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Frequency of menopausal symptoms associated with vascular dysfunction

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April 17, 2018

Kerry L. Hildreth

Increased frequency and severity of menopausal symptoms are associated with vascular dysfunction and lower quality of life during menopausal transition, according to findings published in Menopause.

Kerry L. Hildreth, MD, assistant professor for the University of Colorado School of Medicine’s division of geriatrics, and colleagues analyzed data from 138 women aged 19 to 70 years. Participants were stratified by menopausal stage: premenopausal, early or late perimenopausal, or early or late postmenopausal. Participants classified as premenopausal (n = 41) had regular menstrual cycles (21-35 days) with no change in cycle length and were aged 19 to 49 years. Generally, women aged 43 to 56 years were identified as perimenopausal if irregular cycles were observed. Of that group, participants were further classified as early perimenopausal (n = 25), defined as experiencing at least two menstrual cycles with cycle length changes of at least 7 days, and late perimenopausal (n = 26), defined as experiencing an absence of menstruation or amenorrhea for at least 2 months. Postmenopausal women presented with at least 12 months of amenorrhea and were aged 50 to 70 years. This group was also further categorized as early postmenopausal (n = 22) if the participant did not experience a menstrual cycle for up to 6 years and late postmenopausal (n = 24) if amenorrhea persisted for more than 6 years.

Researchers measured arterial stiffening and endothelial function using ultrasound imaging to determine carotid artery compliance and brachial artery flow-mediated dilation (FMD). Using the Menopausal Symptoms List (MSL), Hildreth and colleagues assessed menopausal symptoms in participants during a 3-month period. Specifically, MSL was used to evaluate the frequency and severity of eight psychological, nine vasosomatic and 10 general somatic symptoms. Depression was measured using the 20-item Center for Epidemiologic Studies Depression (CES-D) scale to assess frequency of depressive symptoms on a weekly basis. The Utian Quality of Life Scale (UQOL) was implemented to assess quality of life, monthly, by focusing on occupational, health, emotional and sexual subsets. To determine differences across the menopausal stages, Hildreth and colleagues used a one-way analysis of variance. To identify associations between vascular measures and MSL, CES-D and UQOL, Pearson’s correlation analysis was used.

While particularly prevalent in perimenopausal women, participants across all menopausal stages experienced worsened menopausal and depressive symptoms and impaired quality of life, according to the researchers. Researchers determined that carotid artery compliance and FMD (P < .05 for all) were inversely correlated with frequency and severity of vasomotor and general somatic symptoms, such as hot flashes. Similarly, there was a positive correlation between quality of life and carotid artery compliance (P = .01). The data did not show a correlation between carotid artery compliance or FMD with CES-D scores.

Researchers found that although frequency and severity of menopausal symptoms and a lower quality of life were associated with vascular dysfunction, depressive symptoms were not. Hildreth and colleagues recommended further study of the factors underlying these associations, such as inflammation or oxidative stress.

“The results suggest that the menopausal transition is a critical time for women’s health and highlight the connections between cardiovascular and mental health,” Hildreth told Endocrine Today. “We can’t make any conclusions about causation, but findings might encourage clinicians to pay closer attention to and routinely ask women nearing and in the perimenopausal and early postmenopausal years about physical, mental and emotional symptoms, in addition to addressing traditional cardiovascular risk factors, such as blood pressure, cholesterol, blood glucose and obesity.”

Disclosures: Hildreth reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.




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Joann Pinkerton

Previous studies have suggested that women with hot flashes have higher risk for heart disease. Menopause itself does not cause heart disease. However, an overall increase in heart attacks among women is seen about 10 years after menopause. The loss of estrogen, when combined with other habits, could increase risk for heart disease, such as eating a diet high in fat, drinking more than one alcoholic drink per night or being sedentary.

Estrogen appears to have a positive effect on the inner layer of the artery wall, which helps keep blood vessels flexible, allowing them to relax and expand depending on amount of blood flow.

This study found that postmenopausal women with more frequent or more severe menopausal symptoms had more arterial stiffening and vascular dysfunction, both of which have been associated with an increased risk for heart disease.

Women with frequent and/or severe menopausal symptoms need to be evaluated in the context of their own health risks and benefits, including their blood pressure, blood sugar and lipid levels (know their numbers), as these affect their risk for developing heart disease. Women who gain weight with menopause, particularly abdominal fat, have a higher risk for diabetes and heart disease. Lifestyle changes can help menopausal women decrease their risk for heart disease. These include regular aerobic exercise, 30 minutes per day, if possible, or 150 minutes over a week; at least 7 hours of sleep per night; management of stress; engagement in social interactions; eating a healthy diet, such as the Mediterranean diet; and working to avoid weight gain (keeping BMI below 25 kg/m2).

In addition to healthy eating and an active lifestyle, hormone therapy when started in women younger than 60 years or within 10 years of menopause has been associated with less heart disease and less mortality. HT is not recommended as the primary reason to prevent heart disease, but for women who are good candidates who have bothersome menopausal symptoms or elevated risk for heart disease, there may be benefits on the heart when started close to menopause. 

More studies are needed to understand the role that inflammation, oxidative stress and how estrogen may help or hurt vascular changes occurring beyond menopause. Is it the effect of the hot flashes on the vasculature, or are the hot flashes a sign of declining estrogen? If we treat the hot flashes with something other than estrogen, do we get the same benefits on the vasculature? Although estrogen is not recommended to prevent heart disease, understanding how it has beneficial effects on the heart when started closer to menopause or younger than 60 years is important to understanding the role of estrogen or its absence on women’s risk for heart disease as they age.

JoAnn Pinkerton, MD, NCMP

Executive Director for The North American Menopause Society

Professor of Obstetrics and Gynecology

Division of Midlife Health at the University of Virginia Health System

Disclosure: Pinkerton reports no relevant financial disclosures.