In a recent study published in the journal Maturitas, researchers conducted a systematic review and meta-analysis to compare the risk of cardiovascular events in women with and without endometriosis.
Study: Endometriosis and cardiovascular disease: A systematic review and meta-analysis. Image Credit: Bangkok Click Studio / Shutterstock
Cardiovascular diseases, including cerebrovascular disease and coronary or ischemic heart disease, account for about 32% of deaths worldwide. While sex and age are some of the non-modifiable risk factors of cardiovascular disease, modifiable risk factors include hypertension, obesity, sedentary lifestyle, smoking behavior, diabetes mellitus, and dyslipidemia. However, various other risk factors specific to women are often overlooked.
Apart from autoimmune disorders, polycystic ovary syndrome, depression, and premature menopause, there are pregnancy-associated risk factors for cardiovascular diseases, such as gestational diabetes, pregnancy-related hypertensive disorders, placental abruption, preterm delivery, and pregnancy loss. Women experience a higher mortality rate due to cardiovascular diseases, and while the treatment methods are the same for men and women, the presentation, symptoms, diagnosis, risk factors, and response to treatment differ for women.
Endometriosis is an estrogen-dependent, benign, chronic inflammatory disease in women of reproductive age where the endometrial tissue grows outside the uterus and causes chronic pelvic pain, dyspareunia, dysmenorrhea, and often infertility. Epithelial ovarian cancer and ectopic pregnancy are other potential complications. While the inflammatory nature of endometriosis makes it a potential risk factor for cardiovascular disease, the association between the two remains largely unexplored.
About the study
In the present study, the researchers reviewed all retrospective and prospective studies that examined cardiovascular events such as cerebrovascular disease, ischemic heart disease, including myocardial infarction, and other outcomes related to coronary heart diseases and mortality related to cardiovascular events in cohorts of women with and without endometriosis.
Cardiovascular mortality, cerebrovascular disease, and ischemic heart disease were the examined outcomes. Endometriosis patients were included in the meta-analysis irrespective of disease severity, duration, or age, and a laparoscopic confirmation of endometriosis was not required.
The results indicated that endometriosis significantly increased the risk of cerebrovascular disease and ischemic heart disease. A total of six studies were included in the meta-analysis comprising 254,929 participants. Three of these studies reported an increased risk of ischemic heart disease in women with endometriosis compared to women who did not have endometriosis.
The researchers discussed various mechanisms that could explain the elevated risk of cardiovascular disease in patients with endometriosis. The inflammation, endothelial dysfunction, increase in oxidative stress, the relationship between inflammatory markers and microvascular dysfunction, and an atherogenic lipid profile associated with endometriosis could increase the risk of cardiovascular disease.
Two of the studies reported that endometriosis in premenopausal women was associated with increased arterial stiffness, which is an indicator of arterial wall changes and linked to a higher risk of cardiovascular events. Endometriosis was also found to be linked to hypercholesterolemia and hypertension, with women suffering from endometriosis having higher levels of low- and high-density lipoprotein levels than women without endometriosis.
The duration of administration of oral contraceptives in women with endometriosis was also positively associated with the risk of cardiovascular disease, as was early menopause. The surgical treatment options for endometriosis are oophorectomy and hysterectomy, which were also found to increase the risk of stroke and coronary heart disease in women. Hysterectomy is believed to increase the risk of cardiovascular events because of the abrupt lowering of estrogen levels after surgery.
Additionally, the use of analgesic medications to manage pelvic pain and the psychological and emotional stress associated with endometriosis are also thought to contribute to the increased risk of cardiovascular events in women who have endometriosis.
To summarize, the researchers conducted a systematic review of studies comparing the risk of cardiovascular diseases such as cerebrovascular and ischemic heart disease among women with and without endometriosis and performed a meta-analysis to determine if endometriosis was a risk factor for cardiovascular events.
Overall, the results indicated that endometriosis significantly increased the risk of cardiovascular diseases in women. Furthermore, the surgical treatment options for endometriosis also increase the risk of stroke and other cardiovascular events. The psychological stress and the analgesic medications prescribed to manage chronic pelvic pain could also contribute to the increased risk of cardiovascular diseases.
- do Couto, C. P., Policiano, C., Pinto, F. J., Brito, D., & Caldeira, D. (2023). Endometriosis and cardiovascular disease: A systematic review and meta-analysis. Maturitas. https://doi.org/10.1016/j.maturitas.2023.04.001, https://www.sciencedirect.com/science/article/pii/S0378512223000567