Dr Nicola Cochrane from the Specialist Menopause Clinic at the National Maternity Hospital in Dublin, answers some frequently asked questions on heart disease, stroke and menopause.

Q. Are women in Ireland aware of heart disease to the same degree as other illnesses that can affect them such as breast cancer?

A. I think most Irish people consider that heart disease is predominantly an issue for men and very elderly people. There have been consistent media campaigns highlighting breast cancer which leaves many women considering that it is much more important. While breast cancer is also a very important issue, current census statistics demonstrate that more women die every year in Ireland from cardiovascular disease (heart disease and stroke) than breast, ovarian and cervical cancer combined.

Q. Are women aware of the impact of menopause on their hearts?

A. Women are consistently surprised to learn of the changes which happen to their heart and circulation as a result of menopause. I think we need to work harder to raise awareness of menopause and heart disease.

Q. What is the impact of menopause on the cardiovascular system?

A. When oestrogen levels decline women undergo profound metabolic changes and may progress to a condition known as Metabolic Syndrome.

Metabolic Syndrome is the medical term for a group of conditions such as high blood pressure, obesity and high blood sugar levels that together increase your risk of developing heart disease, stroke and other conditions.

We know that menopause causes fat to deposit in the trunk and surrounding vital organs. Women develop levels of insulin resistance which provokes weight gain and further fat deposition. Levels of cholesterol rise with higher LDL cholesterol (bad cholesterol) which can then coat the lining of the blood vessels leading to reduced blood flow. Blood pressure levels increase. These changes increase rates of heart disease and stroke in women during the years after menopause.

Q. Does menopause increase a woman’s risk of heart disease/heart attack/ stroke and why?

A. Research has shown that menopause increases the risk of heart disease and stroke in women due to Metabolic Syndrome by 50 per cent (Dr John Stevenson BMS 2022). However, it is important to recognise that each individual may have other factors such as a family history of heart disease, smoking status, activity level, diabetes and overweight or obesity.

Q. Does the age that you experience menopause impact the effect of menopause on your heart? Do any other factors affect this e.g. surgical menopause?

A. Younger women who develop premature menopause, early Menopause or surgical menopause (where the ovaries are removed) have much higher risks of heart disease because they have lost their oestrogen prematurely. They have a reduced life expectancy of more than two years mainly due to heart events and stroke. The International Menopause Society and British Menopause Society recommend that these women are counselled about heart disease and recommended to use hormone therapy until at least the age of 50 unless there is a reason why oestrogen is not recommended.

Q. Are women from certain social groups or ethnicities more prone to heart disease in menopause and why?

A. Women from lower socioeconomic groups will typically have more risk of heart disease due to a combination of poor access to information and healthcare, higher rates of smoking, less exercise and more weight gain.

There is a great opportunity to help these women to protect themselves by providing information about managing menopause and preventing heart disease. They need easier access to trained health professionals to have perimenopause health screening and lifestyle advice.

Risks of heart disease vary widely throughout the world due to genetic, dietary and lifestyle factors. There have been some very interesting studies on people who have migrated around the world and how much their risks change as a result.

Q. Is HRT recommended if you have had a heart attack or stroke?

A. Introducing estrogen after a woman has a heart attack or stroke can be done but the decision needs to be shared with their cardiologist and where possible a menopause specialist while taking all aspects of that woman’s individual medical history into account.

In these cases, a decision to start HRT does carry a small risk of a further event in the first six  months but long term studies show better survival rates in women on HRT. When oestrogen therapy is started , a transdermal (absorbed through the skin like a cream or a gel) oestrogen is used at a very low dose and this dose is increased very slowly over the following months. We have good evidence to support the safety of a gentle introduction of transdermal oestrogen in women after heart attack or stroke.

Q. What are the concerns about HRT treatment for people living with heart disease/stroke does HRT increase your risk of heart disease?

A. The situation for women with established heart disease prior to starting HRT is that they are unlikely to experience specific cardiovascular protection from using HRT but the hormone therapy is also not going to increase their risk of heart disease.

Q. Is HRT safe for people with heart disease/heart attack/ stroke survivors

A. Women who have heart disease have suffered a heart attack or stroke have a higher risk of a blood clot forming in their circulation and for that reason oestrogen is provided trans dermally (absorbed through the skin like a cream or a gel) . Transdermal oestrogen has been found to be safe to use in women who have risks of a blood clot.

Q. What can menopausal women do to reduce their risk of heart disease?

A. There is so much we can do to reduce our risk of heart disease at menopause. Women who smoke can try to quit and use this milestone in their lives to try to break the habit. There are supports available to help people quit smoking like ww.quit.ie

If we walk for 30 minutes every day we protect our hearts. We can also look at making smarter choices at mealtimes by avoiding foods with saturated fats, choosing oily fish, chicken or having meat free days and reducing carbohydrates such as bread. All of this can help balance the changes in our metabolism and prevent cholesterol levels rising. Talk to your GP if you have family members who had a heart attack or stroke under the age of 60 and consider having a cholesterol test .

Q. Can you talk about your work at the specialist Menopause Clinic at Holles St, what types of cases do you see?

A. I work with Dr Deirdre Lundy Menopause expert and Claire McEvoy, Menopause Specialist Nurse at the National Maternity Hospital in Holles St,  where we run a Complex Menopause Clinic. We receive referrals from GPs for women who have had significant health problems that is complicating their menopause care or younger women with premature menopause.

The types of problems we see are women who have had a previous cancer , women with heart disease or problems with blood clotting and those who have liver disease or HIV.

We can arrange suitable investigations according to the clinical problem and have access to specialists where an opinion is needed. We will often provide HRT to these women using strategies to do this safely. In women who have been treated for certain conditions where HRT may not be suitable such as breast cancer, we offer a range of no-risk, non-hormonal options as first line to combat their symptoms.

We hope to expand the range of services available to women over time and are delighted to be part of an establishing network of menopause specialist services around the country.

Q. What advice would you give to women living with heart disease trying to navigate menopause?

A. There are so many things can do to feel stronger, happier and healthier and if menopause symptoms are not solved by simple lifestyle changes then talk to your GP about starting HRT. It can be a whole lot easier to get outdoors and exercise and make smart food choices if you are not drenched in sweat, sleep-deprived and angry.

Q. What one message would you like to give to all women about heart health?

A. Heart health is the most important priority of menopause care. Early treatment with oestrogen in suitable women can delay and prevent changes in our arteries. Treat yourself to a pit stop with your GP to look at the best choices for you.

Dr Nicola Cochrane is a GP and expert in women’s health and the menopause. Coupled with her work in the specialist menopause clinic in the National Maternity Hospital, Holles St she also works as a GP in Greystones, Co Wicklow.