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Menopause, Cholesterol, and Cardiovascular Disease
in particular, an increase in low-density lipoprotein (LDL), lipoprotein-α, and
Figure 1: Causes of Death in European Women
triglycerides and a decrease in high-density lipoprotein (HDL).
7–9
Therefore,
menopausal women are exposed to a more atherogenic lipid profile than
4%
6%
pre-menopausal women. Total cholesterol levels peak in women at 55–65
16%
years of age—about 10 years later than the peak in men (see Figure 3).
Agents that lower cholesterol levels reduce heart disease risk in both men 57%
and women, but it is thought that a larger proportion of women than 17%
men are at high risk and are not being effectively treated. It was shown in
a recent survey that only one in four women associates menopause with
high cholesterol, leading to a lack of awareness of the need to consider
having cholesterol level checked around the time of the menopause.
5
Cardiovascular disease Injuries and poisoning Respiratory diseases
Smoking
Cancers (breast, lung, stomach, colorectal, and others) Other cause
Tobacco use is one of the most important risk factors for CVD in both men
and women, although the risks associated with smoking are consistently Source: World Health Organization, 2004.
2
higher in women than in men. Although in general more men than women
smoke, the important and encouraging decline in tobacco use among men
Figure 2: Percentage of Population Affected by Cardiovascular
is worryingly less apparent in women, while there is a disturbing rising trend
Disease with Increasing Age
in younger women.
60
Diabetes
50
Diabetes is becoming increasingly common in both men and women, and
40
changes in insulin secretion and insulin sensitivity after the menopause
%
contribute to this increase in women. The risk for death from CVD
30
associated with diabetes is higher in women than in men: in the 20-year
20
Framingham study, women with diabetes were 3.3 times more likely to die
from CVD than women without diabetes, whereas the risk for diabetic men
10
was only 1.7 times that of non-diabetic men.
10
0
20–34 35–44 45–54 55–64
The increase in these risk factors leads to a four-fold increased risk in CVD
Age (years)
Men Women
in women in the 10 years after the menopause.
11
The belief that this
increase is menopause- or estrogen-deficiency-related rather than purely
Figure 3: High Cholesterol Levels for Men and Women in
age-related is confirmed by the findings that for post-menopausal women
England, 2003
at any age there is an increased risk for CVD (see Figure 4).
90
Other Problems
80
Symptoms of heart disease manifest themselves differently in women and
70
in men, with women being less likely to present with classic, well recognized
60
cardiovascular symptoms.
7
Angina can be mistaken for indigestion or %
50
heartburn, and symptoms of myocardial infarction (MI) can include
40
overwhelming fatigue, shortness of breath, nausea, or indigestion. Women
30
therefore tend to present late in the disease process, by which time they
20
may also have other medical conditions that may affect the prognosis.
10
Furthermore, it is recognized that women are less likely to be offered
0
16–24 25–34 35–44 45–54 55–64 65–74 ≥75
intervention, and traditionally have been poorly represented in clinical trials. Age (years)
Men Women
Not surprisingly, then, women have a worse prognosis following an MI than
men: in US patients diagnosed with acute MI, 38% of women but only Percentage of adults with blood cholesterol levels ≥5.0mmol/l in England, 2003.
25% of men die within a year. Within six years of a first MI, 35% of women
but only 18% of men will have another MI.
12
be prevented by diet and lifestyle changes and, indeed, a recent European
survey showed that 73% of respondents said that they would prefer to deal
Management of Cardiovascular Disease Risk at Menopause with menopausal symptoms by having the right diet and lifestyle.
6,13
With the onset of menopausal symptoms, women and their doctors and However, for women who are having troublesome menopausal symptoms,
nurses should not only discuss the symptoms, but also think long-term control of the symptoms may be needed first before attention can be given
and consider risk factors for both bone health and heart health. It has been to important diet and lifestyle changes; discussion should still take place early
estimated by the World Health Organization (WHO) that 80% of CVD can and, indeed, some changes such as reducing weight, stopping smoking, and
US CARDIOLOGY 13
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