Menopause and its Cardiometabolic Consequences: Current Perspectives

Accuracy of self-perceived cardiovascular disease risk and factors predicting risk underestimation in perimenopausal and postmenopausal women in Ismailia, Egypt

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death globally, with women at higher risk after menopause. This increased risk is attributed to both aging and hormonal changes. Prior research has established a link between CVD risk perception and adopting healthy behaviors to prevent CVD. This study aimed to assess the accuracy of self-perceived CVD risk in perimenopausal and postmenopausal women, and to identify factors that predict CVD risk underestimation among them.

METHODS

A cross-sectional study was conducted in the administrative sectors of Suez Canal University campus in Ismailia, Egypt, over a period of eight months starting in July 2022. A total of 390 eligible women (employees and workers) were randomly selected. Participants were interviewed to obtain data on demographics, medical history, self-perceived risk of CVD, self-perceived general health, awareness of factors that increase the risk of developing CVD, perceived stress, health literacy, numeracy, and self-perceived 10-year risk of developing major cardiovascular events. They also underwent measurements of blood pressure, weight, and height. The updated 2019 WHO/CVD risk non-laboratory-based prediction chart for the North Africa and Middle East Region was used to predict the 10-year risk of major cardiovascular events for the study participants. Risk accuracy was measured by comparing self-perceived CVD risk with predicted CVD risk.

RESULTS

The ratio of self-perceived to predicted moderate/high CVD risk was 27.7% to 44.3%, respectively. The accuracy of CVD risk perception was 68.2%. Kappa analysis results showed fair and significant agreement between self-perceived and predicted CVD risk (kappa ± SE = 35.9 ± 4.1%, p < 0 .001). The proportion of women who underestimated their risks was 24.1%. Of those in the high-risk group, 93.3% underestimated their CVD risk, compared to 50.6% in the moderate-risk group. Factors that significantly predicted CVD risk underestimation included being married (aOR 14.5; 95% CI 1.4-149.9), low income (aOR 2.321; 95% CI 1.09-4.909), high BMI (aOR 4.78; 95% CI 1.9-11.9), hypertension (aOR 3.5; 95% CI 2-6.2), and old age (aOR 1.46; 95% CI 1.3-1.6).

CONCLUSIONS

Approximately one-third of our study participants misperceived their CVD risk; of those who did, 75.8% underestimated it. Marital status, old age, low income, high BMI, and hypertension strongly predicted CVD risk underestimation. These findings identified the menopausal women subgroups that could benefit from targeted health interventions designed to reduce CVD risk underestimation and improve risk accuracy.

Effects of obesogenic diet and 17β-estradiol in female mice with APOE 3/3, 3/4, and 4/4 genotypes

The main genetic risk factor for Alzheimer's disease (AD) is the apolipoprotein E ε4 allele (APOE4). AD risk associated with APOE4 disproportionately affects women. Furthermore, human and rodent studies indicate that the cognitive deficits associated with APOE4 are greater in females. One modifiable AD risk factor is obesity during middle age. Given that approximately two-thirds of US adults are overweight, it is important to understand how obesity affects AD risk, how it interacts with APOE4, and the extent to which its detrimental effects can be mitigated with therapeutics. One intervention study for women is estrogen-based hormone therapy, which can exert numerous health benefits when administered in early middle age. No experimental studies have examined the interactions among APOE4, obesity, and hormone therapy in aging females. To begin to explore these issues, we considered how obesity outcomes are affected by treatment with estradiol at the onset of middle age in female mice with human APOE3 and APOE4. Furthermore, to explore how gene dosage affects outcomes, we compared mice homozygous for APOE3 (3/3) and homozygous (4/4) or hemizygous (3/4) for APOE4. Mice were examined over a 4-month period that spans the transition into reproductive senescence, a normal age-related change that models many aspects of human perimenopause. Beginning at 5 months of age, mice were maintained on a control diet (10% fat) or high-fat diet (HFD; 60% fat). After 8 weeks, by which time obesity was present in all HFD groups, mice were implanted with an estradiol or vehicle capsule that was maintained for the final 8 weeks. Animals were assessed on a range of metabolic and neural measures. Overall, APOE4 was associated with poorer metabolic function and cognitive performance. However, an obesogenic diet induced relatively greater impairments in metabolic function and cognitive performance in APOE3/3 mice. Estradiol treatment improved metabolic and cognitive outcomes across all HFD groups, with APOE4/4 generally exhibiting the greatest benefit. APOE3/4 mice were intermediate to the homozygous genotypes on many measures but also exhibited unique profiles. Together, these findings highlight the importance of the APOE genotype as a modulator of the risks associated with obesity and the beneficial outcomes of estradiol.

Effect of Crushed Flaxseed Consumption on Cardiovascular Risk Indicators in Menopausal Women

Flaxseed is known for its numerous health benefits and is often used in the prevention and treatment of civilizational diseases. This study aimed to evaluate the impact of consuming crushed flaxseed on cardiovascular risk in 51 menopausal women. The intervention lasted for 8 weeks, during which participants received a daily dose of 40 g of crushed flaxseed from two varieties with differing lignan contents. Participants were divided into three subgroups based on the variety of flaxseed consumed: (1) high-lignan group (HL), (2) low-lignan group (LL), and (3) control group (no flaxseed consumption). Biochemical blood parameters were measured using a BiOLis 24i Premium automatic analyzer. Body composition was assessed using an InBody 720 device. In the lipid profile, we observed a significant increase in total cholesterol (T-C) and high-density lipoprotein cholesterol (HDL-C) levels, along with a significant decrease in low-density lipoprotein cholesterol (LDL-C) levels in both the HL and LL groups. Triglyceride (TG) levels exhibited no significant change, whereas high-sensitivity C-reactive protein (hs-CRP) levels were significantly reduced in both the HL (p < 0.01) and LL (p < 0.01) groups. Visceral fat area (VFA) and percent body fat (PBF) showed a slight decreasing trend in the HL group, whereas in the LL group, VFA showed a slight increase. Body mass index (BMI) remained stable across all groups. These findings suggest that for the modulation of cardiovascular disease (CVD) risk factors, the daily dosage, duration of consumption, form of intake, and the specific variety of flaxseed (based on lignan content) are crucial factors.

Body composition analysis: A snapshot across the perimenopause

During the perimenopause, estrogen concentrations gradually decrease, and this is associated with changes to women's energy expenditure and intake. These changes result in weight gain and altered body fat distribution, with increased abdominal fat deposition and cardiometabolic risk via insulin resistance. Body composition analysis is a useful clinical tool in outpatient settings, as it is simple, not expensive and provides information on body mass index, skeletal mass, fat mass, fat percentage and basal metabolic rate. This review discusses body composition analysis as part of a health assessment for healthy women during the perimenopause and investigates the associations between body composition and cardiometabolic profile.

Menopause Predisposes Women to Increased Risk of Cardiovascular Disease

(1) Background: Menopause is an important event in women's lives, possibly contributing to the development of CVD, which is associated with changes in the cardiovascular risk profile, markers of metabolic health, and subclinical atherosclerosis. The aim of this study was to assess the association of menopause with CVD risk factors and subclinical markers of cardiometabolic disease. (2) Methods: The study involved 235 women from the general population at different stages of menopause. The methods used in this study were: diagnostic survey, anthropometric measurement (WC, height, BMI, WHtR), blood pressure measurement, biochemical analysis of venous blood (lipid profile, glucose, insulin, HbA1c), and CVD risk assessment (ASCVD Risk Calculator, POL-SCORE, SCORE-2). (3) Results: The vast majority of respondents had low cardiovascular risk, irrespective of the scale used for measuring the risk of CVD. The age at menopause was not an independent risk factor for CVD. In Model 1, the age at menopause and the time since menopause were found to be factors that increased CVD risk (OR = 1.186 and 1.267, respectively). In Models 2 and 3, the severity of menopausal symptoms was not a risk factor for CVD. Models 3 and 4 demonstrated that women with metabolic syndrome (MetS) were at a significantly higher risk of CVD. In model 5, the odds ratio of CVD with MetS as a standalone factor was 13.812. (4) Conclusions: Menopause predisposes women to an increased risk and MetS to a significantly higher risk of CVD.

Does the addition of serum antimüllerian hormone concentrations to the Framingham Risk Score and Pooled Cohort Equations improve the prediction of cardiovascular disease?

The present study revealed that the addition of serum antimüllerian hormone concentrations to Framingham Risk Score and Pooled Cohort Equations could potentially improve the risk prediction of cardiovascular disease.

Objective

The current study aimed to examine the added value of serum antimüllerian hormone (AMH) concentration to the Framingham Risk Score (FRS) and Pooled Cohort Equations (PCE) in predicting the risk of cardiovascular disease (CVD) in women of reproductive age.

Methods

Women 30 years and older were considered eligible for this population-based prospective study. The univariate and multivariate Cox proportional hazard models were used to evaluate the association between the serum concentrations of AMH and the risk of CVD.

Results

In the enhanced model, which integrated AMH into FRS and PCE and was adjusted for family history of premature CVD, AMH showed a significant association with the risk of CVD during a 19-year follow-up of 800 women (hazard ratio, 0.77 [95% CI, 0.60-0.99] and hazard ratio, 0.64 [95% CI, 0.48-0.84], respectively). According to the likelihood-ratio test, the addition of AMH measurements to FRS and PCE could significantly improve the risk prediction of CVD (P = 0.02 and P < 0.001, respectively); however, the integration of this biomarker did not improve the classification of risk categories.

Conclusions

The present findings revealed that the addition of serum AMH concentrations to FRS and PCE could potentially improve the risk prediction of CVD.

Menopause-associated risk of cardiovascular disease

Cardiovascular disease (CVD) is of major concern in women entering menopause. The changing hormonal milieu predisposes them to increased CVD risk, due to a constellation of risk factors, such as visceral obesity, atherogenic dyslipidemia, dysregulation in glucose homeostasis, non-alcoholic fatty liver disease and arterial hypertension. However, an independent association of menopause per se with increased risk of CVD events has only been proven for early menopause (<45 years). Menopausal hormone therapy (MHT) ameliorates most of the CVD risk factors mentioned above. Transdermal estrogens are the preferable regimen, since they do not increase triglyceride concentrations and they are not associated with increased risk of venous thromboembolic events (VTE). Although administration of MHT should be considered on an individual basis, MHT may reduce CVD morbidity and mortality, if commenced during the early postmenopausal period (<60 years or within ten years since the last menstrual period). In women with premature ovarian insufficiency (POI), MHT should be administered at least until the average age of menopause (50-52 years). MHT is contraindicated in women with a history of VTE and is not currently recommended for the sole purpose of CVD prevention. The risk of breast cancer associated with MHT is generally low and is mainly conferred by the progestogen. Micronized progesterone and dydrogesterone are associated with lower risk compared to other progestogens.

Polycystic ovary syndrome and type 2 diabetes mellitus: A state-of-the-art review

Polycystic ovary syndrome (PCOS) often coexists with a wide spectrum of dysglycemic conditions, ranging from impaired glucose tolerance to type 2 diabetes mellitus (T2D), which occur to a greater extent compared to healthy body mass index-matched women. This concurrence of disorders is mainly attributed to common pathogenetic pathways linking the two entities, such as insulin resistance. However, due to methodological flaws in the available studies and the multifaceted nature of the syndrome, there has been substantial controversy as to the exact association between T2D and PCOS which has not yet been elucidated. The aim of this review is to present the best available evidence regarding the epidemiology of dysglycemia in PCOS, the unique pathophysiological mechanisms underlying the progression of dysglycemia, the most appropriate methods for assessing glycemic status and the risk factors for T2D development in this population, as well as T2D risk after transition to menopause. Proposals for application of a holistic approach to enable optimal management of T2D risk in PCOS are also provided. Specifically, adoption of a healthy lifestyle with adherence to improved dietary patterns, such the Mediterranean diet, avoidance of consumption of endocrine-disrupting foods and beverages, regular exercise, and the effect of certain medications, such as metformin and glucagon-like peptide 1 receptor agonists, are discussed. Furthermore, the maintenance of a healthy weight is highlighted as a key factor in achievement of a significant reduction of T2D risk in women with PCOS.

Anti-Müllerian Hormone Concentrations Are Inversely Associated With Subclinical Atherosclerosis in Premenopausal Women

Anti-Müllerian hormone (AMH), which is secreted by granulosa cells of late preantral and small antral follicles, is a marker of ovarian reserve. The association of ovarian reserve with subclinical atherosclerosis in women of reproductive age is currently unknown. We primary investigated whether AMH levels are associated with markers of subclinical atherosclerosis in healthy, normally menstruating women. In this cross-sectional study, vascular structure and function were assessed by measurement of carotid and femoral intima–media thickness (IMT), flow-mediated dilation, carotid–femoral pulse wave velocity and augmentation index. Lipid profile and serum AMH concentrations were also measured. Seventy premenopausal women, aged 32.7 ± 6.5 years, were included. Mean AMH levels were lower in smokers than in non-smokers and negatively associated with total cholesterol (TC) levels. An inverse association between mean AMH concentrations and femoral and carotid IMT in all segments was observed. No correlation with other markers of subclinical atherosclerosis or established cardiovascular (CV) risk factors was found. After multivariable adjustment, the association between AMH concentrations and combined carotid IMT or carotid bulb IMT remained significant. In conclusion, in healthy, normally ovulating women, AMH concentrations are negatively associated with subclinical atherosclerosis indices and TC levels, independently of established CV risk factors.