Worldwide, the leading cause of death among women is heart disease. The developing countries contribute to more than three quarters of global cardiovascular disease (CVD) mortality. While menopause is a natural part of women’s life, the physical changes associated with lack of estrogen have an impact on cardiovascular health. As women approach and cross the age of menopause, the risk of ischemic heart disease doubles in the fifth and sixth decade of life. South Asian women with a high prevalence of diabetes, hypertension, dyslipidemias, and obesity are particularly prone to develop CVD. Additional risk factors for CVD are the alarming rise in cigarette smoking among women along with sedentary lifestyle. Population in low- and middle-income countries have less access to appropriate health services, resulting in late presentation with catastrophic expense contributing to further poverty.1,2
The theme of the World Menopause Day this year, celebrated on October 18, 2016, is “Healthy Heart Matters.” Public health preventive strategies include addressing behavioral risk factors as well as early detection and management of aforementioned conditions. Primary health care facilities and the media can take the leadership role by counseling on healthy diet, limiting beverages, sugary foods, salt and red meat while encouraging more whole grains, low fat dairy products, fish, nuts, fruits, and vegetables.2 Screening at-risk population for elevations in blood pressure, blood sugars, fasting lipids, and weight is the domain of the general practitioners and family physicians. The stakeholders in health need to join for devising policies encouraging affordable healthy choices as maintaining a healthy heart requires regular screening.
Promotion of regular physical activity should aim for achieving around 150 minutes of activity per week. Examples of good low-resistance aerobic exercise include simple walking, cycling, dancing, or swimming. Discouraging harmful smoking and alcohol intake is another important message. Similarly, stress is associated with elevated levels of cortisol and adrenaline, leading to elevation of serum lipid, hypertension, and increased tendency to blood clots. Some degree of stress reduction is achievable with Yoga, Tai Chi, etc.
Even in developed countries, there is a notable gender imbalance in preventive as well as curative care provision to women with CVD.3,4 Women have more time to develop CVD as they have longer life span than men. In the United States, women were noted to receive fewer screenings for cholesterol and receive fewer lipid-lowering therapies. Among women who suffer heart attacks, lower use of beta blockers, heparin, and aspirin has been documented. Similarly, referrals for cardiac rehabilitation are less frequent in women.
The earlier observational studies suggesting benefit of hormone therapy in menopausal women were contradicted by later trials, including The Heart and Estrogen/Progestin Replacement Study.5,6 Similarly, the initial publication of Women’s Health Initiative (WHI) reported that hormone replacement therapy (HRT) increased the risk of cardiovascular events. Subsequent analyses of WHI have disputed this association and the risk varies with individual factors. In women who are recently postmenopausal and less than 60 years old with no CVD, initiating estrogen alone reduced coronary heart disease.7 However, the use of postmenopausal hormone therapy should not be initiated for cardiovascular prevention as advised by the American Heart Association. Women with early or premature menopause are routinely advised HRT after appropriate screening and follow-up, till the age of natural menopause due to clearly proven benefits in this age group.8
In conclusion, health practitioners responsible for provision of care to older women including gynecologists, family physicians, internal medicine experts, and, of course, the cardiologist should make particular efforts for primary and secondary prevention of CVD in this high-risk group.