In 2022, Healthcare Care for Women International published an article highlighting the early onset of menopause among women. It also noted a concerning increase in heart diseases affecting women and children. The ratio of men to women was initially 3:2, but after menopause, it equalizes to 1:1. Despite extensive research, a noticeable gender disparity remains, with women being more prone to ischemic heart diseases. The age group most susceptible to cardiovascular disease (CVD) risk is 55 years and above.
The risk factors for cardiovascular disease (CVD) are influenced by various factors, including environmental, economic, social, and biological aspects. A significant study conducted in 1976 by Framingham revealed a 2.7-fold higher incidence of CV diseases among post-menopausal women compared to pre-menopausal women. The physiological process of menopause involves a decline in ovarian follicle function and a decrease in ovarian hormones, leading to several changes. Estrogen, a hormone with direct effects on vascular cells and tissues, operates through two distinct pathways known as the 'genomic' and 'non-genomic' pathways.
The reasons for CVD risk are multifactorial ranging from environmental, economic, social, and biological factors (2). According to Framingham, the earliest study done in 1976 showed a 2.7-fold higher incidence of CV diseases when post-menopausal women were compared to pre-menopausal women (3). During the physiologic wave of menopause, there is a loss of ovarian follicle function with a decrease in ovarian hormone which leads to many alterations.
The estrogen hormone has a direct effect on vascular cells and tissues. It enacts two different pathways the ‘genomic’ and ‘non-genomic’. The ‘non-genomic’ pathway is the main factor that conducts rapid effects like vasodilation. Hence, estrogen plays an important role inhibition of atherosclerosis (4). The transition into menopause also shows a spike in lipid profile making the postmenopausal population inclined to a tremendous amount of weight gain. Though this weight gain is pretty normal, there is fat deposition on both epicardial and pericardial.
The epicardial adipose tissue which lies between the myocardium and pericardium along with paracardial adipose tissue which is anterior to the epicardial can go under alterations due to fat deposition. According to SWAN cardiovascular fat ancillary studies, the peri/post-menopausal women had more than 9.9% more epicardial adipose tissue and 20.7% more paracardial adipose tissue than premenopausal women (5).
The role of estrogen is very prominent in fat deposition in distribution. Pre-menopause the fat is usually deposited in the thighs, hips, and buttocks. During menopause, weight gain is seen steadily, there increase in visceral fat, insulin resistance, diabetes, inflammation, and metabolic syndrome (6). Diabetes Miletus [DM] is the most common metabolic syndrome seen in the Indian population, having DM increases the 1.81-fold increased risk of death from IHD compared to those without DM. Along with this data, the risk of heart failure is 5-fold whereas in non-diabetic women it is 2-fold higher compared to non-diabetic men (7).
Estrogen possesses an antioxidant effect at high concentrations, whereas it tends to be pro-oxidative at low concentrations. The production of free radicals such as reactive oxidization species (ROS) and decreased antioxidant levels can lead to atherosclerosis. Oxidative stress tends to increase the inflammatory cytokines and pro-oxidants, leading to a decreased level of nitric oxide, ultimately causing smooth muscle proliferation, vascular pathogenic, inflammation, and finally endothelial dysfunction (6). The role of estrogen is substantial. It has a trajectory in cerebrovascular which is quite crucial. The neuroprotective functions served by estrogen can lead to cerebrovascular dysfunction and influence adverse cognitive effects (6).
The mortality rate is higher with CVD when compared to breast and other types of cancers. The prevalence of heart failure in women has doubled from 1.1% in 2000 to 2.6% in 2015 (8). These raising numbers are alarming and need an urgent highlighting of this issue. According to the 2019 Lok Sabha report, there are no public health policies in India that exclusively include women undergoing menopause. Therefore, no attempts are yet made to the significance of the Indian context. Regulating awareness, setting up free medical camps, reducing social stigma, introducing a healthy lifestyle, and making healthcare affordable can prove pivotal in improving post-menopause care.
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References
Kisan Algur, Ruchita Sakpal. Premature menopausal women and risk of cardiovascular diseases in India: Longitudinal Aging Study in India, 2017–18. 11 Nov 2022. Healthcare Care for Women International.
Aggarwal NR, Patel HN, Mehta LS, et al. Sex differences in ischemic heart disease: advances, obstacles, and next steps. Circ Cardiovasc Qual Outcomes 2018; 11: e004437.
Kannel WB, Hjortland MC, McNamara PM, et al. Menopause and risk of cardiovascular disease: the Framingham study. Ann Intern Med 1976; 85: 447–452.
Mendelsohn ME, Karas RH. The protective effects of estrogen on the cardiovascular system. N Engl J Med 1999; 340: 1801–1811.
Samargandy S., Matthews K., Janssen I., et al. Central arterial stiffness increases within one- year interval of the final menstrual period in midlife women: Study of Women’s Health Across the Nation (SWAN) heart. Circulation. 2018;137:AP362.
Anjana R. Nair, Aiswarya J. Pillai, and Nandini Nair, Cardiovascular Changes in Menopause. Curr Cardiol Rev. 2021 Jul 20; 17(4): e230421187681. Published online 2021 Jul 20.
Dal Canto E, Ceriello A, Ryden L, et al. Diabetes as a cardiovascular risk factor: an overview of global trends of macro and micro vascular complications. Eur J Prev Cardiol 2019; 26(Suppl. 2): 25–32.
Dr Aditi Singhvi. The silent threat: Women and heart disease in India. April 26, 2023, 3:36 PM IST. The Times of India
