Menopause expert Dr Deirdre Lundy answers some common questions on the menopause and heart health

Following our extremely popular webinar on Menopause and heart health as part of the Her Heart Matters campaign, menopause expert Dr Deirdre Lundy answers some common questions that came up at the event.

Q. What is menopause?

A. The word ‘menopause’ means the end of periods and it usually happens by the time you are in your early 50’s.

The normal functioning of our main sex organs, the ovaries, drops off a cliff around this time and while some people really feel the loss of a regular predictable supply of hormones others may not. Therefore, going through the Menopause (or the Change) is not a nightmare for everybody, it is the luck of the draw really.

Menopause can start when you are much younger and sadly that often brings more noticeable symptoms.

We know that ovary function becomes less predictable as we pass the age of 35. The brain makes hormones that talk to the womb and ovaries and studies have shown that that conversation gets muddled long before the last day of your last ever period.

Q. What is perimenopause and what can I expect?

A. When you get menopause symptoms but are still getting periods, we call that this the perimenopause.

Perimenopause for some people can include, night sweats and hot flushes, period changes; really heavy or skipped bleeds, slowing metabolism leading to weight gain (especially around the middle), loss of collagen strength leading to changes in the walls and moisture of the vagina and more problems with leaking urine, pains in your joints and more.

I think the emotional symptoms, the depression, mood swings and irritability, rage and anxiety, chronic fatigue, memory lapses, poor concentration, brain fog and the loss of libido- might be little scarier to live with and harder to get help for as not all medical professionals recognise these as linked to menopause. You are likely to end up on anxiety / depression medication if you seek help for them.

Q. What about my Heart and the menopause?

A. We know the main ovary hormone  oestrogen to be God’s gift to females – Dr Nicola Cochrane- my partner in the NMH Menopause Speciality Service- calls it the ‘female privilege’.

We know that obstructive coronary heart disease (blockage of the arteries) tends to occur 7–10 years later in women than in men- women have fewer focal coronary artery blockages at all ages. We also know that higher oestrogen levels before the menopause are related to better vascular function, reduced coronary vessel inflammation, healthy kidney to heart ‘conversations and an increase in the width of blood vessels throughout the body but particularly in the circulation of the heart.  Healthy heart vessel lining is sensitive to the relaxing properties of oestrogen, but all this starts to reverse after menopause and vascular stiffness and atherosclerotic disease develops over time.

When we lose oestrogen, we start the slippery slope towards:

• Increased Body Mass Index and altered fat distribution
• Cholesterol: Increased LDL, Reduced HDL and Increased Triglycerides
• Increased Blood pressure
• Impaired sugar metabolism
• Impaired activity in cardiac blood vessel lining (endothelium)

all of which results in a four-fold increase in our risk of heart disease and stroke.

It is thought that premature menopause patients have a 53 per cent increased risk of heart disease however,  it is quite tricky to say how much of this disease is to do with early menopause and how much is associated with genetic factors and other issues such as weight, cholesterol, activity levels and smoking status etc. There are no randomised trials, only observational ones and the most recent, published in the JAMA in 2019- involved 144,260 females in the UK who had confirmed ovary hormone loss before 40 years of age. Researchers found a small but statistically significant increase in CVD with early menopause, but it needs more study.

Q. What can I do to reduce my risk of Cardiovascular disease (CVD) ?

A. We all need to:

• Move as much as we can
• Stop smoking if we can – get your GP to help (12 months after smoking cessation, the risk of cardiovascular disease related death is reduced by 50 per cent)
• Minimise drinking
• Get our Blood Pressure, cholesterol and sugars checked and under control
• Avoid overweight and obesity.

Q. HRT – what is it and can it prevent cardiovascular disease?

A. Irish women are 6 times more likely to die from CVD than breast cancer, but breast cancer is usually the Number 1 concern that people considering using HRT worry about. The good news is that HRT use for people under 50 appears to convey no added risk of breast cancer.

We do see an increased risk of breast cancer in women using HRT for more than five years after the age of 50 – it goes from 23 in 1,000 to 27 in 1,000. So, it is not without risk. However, two small or one large glass of wine a night also increases breast cancer risk to 27/1000 and having a BMI over 30 increases breast cancer risk to 47/1000.  So, we need to put things in perspective.

The bottom line is that for some women, the use of HRT is likely to do their hearts so much better than any harm it might do to their breasts.

But what about people who cannot use hormones- say after breast cancer? What about cancer treatments that can promote heart disease? There’s a lot more work needs to be done for women.

Q. Is HRT the answer?

A. 1 in 4 of us will have a stroke or heart attack in our lifetime and 5,000 Irish women die from CVD each year. Could we help reduce this risk with hormones or HRT? Maybe but we have to remember that there are other bits in us besides our heart and blood vessels so anything we do for one part of our body can have less healthy effects on other parts of us – it is therefore a balance between risk and benefit.

So, HRT is not a magic wand – 1 in 20 Irish Women over 15 yrs. of age are smokers- this is above the EU average. Binge drinking levels among Irish women is the highest in the EU.

With more than 6.8 per cent of women over 18 years of age reporting heavy binge drinking (2014)- there’s only so much an oestrogen pill can do.

Q.  Is there a best time to start HRT for Heart Protection?

A. In April 2022 the British Menopause Society reissued a paper that was first published in 2015 entitled ‘Primary prevention of coronary heart disease in women.’ This paper advised that HRT could protect some people against heart disease but needs to be started before they were ten years into their low oestrogen / post-menopausal life. It was found that oestrogen may have a protective role in CHD prevention especially if started in women under the age of 60 or within 10 years of the start of the menopause. Women with a premature menopause should take oestrogen to reduce the risk of CHD but other cardiovascular risk factors also need to be managed such as stopping smoking, reducing obesity, improving diet and undertaking regular exercise.  See www.womens-health-concern.org and search “heart disease” for more information.

Q. How long should I stay on HRT?

A. The protection afforded by HRT does not appear to last too long after you come off it although the evidence is poor, so we do not know for sure. The guidance groups do not put any arbitrary time limit on how long you might use HRT for – it is entirely up to you, and you might like to stick with it longer term if your main goal is good heart health.

Q. What if I missed the chance to start HRT before I turned 60?

A. If you are over 60 or it has been more than 10 years after your last period you can try HRT if you want it for symptom relief so long as you are well, your blood pressure is controlled, and your cholesterol is managed etc. However, if you try HRT as an older person, you should always start with a low dose, non-oral oestrogen, and ideally one of the more heart friendly progestogens.

Of course, you can try HRT if you are more than 10 years. after you last had a period but unfortunately you are unlikely to gain any heart protection at that point.

The most important things to know about HRT, particularly in relation to heart health, is start it under 60 and for maximal heart safety try and avoid the oral oestrogen- go for patches/ gels or the new spray. We are fussier about HRT products when we advise people wishing to start hormones later in life though. For women deep into their 60’s / 70’s and beyond, the risk of CVD and other circulatory diseases such as blood clots has already risen with advanced age- we know HRT won’t help their hearts much at this stage- but we worry if very late use of HRT might trigger something. In addition, it is unusual for someone to have persistent menopause flushes and sweats later in life and it might be a sign of something else

If you have already had a stroke or a heart attack, you should not start HRT without getting advice from a menopause specialist and/or your heart or stroke doctor first.

We accept patients who have been treated for stroke or heart attack or blood clots in our Holles St Service and would be happy to see you.

Get more information on menopause and your heart health from the Irish Heart Foundation’s Her Heart Matters campaign 

You can watch the webinar back here