As a woman enters menopause, there’s a lot of talk about hot flashes, night sweats, and mood swings—but one crucial aspect of health that often gets overshadowed is cardiovascular health. In fact, heart disease is the leading cause of death for women, and the risk increases significantly after menopause. Let’s talk about why that happens, how cardiovascular risk is assessed, and—most importantly—what you can do to protect your heart.
Why Does Cardiovascular Risk Increase During Menopause?
The drop in estrogen during menopause is linked to various cardiovascular risks. Estrogen plays a protective role, particularly by maintaining flexible blood vessels and favorable cholesterol levels. As estrogen declines, women often experience increased blood pressure, higher LDL cholesterol, and stiffer arteries, raising their risk for heart disease.
Research shows that during perimenopause, women's blood pressure tends to rise, and markers of inflammation like C-reactive protein may increase. The combination of these changes, along with altered cholesterol levels, makes perimenopause a critical time for cardiovascular risk assessment and intervention.
Beyond the hormonal shifts, menopause brings other changes that can further impact cardiovascular health:
Weight Gain: Many women experience changes in body composition, particularly increased abdominal fat, which is closely linked to heart disease.
Higher Blood Pressure: Blood pressure often increases during menopause due to aging and changes in blood vessels, putting more strain on the heart.
Increased LDL Cholesterol: After menopause, LDL cholesterol levels—the type that can clog arteries—tend to rise, while HDL cholesterol (the "good" kind) often stays the same or even decreases.
Insulin Resistance: Menopause can also exacerbate insulin resistance, which raises the risk of type 2 diabetes—another major factor in heart disease.
How Is Your Cardiovascular Risk Calculated?
Understanding your cardiovascular risk is an important step toward prevention. One common way to assess this is through the Atherosclerotic Cardiovascular Disease (ASCVD) Risk Score. This score estimates the likelihood of having a heart attack or stroke in the next 10 years, based on factors like:
Age
Cholesterol levels (both LDL and HDL)
Blood pressure
Smoking status
History of diabetes
Family history of heart disease
The ASCVD risk score helps guide treatment decisions, including whether lifestyle changes are enough or whether medication might be needed, such as statins to lower cholesterol.
The Calcium Cardio Score: A Deeper Look at Heart Health
Another important tool in assessing cardiovascular risk is the Coronary Artery Calcium (CAC) score, often called the "calcium cardio score." This score is derived from a specialized CT scan that detects calcium deposits in the arteries around your heart. The presence of calcium indicates plaque buildup, which can restrict blood flow and lead to heart attacks or other cardiovascular events.
The CAC score can help identify women who may not show traditional risk factors (like high cholesterol or high blood pressure) but still have significant plaque buildup. This test is particularly useful for menopausal women, as it can provide a more complete picture of cardiovascular health. Here’s how it works:
A CAC score of zero indicates no calcified plaque and a very low risk of cardiovascular events.
Scores of 1-99 suggest mild plaque buildup and moderate risk.
Scores over 100** indicate significant plaque, suggesting a higher risk of heart disease or stroke.
When Might Your Doctor Recommend a CAC Test?
The CAC test isn’t routinely performed on everyone. Your doctor might suggest this test if you fall into a gray area where treatment decisions are unclear based on your ASCVD risk score or other cardiovascular risk factors. For instance:
Intermediate ASCVD Risk: If your ASCVD risk score is in the intermediate range (typically between 5-20% risk of a cardiovascular event in the next 10 years), and it's not clear whether you should start on a statin or other preventive medication, a CAC score can help clarify your risk. A score of zero may suggest you don’t need medication, while a higher score could indicate that more aggressive management, like starting statins, would be beneficial.
Family History of Heart Disease: If you have a strong family history of heart disease but don’t have other significant risk factors (like high blood pressure or cholesterol), your doctor might use the CAC test to assess whether you’ve developed early plaque buildup.
Mixed or Conflicting Risk Factors: If your cholesterol levels are borderline or you have a combination of factors that don’t give a clear picture of risk (like normal cholesterol but high blood pressure), a CAC score can offer more insight.
High LDL Cholesterol but No Other Risk Factors: For some women with isolated high LDL cholesterol but otherwise low risk, the CAC score helps gauge whether the cholesterol is leading to plaque buildup. If your CAC score is low, your doctor might opt to monitor rather than start medication right away.
Early Menopause or Other Non-Traditional Risk Factors: If you went through menopause early (before age 40) or have other less traditional risk factors, like autoimmune diseases (which are more common in women), a CAC score could help identify whether your heart health is already being impacted.
In essence, the CAC test allows for more personalized decision-making. If your ASCVD score or other risk factors don’t point clearly to a treatment path, the CAC score can provide clarity about the health of your arteries, helping your doctor tailor recommendations more precisely to your needs.
How Lifestyle Changes Can Help
While tools like the ASCVD risk score and CAC score are helpful for assessing risk, lifestyle changes remain the cornerstone of heart disease prevention. In fact, many women can significantly reduce their risk with a few key modifications:
1. Stay Physically Active
Exercise is one of the best ways to support cardiovascular health. It helps maintain a healthy weight, reduces blood pressure, and improves cholesterol levels. The American Heart Association recommends at least 150 minutes of moderate-intensity exercise per week, which could be brisk walking, cycling, or swimming. Resistance training (with heavy weights) is also important for preserving muscle mass and supporting metabolic health.
2. Adopt a Heart-Healthy Diet
The foods you eat play a significant role in cardiovascular health, especially during menopause. A Mediterranean-style diet—rich in vegetables, fruits, whole grains, lean protein, and healthy fats like olive oil—has been shown to lower the risk of heart disease. It can also help manage cholesterol levels and support weight management. Limit processed foods, added sugars, and unhealthy fats, especially trans fats, which are known to increase LDL cholesterol.
3. Manage Stress
Stress can take a heavy toll on your heart, especially when it becomes chronic. Unfortunately, many women find that stress intensifies during menopause due to physical changes, sleep disruptions, or life circumstances. It’s essential to adopt stress-reducing practices like mindfulness, yoga, deep breathing exercises, or even regular walks in nature. These habits not only soothe the mind but also have positive effects on blood pressure and heart health.
4. Get Enough Sleep
Menopause can wreak havoc on your sleep, and poor sleep is closely linked to heart disease. Research shows that inadequate or poor-quality sleep can increase blood pressure, promote inflammation, and even contribute to weight gain. Prioritize good sleep hygiene by maintaining a consistent sleep schedule, creating a calm sleep environment, and considering strategies like Cognitive Behavioral Therapy for Insomnia (CBT-I) if sleep becomes a persistent issue.
5. Quit Smoking
Smoking significantly raises the risk of heart disease, and that risk becomes even higher after menopause. If you smoke, quitting is one of the best things you can do for your cardiovascular health. There are a variety of tools to help you stop smoking, including nicotine replacement therapy, medications, and behavioral therapy.
Treatment Options to Support Heart Health
If lifestyle changes aren’t enough to bring your cardiovascular risk under control, there are effective treatment options to consider. These include:
1. Statins
Statins are medications that lower LDL cholesterol, helping to prevent plaque buildup in the arteries. If your cholesterol levels are high or your ASCVD risk score suggests you're at moderate or high risk for heart disease, your doctor may recommend statins to help protect your heart.
2. Blood Pressure Medications
High blood pressure is a major risk factor for heart disease, and if lifestyle changes aren’t enough to keep it under control, your doctor may prescribe medications such as ACE inhibitors, beta-blockers, or diuretics.
3. Menopausal Hormone Therapy (MHT)
The long-debated role of hormone therapy in heart health is being re-evaluated. New studies suggest that estrogen-based hormone therapy can have favorable effects on cardiovascular biomarkers, except for triglycerides. However, the risks and benefits of MHT are individualized, and it is typically not used solely for heart disease prevention. Be aware that MHT isn’t for everyone, so it’s important to discuss the risks and benefits with your doctor to see if it’s right for you.
A New Chapter for Your Heart Health
Menopause is not just about managing symptoms; it’s a time to actively protect your long-term health. Taking steps to safeguard your heart during menopause can dramatically improve your quality of life and reduce the risk of heart disease in the future. By staying active, eating well, managing stress, and working with your healthcare provider, you can empower yourself to embrace this new chapter with confidence and strength.
Understanding your cardiovascular risk and knowing what actions to take are key to maintaining heart health for years to come. Your healthcare provider is your partner in this journey—don’t hesitate to ask about your risk score, CAC testing, or treatment options that can help you thrive during menopause and beyond.
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