Heart disease is the number one cause of death for women.
I felt compelled to lead with this as a recent American Heart Association study found that only 40% of women know this important fact.
And because markers of heart health change as we go through the menopausal transition — mostly not in good ways — it feels important to be aware of what those changes are, the metrics that can help us keep track of our heart health and what actions we can take to keep our hearts healthy and reduce the risk of heart disease.
We reached out to Dr. Emily Lau, MD, MPH, a cardiologist and Director of the Cardiometabolic Health and Hormones Clinic at Mass General Brigham for her expertise on these topics.
Midlife women’s heart health— a Q&A with Dr. Emily Lau
Q: What changes occur in women’s hearts in midlife? (i.e., during the menopause transition)?
Dr. Lau: 3 main changes occur in heart health during the menopause transition that may put women at greater risk for later-life heart disease.
1. Unfavorable changes in cholesterol profiles
Several (3) types of “bad” cholesterol often increase, which can lead to plaque build-up in the arteries and heart disease. These are:
- Low-density lipoprotein (LDL) cholesterol, a standard component of conventional cholesterol measurements
- Lipoprotein(a) (Lp(a)) – is a type of LDL cholesterol called “lipoprotein little a”. Lp(a) is genetically determined and 20-30% of the population has elevated Lp(a), which is strongly linked to heart disease. It’s a value that tends to be stable, but it can rise with increased inflammation.
- Apolipoprotein B (ApoB) – measuring ApoB indicates the number of plaque-forming particles circulating in the blood. ApoB is a more precise marker for heart disease risk than LDL alone.
Levels of high-density lipoprotein (HDL) “good” cholesterol decline
- However, some data suggest that HDL does not confer the same heart benefits in women after menopause.
** While measuring LDL and HDL are standard parts of cholesterol measurements, Lp(a) and ApoB are not. They are becoming more common and are most often used to help guide treatment strategies for women who have an intermediate risk of developing heart disease over the next 10 years. In such cases, getting information about Lp(a) and ApoB can provide more detail on heart disease risk. High levels of either or both would indicate a greater risk of heart disease.
2. A change in body composition and location of where fat resides
- There is a shift away from lean body mass to a higher percentage of fat mass.
- Before the menopausal transition, women have a greater proportion of subcutaneous fat or fat that lies under the surface of the skin. During the menopausal transition, women begin to accumulate more visceral fat or fat that surrounds our internal organs and less subcutaneous fat.
- Visceral fat is associated with greater inflammation, insulin resistance, high blood pressure, high cholesterol, and a greater risk of heart disease.
3. Changes in blood pressure may also occur during the menopause transition/midlife, but the data here are more mixed. High blood pressure is associated with a greater risk of heart disease.
- Blood pressure less than 130/80 is considered normal. If either the top (130) or bottom number (80) is higher, a blood pressure reading is considered “high”.
- High blood pressure is also called hypertension.
Q: What metrics from labs or other tests should women ask for and keep track of?
Dr. Lau: Because midlife is a time of accelerating cardiovascular disease risk, it’s a good idea to get a sense of your risk of heart disease starting at age 30.
The American Heart Association offers the PREVENT online calculator to do this.
The inputs to this calculator include:
- cholesterol (lipid) levels
- glucose control (hemoglobin A1c)
- blood pressure measurement (in the calculator, it asks for SBP, systolic blood pressure (the top number in your blood pressure reading)
- If you have high blood pressure (hypertension), you can get a blood pressure cuff and keep tabs on your readings at home
- weight
- eGFR (estimated glomerular filtration rate) is a measure of kidney function
Your healthcare provider may have already measured these factors (log onto your online health information to see if it’s already been done) or you may need to ask your provider to obtain them for you.
Q: What things can we do/control that have the biggest impact on maintaining or improving heart health?
Dr. Lau: Four things that can have a significant impact on improving health.
1. Being aware that heart disease risk sharply rises after menopause is probably the single most important intervention that can improve the heart health of midlife women.
2. Assessing your risk for future heart disease in conjunction with your physician will give you a sense of how much you need to pay attention and/or modify behavior.
- Be aware of your values for the metrics listed above.
- Know your family history that might factor into your risk
- Even if you have a genetic risk, lifestyle behaviors have an impact (link to post once it’s up).
3. Adopting heart-healthy lifestyle measures irrespective of cardiometabolic risk levels. Dr. Lau shared her guidance:
- Regular aerobic exercise.
- 150 minutes per week of moderate-intensity aerobic activity or 75 minutes per week of vigorous aerobic activity or a combination of both
- Add moderate to high intensity muscle-strengthening activity (e.g. resistance or weights) on at least 2 days per week
- Less time sitting (even light-intensity activity can offset some of the risks of being sedentary)
- Gain even more benefits by being active at least 300 minutes (5 hours) per week
- Increase the amount and intensity of exercise gradually over time
- A heart-healthy diet. This is what Dr. Lau shares with her patients:
- Wide variety of fruits and vegetables
- Whole grains and products made up mostly of whole grains
- Healthy sources of protein (plants, nuts, fish/seafood, low-fat or fat-free dairy, lean meat and poultry)
- Olive and avocado oils
- Minimally processed foods
- Minimize intake of added sugars
- Foods prepared with little or no salt
- Limited or preferably no alcohol intake
4. Recognizing that in addition to lifestyle measures, some women may require treatment to modify their cardiometabolic risk factors.
- For example, women with very elevated LDL-C ≥ 190 mg/dL, even in the absence of other risk factors, should be started on a cholesterol lowering medication (e.g., a statin).
