Heart health

Heart health here means the heart and the blood vessels together: heart attacks, angina and stroke, and the things that build towards them, such as high blood pressure, cholesterol and diabetes.

The European Menopause and Andropause Society (EMAS) says heart disease in women is still too little studied, too often missed and too rarely treated.

The Pakistan Menopause Society puts the average age of menopause in Pakistan at between 45 and 49, lower than among white European women.

EMAS adds risks that only women carry: high blood pressure, diabetes or eclampsia in pregnancy, and a premature menopause.

The PMS recommendations add a caution: doctors should avoid implying that every midlife illness comes from falling estrogen, because age, lifestyle and other conditions all play their part (Table 1).

The PMS recommendations treat the menopause visit as a chance for prevention. They list:

• Checks: blood pressure, BMI and ideally waist size, with a fasting blood sugar or HbA1c and a cholesterol test according to age, risk and affordability (Tables 2 and 4).
• Questions: a family history of heart disease and blood clots, and her own history of diabetes, blood pressure, smoking and stroke (Table 2).
• Movement: regular physical activity, which the recommendations say has evidence for protecting the heart (4.2.2). See aerobic exercise.
• Food: they name sweetened drinks and colas as driving weight around the middle and metabolic risk, and encourage dals, channa, saag, methi and whole grains (Table 5). Women's Health Concern says refined starches such as white rice and white bread can be part of a healthy diet and need not be avoided, though more wholegrain is the aim.
• Tobacco: stopping cigarettes, naswar and shisha, which they say lowers heart disease risk. They note that shisha is often seen as less harmful, and ask doctors to address it anyway (Table 7). See smoking, naswar and shisha.

On HRT and the heart, NICE NG23 says two things.

First, HRT is not a heart medicine: recommendation 1.6.4 says it should not be offered to prevent heart disease, and points doctors to separate guidance on lowering heart risk.

Second, for women taking HRT for their symptoms, NICE's table of benefits and risks says: "Coronary heart disease risk does not increase with combined HRT". The same table says: "Mortality from cardiovascular disease does not increase with combined HRT." For stroke, the same table says the risk depends partly on whether the estrogen is taken as a tablet or through the skin.

The PMS recommendations describe what they call the timing hypothesis: the idea that the balance of benefit and risk is most favourable when HRT is started before 60 or within ten years of the menopause, particularly for the heart (section 5). The Menopause Society, rating the evidence as strong, says the same about timing, and that women who start later face higher absolute risks of heart disease, clots and stroke, so starting after 60 needs careful weighing of a woman's own benefits and risks.

For women who already have heart disease, the British Menopause Society's guidance for clinicians says HRT is usually considered high risk and that non-hormonal treatment comes first. It also says a history of heart disease may not be an absolute bar to HRT, and that the choice should be shared, weighing her symptoms against her risk. The PMS recommendations list high heart risk among the reasons to refer a woman to a menopause specialist (3.4).

If your blood pressure, blood sugar or cholesterol have not been checked for a few years, ask at your next appointment.

Some symptoms cannot wait for an appointment. The PMS recommendations list chest pain, swelling in one leg, sudden shortness of breath, neurological symptoms, or a severe new headache as red flags that need evaluation or referral (2.3). Do not wait for a routine appointment with any of these.

Heart palpitations that come with chest pain or sudden breathlessness fall under those same red flags.

Family history is the one test you can do at home. Ask your mother and aunts about heart attacks, strokes, diabetes and blood pressure tablets, and take the answers to your doctor, who the PMS recommendations ask to record it (Table 2).

In Ramadan, women on blood pressure, cholesterol or diabetes medicines often ask how to time them around sehri and iftar, or whether they should fast at all. The question about the fast belongs with a qualified scholar; the question about the medicine belongs with whoever prescribes it, before Ramadan starts.