Study links hot flushes, night sweats to CVD in women

Matt Woodley

6/07/2020 4:50:37 PM

The new research could help identify patients in need of close monitoring in clinical practice. But does it tell the whole story?

Older woman
The study found women who have hot flushes and night sweats are 70% more likely to have heart attacks, angina and strokes than those without symptoms, but others have concerns about its methods.

The meta-analysis, compiled by researchers at the University of Queensland (UQ), found that women who have post-menopausal vasomotor symptoms (VMS) – hot flushes and night sweats – are 70% more likely to have heart attacks, angina and strokes than those without symptoms.
Early-onset menopause has already been previously linked to an increased risk of cardiovascular disease (CVD). But UQ School of Public Health PhD student Dr Dongshan Zhu said the new study shows women of any age who experience hot flushes and night sweats are more likely to experience non-fatal cardiovascular events.
‘Until now, it’s been unclear if VMS is associated with cardiovascular disease, but now we know it to be true,’ Dr Zhu said.
‘Further, VMS before menopause increases a woman’s chance of cardiovascular events by 40%.’
However, Dr Magdalena Simonis, a member of the RACGP Expert Committee – Quality Care (REC– QC) and a GP with a special interest in women’s health, told newsGP that 70% is ‘a very high number’ and she would be ‘very hesitant’ to accept it as a valid figure.
One issue, according to Dr Simonis, is that the study did not include patients’ lipid profile and diabetes status as time-varying co-variates, even though they are important CVD risk factors. She also said the authors ignored other confounding factors.
‘Dyslipidaemia and elevated blood sugar levels are very strongly associated with CVD in females and males, yet poorly or under-treated in females,’ she said.
‘[This is] due to gendered biases in our training and the way studies reporting the incidence of CVD have been conducted to date. 
‘The study [also] focused on other co-variates and factors such as MHT, smoking, body mass index and blood pressure, [but] we are not told if these changed over the course of time.
‘The blood pressure measures were either self-reported as “not on treatment” – therefore not hypertensive – or measured upon recruitment to the study, but not measured over time.
‘[Yet] we know that BP can vary over time and is an important risk factor for CVD.’
Dr Simonis also pointed out that some study participants received menopausal hormonal therapy (MHT) and questioned whether there is any correlation between the taking of MHT and CVD events.
‘One would assume that if they were on MHT, their vasomotor symptoms would be have been already controlled,’ she said.
‘Therefore they would be reporting fewer and less severe symptoms, if any at all. If they were on MHT early, does control of their symptoms therefore equate with a reduction in CVD?’

According to Dr Karen Magraith, President-elect of the Australasian Menopause Society, menopausal hormone therapy (MHT) has an influence on coronary heart disease.
‘Observational and randomised controlled trial data have shown that women who commence MHT under the age of 60 or within 10 years of menopause have a substantially reduced incidence of coronary heart disease,’ she told newsGP.
‘This information has a tendency to be lost in the ongoing discussion about MHT and an increase in breast cancer risk.
‘Women with vasomotor symptoms who are considering using MHT need to be counselled about the potential risks and benefits of MHT, including a discussion about venous thromboembolism and breast cancer risk. 
‘[But] given that MHT initiated close to time of menopause is associated with a reduction in risk of coronary heart disease, do women with severe VMS potentially have the most to gain from the use of MHT, both for symptom relief, and for cardiac disease prevention?’
Meanwhile, Dr Amy Moten, Chair of the RACGP Specific Interests Sexual Health network, also told newsGP the 70% figure is high and may be affected by confounding factors.
Nonetheless, she suggested having another indication to encourage women to be assessed could be valuable, even if GPs are already ‘very good’ at screening for CVD.
‘We known that heart disease is the number-one killer of women in Australia, yet women are less likely to consider themselves at risk and less likely to be screened for this,’ she said.
‘Heart disease in women can also present differently than in men, leading to a delay in diagnosis.
‘It may be particularly helpful in recommending screening for people having perimenopausal symptoms who would otherwise consider their risk to be low.’

Dr Magraith agrees that the research may help clinicians better identify women at higher risk of coronary heart disease that would benefit from closer monitoring, but more research is required.
‘We frequently assess our patients’ cardiovascular risk … [and] we sometimes use risk calculators to stratify risk. [But] it is unclear how the information from this study can be integrated into our risk assessments,’ she said.
‘At this stage it is something to keep in mind when assessing women. All women will benefit from attention to lifestyle factors such as smoking, diet and exercise.’
Dr Simonis said a part of good preventive medicine is to screen for dyslipidaemia, elevated cholesterol, blood pressure and diabetes at the onset of menopausal symptoms, as well as at the 40-plus health check, the 45-plus health check, and from 50 onwards.
‘The family history and other lifestyle factors also need to be taken into consideration, such as diet, exercise, sleep quality and stress levels,’ she said.
‘Talking to women about the risk of CVD is important because it’s preventable. Perimenopause, menopause and discussion around VMS provides an opportunity to educate women around this association and how lifestyle changes can help prevent this.’   
One finding from the study is that the risk of cardiovascular events is more related to the severity of the hot flushes and night sweats, rather than their frequency or duration.
Women with severe VMS were reportedly more than twice as likely to experience a non-fatal cardiovascular event compared with women who had no symptoms.
Senior author on the study Professor Gita Mishra told newsGP the severity of VMS symptoms may reflect greater hormonal changes, which could in turn influence CVD risk.
‘It could also reflect some unmeasured confounders that affect both VMS and CVD,’ she said. ‘We do know that the women were bothered by the symptoms, hence perhaps this could lead to less misreporting of symptoms.’
According to Professor Mishra, while the mechanism behind the relationship between VMS and CVD is unknown – and the topic of ongoing research – patients can still take steps to reduce VMS before or after menopause.
We found that women who maintained a healthy body weight before and during the menopause transition, and those who were never smokers or who quit smoking before the age of 40, had lower risk of VMS,’ she said.
‘Whether VMS is a reflection of the fact that the woman already has a poor underlying CVD profile is not to be ruled out – we know that women with poor CVD profile are at an increased risk of having early menopause.’
Professor Mishra said even when controlling for compounding factors such as higher cholesterol or systolic blood pressure, the observed associations of VMC with CVD were ‘only slightly’ attenuated, ‘suggesting that other mechanisms play a role in the aetiology of CVD’.
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