The Risks We Face
Health conditions and menopause are not something we generally think about. But there are health risks that can sneak up on you during the menopause transition.
Everyone Needs to Know This
My brain feels like a sieve these days (thank you, perimenopause), but when I first read, “If you’re in your late twenties, you are losing bone as you read this” in the ‘Menopause Manifesto’, I couldn’t get it out of my head.1 I thought, everyone needs to know this.
Dr. Jen Gunter, the book’s author and well-known menopause guru, goes on to describe the devastating effects of osteoporosis on her mother’s health, with multiple fractures and literally crumbling bones. And then the heartbreaking truth. How it could have been prevented.
Why didn’t someone tell me this?
That day I started a list of things we should all know as we enter perimenopause, or even better, before then. A list of women’s health risks we need to be talking about, so we don’t find ourselves looking back and saying, why didn’t someone tell me this?
The symptoms we each experience during the menopause transition and the exact chaotic path of our declining hormone levels vary widely. However, the underlying physical changes to our bodies are the same. As are the long-term impacts to our health and well-being.
Three major health risks
Here we explore three major health risks women face, to one degree or another. Thanks (in part) to the hormonal changes we experience during menopause. We’ll also explore how to protect our health in the years to follow.
1. Protect Your Bones
Osteoporosis is when loss of bone mass over time makes the bones weak and more susceptible to breaking (or fracture). Fractures from osteoporosis are more common than heart attack, stroke, and breast cancer combined. At least 1 in 3 Canadian women will break a bone related to osteoporosis during their lifetime.2 Despite these startling statistics, awareness about osteoporosis is low.3
The disease is stealthy
The disease is stealthy, as bone loss happens behind the scenes over years, with no signs or symptoms, until that is, a person breaks a bone. Breaking a bone after a simple fall is called a fragility fracture, and it’s often the first sign of low bone mass. Unfortunately, when bone health reaches this stage it may be harder to treat, which is why early prevention and screening are so important.
Menopause and osteoporosis
Bone density peaks by about thirty years old. After that, there is a slow and steady decline in bone mass over time, for everyone. However menopausal women face the harsh reality that for them bone loss accelerates during the menopause transition.
Bone loss peaks
The culprit is, in part, our declining estrogen. Estrogen helps build bone, so as estrogen fluctuates and drops, so does our bone mass. Approximately two to three years after our last period the rate levels off; we continue to lose bone with age, but not at the same rapid pace.
The good news is that there are effective things we can all do (or not do) to protect our bones.
Lower your risk of bone loss
There is no one cause for osteoporosis. It is a multifactorial condition impacted by several factors, including age, lifestyle, medical history, and genetics. Women who go through menopause earlier (by 45) have an increased risk, simply because they have less years where their bones are protected by estrogen.
While risk factors like family history of osteoporosis or earlier age at menopause are out of our control, there are proactive and meaningful things we can control. Here are four ways to protect your bone health and lower your risk:
Get your daily nutrients.
We’re talking about calcium and vitamin D. Calcium has many jobs in the body. If you don’t get enough in your diet, your body will simply take it from your bones. There are lots of good dietary sources for calcium. Vitamin D increases the absorption of calcium. We get vitamin D from the sun and in our diet.
Talk to your healthcare provider or a registered dietitian to find out if you are getting enough of these nutrients. And if not how to get enough, or if you should think about supplements.
Exercise for your bones.
Weight bearing exercises (like walking, jogging, playing tennis, or skipping rope!) help to build bone and are effective and protective. Working on strength and balance can also reduce the risk for falls. Regular exercise can even reverse bone loss.
Limit your alcohol intake.
Too much alcohol increases the risk for bone loss.
Smoking increases the risk for bone loss.
The greatest risk factor is genetics. If you have a family history of osteoporosis or fragility fractures, talk to your doctor about prevention and screening for you. Bone density testing is recommended by age 65. But if you have other risk factors your doctor may consider screening you earlier.
Don’t wait for your doctor to bring it up.
If you have a first degree relative (parent or sibling) with a fragility fracture or osteoporosis, make sure your doctor is aware. Ask if you need earlier screening. And how you can be proactive to lower your risk.
What about hormone therapy?
Estrogen in menopausal hormone therapy (MHT) can be very effective at slowing (or at least delaying) the accelerated bone loss women experience during the menopause transition. Taking MHT for prevention of osteoporosis in postmenopausal women has been approved by the US Food & Drug Association (FDA).
MHT is not routinely prescribed to perimenopausal women for prevention. However if you have a strong family history of osteoporosis and are considering MHT to ease other symptoms, the potential benefits to your bone health should be part of the conversation with your doctor.
Bone loss is not a natural consequence of aging
For too long osteoporosis has been treated as a natural consequence of aging for women. It is not. Advocate for yourself to access screening, preventive tips, and treatment (if needed). And tell other women, young and old. Baseline bone mass is established early in life and it’s never too late to take preventive action. So let’s spread the word to make a lifelong commitment to protecting our bones.
2. Protect Your Heart
Cardiovascular diseases, like heart attack and stroke, are the leading cause of death for both men and women. Like osteoporosis, these conditions are caused by a complex combination of factors. Some which we can control and others which we can’t. Our risk is impacted by our lifestyle choices. And it’s well established that eating well, exercising, avoiding smoking, limiting alcohol intake, and getting enough sleep lowers our risk.
Risk factors we can’t control
Risk factors that we can’t control include age, race, and family history of heart disease. Indigenous, Black, and South Asian women face a higher risk, since they are more likely to have high blood pressure or diabetes. Having a close family member with heart disease or stroke at an early age also increases your risk.
The role of menopause
What many women don’t realize is that our risk for heart disease dramatically increases after (and because of) menopause. Here’s why.
Estrogen protects our heart health. As women go through the menopause transition, arteries become more prone to inflammation and plaque build up (atherosclerosis). And we accumulate more belly fat, the unhealthy kind that builds up around our abdominal organs. Both contribute to the risk for cardiovascular disease.
While the underlying process is not completely understood, the loss of estrogen during menopause appears to play a direct role.
Important risk factors
Women who experience premature menopause (before age 40) or early menopause (between 40 – 45) have an increased risk for cardiovascular disease, likely because they have less years with the protective effects of estrogen.
And other menopausal factors also appear to impact our risk. Studies show that women who experience hot flashes or night sweats, sleep disturbances, or depression face an increased risk for poor heart health. Perimenopause has been defined as a vulnerable time period which significantly influences a woman’s future risk for cardiovascular diseases.
Healthy strategies matter
This means midlife is a critical time to monitor a woman’s health. It’s also important for each of us to implement life-changing intervention strategies. And strategies matter. Research shows that healthy interventions during midlife and beyond can effectively reduce our risk.
Let’s talk about strategies
It really comes down to the basics: stick to a healthy lifestyle and get your heart checked regularly.
Recent guidelines from the American Heart Association suggest an aggressive prevention-based approach during perimenopause will decrease a woman’s future risk for heart disease. They recommend maintaining a healthy body weight, reducing belly fat, and building lean muscle mass.
80% of heart attacks are avoidable
If you smoke, are overweight, don’t exercise, have high blood pressure or type 2 diabetes, your risk may be further increased. Talk to your doctor about a risk reducing approach for you.
Experts say 80% of the heart attacks experienced by women are avoidable. Be proactive. Ask your doctor what you can do, and when you should have cardiovascular screening. Don’t wait for your doctor to bring it up.
Women more likely to die from heart attack
While men are twice as likely to have a heart attack, women are more likely to die from a heart attack. This is because the symptoms may present differently in women. And all too often they go unrecognized or are dismissed until it’s too late. Studies show half of the women who have a heart attack struggle to have their symptoms recognized.
So learn about the symptoms. Listen to your body. Seek medical help immediately if you experience any symptom. Advocate for yourself to have your heart checked if symptoms are ignored or brushed off.
What about hormone therapy?
MHT is not currently approved by the FDA for the purpose of preventing heart disease. That said, taking MHT right after you reach menopause has a strong benefit for cardiovascular health.
In general, using MHT within 10 years of menopause and under age 60 is associated with a reduced risk for heart disease. However, MHT should not be given to people at high risk for cardiovascular disease or who already have heart disease.
If you are discussing MHT with your doctor and you have risk factors such as family history of heart disease, medical history of high blood pressure or diabetes, or you have experienced early menopause (under age 45), it is worth bringing heart health into the conversation.
3. Protect Your Vagina and Your Vulva
Vaginal and vulvar dryness, which can cause itching, burning and pain during sex, affects over 50% of women during the menopause transition and beyond. Dryness is a common and bothersome sign of genitourinary syndrome of menopause (GSM) which affects your vagina, vulva, bladder, urethra and clitoris–and your sex life.
The role of menopause
As the level of estrogen fluctuates and drops in our bodies, our genitourinary tissues start to thin and shrink. This increases tissue fragility. Reduces elasticity. And can alter the size and structure of our genitourinary body parts. Lack of estrogen, decreased blood flow to the tissues, and reduced collagen production with age, are all contributing factors.
GSM is chronic and progressive and–you may be seeing a trend here–most of us don’t even know it’s happening.
The tissue changes lead to the symptoms of GSM: vaginal dryness, urinary urgency or frequency, vaginal itching, burning or pain, bladder infections, vaginal infections, pain during sex, and incontinence. The symptoms are more frequent and most intense five years after menopause.
Ignored menopausal symptoms
Up to 84% of women will experience symptoms of GSM during her lifetime. However, only a minority will report these symptoms to a doctor and ask for help. There are many reasons why. Lack of trust. Discomfort around the topic. Fear of judgment. And believing there is no good treatment anyways.
Even worse, only about 1 in 10 healthcare providers will initiate a conversation about genitourinary symptoms. So most of us don’t know that there are safe and effective treatments.
Again, don’t wait for your doctor to bring it up.
Don’t grin and bare it
The symptoms can have a huge impact on quality of life and are more pronounced in people who are sexually active. In a study of women with GSM only about 50% sought out treatment.
The problem is, for those that don’t, the symptoms rarely resolve on their own and usually get worse over time. And they can lead to long-term complications due to permanent changes in the genitourinary tissues. So women who decide to ‘grin and bear it’ should think again.
What can you do?
There are effective ways to get relief from the symptoms and treat GSM.
Non-hormonal therapies such as lubricants and moisturizers are an easy and immediate solution; they provide temporary relief from vaginal dryness and pain during sex, and can be purchased over the counter in a drug store.
But the ‘gold standard’ is local topical vaginal estrogen. These treatments are safe and effective and approved by the FDA to treat moderate to severe GSM. While systemic MHT (i.e. oral tablets or the patch) might help, if a woman doesn’t have other troublesome symptoms of menopause, GSM is best treated with local vaginal estrogen tablets or creams.
Vaginal estrogen hydrates, boosts collagen, and prevents the symptoms of GSM. It can be used at any age and for extended duration, if needed. There are no significant risks to vaginal estrogen and, bottom-line, it can dramatically improve a woman’s quality of life.
Here’s the thing. Simply by going through menopause, a certainty for any woman with ovaries (with or without a uterus), women face an increased risk for bone loss, cardiovascular disease, and GSM.
The physiological changes in our bodies which contribute to our risk for these conditions start early in the menopause transition. When estrogen is starting to fluctuate and drop. When we have no idea. And these changes progress silently over time.
Women need to understand just how much our changing biology during menopause impacts our risk for future health conditions. We also need to understand that what we do during these menopausal years truly matters. Early healthy interventions and prevention can lower our risk in a meaningful way.
The onset of bone loss, and changes in our heart health and to our vaginal tissues happen quietly. But we must not remain silent about the health risks women face. We need to start conversations. With our doctors and with each other. And the result will be life-changing.