Women are living longer and a significant proportion of them will spend up to 40% of their lives postmenopausal. This statistic intermingles with the reality that cardiovascular disease is the No. 1 cause of death in American men and women.
Hormone replacement therapy (HRT) has been the gold standard for treating menopause symptoms such as vasomotor symptoms and hot flashes. However, a study released over two decades ago made an alarming connection between HRT and heart disease, which influenced the use of this therapy in menopausal women.
The medical community has since learned a great deal about HRT and cardiovascular disease. But “we still need to do a lot more,” said Annabelle S. Volgman, MD, during an education session at the 2024 AMA Interim Meeting.
“We need help, and our patients need help to see what is best for those symptoms,” said Dr. Volgman, director of the RUSH Heart Center for Women in Chicago.
Rush University System for Health (RUSH) is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Mixed signals, messages
Information about menopause and heart disease hasn’t always been reliable or consistent. In 2002, the Women's Health Initiative study reported that HRT increased the risk of cardiac events, strokes and clots, as well as breast cancer. This left women confused over the safe use HRT.
According to Dr. Volgman, the study was flawed in that researchers started HRT in women with an average age of 62. “They were 10 years postmenopausal, and then unfortunately they probably had already developed atherosclerosis, and it increased their cardiovascular adverse outcomes,” said Dr. Volgman.
A widely read New York Times Magazine article published last year challenged the Women’s Health Initiative study findings, arguing that women have been misled about hormone therapy.
“Hormone therapy eases several menopausal symptoms, and it has additional benefits, but it depends on who you give it to, because it does carry health risks that vary by age,” said Dr. Volgman, summarizing the points made by the article’s author, Susan Dominus, who also argued that menopause was an understudied and undertaught topic in medical school, residency and in fellowship.
Dr. Volgman also cited research showing that women from historically marginalized racial and ethnic groups had lower use of HRT compared with white women. In addition, Black and Hispanic or Latina women report more severe and disruptive vasomotor menopausal symptoms than do white women.
More funding, training needed
Addressing this concern, delegates at the Interim Meeting directed AMA to “advocate for increased funding for biomedical, behavioral and public health research on perimenopause, menopause, and related chronic conditions.”
Delegates also adopted new policy to support:
- Expanded training opportunities for medical students, residents, and other health professions trainees to improve care, treatment and management services for perimenopause, menopause and related chronic conditions.
- Efforts to increase awareness and education to the public, health care professionals, patients and other relevant communities related to menopause, mid-life women’s health and related conditions, treatment, and preventive services.
“It’s good for us to know what women are reading,” said Dr. Volgman. But patients should be getting their information from their doctors, not The New York Times.
“We need to share the information that doctors who are doing a lot of studying and research have written about menopause,” she added.
One 2020 study for which researchers examined menopause transition and cardiovascular-disease risk and early prevention, brought out that as women age and their estrogen levels decrease, their follicle stimulating hormone (FSH) goes up.
“No one ever studies FSH to the effect on cardiovascular disease, but I think that's something we should be doing, instead of just studying estrogen all the time,” Dr. Volgman told the physicians attending the session, which was jointly sponsored by the AMA Women Physicians Section and the AMA Senior Physicians Section.
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Doctors shouldn’t overlook the menopause symptoms that are associated with cardiovascular-disease risk. This may include vasomotor symptoms and depression, which is related to vasomotor symptoms. Sleep disturbance, a common complaint during menopause, “is also a signal that there might be some clinical cardiovascular disease. Also, it's a risk for subclinical cardiovascular disease and worse cardiovascular outcomes in women,” said Dr. Volgman.
Perimenopause often extends to 12 months after menopause.
“This period sees a lot of changes that are bad for our perimetabolic and vascular health,” she continued. During this time, central and visceral fat increases, and lean muscle mass decreases. Central adiposity or a thickening in the abdominal area is associated with increased risk of mortality.
Changes in the lipids also present a big conundrum.
HRT may decrease low-density lipoprotein, “but unfortunately, it also increases triglycerides and your blood pressure, so it may have some negative outcomes as a result of that balance,” noted Dr. Volgman.
Many patients with high cholesterol will say they’re not at high risk because their high-density lipoprotein (HDL) is high. But recent data shows that high HDL “does not provide the protective benefit that we thought it did in a young age,” she said.
The most recent lipid-lowering guidelines recommend statins as first-line therapy for CVD risk reduction, regardless of sex or menopausal status. One study that analyzed data from 47,801 patients (17,008 statin users and 30,793 not taking a statin) with no history of cardiovascular disease showed that the benefit from statins was stronger in women than in men. However, many women don't tolerate this treatment very well.
Alternatives to statins
“The thing about 2024 is that we have so many other options besides statins,” said Dr. Volgman. There are vegan diets and PCSK9 inhibitors that patients inject twice a month. At least in her practice, patients tolerate the PCSK9 very well.
Bempedoic acid is a cholesterol-lowering oral drug that’s easy to take and tolerate. Inclisiran is another low-density lipoprotein receptor that patients inject every few months. “It is a dream drug” that Medicare covers for eligible patients. “So that is really great news, and my patients absolutely love those new drugs,” said Dr. Volgman.
Physicians in the meantime may consider HRT based on their patient’s individual risk, she suggested. Hormone therapy should not be considered if a patient has congenital heart disease or atherosclerosis, if they've had a heart attack or stroke, or if they have breast cancer.
It is a very vulnerable time, “and we need to know how to take care of these women,” she said.
Read about the other highlights from the 2024 AMA Interim Meeting.
