Menopause and Heart Disease
- with Paul Burstein, M.D., obstetrician/gynecologist with Columbia St. Mary's and Clinical Professor of Obstetrics and Gynecology at the University of Wisconsin

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Every few years, statisticians add another year or two to the average life expectancy of American women. Now women are living over a third of their lives after menopause. It's no wonder that physicians, applying the same logic and treatment they use for other hormonal deficiencies such as hypothyroidism, assumed that if menopause was a marker for aging, replacement of the missing hormones could keep women younger.

"This trend, beginning in the 1950s, reached its peak in the late 1960s when some physicians felt that menopause could be eliminated," said Dr. Paul Burstein, a gynecologist with Columbia St. Mary's and a clinical professor of obstetrics and gynecology at the University of Wisconsin.

Until recently, there was much observational data to support the notion that women on hormones were stronger and healthier with lower incidents of coronary disease. But this had not been formally studied. The Women's Health Initiative was intended to apply modern statistical analysis to these observations.

Dr. Paul Burstein, M.D., obstetrician/gynecologist with Columbia St. Mary's and Clinical Professor of Obstetrics and Gynecology at the University of Wisconsin "Prevention of heart disease goes back many years with healthy lifestyles; you can't simply prevent it at a certain stage in a women's life. If you look at women who took hormones, they tended to be leaner, to be less likely to smoke. They were more likely to exercise, to use more alcohol (a cardiovascular benefit) and they tended to be wealthier and have access to better health care. They would get better advice, get regular exams, get treatment for blood pressure. So the use of hormones was a marker for better health, not a cause of it."

But something interesting happened. A study that was expected to yield a 30% to 50% lower incidence of cardiovascular disease instead discovered that women were actually at higher risk for it if they were on hormones. "The study looked at the rest of the data and found more strokes, heart attacks and blood clots in women taking estrogen and progesterone," Dr. Burstein said.

So why the body of evidence suggesting that hormones offered protection? Dr. Burstein believes, as do many, that the observational data on women who chose to take hormones were looking at women who would naturally be healthier.

Preventing heart disease
HRT does alleviate other symptoms of menopause and protect against bone loss, but for women concerned about heart disease, regardless of whether or not they use hormones, other means of prevention need to be practiced.

Dr. Burstein believes women must return to other health-wise suggestions that have been known for years. These include:

• Getting people never to smoke or to stop smoking
• Looking at the huge epidemic of obesity in the U.S.
• Looking at diet, especially the identification and treatment of diabetes
• Looking at the other markers in treating heart disease


Women at risk
Heart disease in women doesn't just skyrocket at the age of menopause, nor do women's rates of heart disease ever quite reach those of men. But as they get older, it reaches a point where the risk of it is nearly equal.

The risk of heart disease is often hereditary. "There's the old saying that in terms of heart disease, like many things, we should pick our parents more carefully. So it's important that women be aware of their family history. If you have a lot of heart disease in the family, it's something your physician should check out," Dr. Burstein said.

Tests used in physicals include a fasting lipid panel, a total cholesterol panel showing the ratio of HDL, and triglyceride level. Many women whose levels are high may not need cholesterol lowering drugs, but should adopt better dietary habits, and lifestyle changes such as increased exercise. High homocystine levels also are an indicator of cardiac risk.

Another problem is high blood pressure. One of the reasons why women who used hormones were observed to have lower rates of heart disease is likely because their physicians did not ignore this problem. As is true with osteoporosis, the symptoms of high blood pressure are stealthy. In a woman who does not get regular checkups, the first sign of a problem may be a stroke or coronary event.

Treating the risk
There are many treatments when a physical or family history suggests heart risks.

For high cholesterol, there are dietary modifications and, for those who do not respond to these, the cholesterol lowering statin drugs. For high triglycerides, many doctors suggest a diet lower in refined sugar and fat. For high homocystine levels, the usual suggestion is to increase folic acid in the diet, either through eating more green vegetables, orange juice and bread or through use of a supplement, including inexpensive multivitamins.

Another easy preventative remedy for women as well as men are low doses of aspirin-81 mg, sometimes called "baby aspirin" although we do not give aspirin to babies anymore. "This is probably the best for women over the age of 50. There is a small potential risk of stomach irritation but it's an inexpensive way of getting cardiac benefit and it also may reduce the risk of colon cancer," Dr. Burstein said.

"Then there is calcium. Evidence suggests that adequate calcium intake is associated with lower risk of hypertension. It's also good for your bones. That's a multiple benefit - cheap and simple with very low risk," Dr. Burstein concluded.

To learn more about heart disease, click here.