Two reproductive health conditions associated with increasing cardiovascular disease risk in women

Two reproductive health conditions common in women, polycystic ovary syndrome and dysmenorrhea, are each associated with increasing cardiovascular disease risk, according to two preliminary studies to be presented at the American Heart Association's Scientific Sessions 2023. The meeting, to be held Nov. 11-13, in Philadelphia, is a premier global exchange of the latest scientific advancements, research and evidence-based clinical practice updates in cardiovascular science.

Cardiovascular disease, including heart disease and vascular diseases such as high blood pressure, is the leading cause of death in women. According to the American Heart Association's Heart Disease and Stroke Statistics-2023 Update, nearly 45% of women 20 years of age and older have some type of cardiovascular disease.

Improved disease prevention would help lower heart disease incidence among young women, according to an author of one of the studies Eugenia Alleva, M.D., M.S., a postdoctoral research fellow at the Windreich Department of Artificial Intelligence and Human Health and the Hasso Plattner Institute for Digital Health at Mount Sinai in New York City.

Menstruation-related factors in general are important to look at since they are specific to the young female population, which is a population overlooked by current risk prediction tools that were developed based on an older and predominantly male population."

Eugenia Alleva, M.D., M.S., postdoctoral research fellow at the Windreich Department of Artificial Intelligence and Human Health and the Hasso Plattner Institute for Digital Health at Mount Sinai

Two new studies, by separate research groups, explored how common reproductive health conditions in women may affect cardiovascular disease risk. One study looks at polycystic ovary syndrome, which is an imbalance in reproductive hormones characterized by irregular or missed periods and cysts on the ovaries that is estimated to impact 1 in 10 women of child-bearing age. The second study evaluates pain with menstrual periods, known as dysmenorrhea, which is the most common menstrual cycle problem women experience.

High blood pressure risk in teenage girls with polycystic ovary syndrome (Abstract 176)

In a study of nearly 170,000 U.S. girls, ages 13 to 17 years, the risk of high blood pressure (blood pressure 130/80 mm Hg or higher) was 30% higher for girls with polycystic ovary syndrome compared with those without the condition. Up to 5% of U.S. children and adolescents have high blood pressure, and as many as 18% have elevated blood pressure.

"While data are emerging on the cardiovascular effects of polycystic ovary syndrome throughout the lifespan, few studies have examined associated health risks specifically among adolescents," said lead study author Sherry Zhang, M.D., a resident physician in internal medicine at Kaiser Permanente Oakland Medical Center in Oakland, California. "Studying adolescents will allow us to better identify possible cardiometabolic complications of polycystic ovary syndrome that may develop at a young age in hopes of reducing future cardiovascular risk."

The researchers found:

• The prevalence of high blood pressure was much higher for those with polycystic ovary syndrome at 18.6% versus 6.9% among those without polycystic ovary syndrome.
• Polycystic ovary syndrome was associated with a 1.3-fold higher risk of having a hypertensive blood pressure reading of greater than 130/80 mm Hg.

"These findings emphasize the importance of routine blood pressure monitoring and lifestyle modification in at-risk adolescents, including those with polycystic ovary syndrome, to prevent the development of hypertension," Zhang said.

Study background and design:

• Health records were data extracted from Kaiser Permanente Northern California from 2012 to 2018.
• More than 1,140 of the nearly 170,000 teenage girls in the database had polycystic ovary syndrome.
• Nearly 66% of all the girls were a healthy weight, nearly 19% were overweight and more than 15% were classified as obese.
• About 3 out of 4 of all girls in the study had normal blood pressure (less than 120/80 mm Hg); 17.5% had elevated blood pressure (120-129/less than 80 mm Hg); and 7.0% had a hypertensive blood pressure.
• According to the medical records of all girls in the study, about one-third were non-Hispanic white; nearly 10% Black, about 30% Hispanic, 20% Asian/Pacific Islander, and about 6% of other or unknown race ethnicity.
• For each of the teenage girls, researchers noted the blood pressure, height and weight taken at one initial well-child visit, along with any polycystic ovary syndrome diagnoses within a year of those visits.
• Of those with hypertensive blood pressure, about 6% of the girls were in the range for stage 1 high blood pressure (130/80-139/89 mm Hg) and less than 1% were in the range for stage 2 high blood pressure (at or greater than 140/90 mm Hg). Blood pressure measures were taken at a single well-child visit, so the authors characterized blood pressure findings in some cases as being in the hypertensive range, rather than as confirmed hypertension, recognizing that blood pressure measures in children can vary over time.

A study limitation is that researchers classified blood pressure based on a single measurement and were not able to draw conclusions about risk of persistent high blood pressure.

Co-authors, disclosures and funding sources are listed in the abstract.

Heart disease risk in young women with dysmenorrhea (Abstract 177)

Another study focused on more than 55,000 women under the age of 50, about 30,000 of whom had been diagnosed with dysmenorrhea, which is characterized by painful menstrual periods. The analysis found that the women with dysmenorrhea were twice as likely to have an increased risk for ischemic heart disease (including angina, heart attack, heart attack complications and chronic or ongoing ischemic heart disease) compared to those who did not have the condition.

According to the American College of Obstetricians and Gynecologists, more than half of women who menstruate have some pain for 1 to 2 days each month. Usually, the pain is mild. But for some women, the pain is so severe that it keeps them from doing their normal activities for several days a month.

"Studying dysmenorrhea is important given that dysmenorrhea stands as the most prevalent menstrual concern. It is associated with heightened stress and disruption of the autonomic nervous system, which influences heart and vessel function and is associated with the increase in certain molecules related to inflammation," said study lead author Alleva. "Both inflammation and stress are also associated with increased cardiovascular risk, with stress particularly noted for its relevance in heart disease among young women."

Researchers found:

• Compared to women without dysmenorrhea, women with the condition were twice as likely to have overall ischemic heart disease, characterized by chest pain or discomfort when part of the heart muscle does not receive enough blood;
• Women with dysmenorrhea were more than three times more likely to experience chest pain known as angina; and
• Women with dysmenorrhea were twice as likely to have chronic or ongoing ischemic heart disease, which is a long-term condition where the heart gets lower blood and oxygen due to narrowed blood vessels.

"Our findings suggest that dysmenorrhea is an important risk factor for heart disease in young females that could be used for refining cardiovascular risk in this population," Alleva said. "These findings also add to the ongoing research efforts aimed at identifying and building tailored risk models for young women, ultimately enabling improved risk prediction and disease prevention."

A major study limitation is that researchers performed a cross-sectional study, meaning they evaluated data for only one point in time, and therefore, they cannot determine if there may be a chronological link between dysmenorrhea and heart disease.

Study background:

• Researchers evaluated U.S. health data of more than 30,500 women with dysmenorrhea and more than 25,300 women without the condition.
• Researchers looked at diagnoses before age 50 years of heart disease overall, as well as heart disease subtypes: angina (heart-related chest pain), heart attacks, complications from heart attacks, as well as chronic heart disease (a long-term condition where the heart gets less blood and oxygen due to narrowed blood vessels). They also evaluated women's menstrual abnormalities, including irregular menstrual cycles, heavy menstrual bleeding and other related conditions, as well as endometriosis, to assess the risk associated with dysmenorrhea independently from these other menstrual conditions.
• Electronic health records of female patients treated at Mount Sinai, primarily between 2011 and 2023, were examined. However, 18% of patients had health information related to earlier times, with the earliest information dating back to 1987.

"These studies are extremely important because they provide insight into how factors specific to young women may impact future cardiovascular risk. The earlier we can identify these unique risks, the earlier we can intervene with treatments to lower those risks and ideally save lives," said Harmony Reynolds, M.D., chair of the American Heart Association's Committee on Cardiovascular Disease and Stroke in Women and Underrepresented Populations, director of New York University Langone's Sarah Ross Soter Center for Women's Cardiovascular Research and an associate professor in the department of medicine at NYU Grossman School of Medicine in New York City. "A particular point to be made here is highlighting the important role a woman's gynecologist can play in her overall health, including heart health. Because many women may use annual "well-woman" visits to their gynecologist as their primary point of care, these visits offer an exceptional opportunity to talk about risks unique to women, along with the importance of maintaining a heart-healthy lifestyle, which is a cornerstone of reducing cardiovascular disease risk."