The Menopausal Heart
Hormonal changes that come with age raise a woman’s cardiac risk.
By Linda Melone
Active and fit, Kimberly Montgomery was far from the classic profile of a heart attack victim.
When Montgomery, 50, of Milwaukee, Wisconsin, became sick after leaving a hot yoga class, she attributed the nausea and sweats to food poisoning. She drove to a friend’s house, where her friend convinced her to go to a nearby urgent care clinic. From there she was rushed by ambulance to a hospital, where a cardiologist told her she’d suffered a heart attack.
“I did not want to believe it,” says Montgomery, a state lobbyist and one of the American Heart Association’s Go Red For Women’s 2012 Real Women (www.goredforwomen.org). “I’ve always led an active life and did some type of exercise every day. My cholesterol and blood pressure were under control and normal.” Until that day, Montgomery had no idea her symptoms could signal a heart attack.
Although many still believe it’s more of a male concern, heart disease is the number one killer of both men and women, according to the Centers for Disease Control and Prevention (CDC). Every minute a woman dies from some form of heart disease in the US and more than one in three women lives with coronary vascular disease. Coronary disease occurs slowly over time, narrowing the arteries that supply blood to the heart itself. It is the most common precursor to heart attacks.
In Montgomery’s case, doctors found one coronary artery with a 75% blockage and another with an 80% blockage. She required two stents (small mesh tubes used to prop open arteries) to restore blood flow to the heart muscle.
Montgomery’s family history was a likely contributing factor to her heart attack. Several years earlier her mother had been diagnosed with atrial fibrillation (irregular heartbeat), and her grandfather had died of heart disease at the age of 80. A younger first cousin had also suffered a heart attack. In addition, hormonal changes related to menopause may have played a role in Montgomery’s attack.
As Montgomery discovered, heart attack symptoms don’t always include the chest-clutching pain depicted in movies. “Women often experience more vague symptoms such as feelings of dread and anxiety as well as flu-like feelings, which they may brush off,” says Kevin R. Campbell, MD, FACC, cardiologist at Wake Heart and Vascular Associates in Raleigh, North Carolina. “We’re not yet sure what causes these symptoms, although hormones may play a role.” Indigestion or heartburn, nausea, shortness of breath and sudden dizziness may also be signs of an attack, and “silent heart attacks” may cause few symptoms at all.
Women’s busy schedules can make it easy for them to ignore early signs of heart disease. “A woman will often take care of everyone else before she takes care of herself,” says Campbell. “On top of that, vague symptoms such as anxiety don’t always get taken seriously by healthcare providers. It’s why women often have more advanced coronary disease than men by the time they get checked.”
A failure to recognize the signs of brewing heart trouble may delay treatment, with potentially deadly consequences. More women than men have died each year from heart disease since 1984, according to the American Heart Association.
For some women, other health issues take precedence. Many women are good about getting mammograms and checking for breast cancer, but in reality five times as many women die of heart disease, says Dipti Itchipouria, MD, FACC, congestive heart failure program director at the Hoag Heart & Vascular Institute in Irvine, California.
Itchipouria says women who smoke have two to three times the risk of developing heart disease. Other risk factors include being obese and sedentary; 25 to 35% of American adults don’t exercise enough and almost 45% are obese, according to the CDC. Diabetes also increases risk: women with type 2 diabetes are more than two times as likely to have a heart attack. What’s more, even women without predisposing factors enter into high-risk heart territory when they undergo changes associated with menopause.
Gradual Risk Increase
Hormonal changes that occur during menopause and perimenopause—the time during which a woman’s body moves away from regular monthly cycles until menstruation completely ceases—increases the risk of heart disease among women going through these stages, says Itchipouria, who notes, “LDL (bad cholesterol) tends to go up and cardio-protective HDL (good cholesterol) decreases.” Estrogen’s protective effect ends with the start of menopause, which levels the playing field for women and men regarding heart disease risk.
This process doesn’t happen overnight, however. “Generally women remain protected until they’re about 10 years post-menopausal, until approximately age 65, depending on when they start menopause,” says Sameer Sayeed, MD, a cardiologist associated with New York-Presbyterian/ Columbia Hospital. “These hormones affect the heart muscle itself as well as lipid levels, keeping blood pressure lower and increasing circulatory health.” But once the effects of the hormones wear off it takes about 10 years for any issues to develop. During this time women have much less protection from cholesterol buildup and stresses on the heart muscle itself. At that time, Sayeed notes, “We start to worry about coronary artery disease developing.”
Smokers are an exception to the hormonal protection rule. “They’re more at risk for arterial plaques rupturing. If a woman smokes, now is the time to quit,” says Sayeed.
“A woman’s estrogen is the fountain of youth. It protects the lining of blood vessels,” says Stephen T. Sinatra, MD, FACC, a Connecticut-based cardiologist and author of The Great Cholesterol Myth (Fair Winds Press). However, when women lose estrogen the heart and blood vessels become stiffer, a syndrome often seen in post-menopausal women. Sinatra says this can lead to diastolic dysfunction, a heart that struggles to fill with blood because its cells lack the energy needed to do their job. “Basically diastolic dysfunction is an energy deficit in a woman’s heart,” Sinatra explains. “Drugs don’t treat it. The only symptoms are fatigue and shortness of breath.” People who have high blood pressure are more likely to develop diastolic dysfunction.
Chronic inflammation also harms the heart. “Smoking, high blood pressure and high cholesterol all create an inflammatory response that then damages blood vessels. It can trigger plaques to rupture, which then causes the heart attack itself,” says Campbell. Inflammation is gauged by measuring levels of C-reactive protein, which increases in response to inflammation, in the blood.
Obesity may trigger inflammation. “Since estrogen is a factor in weight loss, a decrease in estrogen may lead to a bigger waist and inflammatory fat cells,” says Sinatra. A woman with a waist larger than 35 inches (40 inches for men) is at an increased risk for diabetes and heart disease.
Excessive weight is also a factor in metabolic syndrome, a cluster of risk factors that contribute to the buildup of plaque in arteries and is another leading contributor to heart attacks. In addition to obesity, this disorder includes high blood pressure, insulin resistance (the body’s inability to use insulin, which clears sugar from the bloodstream, properly), high triglycerides (blood fats) and low HDL. “Women struggling with their weight should have their HDL checked, as well as their fasting insulin and blood sugar to make sure they don’t have metabolic syndrome,” says Sinatra.
Promoting Cardiac Health
To help reduce heart disease risk, Sinatra recommends a high-quality multivitamin and what he calls the “awesome foursome”: coenzyme Q10 (100 to 200 milligrams a day), L-carnitine (1,000 mg one or two times a day), magnesium (400 to 600 mg a day) and D-ribose (5 grams twice a day). Sinatra says they all have been shown to have a favorable impact on cardiovascular health, adding, “This regimen will improve or offset diastolic dysfunction and improve energy substrates in the heart.” Sinatra recommends this regimen for any woman concerned with her heart health, not just someone at risk for heart disease.
Add fish or krill oil to the mix for even greater benefits. “Omega-3 fatty acids help improve one’s lipid profile and may help lower LDL slightly,” says Sayeed. “They may also help prevent fatal arrhythmias.”
Sayeed recommends avoiding fatty foods (especially fast food), limiting red meat to once a month and increasing both fresh produce and oily types of fish (such as salmon). “Watch portion sizes and high-sodium foods,” he warns. “Sodium contributes to hypertension and stiffness of the heart.”
Exercise also plays an important role in risk reduction. “Thirty minutes a day of cardiovascular exercise helps cut risk by half,” says Itchipouria. “Swimming, biking and brisk walking seven days a week for 30 minutes is helpful,” as is setting a goal of losing 10% of one’s body weight. For best results, though, you’ll need to pick up the pace, according to a study recently published in British Medicine Journal Open. Researchers monitored over 10,000 adults over a period of up to 10 years and found jogging or fast walking (two to four hours a week) more effective than walking at reducing heart attack and stroke risk.
Women also need to address their emotional needs. “Different feelings can release hormones, speed up your heart rate and increase blood pressure, activate various areas of your brain and turn into a catalyst for other physiological responses,” says Malissa Wood, MD, co-director of the Corrigan Women’s Heart Health Program at the Massachusetts General Hospital Heart Center in Boston and author of Smart at Heart (Celestial Arts). Wood recommends not rehashing old wounds—“As you relive events that cause anger or anxiety, your body reacts negatively,” she says—and broadening your perspective on life’s setbacks by being kind to others.
“Menopause is the time of a woman’s life when she needs to take stock of her lifestyle habits and look at ways to make it better,” says Campbell. “Stop smoking, try diet and exercise, and work with your healthcare provider to decide on goals. You can’t change genetics but you can change everything else.”
Dealing with Difficult Relationships
For many women, heart-threatening stress stems from dysfunctional, energy-sapping relationships. Such stress goes beyond marital difficulties to include troubled relationships with parents, children, relatives, friends and coworkers—any interpersonal interaction that consistently leaves you angry, depressed, frustrated or overwhelmed.
“Having healthy, meaningful relationships is just as important to your well-being as being at a healthy weight and not smoking,” says Malissa Wood, MD. “In fact, research shows that the relationship advantage is about the same as the mortality difference between smokers and nonsmokers.”
One way to fortify yourself against toxic relationships you can’t simply walk away from—an overcritical parent, for example—is to surround yourself with a positive, supportive people. Wood cites a 2008 UC San Diego study in which having a generally happy friend who lives nearby raises your chances of being happy by 25%. “I love this study because it proves that your happiness depends on the happiness of others with whom you are connected,” she says. Positive friendships also form a bulwark against loneliness, a significant stressor that leads to such measurable cardiovascular risks as high blood pressure. (Loneliness is not the same as solitude, the quiet alone time that everyone needs to a greater or lesser extent.)
You may have heard that health benefits are associated with marriage. Unfortunately, those benefits, such as better lifestyle habits, can be negated by marital difficulties. According to Wood, problems in a partnered relationship can compromise immune function as well as produce hormonal and other changes that can burden the heart.
Wood says one way to head off relationship problems, especially with a spouse, is spend time together that isn’t taken up with discussions of bills and soccer schedules. “For any relationship to grow, you need to take time to nurture it,” she notes. Many couples set aside a weekly date night so they can reconnect as friends and lovers.
All relationships will hit rocky patches; it’s the response to those times that determines whether people pull closer together or push further apart. The key? “Respect, respect, respect,” says Wood. “Treat your partner as you expect to be treated.”
Acknowledge that the other person has the right to their point of view, whether you agree with it or not, and don’t criticize or blame. Instead of becoming defensive and hostile, let them express their concerns—and separate those concerns from the person. For example, saying “You’ve always been such a lousy money manager. Why can’t you be more responsible?” will only exacerbate the problem. Saying instead, “I know we’re having problems with money right now. How can we work together to fix it?” acknowledges the situation without turning it into a character-bashing slugfest.
What’s more, don’t forget the power of positive reinforcement, even in small doses. “Give a boost to any relationship by doing something special for that person. It doesn’t have to be huge or expensive,” Wood advises.