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Women & Heart Disease | 4 Surprising Links Between Estrogen, Menopause, & Heart Disease

heart disease insulin resistance pcos weight loss women Feb 18, 2021

Note: Reshape Physical Therapy and Wellness evolved into Weight Loss for Health, and finally Zivli. How to Lose Weight After 50 was our first course that eventually grew into Zivli. Some old blog posts or resources mentioned in this episode may have been removed. 

Going through menopause increases a woman's risk for heart disease, type 2 diabetes, and dementia. This episode is going to explain how decreased estrogen after menopause - whether it’s surgical or natural - increases your risk for cardiovascular disease, plus a bonus way that going through menopause can increase your weight and risk for disease. 


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What Is Cardiovascular Disease?

Cardiovascular disease is an umbrella term that covers coronary artery disease, heart attacks, strokes, and peripheral arterial disease, among others. We’ve all heard the standard advice that you’ll find found everywhere on the internet to reduce your risk of heart disease like eat well, exercise regularly, get enough sleep, don’t be too stressed, and don’t smoke or drink too much. 

My goal as an expert weight loss coach and doctor of physical therapy is to dig deeper and up-level the standard advice to give you more specifics and action items that you can easily implement into your lifestyle to reduce your risk for cardiovascular disease.

With heart disease being the number one killer of women in America, it’s important to be informed about your risk factors and take consistent, proactive measures to reduce these risk factors before they become full blown disease.  


Perimenopause, Menopause & Postmenopause

Women can be caught off guard in their 40s and 50s because they weren’t aware of the changes that their body would be going through, or how it would affect their health, waistline, and mood.

Perimenopause is defined as the years leading up to menopause when your period becomes irregular. Menopause is a point in time 12 months following your last period. Postmenopause is the rest of your life after menopause.  

Women can experience perimenopause symptoms like hot flashes, weight gain, insomnia, mood swings, and irritability from fluctuating hormone levels in their early 40s, although most women start perimenopause in their mid 40s. The average age of menopause is 51, but again, some women will experience menopause far sooner, and others a little later. 

We go through perimenopause for several years, and then even after menopause those hot flashes and other symptoms can still come up. We live in a postmenopasal state for 30+ years, and yet we still are treating women over 50 as if they are mini-men, or younger versions of themselves. 


Effects of Lower Estrogen After Menopause

I won’t go into too much detail here, but while lower levels of estrogen after menopause is a natural phenomenon, those lower hormone levels present significant physical and emotional challenges including an increased risk of cardiovascular disease, type 2 diabetes, dementia, and increased fat mass, especially around the midsection. 

I like to say that this is the point in a woman's life where she’s faced with the hard reality that losing weight is not about eating less and exercising more. It’s about hormones. Specifically, it’s about insulin because insulin is your body’s fat storage hormone and the primary determinant of your body's set weight. 

Take a look at common risk factors for various conditions that we know increase after menopause: type 2 diabetes, heart disease, and dementia. Elevated blood pressure, blood glucose, insulin, triglycerides, a larger waist circumference, and lower HDL is not an exhaustive list, but my point here is that all of these risk factors are really symptoms of two underlying conditions: insulin resistance and inflammation. 


When you treat insulin resistance and inflammation, the rest of these risk factors will improve as well. You know the saying, when the tide comes in, all the boats rise? Same thing goes for insulin resistance and inflammation. When you deal with these factors, your entire health profile will improve. 

Something else may happen, especially if you’re following what I recommend which is a lower carb lifestyle with moderate intermittent fasting, and that’s elevated LDL. We used to consider this “bad” cholesterol but this interview with Dr. Nadir Ali and the corresponding blog posts dives into how that may be oversimplified, and why when all other numbers are going in the right direction...for example your triglycerides, insulin, glucose, and inflammation are going down and your HDL is going up, we don’t need to worry about elevated LDL.

The post gives you other tests to determine your heart disease risk rather than just having high LDL and starting a statin...which is the standard of care in medicine today.


Lower Estrogen, Insulin Resistance, & Heart Disease

Let’s talk about the three ways that a decline in estrogen may lead to high insulin levels, and subsequently the secondary side effects of elevated insulin like higher blood glucose, triglycerides, lower HDL cholesterol, and increased risk for cardiovascular disease. 


Estrogen Is Protective Against Insulin Resistance & Belly Fat

The more estrogen you have, the more sensitive you are to insulin and the less insulin you’ll need to get sugar from your bloodstream into your cells for energy. Some common signs of insulin resistance are increased blood sugars, increased carb cravings, fatigue, weight gain, elevated triglycerides, low HDL, and elevated blood pressure. 

Estrogen causes a preferential storage of fat in your subcutaneous stores. Subcutaneous fat is under your skin, but above your muscle layer. This is the stuff you can grab with your hands, where fat is meant to be stored and estrogen helps store fat here, particularly around your hips and thighs. 

When estrogen levels fall, you lose this protection, and fat shifts from subcutaneous to visceral stores, also known as belly fat. This visceral fat is under your abdominal muscles and is more inflammatory than subcutaneous fat, and can worsen inflammation and insulin resistance. That’s why abdominal obesity, not overall obesity, is one of the criteria in metabolic syndrome, which a cluster of risk factors for cardiovascular disease. 


Estrogen Is Protective Against Bone Loss

Decreased estrogen from your ovaries leads to weaker bones, which is one of the reasons a woman's risk for osteoporosis increases with age. There is some debate as to whether age or declining estrogen is responsible for decreased bone mineral density in women and one study I found compared three groups of women.

The researchers in one study compared 14 women who had undergone oophorectomy, or removal of the ovaries during young adulthood, 14 normal perimenopausal women, and 14 normal postmenopausal women. 

They found that bone loss was similar in the groups who had their ovaries surgically removed and the postmenopasal women. But women in natural perimenopause who still had higher levels of estrogen, had better bone mineral density. 

Because bone loss in the group of young women who had their ovaries removed (differing from the perimenopausal group in menopausal status but not in age) was almost as great as in the postmenopausal group (differing both in age and menopasal status). The authors suggested that estrogen deficiency, and not aging, may be the predominant cause of bone loss occurring during the first two decades after natural menopause. 

When you get less estrogen from your ovaries, either because they’ve been surgically removed, or you go through menopause naturally, your fat cells start to pick up the slack. In case you were multi-tasking let me say that again because I found this really interesting when I first learned about it. Your fat cells make estrogen. 

More and more research is coming out about adipose, or fat tissue. And it’s now considered an endocrine organ like your ovaries, pancreas, and thyroid gland, among others. So when estrogen goes down due to aging or removed ovaries, your fat tissue becomes your primary source of estrogen. 

Your body knows that estrogen is important, so it likes to hang onto fat tissue more than before menopause. That’s just one of the reasons that weight loss becomes harder for women as we age, and highlights the importance of adopting a healthy lifestyle as soon as possible. 

There’s a direct link between your bone health and adipose tissue. Our body does need a certain amount of fat, but too much - which is very common especially after menopause, increases our cardiovascular risk.

That’s why I’m a huge proponent of adequate protein intake and strength training for women in perimenopause and beyond. You need both adequate protein, and resistance training to build muscle. If you have strong muscles and bones from diet and exercise, your body will rely less on fat tissue for bone strength. And, increased muscle mass improves insulin sensitivity and metabolism to make weight loss easier to maintain. 


Estrogen Is Protective Against High Blood Pressure

Lastly, there’s evidence that estrogen can stimulate nitrous oxide production in the vascular walls. Nitrous oxide is a vasodilator, meaning it expands the blood vessels, allowing more blood to flow through. This can not only reduce blood pressure, but increase the diameter of potentially constricted blood vessels due to atherosclerosis, or a buildup of plaque within the blood vessel that reduces the diameter of the vessel itself. The nitrous oxide would help increase the diameter of that blood vessel and potentially reduce a complete blockage - like in the event of a heart attack or stroke. 

Before we get to our bonus item, let’s do a quick recap here for the ways that a decline in estrogen can increase your risk for heart disease.  

Number 1: Reduced estrogen leads to increased fat mass, and a redistribution of that fat mass to the visceral area. 

Number 2: Reduced estrogen leads to lower bone mineral density. The body relies even more on adipose tissue for estrogen, and shear weight, to maintain bone health. 

Too much adipose tissue, especially around the midsection will increase inflammation, insulin resistance, and total body weight. It’s kind of a nasty cycle in that fat leads to more fat. 

Number 3: Reduced estrogen leads to lower nitrous oxide levels and more vasoconstriction, leading to and increased risk for elevated blood pressure and blockages. 

Those are just three! New research is coming out all the time and there may be more ways, including how estrogen interacts with different types of fat cells to influence energy storage and expenditure. 

Unless you’re taking hormone replacement therapy - which isn’t a long-term solution - you’re going to be faced with the harsh reality that prioritizing your health is a must, especially in perimenopause and postmenopause, if you want to reduce your risk for cardiovascular disease, dementia, type 2 diabetes, fractures, and a host of other health conditions. 

Ready for the bonus way that menopause increases a woman's risk for cardiovascular disease? It’s any and every form of stress. 


Menopause, Stress, & Heart Disease

For women experiencing night sweats or insomnia, or just general anxiety and depression that increase after menopause, getting restful sleep becomes harder, and downright impossible for some women. 

That chronic sleep deprivation is a form of stress on your body. Stress increases cortisol, which increases blood sugar, which increases insulin, which increases insulin resistance and elevates your body set weight. 

Further, you’re not getting as much human growth hormone that’s released when we sleep. Human growth hormone is important to build muscle and burn fat so getting less of it slows your metabolism. 

This is a double whammy for your weight and heart health. If you’re in perimenopause and beyond and you’re really struggling with weight loss, I’d encourage you to take a closer look at your sleep and stress habits. I like to say no amount of diet and exercise will help you lose weight if the underlying problem is chronic stress and or sleep deprivation. 

Here’s a fun physiological fact about how cortisol works to further decrease estrogen levels I learned in a fascinating book called The XX Brain by Dr. Lisa Mosconi. If you haven’t picked it up yet I highly recommend you do! I’m learning a lot from it. And I’m paraphrasing this next little  bit from her book. 

“All sex hormones start with cholesterol. The body uses cholesterol to make a hormone called pregnenolone, which is also known as the mother of all sex hormones. Pregnenolone is converted into progesterone, and progesterone can then be used to make estrogen or testosterone. 

This process is hijacked by cortisol when you’re stressed. Your adrenal glands use pregnenolone, too, but to make cortisol. When you’re under acute but temporary stress, your body will reroute some of its pregnenolone to make more cortisol. 

Once the stressor is gone, cortisol production slows and your body resumes its usual estrogen and progesterone production. But when you’re under chronic stress, your cortisol levels go up and remain high for extended periods of time. 

Your body has no choice but to keep making cortisol by stealing pregnenolone away from your sex hormones. There are four main consequences of this cortisol hijacking process: your pregnenolone goes down (making you feel irritable), your progesterone goes down (keeping you up at night), your estrogen goes down (giving you hot flashes), and your thyroid slow down your metabolism, causing more fatigue and weight gain.”

Here are a couple more insights about sleep that contribute to weight gain. First, consider sleep like recharging your willpower and self-control. These aren’t things we should rely on to lose weight, but we do need to use them everyday. 

When we are drained, we just don’t have the energy to always choose healthy things. Second, poor sleep increases ghrelin, your hunger hormone and you’ll typically experience more carb and sugar cravings. Third, poor sleep reduces leptin, or your satiety hormone. So you’re hungry, but you’re less likely to feel full.  


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Resources From This Episode

>> Join Zivli

>> Freebie: Weight Loss Mindset Audio Training

>> Freebie: The Ultimate Food Guide

 >> Interview with Dr. Nadir Ali

>> Dr. Lisa Mosconi