By Jayne Morgan, M.D.

You may have heard me speak frequently on issues of health equity and marginalized and/or underrepresented groups. Well, you may be surprised to learn that women in menopause and pre-menopause are one of those marginalized, poorly understood and underrepresented groups. There is a lack of information on the actual therapy and support required for those going through menopause, with much of it still being slightly condescending. For instance, the following are real recommendations taken from recent print:

• Stay positive
• Do not smoke
• Make-over your make-up (to look better and therefore “feel” better, although so far, make-up has not been shown to relieve the physical symptoms of menopause nor provide protections for the heart)
• Color and cut thin hair to improve it
• Get good running shoes
• Breathe deeply
• Practice relaxation techniques

Part of the issue is that there hasn’t been sufficient data/information on menopausal women since the Women’s Health Initiative more than 25-30 years ago. After that, nothing further was done. That study essentially “proved” that not much could be done for menopausal women that would not increase the risk of breast cancer. It is a leading reason why increased female representation is needed in research leadership as well as Principal Investigators of clinical trials. Complicating the matter, heart disease is the #1 killer of women over the age of 25 and only increases after menopause.

What is the emerging thought now?

Estrogen MHT (menopausal hormone therapy)

Menopausal hormone therapy is medication that contains female hormones, usually either estrogen or a combination of estrogen and progestin. It was once routinely used to treat menopausal symptoms and protect long-term health. So how does it work?

You take the medication to replace the estrogen/hormones that your body stops making during menopause. Hormone therapy is most often used to treat common menopausal symptoms, including hot flashes and vaginal discomfort, and has been proven to prevent bone loss and reduce fractures in postmenopausal women. It’s also thought to decrease the risk of cardiovascular disease.

What else does it do for the heart?

In addition to decreasing the risk of osteoporosis and fractures (broken bones), it also increases the elasticity of blood vessels, allowing them to dilate and let blood flow more freely throughout the body. There can also be a potential improvement in glucose levels, thereby reducing the cardiovascular risk of prediabetes and diabetes. Additionally, estrogen has anti-inflammatory properties, and we now know that heart disease is often an inflammatory process.

Is hormone therapy right for you? Possibly. Speak with your doctor as it may not be recommended with the following conditions:

• History of prior heart attack or stroke and/or increased risk of vascular disease
• History of breast cancer
• Liver disease
• History of uterine cancer
• Elevated risk for blood clots or history of blood clots
• Unexplained vaginal bleeding

So, what is the bottom line?

New research continues to emerge on menopause and potential treatments. Talk with your doctor about whether MHT is an effective treatment option for you, especially regarding your cardiovascular status. This is both a complex and emerging topic, and you may want to seek out a physician with specific menopausal certification. As researchers learn more, recommendations may change.

What about cholesterol-lowering agents like statins?

During menopause, lipid levels can rise. Cholesterol-lowering statin drugs are a strategy employed to lower cholesterol in menopause and thereby decrease cardiovascular risk. Emerging data now shows that statins may negatively affect osteoporosis risk depending on the dose. In fact, although a low dose of statins may lower cholesterol and protect against osteoporosis, higher doses may increase the risk of osteoporosis. One recent research study out of Austria revealed that osteoporosis was more than three times as common in menopausal women who took statins, especially at higher doses.

What about menopausal symptoms?

• Hot flashes – both duration and intensity have a correlation to heart disease.
• Insomnia – shortened duration of sleep, inability to fall asleep, inability to stay asleep and frequent awakenings all increase the risk of hypertension.  If one enters menopause with hypertension, the symptoms of sleeplessness can further worsen blood pressure. Generalized decreased sleep (less than five hours per night) is also linked with an increase in heart disease.
• Beginning and/or worsening hypertension increases the risk of heart disease during and after menopause.

It is therefore important to speak with your doctor regarding the following:

• Sleep hygiene
• Blood pressure control
• Cholesterol re-assessment
• MHT