRT safe?

Short-term hormone replacement therapy is safe for most menopausal women who take HRT for symptom control. However, before HRT is prescribed, make sure you review your medical history with your health care provider. Together, you and your health care provider can decide if you have conditions or inherited health risks that would make HRT unsafe for you. HRT is not recommended for women who have:

• History of prior heart attack or stroke and/or increased risk for vascular disease
• Unexplained vaginal bleeding
• Active or past breast cancer
• Fibrocystic breast disease
• Active liver disease
• Endometrial cancer
• Gall bladder disease
• High risk for blood clots or a history of blood clots

What are the risks of HRT?

The health risks of HRT include:

• Increased risk of endometrial cancer (only when estrogen is taken without progestin) For women who have had a hysterectomy (removal of the uterus), this is not a problem.
• Increased risk of breast cancer with long-term use
• Increased risk of cardiovascular disease (including heart attack)
• Increase in inflammatory markers (such as C-reactive protein)
• Increased risk of blood clots and stroke, especially during the first year of use in susceptible women

All women taking hormone replacement therapy should have regular gynecological exams (including a PAP smear). The American Cancer Society also recommends that women over age 50 should:

1. Perform breast self-examination once a month;
2. Have a breast physical examination by her health care provider once a year; and
3. Have a mammogram once a year.

What are the side effects of HRT?

About 5 to 10 percent of women treated with HRT have side effects which may include breast tenderness, fluid retention and mood swings. In most cases, these side effects are mild and do not require the woman to stop HRT therapy.

If you have bothersome side effects from HRT, talk to your doctor. He or she can often reduce these side effects by changing the type and dosage of estrogen and/or progestin.

If you have a uterus and take progestin, monthly vaginal bleeding is likely to occur. If it will bother you to have your monthly menstrual cycle, discuss this with your health care provider.

Is HRT the same as birth control?

No. Although women who take birth control pills are also taking estrogen and progestin, the effect is not the same. Women who take birth control pills have not been through menopause and need higher levels of hormones to prevent ovulation. HRT is not a high enough strength to stop ovulation.

After menopause, estrogen levels are low and HRT is used at a low dose to restore hormone levels to a more normal level.

How do I decide if HRT is right for me?

Even the best candidates for HRT need to periodically evaluate if HRT is the right treatment for them. You and your health care provider should discuss your medical history and risk factors, as well as how HRT can be tailored to your needs.

Here are some questions you can ask yourself and discuss with your physician:

Am I experiencing difficult menopause symptoms?

Do I have any medical conditions or a family history of certain conditions that might make HRT beneficial for me?

Do I have any medical conditions or a family history of certain conditions that might make HRT riskier for me?

Have I considered alternatives to HRT?

To schedule an appointment to:

• lessen your risk factors, call the Preventive Cardiology & Rehabilitation Center at 216/444-9353 or 800/223-2273 and ask for extension 49353.
• discuss hormone replacement therapy, please see the Women's Health Center or call 216/444-4HER to schedule an appointment.

This information is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition.

1. Menopause, American Heart Association, http://www.americanheart.org/presenter.jhtml?identifier=4658
2. Postmenopausal Hormone Replacement Therapy and Cardiovascular Disease in Women, American Heart Association, http://www.americanheart.org/presenter.jhtml?identifier=4536
3. Postmenopausal Hormone Therapy, National Heart Lung & Blood Institute, http://www.nhlbi.nih.gov/health/women/index.htm
4. Writing Group for the Women's Health Initiative Investigators, Risks and Benefits of Estrogen Plus Progestin in Healthy Postmenopausal Women: Principal Results From the Women's Health Initiative Randomized Controlled Trial. JAMA. 2002;288:321-333, http://jama.ama-assn.org/cgi/content/abstract/288/3/321