Perimenopause & Heart Health – Podcast Transcript

December 14, 2023.

Perimenopause and Heart Health’ is the focus of today’s episode on the Perimenopause WTF! podcast. Listen to Dr. Jayne Morgan & Dr. Nicole Harkin talk about everything heart disease related, from increased blood pressure, to sleep disturbances, to hot flashes.

They talk about the controversies and cutting edge research happening today, so tune in as these two powerhouse MD’s advocate for deeper cardiac evaluations for women, they underscore the need for a more nuanced approach in addressing menopausal health concerns, suggesting that cardiologists take a more central role in managing menopausal heart risks. 

Full Podcast Episode

Introduction to Speakers

About guest Dr. Jayne Morgan: 

Dr. Jayne Morgan is a cardiologist, entrepreneur and innovation leader with deep expertise in medical devices, startup companies, healthcare management and clinical research. She earned her B.S. degree in biology and biochemistry from Spelman College and M.D. from Michigan State University. Jayne currently serves as director of innovation for Piedmont Healthcare, where she leads the development of treatments & therapies across the system. 

Learn more about Dr. Jayne Morgan:

⁠https://www.instagram.com/pilateswithdrjayne/?hl=en⁠

⁠https://www.linkedin.com/in/jaynemorgan⁠

⁠https://www.facebook.com/piedmonthealth⁠

⁠https://www.instagram.com/drjaynemorgan/?hl=en⁠

About guest Dr. Nicole Harkin:

Dr. Harkin is the founder of Whole Heart Cardiology. She is board certified in Internal Medicine, Cardiology, Echocardiography, Nuclear Cardiology, and Clinical Lipidology (cholesterol management).

After graduating from Boston University School of Medicine magna cum laude, she attended Columbia University for Internal Medicine residency and New York University for Cardiology fellowship. Upon completion of her Cardiology fellowship, including serving as a chief fellow, she remained at NYU as an Assistant Attending until moving to San Francisco. She’s also the Chief Medical Advisor for PlateUp, a health tech start-up dedicated to improving health through nutrition, & is a member of Planted Forward, a comprehensive, multi-speciality telemedicine team. 

Learn more about Dr. Nicole Harkin:

⁠https://www.wholeheartcardiology.com/about⁠

⁠https://www.facebook.com/wholeheartcardiology⁠

⁠https://www.instagram.com/nicoleharkinmd⁠

⁠https://www.linkedin.com/in/nicole-harkin/

Dr. Jayne Morgan (JM) – Well, welcome, everybody. I am Dr. Jayne Morgan, and I am here with the incredibly esteemed Dr. Nicole Harkin. We are so happy to have her here and so glad to have this conversation between the two of us.

So, I don’t know if you’re on the West coast or the East coast or what time it is where you are, but we’re happy to have you join, and I’m going to just kick it over to Nicole. Just start.

Dr. Nicole Harkin – (NH) – Thank you. All right, I love it. Thanks so much. I’m so excited to be able to have this opportunity to have this conversation with you. Super important topic. Not discussed enough.

I think it is incredibly relevant to all women because we will all go through the perimenopause and menopause transition.

So my name is Dr. Nicole Harkin. I am a preventive cardiologist and a clinical lipidologist, which means I’m also board certified in the study of cholesterol. And I have a direct care cardiology practice in San Francisco, California, called Wholeheart Cardiology. And my practice is really dedicated to heart health optimization. All of my patients who tend to find me are looking for a very data driven, high touch, and more proactive approach to their heart health, rather than a more reactive approach. And so I tend to see patients who either have established heart disease or have risk factors for heart disease, like a strong family history or obviously, cholesterol issues. And we do a lot of work to gather data and then create our therapeutic plan using lifestyle as well as pharmaceutical medications when needed.

So that’s sort of the essence of my practice and what I do, I really enjoy working with women in particular. A lot of women come to find me because there’s not, unfortunately, a lot of us female cardiologists or those of us who kind of specifically work in this area. And I find it really rewarding.

So I will stop there. I’ll let Dr. Morgan introduce herself, and then maybe we can both also get into a little bit more about what we do and what brought us to this journey. Oh, and the last part, my practice, Wholeheart Cardiology. So you can find my website, www.wholeheartcardiology.com. And then I’m also pretty active on Instagram at @nicoleharkinmd, and I post a lot of material there about heart health in general and obviously prevention in specific.

JM – That’s great. I’m Jayne Morgan, and I am a cardiologist. I’m nuclear trained, but have spent a good part of my career, really, in research, leading clinical trials, and study sites specifically focused on cardiology. Spent quite a bit of time in the structural heart disease space and came out of industry as well. Spent several years in industry at Solve A and Abbot in R&D, creating compounds for the heart and also creating devices. In fact, I was a cardiologist developing the mitroclip, which is really now used pretty widely within the structural heart.

I have transitioned almost completely into education. I spent a lot of time in education, in giving lectures, grand rounds, that type of thing. And it has brought me on this journey towards menopause and perimenopause and how this intersection occurs with women from pregnancy through all the different phases of our lives. And I’ve begun to understand how it’s all interconnected and how it really leads to an increased risk of heart disease and how it’s really underappreciated.

And then we add that into the disservice of the Women’s Health Initiative and how women are under treated and how hormones are also not well understood. And I think you see how Nicole and I have come together, have found each other on different coasts, because we are kind of working towards the same goals. We’ve gotten here via different routes, we have different backgrounds, different levels of expertise, but we found this same niche and this same unmet need, and we are working to have a greater understanding and create a bigger conversation around this.

What can we learn? Why haven’t we learned it? Where are some of the blind spots? Who’s moving in the direction towards improving women’s health, improving heart health? Who’s taking this seriously? Who isn’t? And shouldn’t we be taking it seriously? Shouldn’t we be moving it forward?

And so this is a conversation we’re going to have. We’re just going to have a conversation about it. We have a lot of expertise between the two of us from different aspects of cardiology, and we want to begin to bring all of these pieces together as we find our tribe, as we find our community. Everybody has little pieces of this puzzle, and we are starting to put this together.

And Nicole and I are really looking forward to this conversation. We’re so glad that people have joined because it is an area that is murky. It’s hard to understand. And guess what?

Even doctors don’t understand it. That’s why we’re here. Doctors don’t even practice it. And so, really, we’re on the cutting edge of something that I hope that for our daughters, it will just be normal at that point. It’s not normalized, and we’re really on the cutting edge and trying to push this information.

So welcome. And I’m so happy to have this conversation with Nicole. Nicole’s practice is so super interesting, focusing on what you all know as fats and cholesterol and lipids. She focuses on that with cardiology, and I’m just fascinated by everything that she’s doing.

NH – You’re so sweet. It’s fun, and it’s important work that we’re doing, right? So I think I’m so excited that there is not only this heightened conversation and this national conversation about perimenopause and menopause, but specifically that heart health intersection. Right?

Because you and I both know that heart health is statistically the number one cause of death for everybody but women in specific, globally. And certainly as we enter into that transition, our risk goes up dramatically. And so I love that people are having this conversation and talking about it because it is so, so important.

And there’s lots of things that we can do earlier in our life and then also throughout our life to really work on our heart health from a preventive standpoint.

And as I tell all of my patients, I would much rather, it’s never too late, but I would much rather work with people sort of early on to get a lot of these risk factors under control, keep an eye on things. We got lots of questions about screening. I’m excited to talk about that as well. But you really know where you’re at, and you can take the appropriate steps to hopefully prevent events later in life. So it’s just such an important topic, and I love that it’s finally getting airplay. 

JM – I know. And what people don’t really understand is that a woman’s risk of heart disease is really about half that of man before menopause and perimenopause. And then as you start to go through this perimenopause transition, your estrogen levels drop, your heart disease risk increases, and by the time you actually reach menopause, your risk of heart disease is actually equal that of a man. 

And I was reading data recently that women in their 70s actually now have an increased risk of heart disease over men. So this is one area where we are not trying to outdo men in that area. We want to dial it back and actually return to our healthier state. And part of that was because of the protection of our hormones, of our estrogen during sort of our reproductive years.

And what Nicole and I understand is that heart disease, for a large part of it, is an inflammatory process. We are now starting to understand the effects of chronic inflammation on the body in all systems. Cancer, arthritis, autoimmune diseases, the gut.

But guess what? Also the heart.

And this causes a progression of this atherosclerosis, these plaques and things. And that’s what Nicole focuses on with these plaques that can be part lipid, part calcium, part fat deposits, those kinds of things. But estrogen has anti-inflammatory properties as well, just in itself. And so as we see this risk of heart disease rise, it actually has an inverse relationship to estrogen levels dropping. And what are we going to do about that? And why haven’t we done anything about it? And that takes us all the way back to the Women’s Health Initiative.

Nicole, I don’t know if we even want to discuss that here. Maybe we do. What happened? We’re going to forget it. Let’s move on. Or maybe we give some background. I don’t know. What do you think, Nicole? Should we talk about it?

NH – I feel like if we start talking about it, we’re going to talk about it for like 40 minutes, because it’s just so all consuming. Right. But I do think it’s important that for women that haven’t heard of this study, it was one of, unfortunately, the larger randomized controlled trial data, studies looking at women and hormone replacement therapy and sort of the effects of that. And unfortunately, it’s one of the bigger trials that we have. And because it’s what’s called a randomized controlled trial, which is where you divide two groups that are supposed to be pretty equivalent, give one an intervention and the other not, and then see what happens. That’s considered our gold standard. And so it gets a very high level of importance.

But when it’s not done super well or super relevant to how it would have been done in the real world, you end up with data that has this relevance, this importance, but many of us that do this, and menopause experts really have dove into the data and exposed a lot of, unfortunately, the flaws and how it really hasn’t informed sort of how HRT would be prescribed in sort of the real life.

And so in particular, the different data that emerged from that was the risk of breast cancer and the risk of heart disease. And actually all of the data leading up to that, the epidemiologic data, all of the data we’ve had before and more or less after showed that actually hormone replacement therapy reduced the risk of cardiovascular disease. And that was actually the hypothesis going into the trial. 

This is maybe a good time for us to talk about why that might be the case. So we know that as women go through perimenopause and into the menopause transition, there’s a lot of adverse cardiometabolic changes that occur, exactly as you said, from that sort of withdrawal of the estrogen. Right. And so we see, in general, LDL, the quote unquote bad cholesterol. And I can get into all of the different cholesterol stuff if we want to at some point. But that goes up, HDL goes down, triglycerides go up, body adiposity and body composition changes occur to favor the deposition of fat storage within the abdomen, which is where it tends to be more cardio-metabolically active. We see insulin resistance rise and glycemic numbers go up. So all of these things that we know that increase our risk of blood pressure goes up.

So all of these things that we know that these are the things I’m checking when you come into my office and I’m trying to, along with inflammation, which you mentioned, thinking about someone’s risk, they all change in sort of, unfortunately, the wrong direction. And so with hormone replacement therapy, we see that many of those changes can be ameliorated. And so really, the hypothesis going into this trial was, oh, it’s going to reduce cardiovascular events. And again, we don’t have time to go into all of the reasons why, but it was done in a way that was probably not consistent with how it’s traditionally prescribed in women that were really far out from that transition and all of these sorts of things.

And so when you end up parsing down the data in the women who were prescribed hormone replacement therapy, who were younger than 60, less than ten years from that transition, they actually did see a reduction in the cardiovascular endpoints. And we can get into all the reasons why. But I think where we were going with this was that that trial sort of created a lot of uncertainty and has really set us back many, many decades in terms of our understanding and where to go from here as it relates to hormone replacement therapy. Yeah.

JM – And what was the big reason? The big C word cancer.

What they purported, incorrectly, was that hormone replacement increased the risk of breast cancer, even though it was a relative risk, not an absolute risk. I won’t even talk about that. It’s an epidemiologic term which kind of leads to a little bit of nonsense, but just that little bit of an increase of breast cancer in erroneous data. And all hormone replacement therapy was shut down. And when I say shut down, as Nicole knows, it was no longer taught in medical schools. It was removed from all residences. It disappeared. It was a non discussion. Hormone replacement therapy caused cancer with this faulty data, with this small relative risk increase, not an absolute risk. And then that was in the group with estrogen and progesterone, specifically for black women who were in the trial, most of whom had had hysterectomies and were only in the estrogen RN group.

So just women who were receiving estrogen, it actually did demonstrate an improvement in cardiovascular endpoint and a reduction in breast cancer. That probably was the only group. That was the actual premise of the entire study, and that got lost. There was one subgroup that was actually what the trial was actually about, and that subgroup got lost in the whole context of these thousands of women. And that was the subgroup that actually showed, hey, there was a decreased risk of breast cancer and there was a decreased risk of cardiovascular disease.

But that’s the women’s health initiatives kind of in a very confusing nutshell. But we’re trying to get beyond it because the damage has been done. That’s why we’re having this conversation from coast to coast here on, you know, hey, Nicole, I want to talk with you about as well for our audience, with all of your experience with lipids.

You did such a great job talking about, as we go through this menopausal and perimenopausal transition, our lipids increase, the bad cholesterol increases, the good cholesterol goes down, our blood pressure increases. We get this fat deposition called visceral fat in our midsections. Right. We start to preserve fat in areas where we don’t want to have it. And that is an area we call that central adiposity that actually is shown to increase your risk of heart disease. So where your fat is deposited, it also increases your risk of heart disease. And then the symptoms of menopause. Some of the common symptoms, like sleeplessness, are now linked to heart disease independently of menopause.

Just people who have disrupted sleep, difficulty getting sleep, insomnia, the duration of sleep is related to your risk of heart disease and sleeplessness. And insomnia is one of the symptoms, again, of perimenopause and menopause. And now we also see this link with hot flashes, or as we’re calling them now, hot flushes.

So if you hear either of those terms, there’s a movement to change the word from hot flash to hot flush, because apparently the thought is, and nobody asked me. So let me just be clear. No one’s asked me about this term. I’m just explaining it as I understand it, that it’s not a flash. It lasts for longer than a flash. That’s a misnomer. It’s a long process. And we want to make certain we think flush better characterizes what is really happening. Again, I was not consulted on this terminology, so if you hear hot flash or hot flush, we’re kind of using them interchangeably as we’re going through this. But hot flushes also. The duration, the intensity, the frequency is also associated with heart disease. 

So Nicole’s practice is super interesting. What we’re doing know there’s some controversy over statin use. Statins are a type of category of lipid lowering drugs. The whole category is sort of called statin. And this category of drugs is often used to treat cholesterol, but also as preventive measures for people with risk factors, that type of thing. But as we go through perimenopause, the question is, do you prescribe statin, or are your lipid levels rising because your estrogen levels are dropping? So should you provide estrogen? Estrogen and lipids are kind of related. If you don’t know, cholesterol is kind of one of the building blocks of estrogen.

And so it’s all interrelated. And then we also have data that really shows that high dose statin therapy in women may be actually detrimental, may not actually be giving us the effects that we thought it would, and that low dose statin therapies may be better. So, as you know, a lot of this conversation is evolving. I want to say that for people who are listening, Nicole and I are having a conversation about an entire area that is evolving. So what we know today may actually be different next Saturday. So we’re going to talk to you about what we know this Saturday because the landscape keeps moving. And so I thought it would be interesting to talk with you, Nicole, about how you treat perimenopause in patients where you start to see their cholesterol levels increasing, but you also know that estrogen is decreasing.

How do you manage that? How do you address those patients? 

NH – Right. Great question. So I think in general, I’ll probably start by taking a step back in terms of how I think about a woman who comes into my office and who is potentially in this transition. And how am I thinking about their heart health in general?

So, listeners that can start to think about what their risk is, thinking about their hormonal history is an important part of their personal medical history as well. So how long they’ve been exposed to estrogen, actually, throughout their lifetime, is an important female specific risk factor, which doesn’t get talked about enough, but I think nicely ties into what we’re talking about.

So women who are, if they’re younger, when they’re going through this transition, so younger, and it’s variably defined, but premature menopause for the age of 40, 45 is a great example of how that early withdrawal of estrogen is associated with an increased risk of cardiovascular disease. And that’s pretty well established.

So I take kind of a thorough history. So thinking about not only your personal risk factors that apply to everyone, blood pressure, we’ve talked about cholesterol issues, and we’ll get into the nuances. Insulin resistance, prediabetes, inflammation, chronic inflammation. So do you have an autoimmune condition or something else that’s increasing your risk of chronic inflammation and body composition? All of these things that we can think about and then obstetric history.

So it’s also well established at this point that women who have adverse events during pregnancy, such as preeclampsia, gestational hypertension, gestational diabetes, actually, premature birth, in some cases increases the risk of cardiovascular disease later in life as well. Not many doctors will ask you about that, but you should know if you have that, bring that to your physician’s attention that you have.

JM – Know, Nicole, that is so important. I talk about that all the time. We do not do this handoff between the Obgyn and a cardiologist because how have we been trained? The treatment for preeclampsia, the treatment for eclampsia, the treatment for gestational diabetes, the treatment for gestational hypertension is to deliver the baby.

But the fact of the matter is, after that baby is born, it is now time to think about the mother, because the mother’s risk of heart disease has now been demonstrated to be twice that of another age matched female. And in addition to that, think about this. Pregnancy is actually a volume overload. It is really a woman’s first stress test. And if you develop any of these things, if any of those terms you’ve heard before in yourself, or your family member, your sisters, your cousins, preeclampsia, eclampsia, gestational diabetes, gestational hypertension. Then you should have seen a cardiologist, because, in effect, you have just failed your stress test. And like any other patient who fails a stress test, they get a referral to a cardiologist. So here’s how an OBGYN characterizes that patient. I have a pregnant female with preeclampsia. Here’s how a cardiologist looks at that patient. I have a volume overloaded patient with a failed stress test. 

And why that handoff needs to occur. Two doctors looking at the patient from their specific lens that directs a different type of care. You still have to advocate for yourself. We now are telling you something that many doctors still don’t know and still don’t practice, and you still have to advocate for yourself to push it forward, not denigrating any of our colleagues. I think, as we said in the beginning, it simply isn’t tall. We are really on the cutting edge. Congratulations for coming to this webinar today. You’re learning things that most of our colleagues don’t know and don’t practice. So you really have to advocate for yourself. So not cutting you off, Nicole. Just wanted to jump in there and talk about it.

NH – Absolutely important point. I love that. And I tell any of my MFM or OB colleagues, if they have patients that have had preeclampsia, gestational hypertension, gestational diabetes.

Yes. Take care of baby and mom in that moment. Good job. Thank you.

And then once there’s one more step. Exactly. Once you see them in that follow up visit, make sure they know that exactly as you stated, and then try to hand them off to us at some point and make sure they follow up. Important. 

So these are all the things that you, as a woman who, especially as you’re going through this transition, it’s important to sort of reflect on these risk factors, because these things sort of add up in terms of thinking about your heart health. And then family history is also a really important one, that if there is particularly a pattern of premature coronary artery disease, which we define as a cardiac event before the age of 55 and a man, or before the age of 65 and a female, that is an important, very important data point to know.

And again, all of these things are important throughout your life, but particularly at sort of this point in time, this is a really good time to sort of really get a handle on all of these things, get a thorough checkup, and sort of get an assessment of what’s going on and where you’re at. So blood work, body composition, all of these things. Blood pressure checks. I love a home blood pressure monitor. I have all of my patients doing those on an annual or quarterly basis. Check those every day, once a week, every day for a week or two, and send them to me. Blood pressure and cholesterol, man, you don’t feel them, but they, over time, if they are left unchecked for years and years and years, increase this risk of cardiovascular disease.

I look at sort of all of these things kind of together, and then we have a really informed conversation about specific risks. And I’m sure we could spend as much time railing about the Framingham risk score as we do about sort of the wHi. For all of our listeners, there is what’s called a ten year risk calculator that we, as cardiologists, are supposed to use when we think about a female’s risk and what to do. And many of us who do this in prevention full time feel like it’s a very short sighted sort of calculator. There’s many populations, women, women of color, and specifically all kinds of populations, that just really drops the ball for and either under or overestimates risk in dramatic ways.

JM – I am so glad that you said that, Nicole. I’ve spent time just playing with that calculator because I have a particular interest in all of these algorithms and formulas that we use in medicine that really are to the detriment of people of color and women of color. And I put in all of my demographics, my age, my systolic pressure, my diastolic pressure, what my cholesterol is, blah, blah, blah. And then they ask this race question, which I always say, uhoh. So I put in that I’m white, and at the end I get a risk score.

I think it was 0.2. And then I said, okay, I’m going to keep everything the same. I’m just going to change my race to black, change my race to black, and then my score, my risk was 2.2. But nothing else changed, just the race. And what bothers me about that is, does that put me in a category where I’m going to get better care? When I say me, I mean any person in that situation that you’re putting in a black race, do I get better care or now am I going to not be a candidate for estrogen therapy? Because maybe it looks like I’ve got advanced heart disease and maybe that’s going to be a contraindication. And so now I won’t have the benefits of hormone replacement therapy that I know are going to reduce my risk just because I answered ten questions and one of them was race, and that race kind of eliminates me from therapy. I don’t know. These are the things that I kind of grapple with. But you’re right, that’s one of the things. That’s just one with that calculator.

NH – So I’m glad you brought it up. Right. And a lot of that’s a function of who is it studied in and who was represented and all these things. So those are major limitations. And then also just sort of this focus on just our tenure risk. Right. And as I tell all of my patients, yes, I don’t want you to have a cardiac event in ten years, but I also don’t want you to have a cardiac event in 20 years. So let’s focus on our lifetime risk and what are all the things that we can be doing to sort of prevent that in the long term. Right. We use them, but they are definitely not the whole story. And unfortunately, studies show that 50% of patients who have a cardiac event are considered low risk in some studies by these calculators. So clearly they do not capture everyone who’s going to have an event.

So that’s where I think not only looking at sort of all of these risk factors and anyone listening can hopefully do this because blood pressure monitors are very accessible. Hopefully you’ve had lab work. If you haven’t, have it done, and then talk to your doctor about screening. And I think that there’s a lot of tools that we have at our disposal now to get a better assessment of your current Vascular health. So these things range from. So probably one of the better known tests are coronary artery calcium scans. They are very cheap and very widely accessible and unfortunately, still not mostly covered by insurance. But many institutions will do them for under $100. And they look at the amount of calcium buildup within the coronary arteries. It’s a low dose screening CAT scan. These sorts of tests can really help us get a better understanding of what’s going on with your current Vascular health. And then there’s tests in my office. We do crude ultrasounds to look for plaque and look at the Vascular wall thickness. And then increasingly, there’s companies that are doing CT angiograms for screening sort of purposes as well. So we have a lot of tools at our Disposal, and hopefully we’ll just keep getting more and more because we do such a good job of screening and looking for early evidence of disease in other areas. And yet, when it comes to the number one cause of why all of us will die, we just don’t. We just kind of Calculate it based on risk factors and make decisions there. And I, in my practice, use these tools quite a bit, and they are absolutely Game changing in terms of not only how I think about someone’s risk, but for an individual as well, including the calcium score.

JM – You utilize the calcium score?

NH – I do.

JM – And the calcium score for your patients who may have a zero, you repeat it every three to five years, or you kind of Manage it at zero, or do you repeat it, or is it based on the patient’s request?

NH – Yeah, really good question. So I think, first and foremost is making sure that the test is done in sort of a well validated kind of population. Right. Every now and then, I’ll get patients who are much younger who come in because they have a very strong family history. So sort of really, under the age of 45, a coronary calcium scan is not a great test for you. And the reason for that is that the pathophysiology of coronary atherosclerosis is such that calcific plaque is somewhat of a later Plaque stage. And so in our younger Years, particularly Women, we have plaque if we have any plaque, and so the coronary calcium scan will miss those, and so you’ll sort of be Falsely reassured by a zero. So at the age of 40, sure, anything that’s non zero is informative, because that’s a particularly high risk patient. But if it’s zero, it doesn’t mean that there’s absolutely nothing there. So I just think that’s an important Caveat.

But, yes, in general, say it’s appropriately aged. A six year old woman walks into my office and we decide to do a coronary calcium scan. And if it’s zero, that’s pretty reassuring that at least her five to ten Year risk is very low. It doesn’t mean we’re not going to work on maybe her blood pressure is borderline elevated and we’re going to start working on creating an exercise program and packing fiber rich and potassium foods and all these Sorts of things that we would do. But it’s reassuring that we’re in a pretty good place right now. And let’s just optimize from here. So in terms of repeating it, yes. In general, we think about repeating it every couple of years. It’s a very low risk test. And so in general, it’s pretty appropriate to repeat it in a couple of Years, particularly if you have elected, say, not to start any medications at that point. 

So I think there’s lots of Ways that we can fine tune and sort of personalize our plans. Thinking about exercise, stress, sleep, which you brought up, which doesn’t get talked about. I feel like we’re probably two of the only cardiologists talk about sleep. No, I’m just kidding. But in general, it’s finally getting talked about and exercise, food, all these things that we can kind of do and sort of lay the foundations for now. 

JM – What’s really interesting is that the approach to the perimenopausal woman is individualized. So I saw in the question that someone stated, they’re in their 40s, they’re having palpitations. What should they do? And it’s kind of the same question of, you’re in your 40s, your cholesterol is going up. How is this to be managed? And the question is, why are these things happening? And we know that they are happening.

So let me just talk about palpitations for a minute. I was going to say, we know that they’re happening because your estrogen levels are dropping. But I want to back up because I want to be clear because there’s another question specifically about heart disease. If you’re having palpitation, and I just want to be very clear about this, do not immediately jump to, oh, I’m perimenopausal. This is nothing. You need to see a cardiologist and get an appropriate workup, a cardiac, a serious cardiac workup, to rule out any cause of those palpitations. Cardiac cause, including your risk of a heart attack. And after your cardiologist has deemed that your entire workup is negative and we can find no cardiac, anatomic, or neurologic reason for why you’re having those palpitations, then we can begin to talk about hormones at that point.

So I just want to be clear because I saw those questions on palpitations. You’re right. Palpitations in your 40s, your early forties, may not be heart disease. It may be related to your hormones. You may need to start to begin to think about what that dropping estrogen level means and have that conversation. But I don’t want that to be the first thing, because heart disease is the number one killer of women. And we still, if you are having symptoms that are a cardiac symptom, I want you to rule out the things that can kill you early and that we know are killing us the most. I want you to rule those things out first. And then we start to deal with some of these nuances that we’re talking about. That’s why we’re here today to talk about how other palpitations should be addressed, because the fact of the matter, including myself, had palpitations in my 40s. Went to the cardiologist, big cardiac workup. We could find nothing. I got what I call the garbage diagnosis. I shouldn’t say this about my profession of mitral valve prolapse. And I was put on the calcium channel block. You’ve got mitral valve prolapse, blah, blah, blah.

The fact of the matter is, after that, cardiac workup was negative, probably migravarial prolapse wasn’t the right maybe. I probably had a little bit on the echo. It’s not enough to really give me symptoms. So probably at that point, I should have seen a menopause specialist to find out whether or not I actually was in perimenopause and whether this was related to hormones, but it wasn’t. I started on a calcium channel blocker, which made me dizzy. I felt worse. I finally got rid of it. So what do we do? Do we just suffer? We’ve done everything we could. We went to the doctor. We got all of our work up. They gave us something that really wasn’t treating the cause made us feel worse. And listen, I’m a cardiologist. I had no objections. My colleagues had done everything.

They did exactly what they were supposed to do. I felt worse. I was my own worst patient, right? I just took myself off of it, didn’t take it anymore. I do not recommend that you do that. Follow your doctor’s advice. I did not follow my doctor’s advice. And I had palpitations, and I suffered. And after a while, they kind of went away. And it wasn’t really until years later that I began to study menopause and the menopause journey. I went back to that experience and said, oh, my God, that’s what was happening to me, and nobody knew it and nobody understood it. And so the question is, should you be on statins as well? Maybe not. Should you be having your hormones adjusted? Maybe, maybe not.

These are all individual decisions that you need to discuss with a physician who’s either menopause certified or a physician who has taken the time to learn about it and is interested about it, in it, and is hearing you and seeing you and understanding the validity for it. It doesn’t mean that if you’re seeing a doctor who does not have this certification that they are unqualified. That does not mean that. But at this point, when, you know, Nicole and I are on the cusp, the cutting edge of it, that at least is an indicator that you found someone who’s interested enough to learn more and address it. But it doesn’t mean that doctors who don’t have it aren’t addressing it. But for the most part, right now, it does mean that, unfortunately.

What do you think, Nicole? 

NH – No, I think that certainly, as you said, there was an entire generation of graduates and medical school trainees, certainly when I was in medical school, that we were just cancer. That’s it. And so I think there has been sort of a reeducation that is needing to occur of sort of much more of the nuances there. I think that more and more are doing so. And I think certainly a good place to start is Nams. But certainly there’s other physicians out there that are also learning about this and educating themselves and have taken courses or what have you, because this should certainly fall within bread and butter, really, internal medicine, frankly, it’s women’s care.

JM – There’s so much heart risk that cardiologists need to own this whole section and take care of the heart risk, which is really what we’re talking about. We’re talking about trying to mitigate and prevent the heart risk of a patient. My thought is that cardiologists should own that. Certainly primary care physicians, OBGYNs, are sitting in the catbird seat, obviously, to really have these discussions. They’re the ones who best understand and are trained on hormones. But honestly, I’m starting to think that the buck stops at the cardiologist. This is where we just draw the line and say, this is it. We’ve got to really own this space and drive this, because this is the biggest risk for these women. It is heart disease, even though it’s menopause and this is a gynecologic traditionally, this is a gynecologic issue. The outcomes are cardiovascular. Cardiologists have got to own them. Maybe we’ve got to have a subspecialty in it, or maybe we’ve got to make certain that we have training in it. Maybe we’re starting to have cardiac OB programs or obsectoral cardiology programs or whatever we’re calling them. As we’re starting to understand that kind of connection as well, we may need to also start to encompass this. I’m moving in that direction, actually. 

NH – I like that.

No, I think that’s totally true. I think anyone that’s willing to take it on for sure. But yes, I think you’re right. Cardiologists need to take more ownership of this space because it’s really important. And as we sort of have discussed throughout this, all of these different hormone aspects of what make us female and hormones and all of this stuff throughout our life can certainly have unique, pose unique risk to us as it relates to cardiovascular disease. And as you mentioned, many academic institutions are now recognizing that important relationship in our younger years from an obstetrical standpoint. But hopefully coming soon will also be that fir relationship in the menopause transition and sort of unique groups and specialties that form out of that, because this is so important. And as we said at the onset, every single woman will go through this transition. So this is not like this, it affects 50% of our population. 

No, this is all women. And so it’s such an important topic. And I think we could also spend all day talking about the lack of, and you probably know this even better than I do, the lack of research funding when it comes to female specific conditions and why this has just sort of not been as well studied and why, as you said, we are in this awkward sort of gray zone when it comes to hormone replacement therapy and women’s health. The current FDA approved indications are certainly not for cardiovascular prevention. It’s for osteoporosis prevention, which is very important. Very important. Vasomotor symptoms, things like that, which are, again, important. But we have this awkward sort of gray zone when it comes to hormone replacement therapy and cardiovascular disease, that is not FDA approved. So we do need more research there. 

JM – Cardiologists another reason that I think cardiologists really are moving in the direction that we’ve got to own this space, because not only is heart disease the number one killer of women, and number two, we’ve got an increased risk of heart disease with these women with pregnancy complications. Number three, we’ve got an increased risk of heart disease during menopause. And so far, nobody’s understanding it, and very few people are connecting it. And then we add on top of that that sometimes a woman presenting symptoms of a heart attack might be different from that of a man. And we actually did a survey, and only 42% of cardiologists even felt comfortable treating a woman with heart disease. And that sounds completely nuts until you think, don’t look at Nicole and I as the standard. We’re not the standard. That’s not nuts. When you think about most cardiologists are actually men, and so 40, only 42% feel comfortable. Nicole and I are not the standard. You guys are looking at something that’s not the standard. And so, again, we’ve got to start to own this women’s space to understand. And here’s my other thing. I’m just jumping around there. I’m starting to get on my soapbox, but I’m going to come down in just a minute. Here’s the other thing. We talk about women’s heart disruptions as atypical. That’s actually how we learn them.

This lexicon, this word atypical, which is somewhat annoying because it really puts in the mind of the physician, the medical student, and the patient that this is some deviation from the norm, this is an aberration. This is something away from mainstream or mainline, something extra. We have to learn that it’s not as important when, in fact, we’re almost 52% of the population.

Women. I mean, I’m thinking we’re the ones having the typical symptoms, and it’s the men who are having the atypical symptoms. Maybe the typical symptom isn’t this crushing chest pain and left arm Blaine and diaphragms, and you collapse and everybody calls 911. I don’t know. So I’m starting to kind of move down that road of even our language. And the language that we use is important because it translates into the lay population and women, not only physicians, also minimize our symptoms because we are not taught to recognize these symptoms that are termed atypical. So we don’t recognize chronic fatigue might be a symptom, jaw pain might be a symptom. Which actually might drive us to the dentist. Right.

We don’t think of low back pain or just these chronic, rundown, flu like symptoms, you can’t shake all these kinds of things. We don’t think about that. Nobody tells us that. Right. And then the first heart attack to a woman is more often fatal than the first heart attack of a man.

Why is that? Because our care is so delayed. We have had symptoms for such a long period of time before we seek medical care. And even when we seek medical care, only 42% of cardiologists even feel comfortable. They may not take those symptoms seriously, or they may not connect them to heart disease because they are, quote unquote, nonspecific.

Back pain can be attributed to a lot of things. Fatigue can be attributed to a lot of things. So we’ve got to begin to kind of unravel that as well, because it’s complicating the entire picture of menopause. And so all of these things are kind of moving together. I saw in the chat, Nicole, that somebody wrote that they were on menopause, hormone therapy, but then had a PFO patent for Raymond O’Valley diagnosed, and then had maybe a calcium score done that was elevated, and their doctor then removed them from therapy because of the PFO, which is like a small hole in your heart for the audience, and the advancing atherosclerosis on the calcium score. I’m trying to remember the question, but I think that’s kind of the Question, and they wanted to know if that was the right thing to do. So here’s my answer, and you can give your answer, Nicole. Let’s Discuss it.

I thought it was really an interesting thing to Discuss that still, for hormone replacement therapy, for good or bad, congenital heart disease is considered a contraindication. And anything that’s at risk puts you at risk of aortic dissections. And these kinds of things are a contraindication. Advanced atherosclerosis is still a contraindication. And you can probably tell by the way that I’m talking, I’m not certain I agree with it. I’m just telling you what the data is showing, and your doctors are treating you based on evidence based medicine. So I don’t know.

What did you think about that?

NH – Yeah, no, I think, again, hitting on some of sort of the gray areas, but I do think when it comes to things, I think one of the better sort of established risk factors of hormone replacement therapy, or really any hormones, including oral contraceptive pills, is that of clot formation. So deep vein thrombosis and so I think probably the patent firing monovalley would be a particularly real contraindication, because then you could have a stroke. Right. And stroke is probably a real Potential risk. We can get into the nuances. This is exactly where that sort of risk benefit conversation comes into play. And certainly, as you Said, established coronary artery disease, which, again, is variably Defined. Now that we have these screening Tools, what is coronary artery disease at this point? Right.

And that gets very Complicated. And that is a real question within the preventive cardiology community of when do we establish someone as having coronary artery disease?

Typically for the purposes of something like hormone replacement therapy or certain other scenarios, we define it as someone who’s had a heart attack or has pretty significant plaque. In some areas, it’s defined as any coronary calcium score that’s over 300, because there is some data to say that once your score is over 300, your risk approaches that of someone who’s had a heart attack. And then there are some Communities who say, if I see any Plaque, even a one, that it is considered heart disease now.

Right. As we fold these Tools into Our practice, we’re also Having to kind of Take STEPs back and try to understand when does that risk apply? But getting back to the original question, yeah, I think certainly hormone replacement therapy, again, we’ve touched on a lot of the benefits that it can do, but there are some real risks, and it obviously applies to each individual female very specifically.

And that’s where it’s important to have that Conversation with your provider about kind of risk benefits and getting back to the chest pain question, because that was one of our questions as well, was the chest pain and having chest pain as this perimenopause.

And I’m so glad that you touched on the fact that women’s first Heart attack is more likely to be fatal because we think it’s something else. We’re taking care of everybody else. We don’t think that it’s Heart disease. And this gets back to taking these symptoms seriously, get them worked, once you have the workup and it’s not Heart disease, then we can talk about all the different stress management strategies, this, that, and the other. 

JM – That’s right. Nicole and I are saying the same thing. We are here to talk about the benefits of hormones, but we’re also making certain that you understand, have your symptoms worked up first, do not minimize them and jump to something else, because it’s also real. Something, could be something, and we want to make certain that you do that. And we get that message. I want to be clear. We’re not saying to ignore it. In fact, the opposite. We want you to have quick and speedy action and get that work up and get to the answer and figure out what your options are. 

NH – Yeah, absolutely. Chest pain would be a symptom that certainly would not be sort of classically associated with perimenopause or menopause. So that’s certainly something. Please get that checked out sooner than later. And this is where some of what we were talking about earlier comes in, in terms of knowing your risks and things like that. Because certainly, particularly if you have a very strong family history or anything, that should really prompt pretty urgent action. Right. I know we’re going to start running out of time, but we have so many things to say. But I did want to, there was a lot of questions about, aside from just hormone replacement therapy, what are other things, how much should I be walking and what are I want to close with us giving in terms of how other things that I want to end on a high note, empowerment message of what we should be doing.

JM – So let’s talk about walking. I actually talk about walking. So let’s maybe start there. We can go to nutrition. We can go to things really quickly to wrap it up. But walking, this whole thing of walking 10,000 steps, we’ve kind of thrown that out of the door. You don’t really have to walk 10,000 steps to get cardiovascular benefits. In fact, we see that you can walk just 7000 steps. 7500 steps is your maximum. It’s probably the peak. We don’t see much advantage over 7500 or 8000 steps per day. But guess what? As low as 2000 or 2500 also gives you cardiac improvement. And this is especially important to the population as it ages. And here’s the other thing, the rate at which you walk, the faster your pace, the better your cardiovascular endpoints. Now, what we don’t understand is, are people who happen to be people who are healthier, happen to walk faster and we see better endpoints or is it actually the fast walking that’s driving those better endpoints? But we do see that pace and steps, but it’s not 10,000 steps. So don’t be discouraged if you can get out there and do 2000 steps. And look at this, 500 steps is a quarter of a mile. So 2000 steps is a mile. So just think about that. Just on average, just walking, keeping the body in motion is really good. 

I talk a lot about Pilates. I’m a Pilates instructor as well. So kind of resistance training and weight bearing and that kind of thing. But if you can just walk and it’s something that most people can do on their own, then the body is heart disease, chronic inflammation. So diet and nutrition. I met with the FDA just yesterday. Really, we’re talking about front of package labeling. What kind of labeling? Right on the front of the package do we need? And I was there to kind of represent the cardiac perspective. What are we looking for in front of package labeling that is applicable, really, to all groups that people can understand what foods are healthy, which foods are not healthy, which foods advance heart disease, which foods do not. As we are fighting this whole burgeoning obesity and chronic diseases caused by bodies being in this state of chronic inflammation, including the conversation we’re having today on heart disease.

What do you think, Nicole?

NH – Yeah, no, I love that we started with exercise. I spend so much time in my practice talking about nutrition and diet simply because it’s one of the bigger levers that we can pull to reduce bob and cholesterol and all these other things. But exercise, actually, if you look at a whole host of risk factors or both positive and negative things, cardiorespiratory fitness or how in shape you are, is the number one predictor not just of dying from heart disease, but all cause of mortality. So it is one of the more powerful things that we can do throughout our lifespan to improve and increase our lifespan and vitality. Certainly, it doesn’t have to be this vigorous, sweaty breathlessness that we get. Personally, that’s my preferred style of exercise. But actually, lots of studies show that zone two, this kind of, like, more moderate intensity or fast walk, et cetera, is great and just as good. I love talking about exercise. I think there’s lots of ways that you can build an exercise program that works for you. That’s something that you enjoy. But getting your body moving is really important.

And I love that you highlighted something’s better than nothing, because there’s really good research to show just that transition from not doing anything to doing something is positive in terms of benefiting your cardiovascular system. So we do have these sort of set guidelines of where we try to aim for. But if you’re not someone who’s doing exercise right now, just getting up and moving, you’re helping your body a lot. So that’s an excellent, excellent tip. Because it’s very easy to get intimidated by these very large 150 to 300 minutes of exercise a week and all this stuff. And for some people. Right. And if that’s not your thing, yeah, I love that walking is getting a resurgence, some of my favorite tips with my patients is to make it a bit more intense, is getting weights, ankle weights or wrist weights or rucking is now very popular. So getting a weighted backpack if you don’t have back issues, different ways to try a hillier path or some stairs.

Lots of ways to kind of increase the intensity a little bit so that you’re in that zone. Two, five out of ten efforts are fantastic. I love that. And I’m also glad you highlighted the sort of exercise and the resistance training as well. Lots of studies show that a combination of aerobic plus some sort of either dynamic or isometric resistance training program is superior to just exercise alone when it comes to blood pressure, body comp and all these other things. So great to try to get some sort of combo program as well. And we’ve got great data for women in particular as well with exercise. So I think that’s great. And then I know we are basically completely out of time but also working on diet in terms of, and when I say diet, not diet, deprive yourself.

I mean your nutrition, how you’re fueling your body with lots of Whole foods and things like that. Not smoking, if you smoke, not smoking. Alcohol, we didn’t get to, but I think that’s another really important topic when it comes to heart health prevention and particularly women. So I think there’s a lot that we can do in our daily lives to work on our heart health prevention in conjunction with seeking advice from a trusted physician, getting screened and kind of getting appropriate therapy. 

JM – Well, thank you, everybody, for joining us. I’m Dr. Jayne Morgan. You can follow me on Instagram @jaynemorgan. D-R-J-A-Y-N-E-M-O-R-G-A-N. I’m on Instagram. I’m on X on TikTok. I’m also on Linkedin if you’d like to follow me there. And we’ve had Dr. Nicole Harkin today with us. Nicole, do you want to tell us how we can follow you and everybody? Have a great Saturday. 

NH – This has been so wonderful. So, Dr. Nicole Harkin. My practice is called Wholeheart Cardiology. It’s in San Francisco. The website is www.wholeheartcardiology.com. And then I am. I am active on Instagram, mostly at Nicole Harkin, MD, also on other platforms and various forms of my name. This has been a fantastic conversation, Jayne. I’m so privileged to have had the opportunity to chat with you about this.

Thank you to everyone for joining, and hopefully we have so much more to talk about. So hopefully perry will have us on to have another one of these. 

Disclaimer: This is not medical advice, it does not take the place of medical advice from your physician, and is not intended to treat or cure any disease. Patients should see a qualified medical provider for assessment and treatment

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