Experiencing premature menopause can significantly increase women’s risk of cardiovascular events. Such is the conclusion of a study recently published in The Lancet Obstetrics, Gynaecology & Women’s Health, in which over 111,000 women from 26 countries participated. Backed by more than 30 academic and medical institutions, it is considered the biggest international study of the subject to date.
The Prospective Urban Rural Epidemiology study analyzed the relationship between age of menopause and risk of cardiovascular events like stroke, myocardial infarction and heart failure among participants, whom it followed for over 15 years. “Women with premature menopause had about a 30% greater risk of major cardiovascular disease events,” states its analysis, even after adjusting for traditional risk factors.
In contrast to previous studies, the investigation includes patients from varying income groups and ethnicities, applying the same data collection method to all participants, which allowed it to obtain more consistent results, say its authors. Its team of scientists concluded that premature menopause (which takes place before the age of 40) and early menopause (from 40 to 45 years old) increase generalized cardiovascular risk in women.
“They seem like logical conclusions and a very complete investigation,” says Francisco Carmona, director of the endometriosis unit at the Hospital Clínic of Barcelona, who was not involved in the study. “Premature menopause is clearly a risk factor when it comes to life expectancy in general, and particularly for life expectancy for those in good health,” says the gynecologist.
In addition, the study’s international team proved that in low-income countries, menopause arrives three years earlier and affects nearly double the number of women as compared to high-income countries, multiplying cardiovascular risk in low-income nations. For example, in Pakistan, Tanzania, Bangladesh, India and Zimbabwe, nearly 43% of post-menopausal women experienced premature or early menopause. Meanwhile, in Canada, Saudi Arabia, Sweden and the United Arab Emirates, the percentage is 23%. The study uses the example of Pakistan and Tanzania, where half of the women who participated in it reached menopause before turning 45 years old. In Sweden, only 13% of women hit the milestone by that age.
Behind this gap is a series of contributing factors: poor nutrition, low body weight, tobacco usage, less access to education and health care, and even adverse prenatal conditions, like exposure in the womb to tobacco and low birthweight. Carmona is cautious when it comes to these findings. “I’m not so sure the relationship between poverty and premature menopause is cause-effect,” he says, suggesting the existence of an unknown third variable.
The study — whose participants include the University of Sydney, the University of Beijing’s Fuwai Hospital, University of Gothenburg, the College of Medicine at King Saud University and Queens University in Canada, among others — mentions one qualification that is important to note. In low-income countries, chronic malnutrition and physical fatigue stemming from extreme living conditions may lead to hypothalamic amenorrhea, an interruption of menstruation caused not by the arrival of menopause, but rather, the stress the body imposes upon itself when it lacks resources. This lack of period could easily be confused with menopause by women themselves, in the context of their interview or health survey.
That means that the age of menopause reported in some cases could be apparent rather than real, and that the gap between high and low-income countries could be partially inflated by such confusion. Authors say that the observation does not invalidate the study’s conclusions, but do offer a reminder that measuring the health of the most vulnerable women requires work that goes beyond the collected data.
Estrogen shield
The body does not just lose fertility through early menopause. Estrogens act as a cardiovascular shield. “They reduce fats, reduce cholesterol and triglycerides, and that translates into lower risk of experiencing stroke or heart attack,” says Carmona. They also keep blood veins in good shape and halt the accumulation of body fat. “Plus, ovaries produce other substances that are correlated with quality of life. Women who have their ovaries extracted before they turn 60, even if they are menopausal, have a higher risk of death and bigger loss of quality of life. [Their ovaries] are producing other substances that protect them,” he says.
When this shield falls too early, atherosclerosis — a chronic disease in which fatty deposits build up on the walls of the arteries — progresses more rapidly, metabolism declines, and the risk of heart attack, stroke, and heart failure can increase significantly. One of the study’s most significant findings is that this risk persists even after accounting for age and other risk factors such as high blood pressure, diabetes, or a sedentary lifestyle.
Such results have direct implications for public health. Experts say that women who experience early or premature menopause should be considered a priority for cardiovascular prevention. Not just in visits to their gynecologist, but also in cardiology and general practice. Identifying them on time could save lives and above all, reduce inequality that for a long time has gone unseen.
Meanwhile, available evidence points to specific habits like maintaining a healthy weight, not smoking, getting regular exercise and eating healthily. Carmona mentions the importance of hormone replacement therapy and particularly, a consistent routine. “Hormones are important, but having a healthy lifestyle is more important than the hormones,” he says. Such habits won’t just delay menopause — they also protect the heart.
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