As awareness of perimenopause and its symptoms continues to grow, the broader and more lasting impact of menopause on women’s health and longevity doesn’t get nearly enough attention. While estrogen deficiency during perimenopause is often linked to well-known symptoms like hot flashes and night sweats, its long-term health implications—such as increased risks of cardiovascular disease, stroke, osteoporosis, and weight gain—are frequently overlooked. Read on to learn more about the heightened health risks women face after menopause and what they can do to stay proactive and healthy.
Cardiovascular Disease and Stroke
Cardiovascular disease is a major cause of morbidity and death in the United States and is the leading cause of death in women. The risk factors that predispose to cardiovascular disease are similar to those that predispose to stroke and include age, hypertension, smoking, and cholesterol. The American College of Cardiology (ACC) and the American Heart Association (AHA) recognize the post-menopause state as a risk factor for cardiovascular disease.
Cardiovascular disease is characterized by atherosclerosis of coronary arteries, leading to heart attack, arrhythmias, and heart failure. Atherosclerosis of the arteries going to and in the brain leads to stroke. The risk of cardiovascular disease increases after menopause. Although it is not known exactly why, it is thought to be related to estrogen deficiency. Cholesterol and lipid levels begin to change during perimenopause. LDL, classically known as the “bad cholesterol,” increases during the menopausal transition.
Even though it is not clear why menopause may increase cardiovascular disease risk, hormone replacement therapy does not appear to be protective. When it was studied by the Women’s Health Initiative (WHI), hormone replacement had no protective effect and may even have been harmful, so hormone therapy is not recommended to prevent cardiovascular disease based on the current evidence.
Screening for Cardiovascular Disease
Screening for risk factors of cardiovascular disease begins in early adulthood. A primary care provider should identify risk factors including hypertension, diabetes, cigarette smoking, family history of cardiovascular disease or high cholesterol, kidney disease, and obesity. A lipid profile (cholesterol blood test) is also included. In older adults and postmenopausal women, a 10-year cardiovascular disease risk score can be calculated.
How Women Can Prevent Cardiovascular Disease
Specific to postmenopausal women, hormone replacement therapy has not been shown to reduce cardiovascular risk; therefore, the major components of risk reduction are the same as those of the general population. These include a heart-healthy diet smoking cessation, controlling high blood pressure, lowering high cholesterol, exercise, weight loss, and diabetes management.
Aspirin therapy does have a significant reduction in the risk of first heart attack, although it has not been shown to reduce mortality or stroke. Taking aspirin for primary prevention of cardiovascular disease should be discussed with a primary care provider based on an individual’s risk profile. Other therapies, such as statin for cholesterol or the newer “polypills” (combination of aspirin, anti-hypertensives, and statins), may also be prescribed at a physician’s discretion.
Osteoporosis
Osteoporosis, or classically known as bone loss, also begins during the menopausal transition. It is a common condition, and bone loss can predispose women to fractures such as hip fractures and vertebral fractures due to fragile bones. Fragility fractures are fractures that happen after low or minimal trauma (such as a fall from standing) and are most commonly in the hip, spine, and wrist.
Most experts in the United States and Canada recommend bone mineral density measurement in postmenopausal women 65 and older. Screening is also recommended for those younger than 65 but with additional risk factors for fractures, such as previous fracture, steroid therapy, smoking, or low body weight—the rate of osteoporosis increases after menopause. In fact, the rate of bone mineral density loss is the highest during the one year before menopause and through two years afterward.
How Is Osteoporosis Diagnosed?
Osteoporosis is diagnosed based on the DXA score. Osteopenia (or low bone mass) is defined as a T-score of -1 to – 2.49, and osteoporosis is a T-score of -2.5 or less. After initial screening, doctors generally recommend a follow up DXA assessment in 2 years (if osteopenia is diagnosed) or even up to 10 years (if normal bone mass at the initial screen). However, the timing of screening and follow-up screening is highly individualized and should be discussed with the primary care provider.
How to Prevent Osteoporosis in Perimenopause & Menopause
To prevent osteoporosis after menopause, women are recommended to adopt several lifestyle measures, including adequate calcium and vitamin D intake, perform routine exercise, stop smoking, and avoid heavy alcohol use. In addition, it is best to avoid medications that increase bone loss, such as glucocorticoids (at the discretion of a doctor). Postmenopausal women should have approximately 1200mg daily of calcium intake. The National Osteoporosis Foundation has a guide to dietary calcium intake. Women with inadequate nutritional intake should take calcium supplements. Women should also take a total of 800 IU of vitamin D daily. Higher doses of vitamin D are needed if advised by a physician.
Women who have osteoporosis or who are postmenopausal and wish to prevent osteoporosis should exercise at least 30 minutes three times per week. In large trials, exercise reduced the risk of fracture in older women, presumably due to stronger bones. Of note, low-intensity exercise (such as walking) is possibly just as effective as high-intensity exercise (such as running). The most important thing is for the exercise to be enjoyable so that it is easy to keep up with it regularly. Quitting smoking is essential to prevent bone loss as well. Smoking one pack per day throughout adult life has been associated with a 5 to 10% reduction in bone density.
Some medications may be prescribed for women at high risk of fractures from low bone mass; these therapies are of the Bisphosphonate class of drugs and include medications such as alendronate, risedronate, ibandronate, and zoledronic acid. They work by preventing bone resorption and thereby increasing bone mass.
Postmenopausal Weight Gain
In early post-menopause, women gain fat mass and lose lean body mass. The collagen content of skin and bones is reduced due to estrogen deficiency as well, which may lead to aging and wrinkling of the skin. So, what causes menopause weight gain? Hormone changes are believed to be the cause, particularly around the abdomen.
However, hormone changes don’t necessarily explain the whole picture; weight gain may be related to aging, lifestyle, or genetics. In aging, muscle mass decreases, and fat increases. This slows down the body’s metabolism, making it even more challenging to maintain a healthy weight. Some studies suggest hormone replacement therapy decreases central fat, but it is not clear to what extent or how significant the effect is.
How to Prevent Weight Gain After Menopause
The basic principles of weight control include physical activity, controlled diet and sugar intake, and limiting alcohol. Experts recommend 150 minutes a week of moderate exercise (brisk walking) or 75 minutes a week of more vigorous activity (jogging). Due to decreased metabolism, women may need fewer calories after 50 than in their 30s and 40s to maintain the same weight; this amount is about 200 fewer calories.
To rescue calories, pay attention to daily food intake. A calorie counter application could be helpful. A plant-based diet is healthier, and plenty of legumes, nuts, soy, fish, and low-fat dairy products are optimal. Red meat, butter, and foods high in sugar or processed should be avoided. In addition, hidden sugars that come from beverages such as coffee or alcoholic drinks should be avoided.
Bottom Line
There are several health risks to be aware of after menopause, including increased risk of heart disease and stroke, weight gain, and osteoporosis. There are, however, measures women can take to reduce their risk of each of these over the years. Most importantly, sticking to a heart-healthy diet and getting the recommended amount of exercise are essential for preventing cardiovascular disease, promoting healthy bones, avoiding bone loss, and regulating weight after menopause. Lastly, inquiring about screenings for cardiovascular disease and bone loss is a good conversation to have with a primary care provider prior to or around the time of menopause.
Dr. Yasmin Aghajan is a neurology resident physician at Harvard University in Boston, Massachusetts. She earned her medical degree (MD) from the University of California, San Diego, where she also completed her medical internship. She is interested in disorders of the brain, including stroke, neurocritical care, and certain types of dementia, and currently sees a wide variety of neurologic disorders or neurologic issues in her patients.
Disclaimer: This article is for informational purposes only, even if and regardless of whether it features the advice of physicians and medical practitioners. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment and should never be relied upon for specific medical advice. The views expressed in this article are the views of the expert and do not necessarily represent the views of The Peri-Winkle Wellness Blog.