Diabetes affects blood vessels, increasing the risk of their becoming narrowed by deposits of the fatty substance atheroma. This in turn may lead to blockage of arteries by blood clots causing a coronary thrombosis (heart attack) or stroke. After the menopause women with diabetes have three to five times the risk of a heart attack and twice the risk of a stroke when compared with women without diabetes. These risks may be reduced by careful control of diabetes, avoiding obesity and taking HRT.
High blood pressure
Regular blood pressure checks are important to identify women with raised blood pressure, because high levels are linked to heart disease and strokes.
The average blood pressure is 120/80 millimetres of mercury but it rises with age so that a measurement of 140/90 is acceptable in the postmenopausal group. Sometimes a treatable cause for high blood pressure is found but, in most cases, it runs in families with no clear identifiable reason. If you are overweight or smoke, losing weight or stopping smoking may be sufficient to control the blood pressure.
If your blood pressure is high on at least three consecutive occasions, your doctor will probably recommend that you take daily treatment to reduce it. Many people find daily drugs difficult to take as they usually feel otherwise well – high blood pressure, in itself, does not give rise to any symptoms. However, it is important to realise that treatment is aimed at prevention – stopping the development of heart disease is a much more effective medicine than treating a heart attack.
Cholesterol levels below 5.2 milli-moles per litre (mmol/l) indicate a low risk of heart disease, levels above 6.5 mmol/l denote a greater risk. The average measurement of cholesterol is around 5.6 mmol/l. A well-established link exists between heart disease and high cholesterol in men, but for women an association remains uncertain and the risk appears to diminish with increasing age. However, there is evidence to suggest that lowering cholesterol reduces heart disease. Modifying your diet is the best treatment; drugs are available but many have unwanted side effects. Routine tests of cholesterol are controversial because other risk factors, such as obesity or smoking, need to be taken into account. Many do-it-yourself kits produce unreliable results so go to your doctor or well-woman clinic for a more reliable test.
Aggressive and ambitious people -so-called type A personalities -appear to have twice the risk of heart disease compared with the calmer type B personalities.
Previous heart attack
As with angina, a previous heart attack shows the presence of existing heart disease. The already weakened heart is more susceptible to further damage
Special cases Arthritis
Increasing evidence suggests that HRT reduces the impact of arthritis by increasing bone density. This is true for both osteoarthritis and rheumatoid arthritis; although HRT does not reverse the process of the disease, it is a useful adjunct to conventional therapy.
Results of recent studies suggest that long-term use of oestrogens can reduce the risk of developing Alzheimer’s disease and may also reduce the severity of the condition.
Smoking is a risk factor for heart disease and osteoporosis, but it is included under this separate heading because its effects are even more wide reaching. More than 9,000 women die each year from lung cancer directly related to smoking. It is also linked to cancers of the cervix and bladder. Smoking affects the way that your body uses oestrogen, so that oestrogens are broken down at a faster rate than usual. Women who smoke have an earlier menopause, by one or two years, than women who do not smoke, so they are at greater risk of oestrogen deficiency. Campaigns to stop smoking have been very successful in the overall population but unfortunately smoking is on the increase in young women, the group most vulnerable to its long-term effects.
Women who have an early menopause – before the age of 45 – are considered to be a ‘high-risk’ group for the consequences of oestrogen deficiency, because they are particularly susceptible to osteoporosis and heart disease. An early menopause is caused by failure of normal ovarian function, which has been linked to certain genetic disorders. Treatment with radiotherapy or chemotherapy for conditions such as leukaemia may also induce ovarian failure. The diagnosis is made on the basis of menopausal symptoms and is confirmed by a simple blood test to measure hormone levels.
Preventive action against oestrogen deficiency should begin as soon as possible. Women choosing to take HRT are advised to continue treatment at least until the age of 50 but may wish to take it for longer.
Removal of both ovaries at hysterectomy induces an immediate menopause which can be treated with oestrogen replacement or alternatives. Studies show that women who have this ‘surgical’ menopause develop more severe menopausal symptoms than those who have a ‘natural’ menopause. This may be because the body does not have the usual time to adapt to hormonal fluctuations.
In most hysterectomy operations the ovaries are not removed, but even this can trigger a menopause about four or more years earlier than the natural menopause. Without the evidence of irregular periods or other changes in the menstrual cycle, it can be difficult to assess the onset of the menopause, although hot flushes and other symptoms are sufficient indicators.
Young women whose periods have ceased
Periods often cease in women who exercise excessively or who are anorexic and whose oestrogen levels fall. Many doctors consider that this group should be offered HRT to protect against the long-term consequences of oestrogen deficiency.