Menopause transition and CVD risk: Scientific statement by AHA
USA: The American Heart Association (AHA) has released a scientific statement on menopause transition and cardiovascular disease risk: implications for timing of early prevention. The scientific statement provides an up-to-date synthesis of the existing data on the menopause transition and how it relates to cardiovascular disease (CVD).
CVD is the leading cause of death in women, who have a notable increase in the risk for this disease after menopause and typically develop coronary heart disease several years later than men. This observation led to the hypothesis that the MT contributes to the increase in coronary heart disease risk.
Over the past 20 years, longitudinal studies of women traversing menopause have contributed significantly to our understanding of the relationship between the MT and CVD risk. By following women over this period, researchers have been able to disentangle chronological and ovarian aging with respect to CVD risk. These studies have documented distinct patterns of sex hormone changes, as well as adverse alterations in body composition, lipids and lipoproteins, and measures of vascular health over the MT, which can increase a woman's risk of developing CVD postmenopausally. The reported findings underline the significance of the MT as a time of accelerating CVD risk, thereby emphasizing the importance of monitoring women's health during midlife, a critical window for implementing early intervention strategies to reduce CVD risk.
The 2011 American Heart Association guidelines for CVD prevention in women (the latest sex-specific guidelines to date) did not include information now available about the contribution of the MT to increased CVD in women. Therefore, there is a crucial need to discuss the contemporary literature on menopause and CVD risk with the intent of increasing awareness of the significant adverse cardiometabolic health–related changes accompanying midlife and the MT.
To summarize, key points from the statement include:
- The menopause transition (MT) represents the transition to a nonreproductive phase of life with cessation of ovarian function, accompanied by hormonal changes and physiological and psychological symptoms.
- A growing body of literature supports an acceleration of cardiovascular disease (CVD) risk among women during the MT.
- Menopause is defined as the experience of 12 consecutive months of amenorrhea. The median age at natural menopause is 50 years (interquartile range, 48-53 years). Premature menopause occurs before 40 years of age. Early menopause occurs between 40 and 45 years of age.
- There are several stages of reproductive aging, which are experienced differently among women. The MT has an early stage with menstrual cycle irregularities of at least 7 days and a late stage that includes at least 60 days of amenorrhea. Perimenopause encompasses the MT and 12 months after the final menstrual period.
- Longitudinal studies have shown that the MT is accompanied by distinct changes in endogenous sex hormones, changes in body fat distribution, lipids, lipoproteins, and vascular health.
- Perimenopause is the most highly symptomatic stage. Vasomotor symptoms affect 80% of midlife women, may require treatment if severe, and are associated with subclinical atherosclerosis and worse CVD risk factors.
- Sleep disturbance is a common complaint during the MT, but some of these changes may be related to chronological aging. Poor sleep quality is associated with greater risk of metabolic syndrome and vascular changes.
- Depression and anxiety are more common during perimenopause, and tend to decline after menopause. Depressive symptoms during the MT are linked to increased CVD risk.
- Later age at natural menopause is associated with longer life expectancy, higher bone density, and reduced CVD and death.
- Several cardiometabolic health changes accompany the MT. Hypertension is the most prominent modifiable CVD risk factor that increases with age among women.
- Lipid changes (increased low-density lipoprotein cholesterol and apolipoprotein B), metabolic syndrome, and vascular remodeling occur more in response to the changes of menopause. Blood pressure, insulin, and glucose changes are influenced more by chronological age.
- Postmenopausal women have increased central/visceral adiposity and decreased lean muscle mass. These changes are associated with increased risk of CVD, even among those women with normal body weight.
- There are limited data about the ideal CVD risk profile in women during the MT. It is estimated that only 7% of perimenopausal women have a physical activity level that matches current recommendations and <20% maintain healthy eating.
- Randomized trials suggest that lifestyle interventions in women undergoing the MT can be effective in preventing weight gain and lowering triglycerides, blood pressure, blood glucose, insulin, and subclinical carotid atherosclersosis. More research is needed.
- The initiation of hormone replacement therapy in women <60 years of age or within 10 years of menopause appears to be associated with reduced CVD risk. More research about the different forms, route, and duration of hormone treatment is needed.
"Menopause Transition and Cardiovascular Disease Risk: Implications for Timing of Early Prevention: A Scientific Statement From the American Heart Association," is published in the journal Circulation.
DOI: https://www.ahajournals.org/doi/10.1161/CIR.0000000000000912
