Monitoring the risk of cardiovascular disease during menopause.

How does menopause increase the risk of heart disease? Understand the causes, prevention methods, and self-care to reduce severe risks.

Menopause is an important period of physical changes that everyone must face, especially women who experience clear changes due to the cessation of ovarian function. What many may not know is that menopause does not only cause hot flashes or mood swings but also increases the risk of cardiovascular diseases.

How are heart disease and menopause related? Can it be prevented? What symptoms should be monitored? Check your health and your loved ones before it’s too late, along with appropriate health care guidelines.

How are heart diseases related to menopause?

Menopause is a period when the body produces fewer sex hormones, especially estrogen in women and testosterone in men. These hormones play an important role in protecting the heart and blood vessels.

Effects of hormone decline

• Changes in estrogen: Loss of estrogen causes arteries to lose elasticity, leading to stiffening of the vessel walls and increasing the risk of blood clots.
• Worsening cholesterol levels: Cholesterol levels change, with LDL (bad cholesterol) increasing and HDL (good cholesterol) decreasing.
• Blood pressure tends to rise: Due to stiffening and loss of elasticity in blood vessels.
• Metabolic changes: Metabolism may slow down, causing easy weight gain and increased abdominal fat, which is a risk factor for heart and vascular diseases.
• Increased insulin resistance: Leading to higher risks of diabetes and heart disease.

Important to know:

Studies have found that women entering menopause have a 2-3 times higher risk of heart disease compared to premenopausal women. In men, the risk of cardiovascular disease also increases during andropause due to declining testosterone levels, which is associated with various health conditions, especially cardiovascular system issues, high blood lipids, and in men over 70 years old, it is linked to depression, muscle mass loss, coronary artery disease, and heart failure.

Are heart diseases different between men and women during menopause?

Although both men and women in menopause have increased heart disease risk, there are important differences.

Men in menopause:

Menopause in men typically begins around age 40 and older, with hormone decline occurring gradually. Changes are slow but accumulate over time. If heart disease symptoms appear, they are usually clear, such as chest pain, chest tightness, and shortness of breath.

Women in menopause:

Women generally enter menopause between ages 45-55 when menstruation stops. Hormonal changes occur rapidly, causing a sudden increase in heart disease risk. Symptoms are often unclear and may include fatigue, nausea, and easy tiredness rather than typical chest pain.

This causes many to neglect health checks, leading to women often being diagnosed with heart disease later than men due to less obvious symptoms, resulting in higher mortality rates among women.

Menopausal women and heart disease that should not be overlooked

In the past, menopausal symptoms in women occurred naturally due to ovarian cessation, usually over age 40, leading to increased risk of coronary artery disease after age 40-45.

However, current data shows menopause symptoms can appear earlier, even as young as 30 years old, increasing the risk of coronary artery disease. This increased risk is due to factors such as stress, smoking, consumption of junk food and high-fat diets, and lack of exercise.

Including cases where both ovaries are surgically removed, which can occur before age 40. These factors all increase the risk of coronary artery disease.

Early menopause (after ovary removal surgery) increases the risk of coronary artery disease

Early menopause or premature menopause caused by surgery is menopause resulting from ovary removal surgery (Surgical Menopause), which increases the risk of coronary artery disease and arterial stiffness more than natural menopause (Natural Menopause) due to the following reasons:

1. Abrupt hormonal withdrawal

2. Longer duration of estrogen deficiency

If ovary removal surgery occurs after age 40, the body will experience estrogen deficiency longer than those with natural menopause.

• Normally, women reach menopause at an average age of about 51 years.
• If surgery occurs before this age, e.g., at 40 years old → it means the body lacks estrogen earlier and for about 10–15 years longer.

Consequences

1. The body is increasingly affected by a hypoestrogenic state over time.
2. This impacts the heart, blood vessels, bones, metabolism, and increases menopausal symptoms.
3. Effects of estrogen deficiency on blood vessels.

Estrogen is an important hormone that protects the heart and blood vessels. When estrogen rapidly decreases (e.g., after ovary removal surgery), vascular function worsens and heart disease risk increases.

Metabolic profile changes

After ovary removal surgery (Surgical Menopause), estrogen drops rapidly, causing multiple metabolic changes that increase the risk of heart disease, diabetes, and central obesity.

Common findings after Surgical Menopause

• Increased total cholesterol and LDL-C (bad cholesterol)
• Decreased HDL-C (good cholesterol)
• Increased triglycerides
• Increased abdominal fat (central obesity/visceral fat) → leading to easier belly fat accumulation
• Increased insulin resistance → poorer blood sugar control
• Higher risk of metabolic syndrome (a cluster of high blood pressure, abnormal lipids, high blood sugar, and central obesity)

The importance of estrogen in heart disease

Estrogen is crucial for heart health, playing roles such as:

• Helping blood vessels dilate well through nitric oxide production
• Reducing bad cholesterol (LDL) and increasing good cholesterol (HDL)
• Reducing oxidative stress
• Reducing inflammation in blood vessels
• Preventing damage to endothelial cells (endothelial dysfunction)
• Slowing arterial stiffness

What happens when estrogen drops abruptly?

• Endothelial dysfunction occurs faster
• Atherosclerosis develops more quickly
• Blood vessels stiffen more, impairing blood flow

Recognizing cardiovascular symptoms during menopause

Knowing the warning signs of heart disease can save lives, especially during menopause when risks increase.

Warning signs of heart disease during menopause that require medical evaluation

• Palpitations or irregular heartbeat – may indicate arrhythmia
• Leg pain when walking – may be a sign of arterial stenosis
• Swelling in legs or ankles – may indicate heart failure
• Chronic fatigue or weakness – especially if worsening
• Loud snoring or sleep apnea – a risk factor for heart disease
• Persistent cough, especially when lying down – may signal pulmonary congestion

Emergency heart disease symptoms during menopause requiring immediate medical attention

• Chest pain or tightness, feeling like pressure or squeezing, possibly radiating to shoulders, arms, neck, jaw, or back
• Palpitations, feeling of rapid or irregular heartbeat
• Shortness of breath or difficulty breathing, especially at rest or with minimal exertion
• Unexplained cold sweats
• Leg pain when walking, weakness in limbs – risk of arterial stenosis
• Nausea or vomiting, especially in women – may be a sign of heart attack
• Dizziness or sudden fainting – may indicate insufficient heart pumping
• Unusual fatigue, especially in women, with easy tiredness from normal activities

If any of the above emergency symptoms occur, especially chest pain, difficulty breathing, or sudden fainting, go to the hospital immediately. Do not wait for symptoms to resolve on their own, as time is critical in treating acute heart disease.

Guidelines for cardiovascular screening during menopause

Cardiovascular screening during menopause should start with basic annual health checks such as:

• Blood pressure and blood lipid level tests
• Electrocardiogram (EKG) to check the heart’s electrical signals for rhythm and initial abnormalities
• Echocardiogram using high-frequency sound waves to image the heart, assessing size, muscle function, and valves
• Coronary artery calcium score to evaluate heart risk and function

If symptoms are suspicious, further tests such as coronary CT angiography and other cardiac function tests may be performed based on indications and physician discretion.

Self-care to reduce heart disease risk during menopause

• Consult a doctor regularly for physical exams and heart health checks if indicated
• Manage chronic diseases such as diabetes, hypertension, and high cholesterol according to medical guidelines
• Eat a healthy diet focusing on low-fat, high-fiber foods, vegetables, and fruits; reduce sweet, fatty, and salty foods
• Exercise regularly, such as aerobic activities
• Maintain a healthy weight
• Get enough sleep
• Avoid smoking and limit alcohol consumption, as both increase heart disease risk
• Manage stress to reduce its impact on heart health

Self-care for those with premature menopause due to ovary removal surgery

Self-care for those with Surgical Menopause or premature menopause from ovary removal surgery at a young age (< 40–45 years) should focus on preventing long-term effects on the heart, bones, and metabolism as follows:

1. Consider hormone replacement therapy (HRT)

It is recommended to continue HRT until about age 51, the average age of natural menopause → to help reduce risks of heart disease, osteoporosis, and improve quality of life.

2. Monitor cardiovascular risk factors

Regularly check risk indicators such as blood lipids, blood pressure, weight, waist circumference, and blood sugar.

3. Lifestyle modification

Focus on three main areas:

1. Heart-healthy diet, reducing sugar, fat, and salt

2. Regular exercise including cardio and weight training

3. Weight control, especially reducing abdominal fat

4. Regular health check-ups

Follow up on key values at least once a year, including lipid profile, blood pressure, and glucose levels.

Summary: Heart disease during menopause can be managed by early awareness, monitoring, and risk reduction

Heart disease during menopause can be managed by adopting healthy behaviors such as eating nutritious food, controlling weight, exercising regularly, avoiding smoking and alcohol, managing stress, and having regular annual health check-ups to reduce risks. However, upon entering menopause, it is important to observe any bodily changes, maintain good health, and especially undergo health screenings to prevent and manage related chronic diseases, including heart disease, to reduce severe risks.

Dr. Jeerasak Sirithanyanon
Cardiologist
Heart Center, Phyathai 3 Hospital