Menopause, often characterised by the cessation of menstruation and the decline of estrogen levels, is a natural phase in a woman’s life. The transition period, known as perimenopause, brings with it many well-known symptoms such as hot flashes, night sweats, and mood swings; however, the effects of menopause go beyond these commonly known symptoms and can put women at risk of rapidly declining health. One of the lesser-discussed but highly significant impacts of menopause is its effect on cardiovascular health and the increased risk of obstructive sleep apnea. Understanding these connections and how to self-advocate for testing and support is crucial for healthy aging.
MENOPAUSE & CARDIOVASCULAR HEALTH
Cardiovascular disease (CVD) is the leading cause of death among women in Canada and globally, and the risk sharply increases after menopause. This rise is predominantly due to the hormonal changes that occur during this time, primarily the drop in estrogen levels. Estrogen has a protective effect on the cardiovascular system, influencing several factors that contribute to heart health.
Before menopause, women have a lower risk of developing cardiovascular disease compared to men, largely because estrogen helps maintain the flexibility and health of blood vessels. Estrogen promotes vasodilation—the widening of blood vessels—which improves blood flow and reduces blood pressure. It also has anti-inflammatory properties that protect the endothelial lining of blood vessels, reducing the risk of atherosclerosis or plaque buildup in arteries. As estrogen levels fall during menopause, these protective effects are reduced, leaving an increased risk of high blood pressure, atherosclerosis, and other health issues that can directly or indirectly influence the cardiovascular system.
The decline in estrogen also leads to changes in cholesterol levels, which can negatively affect heart health. Menopausal women often experience an increase in total cholesterol, low-density lipoprotein (LDL)—usually referred to as "bad cholesterol”—and triglycerides. At the same time, high-density lipoprotein (HDL), or "good cholesterol," may decrease or stay consistent. This shift in lipid levels can promote the development of atherosclerosis, increasing the risk of heart attack and stroke.
Menopause is also associated with a rise in markers of inflammation, such as C-reactive protein (CRP), a known risk factor for cardiovascular disease. Chronic inflammation can damage the lining of the blood vessels, contributing to the formation of plaque and the narrowing of arteries. The interplay between hormonal changes and inflammation creates a perfect storm for cardiovascular problems in postmenopausal women.
Weight gain and an increase in visceral fat (fat around the abdomen) is common during menopause. This type of fat is more metabolically active than subcutaneous fat (just under the skin), releasing substances that contribute to insulin resistance and chronic inflammation. The combination of weight gain, insulin resistance, and inflammation significantly increases the risk of developing metabolic syndrome—a cluster of conditions like high blood pressure, high blood sugar, and abnormal cholesterol levels, all of which negatively impact cardiovascular health.
MENOPAUSE & OBSTRUCTIVE SLEEP APNEA
Obstructive sleep apnea (OSA) is a condition characterised by repeated episodes of partial or complete blockage of the upper airway during sleep, leading to disrupted breathing and poor-quality sleep. While OSA is more commonly diagnosed in men, its prevalence in women increases significantly after menopause. Studies have shown that postmenopausal women face a higher risk of developing OSA versus women who are not postmenopausal.
The drop in estrogen and progesterone during menopause contributes to the development of OSA. Both hormones (particularly progesterone) play a role in maintaining muscle tone in the upper airway. Estrogen helps regulate breathing patterns, while progesterone acts as a respiratory stimulant, keeping the airway open during sleep. As levels of these hormones decline, the muscles in the throat can relax more than they should, increasing the likelihood of airway collapse and obstructed breathing during sleep.
As mentioned earlier, weight gain is common during menopause, and it is a significant risk factor for OSA. Excess weight, particularly around the neck and abdomen, can put pressure on the airway, making it more likely to collapse during sleep. Accumulation of fat in the upper body can also affect lung function and reduce airflow, exacerbating sleep apnea symptoms.
Cardiovascular Implications of Sleep Apnea
OSA is not just a sleep disorder; it has far-reaching effects on cardiovascular health. Repeated episodes of oxygen deprivation during sleep put significant stress on the cardiovascular system, leading to increased blood pressure and heart rate. Over time, this can contribute to the development of hypertension, arrhythmias (irregular heartbeats), and even heart failure. OSA is also associated with an increased risk of stroke and heart attack.
Recognizing the Signs
One of the challenges in diagnosing OSA in postmenopausal women is that the symptoms can be different from those experienced by men. While snoring and gasping for air during sleep are common signs of OSA, along with daytime fatigue and headaches upon waking, women are more likely to report non-specific symptoms such as insomnia, fatigue, restless legs, and mood disturbances. These symptoms can easily be mistaken for other conditions, including depression or the typical side effects of menopause.
WHAT TO DO
Considering the complex interactions between menopause, cardiovascular health, and sleep apnea, a comprehensive approach is vital for women during this life stage. Several key areas of focus can support overall well-being and address these interconnected health concerns.
Heart-Healthy Lifestyle Changes
Adopt heart-healthy lifestyle habits, including regular physical activity, a balanced diet, and weight management. Regular exercise can improve cardiovascular health, reduce the risk of sleep apnea, and alleviate some menopausal symptoms such as mood swings and sleep disturbances.
A diet (such as the Mediterranean diet) which is rich in fruits, vegetables, whole grains, and a combination of lean and plant-based proteins can help manage cholesterol levels, blood pressure, and weight. Reducing the intake of processed foods, saturated fats, and added sugars is also crucial for cardiovascular health. Additionally, incorporating foods with anti-inflammatory properties, such as omega-3 fatty acids found in fatty fish, nuts, and seeds, can help reduce inflammation and support heart health.
Hormone Replacement Therapy (HRT)
Hormone replacement therapy (HRT) can help alleviate some of the symptoms of menopause, including hot flashes and sleep disturbances. There is some evidence to suggest that HRT may also have a protective effect on cardiovascular health by improving cholesterol levels and blood pressure; however, the decision to use HRT should be made on an individual basis that includes your healthcare team and adequate data (blood work, family history, etc.).
Treatment for Obstructive Sleep Apnea
For women diagnosed with OSA, treatment may include continuous positive airway pressure (CPAP) therapy, which keeps the airway open during sleep by delivering a steady stream of air through a mask. Other options include lifestyle changes such as weight loss, and in some cases, surgery to remove excess tissue from the airway.
Addressing OSA is critical for preventing cardiovascular complications, improving sleep quality, and enhancing overall quality of life. Women with OSA who receive treatment often experience significant improvements in energy levels, mood, and cognitive function.
Prevention
Regular monitoring of blood pressure, cholesterol levels, and blood sugar is essential for postmenopausal women. Early detection and management of these risk factors can help prevent the development of more serious cardiovascular conditions.
Menopause is a significant transition in a woman’s life that affects more than just reproductive health. By understanding the connections between menopause, cardiovascular health, and sleep apnea, women and their healthcare providers can take proactive steps to manage these risks. A well-rounded approach that includes lifestyle modifications, hormone therapy when appropriate, and treatment for sleep apnea can help women navigate menopause with better overall health outcomes and improved quality of life.
