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Cardiovascular Health

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The healthyher.life team supports a holistic approach to managing women’s hormonal healthcare. Our goal is to help our members be well-informed about their hormonal health, by providing them with evidence-based integrated health information that includes the current standard of medical care advised by qualified physicians, clinical insights from licensed allied health professionals (naturopathic doctors, nurse-practitioners, nutritionists, psychotherapists) and new health innovations that will be soon coming to market. Always consult with your doctor regarding your medical condition, diagnosis, treatment, or to seek personalized medical advice. 

Women’s Heart Health: What You Need to Know

Reviewed by: Henry Xu, PhD and Joanne Tejeda, PhD
May 15, 2024

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Women’s hormones and their heart health are in a continuously changing symphony. Through the journey of a woman’s life, there will be several significant stages of hormonal transitions and fluctuations that will naturally occur. Beginning with adolescence and the onset of menstruation, and often followed by the young adult period when considering the use of contraceptives, to  prenatal fertility planning, followed by the radical post-partum hormonal fluctuations women encounter, and eventually onto mid-life decades with the onset of perimenopause leading to menopause – the day menstruation as stopped for one full year - all of these stages can and will impart a noticeable change to a woman’s cardiovascular health. Understanding the factors at play between women’s hormones and heart health is essential for early detection, prevention, and effective management of heart disease.  

It’s important to first consider the factors that may impact cardiovascular health and longevity in women. Medicine has traditionally viewed heart disease as mainly affecting men, which has unfortunately led to insufficient attention to investigating the gender-specific differences in cardiovascular health. This oversight has left women disproportionately impacted and underserved in the delivery of appropriate health care services. 

At Healthyher.Life, we encourage you to learn proactively about heart health for women. Whatever age you may be in, it’s critical for you to learn and understand how your natural hormonal cycles, and any hormonal supplements you may be taking, can affect your heart's function for maintaining vitality, longevity, and to help you live a healthyher life

Burden of Heart Disease in Women 

Recent studies have revealed a concerning truth: in 2019 over 275 million women worldwide were diagnosed with heart disease and led to 36% of all deaths among women [1]. Similarly, more than 600 million women in the world between the ages of 30-70 were diagnosed in 2019 with high blood pressure (hypertension) [2]. Since high blood pressure is a major risk factor for heart disease in women [3], this high prevalence in women significantly increases the at-risk population for heart disease. 

In the United States, over 60 million women (44% of all women) are living with some form of heart disease [4], and it is the cause of about 1 in every 5 female deaths in 2021 [5]. While in Canada, heart disease was the second leading cause of death, accounting for over 16% of all deaths among females in 2022 [6]. 

The American Heart Association emphasized the urgent need to address gaps in knowledge and health care service delivery for women's cardiovascular health, in an official Presidential Advisory [7]. It highlights that cardiovascular disease (which includes heart disease) remains the leading cause of death among women and underscores the importance of understanding biological differences, social determinants of health, and the impact of sex and gender on health outcomes. 

As with heart disease, cardiovascular disease (CVD) was historically seen as a predominantly male health concern. It is now recognized as a disease that is more prevalent in women, and is often unnoticed and undetected even by practitioners. Recent research has highlighted new evidence suggesting that certain risk factors for CVD may be unique to women, such as conditions related to gestational hypertension and gestational diabetes during pregnancy, as well as reproductive endocrine disorders like polycystic ovary syndrome (PCOS), premature ovarian insufficiency (POI) and early menopause. These conditions have been associated with an accelerated development of CVD and a decrease in CVD-free survival [8]. 

What are Common Types of Heart Diseases? 

There are three most common types of heart disease occurring in women [5]: 

  • Coronary Artery Disease (CAD) is the most prevalent heart condition and is the leading cause of death among women. It occurs due to the buildup of plaque in the arteries that supply blood to the heart and other body parts. Women, especially after menopause, face an increased risk of CAD due to hormonal changes. 

  • Arrhythmia refers to abnormal heart rhythms, which can manifest as the heart beating too slowly, too quickly, or irregularly. A well-known type is Atrial Fibrillation (AFib). 

  • Heart Failure (HF) indicates that the heart is too weak to efficiently pump blood to support the body's organs. This condition is severe, though it does not imply that the heart has stopped beating. 

 

What Causes Heart Disease in Women? 

 

Common risk factors of heart disease in women include [5, 9, 10]: 

  1. Traditional Risk Factors: These factors are similar to those found in men and include high blood pressure, high cholesterol, diabetes, smoking, obesity, and a sedentary lifestyle. 

  2. Menopause and Hormonal Factors: Estrogen has a protective effect on the heart, so changes in estrogen levels throughout a woman's life can influence her heart health. Hormonal birth control (contraceptives) and hormonal therapies, while being highly effective for their primary indicated uses in contraception and for managing symptoms of perimenopause, may also affect a woman’s risk of developing hypertension and heart disease. 

  3. Mental Stress and Depression: Women may be more susceptible to mental stress and depression caused by hormonal fluctuations, which can increase the risk of developing heart disease. Chronic stress and depression can lead to unhealthy coping mechanisms like overeating or smoking, which in turn can increase the risk of heart disease [11]. 

  4. Genetics and Autoimmune Conditions: Conditions like lupus and rheumatoid arthritis, which are more common in women, can increase the risk of heart disease. A family history of heart disease can also increase a women’s risk. 

  5. Pregnancy Complications: Certain pregnancy complications such as gestational diabetes and preeclampsia can increase a woman's risk of developing heart disease later in life. 

  6. Socioeconomic Factors: Socioeconomic factors like income, education, and access to healthcare can also influence heart disease risk in women. 

What are the Symptoms of Heart Disease in Women? 

 

Some common symptoms of heart disease in women that differ from those experienced by men include [5, 12]: 

  1. Pain or discomfort: women may not always experience the classic chest pain that men often do. Instead, they might have discomfort in the neck, jaw, throat, abdomen, or back. This discomfort can vary in intensity and may come and go. 

  2. Shortness of breath:  can occur with or without chest discomfort and may happen during physical activity or while resting. 

  3. Nausea or vomiting: some women may experience these symptoms, which can be mistaken for other conditions like the flu or indigestion. 

  4. Sweating: some women may break out in a cold sweat, which can occur unrelated to physical activity or temperature. 

  5. Fatigue: Feeling unusually tired, even after a good night's sleep or with minimal exertion, can indicate heart disease in women. 

  6. Dizziness or light-headedness: this sensation can occur with or without chest discomfort. 

  7. Sleep disturbances: heart-related symptoms may cause difficulty sleeping in some women.   

 

What role do Female Reproductive Hormones have on Heart Health?  

Women's hormones play a significant role in heart health throughout their lives [13]. Estrogen has a protective effect on the cardiovascular system, helping to maintain healthy blood vessels, lower the levels of bad cholesterol, or hypertension.  

As women age and reach menopause, their estrogen levels decline. This change can impact the cardiovascular system, increasing the risk factors for heart disease. Additionally, hormonal shifts during the menstrual cycle can affect blood vessel function and lead to fluctuations in heart rate and blood pressure. It’s important to recognize how hormonal levels can raise the risk of heart disease for women, and so adopting some preventive measures is advisable. 

Regarding the use of hormonal contraceptives such as progestins and progestin-estradiol combination therapies, the clinical science literature does not provide strong evidence about the use of hormonal contraceptives and the risk of developing cardiovascular disease (CVD) as an adverse health outcome [14, 15]. Rather, the clinical evidence suggests that there is an increased risk of blood clot in women who are already diagnosed with congenital heart disease [16]. Therefore, previously published reports of significant cardiovascular health risks being associated with the use of hormonal contraceptives may not be as conclusive as once thought.  

 

Menopausal Hormone Therapy and Heart Health 

Menopausal Hormone Therapy (MHT) can have various effects on menopausal women with heart disease. While MHT was once widely prescribed to manage the symptoms experienced by women during perimenopause and potentially reduce their risk of heart disease, recent research has shown conflicting results regarding its impact on heart health [17]. For some women with heart disease, particularly those experiencing severe vasomotor symptoms like hot flushes and night sweats, MHT can provide relief and significantly improve their quality of life. However, the decision to use MHT should be carefully weighed against potential health risks and personal medical history in consultation with a family medicine practitioner or gynecologist, especially for women with pre-existing heart conditions or who have other significant risk factors of heart disease (such as diabetes). To determine if MHT is right for you, please consult with your healthcare provider to make an informed decision that is personalized to your needs and medical history. 

Impact of Heart Health and other Chronic Hormonal Health Conditions 

 

Endometriosis

A recent systematic clinical review examined the potential connection between endometriosis, which is a chronic pelvic inflammatory condition affecting approximately 200 million women worldwide, and cardiovascular disease or CVD [18]. The goal of the clinical review was to evaluate the incidence of cardiovascular events, including coronary heart disease, stroke, and hypertension, in women who are diagnosed with endometriosis, and determine whether the presence of endometriosis might be considered a risk factor for developing CVD.

The study revealed that there was a significant association between endometriosis and an increased risk of various cardiovascular diseases. Women with endometriosis were found to have an elevated risk of experiencing coronary heart disease and stroke compared to women who do not have endometriosis. The proposed underlying mechanisms for this association include chronic inflammation, hormonal imbalances, and the presence of endometriosis lesions that can contribute to vascular changes, and an increased cardiovascular risk profile.

Based on the findings of this systematic clinical review, it was recommended to have more cardiovascular risk assessments conducted for women diagnosed with endometriosis and more proactive management of their condition. Given the chronic nature of endometriosis and its tendency to exacerbate cardiovascular health issues, the authors advocate for an integrated healthcare approach covering both gynecological and cardiovascular monitoring and treatment. An integrated approach would involve regular cardiovascular screenings, lifestyle changes, and targeted medical therapies to reduce the risk of CVD.

 

 

PCOS

Polycystic ovary syndrome (PCOS) is a common endocrine disorder among women of reproductive age, characterized by irregular menstrual cycles, hyperandrogenism, and polycystic ovaries. The association between PCOS and the risk of developing cardiovascular diseases (CVD) such as coronary heart disease (CHD) and stroke, was investigated with the goal of determining whether women diagnosed with PCOS have an elevated risk of CVD and whether obesity, which is often associated with PCOS, influences this risk [19].

The study’s authors found women diagnosed with PCOS have a higher prevalence of cardiovascular events such as stroke and CHD compared to women without PCOS. The analysis also highlighted that the presence of obesity significantly raises this risk of cardiovascular complications.

The importance of having comprehensive cardiovascular risk management in women with PCOS, particularly patients who are obese, is paramount to having good health outcomes. The study’s authors advocate for regular cardiovascular screenings, lifestyle interventions that are primarily aimed at weight management, and targeted medical treatments to address both PCOS and related metabolic disruptions. Addressing these health concerns through an integrated healthcare approach will improve the cardiovascular health and general health outcomes for women with PCOS.

 

Lifestyle Changes for Reducing Risk of Heart Disease 

There are recommended lifestyle modifications that a person can make to maintain a healthy heart as they age – these modifications include [20, 21]: 

  • Exercising regularly: Aim for at least 150 minutes (2.5 hours) per week of moderate-intensity aerobic activity or 75 minutes per week of vigorous exercise. Activities like brisk walking, jogging, swimming, or cycling can improve cardiovascular health.

  • Follow a healthy diet: Try to adopt a nutritionally balanced diet that is rich in fruits, vegetables, whole grains, lean proteins, and healthy, unsaturated fats like avocados and olive oil. Limit saturated and trans fats, prepared or packaged foods with high sodium and added sugars. Consider adopting the Mediterranean diet or DASH diet to lower your risk of heart disease. 

  • Maintaining a healthy weight and BMI, especially around the waist area, will reduce the physiological strain on the heart and lower the risk of developing cardiovascular disease.

 

  • Quit smoking: Smoking is a major heart disease risk factor. Quitting smoking can significantly improve heart health and your general well-being. 

  • Limit alcohol intake: Recent research suggests that women are more vulnerable to the adverse effects of alcohol than men. This is partly because women generally have a higher concentration of alcohol in their blood after drinking the same amount as men, due to having less body water. There's also an increased risk of breast cancer associated with alcohol consumption in women. New 2023 guidelines for Canadians recommend 2 drinks or less in per week for women, citing that health risks increase more steeply for females than for males when drinking more than 6 drinks per week [22]. 

  • Manage stress: Chronic stress contributes to heart disease risk. Practice stress-reducing techniques like mindfulness, meditation, yoga, or deep breathing exercises to promote relaxation. 

  • Prioritize sleep: Aim for 7-9 hours of quality sleep per night. Poor sleep increases heart disease and other health risks. 

  • Schedule regular health check-ups: Monitor blood pressure, cholesterol, blood sugar, and other heart disease risk factors with regular check-ups. Discuss any concerns or symptoms promptly with your healthcare provider. 

The Framingham Risk Score 

The Framingham Risk Score (FRS) is a sex-specific algorithm used to estimate the cardiovascular risk of an individual over the next 10 years. It was developed from data obtained from the Framingham Heart Study and considers factors like age, cholesterol levels, blood pressure, diabetes, and smoking status. This score is widely used by physicians and cardiologists to guide their clinical decisions on a suitable preventive health plan to reduce the risk of developing heart disease [23, 24]. 

To learn more and calculate what is your personal Framingham Risk Score, you can use the FRS Calculator which is free to use from the Canadian Cardiovascular Society. Cardiovascular risk level thresholds are as follows: 

  • High Risk – FRS ≥ 20% 

  • Intermediate Risk – FRS between 10-19% 

  • Low Risk – FRS < 10% 

Based on your FRS risk level, doctors will typically ask to see additional blood test results to look at other risk modifiers such as different lipoprotein concentrations and any family history of cardiovascular disease. Based on your specific condition, doctors will decide whether to prescribe statin treatment. 

Dr. Shafeena Premji has also recently spoken about the Framingham Risk Score in our latest women Talking™ Wednesday presentation on "Women's Hormones and Heart Health", May 29, 2024. You can catch her suggestion regarding the FRS below or on Healthyher.life’s YouTube channel. 

Please note the content here is for informational purposes and cannot be used as medical advice. You should consult licensed practitioners on your condition and treatment. 

Got a question about how your women’s hormones can impact your heart health?  

On May 29th, 2024, Healthyher.Life proudly presents Women Talking™ Wednesday virtual learning event on "Women's Hormones and Heart Health: What You Need to Know", a conversation with invited speaker and Canadian family physician Dr. Shafeena Premji, who is a women's health expert and a Menopause Society Certified Practitioner (MSCP).   

A video recording of this presentation is available on the Healthyher.Life YouTube channel.

References:

References: 

[1] Vogel, Birgit et al. “The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030.” Lancet (London, England) vol. 397,10292 (2021): 2385-2438. doi:10.1016/S0140-6736(21)00684-X 

[2] NCD Risk Factor Collaboration (NCD-RisC). “Worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1201 population-representative studies with 104 million participants.” Lancet (London, England) vol. 398,10304 (2021): 957-980. doi:10.1016/S0140-6736(21)01330-1 

[3] Gerdts, Eva et al. “Sex differences in arterial hypertension.” European heart journal vol. 43,46 (2022): 4777-4788. doi:10.1093/eurheartj/ehac470 

[4] Tsao, Connie W et al. “Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association.” Circulation vol. 147,8 (2023): e93-e621. doi:10.1161/CIR.0000000000001123 

[5] About Women and Heart Disease, Center for Disease Control and Prevention, May 2024, https://www.cdc.gov/heart-disease/about/women-and-heart-disease.html  

[6] Leading causes of death, total population, by age group, Statistics Canada, Nov 2023, https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310039401&pickMembers%5B0%5D=2.1&pickMembers%5B1%5D=3.3&cubeTimeFrame.startYear=2018&cubeTimeFrame.endYear=2022&referencePeriods=20180101%2C20220101  

[7] Wenger, Nanette K et al. “Call to Action for Cardiovascular Disease in Women: Epidemiology, Awareness, Access, and Delivery of Equitable Health Care: A Presidential Advisory From the American Heart Association.” Circulation vol. 145,23 (2022): e1059-e1071. doi:10.1161/CIR.0000000000001071 

[8] Appelman, Yolande et al. “Sex differences in cardiovascular risk factors and disease prevention.” Atherosclerosis vol. 241,1 (2015): 211-8. doi:10.1016/j.atherosclerosis.2015.01.027 

[9] Women’s risk factors, Heart and Stroke Foundation of Canada, 2024, https://www.heartandstroke.ca/women/womens-risk-factors 

[10] Women and Heart Disease, National Heart, Lung, and Blood Institute of NIH, Dec 2023, https://www.nhlbi.nih.gov/health/coronary-heart-disease/women 

[11] Depression Among Women, Center for Disease Control and Prevention, May 2023, https://www.cdc.gov/reproductivehealth/depression/index.htm 

[12] Heart Disease in Women, MedlinePlus National Library of Medicine, Mar 2024, https://medlineplus.gov/heartdiseaseinwomen.html 

[13] Knowlton, A A, and D H Korzick. “Estrogen and the female heart.” Molecular and cellular endocrinology vol. 389,1-2 (2014): 31-9. doi:10.1016/j.mce.2014.01.002 

[14] Brabaharan, Sharmila et al. “Association of Hormonal Contraceptive Use With Adverse Health Outcomes: An Umbrella Review of Meta-analyses of Randomized Clinical Trials and Cohort Studies.” JAMA network open vol. 5,1 e2143730. 4 Jan. 2022, doi:10.1001/jamanetworkopen.2021.43730 

[15] Bassuk, Shari S, and JoAnn E Manson. “Oral contraceptives and menopausal hormone therapy: relative and attributable risks of cardiovascular disease, cancer, and other health outcomes.” Annals of epidemiology vol. 25,3 (2015): 193-200. doi:10.1016/j.annepidem.2014.11.004 

[16] Abarbanell, Ginnie et al. “Safety of contraceptive use among women with congenital heart disease: A systematic review.” Congenital heart disease vol. 14,3 (2019): 331-340. doi:10.1111/chd.12752 

[17] Prabakaran, Sindhu et al. “Cardiovascular risk in menopausal women and our evolving understanding of menopausal hormone therapy: risks, benefits, and current guidelines for use.” Therapeutic advances in endocrinology and metabolism vol. 12 20420188211013917. 30 Apr. 2021, doi:10.1177/20420188211013917 

[18] Okoli, Unoma et al. “Endometriosis and Risk of Cardiovascular Disease: Systematic Review and Meta-Analysis.” Journal of women's health vol. 32,12 (2023): 1328-1339. doi:10.1089/jwh.2023.0091 

[19] de Groot, P C M et al. “PCOS, coronary heart disease, stroke and the influence of obesity: a systematic review and meta-analysis.” Human reproduction update vol. 17,4 (2011): 495-500. doi:10.1093/humupd/dmr001 

[20] How to Help Prevent Heart Disease At Any Age, American Heart Association, Apr 2015, https://www.heart.org/en/healthy-living/healthy-lifestyle/how-to-help-prevent-heart-disease-at-any-age  

[21] Prevent Heart Disease, Center for Disease Control and Prevention, Mar 2023, https://www.cdc.gov/heart-disease/prevention/index.html   

[22] Paradis, C., Butt, P., Shield, K., Poole, N., Wells, S., Naimi, T., Sherk, A., & the Low-Risk Alcohol Drinking Guidelines Scientific Expert Panels. “Canada’s Guidance on Alcohol and Health: Final Report.” Canadian Centre on Substance Use and Addiction, Jan 2023, https://www.ccsa.ca/sites/default/files/2023-01/CCSA_Canadas_Guidance_on_Alcohol_and_Health_Final_Report_en.pdf   

[23] D'Agostino, Ralph B Sr et al. “General cardiovascular risk profile for use in primary care: the Framingham Heart Study.” Circulation vol. 117,6 (2008): 743-53. doi:10.1161/CIRCULATIONAHA.107.699579 

[24] Wilson, P W et al. “Prediction of coronary heart disease using risk factor categories.” Circulation vol. 97,18 (1998): 1837-47. doi:10.1161/01.cir.97.18.1837 

Evaluating the safety of estrogen delivery format when using hormone replacement therapies for relieving menopause symptoms

Reviewed by Rina Carlini, PhD, Joanne Tejeda, PhD and Azi Nia, PhD
October 13, 2023

The majority of women worldwide struggle with menopausal symptoms, which can include hot flashes and/or night sweats (vasomotor symptoms), mood changes (anxiety, depression), vaginal dryness (genitourinary symptoms), irregular and/or heavy menstruation, weight gain, thyroid disorders (metabolic symptoms), anemia (low iron stores), fatigue and hair loss, joint pain (musculoskeletal symptoms), irritable bowel (gastrointestinal symptoms), dry skin, dry eyes, insomnia and others [1]. Unfortunately, only a quarter of women in the USA actually seek treatment options to manage their symptoms, which indicates that the conversion about how to get qualified menopause care should be amplified in every family household and workplace setting.

The Menopause Society (formerly known as the North American Menopause Foundation) and also the Canadian Menopause Society have advocated that the first line of treatment for relief of menopausal symptoms and complications is Hormone Replacement Therapy, or HRT [2]. HRT can be administered as either estrogen-progesterone combination therapy (which is a  common approach), progesterone-only therapy, or estrogen-only therapy. The latter is typically prescribed to women who no longer have ovaries following a hysterectomy.

Recently, a large clinical study was conducted in Alberta, Canada involving more than 112,000 women aged 45 years or older to examine the safety of the various formats and routes of administration for estrogen-only hormone therapies, which included oral pills, transdermal patches, and vaginal creams [3]. The clinical study enrolled women who had used at least two consecutive treatments of estrogen-only HRT during the period of 2008 to 2019, and the primary outcome of the study was to evaluate the risk of developing high blood pressure (incident hypertension) [3]. The effect of the source of estrogen being taken – where the majority of study participants were taking either conjugated equine estrogen (CEE; 40%) or synthetic estradiol (55%), and a minority of participants were taking synthetic estrone (5%) –  was also investigated.

The key findings learned from the study:

  • Women taking oral estrogen had a 14% higher likelihood of developing hypertension than those using transdermal estrogen.

 

  • Women taking oral estrogen had a 19% elevated risk of developing hypertension compared to women using vaginal estrogen creams. Notably, this association was more notable in women below the age of 70 years.

 

  • No differences in the risk of hypertension were observed for the study participants taking either transdermal or vaginal estrogen across all age groups.

 

  • When comparing the two different sources of estrogen, conjugated equine estrogen was linked to an 8% heightened risk of high blood pressure.

 

  • Higher daily estrogen dose in oral form, compared with the same dose in transdermal and vaginal forms, was associated with a significantly greater risk of hypertension.

 

  • Long-term administration of any form of estrogen-only HRT may increase the risk of developing hypertension.

 

To reduce the risk of developing hypertension while managing menopausal symptoms, a physician may prefer to prescribe estrogen HRT treatment delivered as a transdermal patch or vaginal cream rather than the oral pill. The study also emphasized that HRT therapies are prescribed based on the specific needs and health profiles of each individual. Most women who are already taking oral estrogen – and are at low risk of developing hypertension – can continue their estrogen-only HRT safely based on the recommendations and health monitoring by their healthcare provider.

Interested to know more about menopause?

Visit our Knowledge Centre here :

References

[1] Santoro, N., Roeca, C., Peters, B. A., & Neal-Perry, G. (2021). The Menopause Transition: Signs, Symptoms, and Management Options. In Journal of Clinical Endocrinology and Metabolism, 2020, 106, 1-15. https://doi.org/10.1210/clinem/dgaa764

[2] The 2022 hormone therapy position statement of The North American Menopause Society. Menopause: The Journal of The North American Menopause Society, 2022, 29, 767-794. DOI: 10.1097/GME.0000000000002028

[3] Kalenga, C. Z., Metcalfe, A., Robert, M., Nerenberg, K. A., Macrae, J. M., & Ahmed, S. B. (2023). Association between the Route of Administration and Formulation of Estrogen Therapy and Hypertension Risk in Postmenopausal Women: A Prospective Population-Based Study. Hypertension, 2023, 80, 1463-1473. https://doi.org/10.1161/HYPERTENSIONAHA.122.19938

Related Readings
 

Coming soon

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Endometriosis and cardiovascular disease: a population-based cohort study

Source: Canadian Medical Association Journal March 7, 2023

A Canadian population study published in the Canadian Medical Association Journal (CMAJ) revealed that individuals with endometriosis may be at an increased risk of cardiovascular disease (CVD) due to chronic inflammation or early menopause. The study analyzed administrative health data from Ontario residents from 1993 to 2015 to identify risk factors of CVD in young individuals with endometriosis.

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