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By : (from l. to r.) Céline Fiset, B Pharm, PhD^1,2 and Catherine Martel, PhD^1,3

1. Research Center, Montreal Heart Institute, Montreal, Quebec, Canada  /  2. Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada  /  3. Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada

Atherosclerosis, the main cause of cardiovascular diseases, is characterized by elevated circulating lipid levels, an exaggerated inflammatory response, and the accumulation of cholesterol within the arterial wall. Numerous factors, whether extrinsic like lifestyle choices or intrinsic such as genetic predispositions, exert influence over the development of this chronic inflammatory condition and its acute clinical outcome across one’s lifespan. In menopausal women, the risk of cardiovascular diseases significantly escalates. Moreover, women aged 45-74 years old have a 30% higher risk of mortality from acute myocardial infarction compared to men. Menopause signals a profound juncture in a woman’s journey, marked by the natural cessation of menstruation and substantial hormonal shifts, including diminished levels of estrogen and progesterone. This hormonal decline holds significant implications for cardiovascular health. Estrogens, particularly, play a pivotal role in preserving vascular function by fostering artery dilation, regulating cholesterol levels, and imparting anti-inflammatory effects on the vascular endothelium. As a result, the decline in estrogen levels after menopause contributes to the increased cardiovascular risk in women.

As for hormone therapy, also known as hormone replacement therapy (HRT), its impact on cardiovascular risk remains under perpetual investigations. The timing of HRT initiation is crucial. Early evidence suggests that HRT might mitigate the risk of adverse cardiovascular events in women experiencing premature menopause (before 45 years old). However, recent findings from the Society of Obstetricians and Gynaecologists of Canada (SOGC) caution against commencing combined HRT a decade or more after menopause, which appears to elevate the risk of cardiovascular complications, including stroke, compared to initiating HRT early (within 10 years) and maintaining it. Nonetheless, while HRT finds indication in alleviating menopausal symptoms, it is not endorsed for cardiovascular disease prevention, notwithstanding its potential benefits on lipid profiles and vascular function.

Given these insights, it is crucial to regularly monitor the cardiovascular health of women during menopause and promptly address modifiable abnormalities, such as circulating lipid levels. Women should discuss the benefits and risks of hormone therapy with their doctor, taking into account their medical history and cardiovascular risk profile.

References

1. J Obstet Gynaecol Can 2021;43(12):1444−1449
2. Coeur et AVC Canada (https://www.coeuretavc.ca)
3. Rapport du Système canadien de surveillance des maladies chroniques : Les maladies du cœur au Canada, 2018
4. S. Preventive Services Task Force, Grossman DC, Curry SJ, et al. Hormone Therapy for the Primary Prevention of Chronic Conditions in Postmenopausal Women: US Preventive Services Task Force Recommendation Statement. JAMA 2017;318:2224–33.7.