Women and heart disease: The menopause years

I remember when I experienced my first night sweat.  It was a couple of days before my 50th birthday. I had already been experiencing poor sleep for years. 

I knew these were all signs of impending menopause, but I also knew there wasn’t much to be done to treat the symptoms. After all, hormone therapy was dangerous. 

At least that’s what I had been told based upon the findings of a seminal scientific study.

Turns out, that study was flawed…

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Jumping to conclusions

The Women’s Health Initiative (WHI) was meant to evaluate the long-term health outcomes of postmenopausal women placed on hormone replacement therapy (HRT). It commenced in 1998. 

Based on signals from smaller studies, there were high hopes that placing women on HRT was going to help them live longer better and that this large study would finally prove it. 

Instead, the study was stopped abruptly in the early 2000s when investigators found that HRT put women at increased risk of heart disease, blood clots and breast cancer. 

Panic ensued and women taking HRT were taken off the drugs immediately while women entering menopause were advised against ever using hormones.

However, if you look at the trial design in retrospect, there were many shortcomings that clearly influenced the results…  

The study used estrogen pills not patches — and we now know that estrogen delivered through the skin is processed completely differently inside our bodies and has much different effects on blood clotting. In addition, many of the women included in the trial were years, if not decades, out from menopause, complicating results interpretation.

A second look

When researchers subsequently reanalyzed the data they came to a different conclusion…

Women who used hormone replacement therapy near the onset of menopause were at no greater risk of negative health events.

In fact, using hormone replacement therapy at the correct time in the correct patient at the correct dose and in the correct combinations helps prevent osteoporosis, has little effect on cancer risk and could even lessen the risk of heart disease.

A couple of caveats: women with a history of breast or reproductive system cancers — or a strong family history of these — should probably still avoid HRT, and HRT should not be used to prevent heart disease as the sole indication (modification of other risk factors is a far more powerful intervention).

Unfortunately, the corrected message came too late to undo the dire headlines published in the early wake of study results or the original treatment guidelines that followed.

Today many women — and even doctors — still aren’t up to date on the current research. That’s a problem for many reasons, the most important being the unnecessary withholding of therapy that could markedly improve quality of life. 

Not to mention that, according to a new Mayo Clinic study, managing menopause symptoms comes at an estimated societal cost of $1.8 billion in lost work time per year and $26.6 billion annually when medical expenses are added.

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HRT is not for everyone

Women need to determine if this is an appropriate treatment for them given symptom severity, their individual risk of cancer, and other health issues that may be present. 

My best advice is to talk to your doctor about hormone replacement therapy and other, nonhormonal options that could be available to you, especially if you are experiencing perimenopausal symptoms and are under age 60. 

Your OBGYN is probably your best resource, and I would start there. If you don’t have an OBGYN or your doctor is not trained in menopause — not all are — here is a list of providers who have this expertise, courtesy of the North American Menopause Society.

Beyond dealing with perimenopause and the symptoms that go along with hormone changes, it bears emphasizing that heart disease risk accelerates during this time. 

Loss of estrogen, specifically, causes LDL (bad) cholesterol to rise. So make sure you’re taking advantage of all the ways that nutrition and lifestyle can help keep your cholesterol profile in a healthy range.

If you’re thinking about making dietary changes, remember that Step One Foods can kickstart that process with easy, twice-a-day food swaps.

Next week, I’ll be back with tips for keeping your heart in tip-top shape after menopause.

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Dr. Elizabeth Klodas MD, FACC

By Dr. Elizabeth Klodas MD, FACC

"Diet is a major driver of high cholesterol, but instead of changing the food, we prescribe medications. This never seemed logical to me.” Dr. Klodas has dedicated her career to preventive cardiology. Trained at Mayo Clinic and Johns Hopkins, she is the founder and Chief Medical Officer for Step One Foods. Dr. Klodas is a nationally sought out speaker and has an active role at the American College of Cardiology. Her clinical interests include prevention of heart disease and non-invasive cardiac imaging and she has published dozens of scientific articles throughout her career. Dr. Klodas has been featured on CNN Health for her mission to change how heart disease is treated. An independent study performed at leading medical institutions affirmed the ability of Step One Foods to deliver measurable and meaningful cholesterol-reduction benefits in the real world. The results of the trial were presented at the 2018 American Heart Association’s Scientific Sessions. Dr. Klodas has also authored a book for patients, "Slay the Giant: The Power of Prevention in Defeating Heart Disease," and served as founding Editor-in-Chief of the patient education effort of the American College of Cardiology. In addition to her practice and her duties at Step One Foods, she also serves as medical editor for webMD.