How Your Heart Changes After Menopause

Much of the conversation around perimenopause and menopause is about symptoms — hot flashes, night sweats, brain fog and more — but another issue, potentially even more disruptive, is rarely talked about. Menopause is a risk factor for heart disease, increasing a woman's risk for heart attack and stroke.

Only 56% of women are aware that heart disease is the leading cause of death in women, according to a 2020 study in Circulation. And as millennials enter their perimenopausal years, only 12% of millennials feel "well-informed" about going through menopause, according to a survey report from Wrapp Consulting.

We spoke with Dr. Karla Kurrelmeyer, a Houston Methodist cardiologist who specializes in the treatment of heart disease in women, about how menopause affects the heart and what women can do to lower their risk for heart disease and stroke.

How does menopause affect heart disease risk?

Women are officially in menopause after going without a period or spotting for a full calendar year. The transition to menopause is different for every woman, but most women will enter perimenopause (the symptomatic period leading to menopause) between the ages of 45 and 55.

The average age of menopause for women in the U.S. is 52 years old, but women can reach menopause earlier or later based on a variety of factors. It's during this perimenopausal period that the body gradually produces less estrogen and progesterone, two endogenous hormones important to many of the body's functions, and heart disease risk factors develop.

"It doesn't happen all at once," Dr. Kurrelmeyer says. "People think when the period stops, then the hormones are gone. That's not the way it works; the hormones just slowly dip down. All the changes in risk factors that we see are just mirroring what's happening to those hormone levels. As the levels slowly dip over five to 10 years, we see the effect on the cholesterol panel: The triglycerides go up, the LDL goes up, and the good cholesterol, HDL, goes down."

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These hormonal changes also affect our blood pressure and body weight. Dr. Kurrelmeyer says that estrogen and progesterone have protective effects on the heart, as they help naturally lower blood pressure and relax blood vessels, allowing for increased blood flow and protection against plaque formation and narrowing of the vessels. Losing estrogen and progesterone triggers metabolic changes that affect our muscle tone.

"When you lose your endogenous hormones, your blood pressure goes up, and it affects your muscle mass," Dr. Kurrelmeyer says. "As you lose muscle mass, it's not like you lose weight. You actually put on fat mass, especially around the midsection, which is another risk factor. During menopause, you can easily slip into metabolic syndrome, which also puts you at increased risk for heart disease unless you work really hard with your diet and exercise."

Dr. Kurrelmeyer also emphasizes that developing metabolic syndrome increases the risk of developing insulin resistance, which causes prediabetes or diabetes. Both conditions are risk factors for heart disease.

Menopause can be a perfect storm, Dr. Kurrelmeyer emphasizes. These risk factors can develop all at once, albeit slowly, even if blood pressure, cholesterol, blood sugar or weight issues weren't part of a woman's life before the change. The net result: additional stress on top of any perimenopausal symptoms.

Does early menopause put women at even higher risk for heart disease?

Women may reach menopause at younger ages for a variety of reasons. It can occur naturally or be induced medically by surgical removal of the ovaries or due to a variety of different medical conditions. Dr. Kurrelmeyer says that defining early menopause can be confusing, as some literature defines it as occurring before age 45, while other studies define it as occurring before age 40. Whether before 40 or 45, what's true is that your risk timeline moves up.

"It increases your risk for future cardiovascular events significantly because you've lost 5 to 10 years of the protective effect of estrogen," Dr. Kurrelmeyer says. "Early menopause is considered a risk enhancer, and a risk enhancer is just that, it elevates your risk, but not to the same degree as a risk factor like diabetes, high blood pressure or high cholesterol. Family history is also a risk enhancer, but enhancers don't have as high a predictive power as the risk factors do."

Do other conditions increase heart disease risk during menopause?

Women with certain autoimmune conditions or who experienced challenges during pregnancy may want to pay particular attention to their heart health during the perimenopausal period.

"There are other sex-specific risk enhancers women need to be aware of that elevate their risk," says Dr. Kurrelmeyer, who adds that these women may want to come in and see a cardiologist earlier. "Autoimmune diseases like lupus, rheumatoid arthritis and psoriasis may cause inflammation levels in your blood to be high, which increases your risk of plaque rupture even if there is a small amount of plaque in the blood vessels in the heart, causing a heart attack."

According to Dr. Kurrelmeyer, data shows that experiencing pregnancy complications is another risk enhancer. Conditions including gestational hypertension; gestational diabetes; maternal placental syndromes, such as preeclampsia or placental abruption, where there was fetal demise; pregnancy with a fetus small for gestational age (SGA); and HELLP (hemolysis, elevated liver enzymes and low platelets) syndrome are all risk enhancers of developing heart issues.

"Pregnancy is like a stress test, right? When women experience conditions like these, it shows that their cardiovascular system has trouble adjusting to their body's demands," Dr. Kurrelmeyer says. "If you've had one of these pregnancy experiences, it significantly increases your risk for future heart events, so you need to come in early for a preventive visit. Don't wait until you're 60 or 65, you need to come in when you are going through menopause in order to know your numbers and get them where they need to be to lower your risk of a future heart attack."

Does menopause cause heart palpitations?

Estrogen and progesterone levels can affect the heart's electrical system. As levels of these hormones decline, it can cause "misfires" within the electrical system, causing heart palpitations.

"Though it's sometimes premature ventricular beats, it's usually just premature atrial beats that will sometimes occur in a row and cause paroxysmal atrial tachycardia," Dr. Kurrelmeyer says. "That just means premature beats in a row for seconds to minutes, and then they are gone."

Dr. Kurrelmeyer says that patients describe paroxysmal atrial tachycardia as feeling like a flutter sensation, or a flip-flop sensation if they have premature atrial beats. Women are most at risk for these heart palpitations during times of significant hormonal changes, including puberty, pregnancy and menopause.

"Usually, they're short-lived as the body adjusts to those decreasing levels of hormones, or those increasing levels of hormones, as it is in pregnancy and menarche (the first menstrual cycle)," Dr. Kurrelmeyer says. "But, again, usually they're just a nuisance, and it's usually not any sort of pathological arrhythmia."

It's important to note that heart palpitations aren't always related to hormone levels. Anything from dehydration, lack of sleep, caffeine intake and stress can play a part in the heart skipping a couple of beats. While the occasional palpitation is benign, not all are. Seek care if you're experiencing:

• Chest or back pain
• Shortness of breath
• Trouble breathing
• Fainting or dizziness
• Nausea
• Vomiting
• A prolonged period of heart palpitations

Does hormone replacement therapy affect heart health?

While the use of hormone replacement therapy (HRT) has been a hotly debated topic for many years due to concerns about health risks with long-term use, it remains one of the most effective treatments for menopausal symptoms. A recent study published by the Menopause Society reported that women who took conjugated equine estrogens (CEE) alone or CEE plus medroxyprogesterone acetate (MPA) also had improvements in all heart biomarkers except for triglycerides.

Both treatment courses showed favorable results, but CEE alone showed more improvements in heart risk factors. And while this is good news, the truth is that HRT is not for everyone (more on that later), especially those with pre-existing heart disease or a high calcified plaque burden in their heart arteries.

Do women with a family history of heart disease need to manage menopause symptoms differently?

A woman's total risk profile, including family history, needs to be taken into account when considering appropriate treatments for menopause symptoms.

"If a heart scan shows that they're in the high-risk category for the short term or long term, such as a calcium score of more than 300, then I recommend not taking hormone replacement therapy, because of a high risk for cardiovascular events which may be increased event higher with HRT," Dr. Kurrelmeyer says. "Those women would need to talk to their gynecologist about other options to treat menopause symptoms. Based on the HERS trial, we know that in women who previously had stents, bypass, heart attack or strokes, hormone replacement therapy increased risk for more events."

Dr. Kurrelmeyer says that women with a calcium score less than 300 can take HRT for a very short term, because their risk of a heart event is lower. Women should work with their OB-GYN or cardiologist to understand if HRT is appropriate for them based on their current heart health determined by risk factors, risk enhancers and most importantly, their coronary artery calcium score.

What can women do to protect their heart health during perimenopause?

While perimenopause lasts about four years for most women, others may be in the transition for only a few months, and some can experience symptoms for a decade. Whether your time in perimenopause is long or short, the same healthy habits can get you through vasomotor symptoms of menopause, such as hot flashes and night sweats.

Dr. Kurrelmeyer recommends that women follow a heart-healthy diet, such as the Mediterranean diet, since it is the most rigorously studied.

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Additionally, Dr. Kurrelmeyer recommends getting 150 minutes of vigorous exercise each week — this should include moderate- to high-intensity aerobic activities at least three times a week combined with strength training on other days. Strength training isn't about powerlifting or bodybuilding, she says, it's about combating muscle loss so you can stay active and maintain everyday activities as you age.

"If you're doing all of these things and having issues, it's crucial to talk with your doctor," Dr. Kurrelmeyer says.

When should a woman consider seeing a cardiologist?

Dr. Kurrelmeyer recommends that women consider a checkup with a cardiologist after they've confirmed with their gynecologist that they've experienced menopause or they know that they haven't had a period in a full year. Women who experience surgical, medical or premature menopause will come in for evaluation at younger ages, usually in their 40s. But for most women, this visit will occur in their 50s.

"When women are perimenopausal, hormone levels are rapidly changing, and your cholesterol, blood pressure, weight, fasting glucose levels may not be at their new levels until menopause has occurred," Dr. Kurrelmeyer says. "If you have not had a heart attack, stroke, stent, bypass, diabetes mellitus, peripheral vascular disease or chronic kidney disease, I suggest waiting to see a cardiologist until after menopause has been confirmed to avoid a false sense of security when you receive your numbers, since they may still reflect the beneficial effects of estrogen if you are in the pre or perimenopausal period."