Heavy menstrual bleeding raises heart disease risk in young women

In a recent study published in the journal BMC Medicine, researchers determined the relationship between heavy menstrual bleeding (HMB) or menorrhagia and cardiovascular disease (CVD) in the presence and absence of irregular menstruation (IM) among females hospitalized in the United States (US).

Cardiovascular disease is the primary cause of death globally. Given gender disparities and the rising incidence of cardiovascular disease and metabolic syndrome (MS), particularly among females, it is crucial to discover modifiable contributory risk factors for cardiovascular disease prevention in the female population. Menorrhagia is defined as excessive blood loss during menstruation or clinically excessive menstrual bleeding impairing the physical, mental, and social well-being and life quality of afflicted women. Menorrhagia imposes a significant financial burden on affected individuals regarding treatment expenses and productivity losses. It is also related to anemia, exhaustion, headaches, and discomfort. The link between menorrhagia and iron deficiency-type anemia may impede oxygen transfer and alter heart function.

Study: Association of heavy menstrual bleeding with cardiovascular disease in US female hospitalizations. Image Credit: Emily Frost / ShutterstockStudy: Association of heavy menstrual bleeding with cardiovascular disease in US female hospitalizations. Image Credit: Emily Frost / Shutterstock

About the study

In the present retrospective, cross-sectional study, researchers explored the influence of menorrhagia and irregular menstruation on cardiovascular disease risk.

The researchers extracted records of hospitalizations among females with menorrhagia and regular menstrual cycles between 18 and 70 years old in 2017 from the publicly accessible National Inpatient Sample (NIS) Database. They used the International Classification of Diseases, tenth revision (ICD-10) to define menorrhagia, including current or prior history of menorrhagia.

The study excluded hospitalizations due to amenorrhea, hematocolpos, excessive menstrual bleeding at puberty, dysmenorrhea, ovulation bleeding, and those with only irregular menstruation. The primary study exposure was heavy menstrual bleeding. Outcomes included major-adverse cardiovascular events (MACE), stroke, atrial fibrillations (AF) or arrhythmias, coronary heart disease (CHD), diabetes (DM), heart failure (HF), and myocardial infarctions (MI), ascertained by ICD-10 diagnostic codes.

The researchers performed prosperity score matching and logistic regression modeling to determine the odds ratios (OR) for analysis. Study covariates included age, ethnicity, race, household income, primary payer, smoking status, alcohol intake, adiposity, hormonal or contraceptive use, metabolic syndrome, polycystic ovary syndrome (PCOS), leiomyoma uterus, non-steroidal-type anti-inflammatory drug (NSAID) prescriptions, and anticoagulant medication use.

Results and discussion

Out of 2,430,851 hospitalized females with a mean age of 44 years, menorrhagia occurred among 0.7% (n=7,762) of females aged 40 years or below and 0.9% (n=11,164) of those aged above 40 years. In the study cohort, 0.8% (n = 18,926) had a heavy menstrual bleeding diagnosis, including 15,180 (0.6%) hospitalizations without irregular menstruation and 3,746 (0.2%) with irregular menstruation. Over 50% of hospitalizations were non-Hispanic white, non-Hispanic black, and Hispanic, with most women having household incomes in the first quartile. Only 20% were obese, and only 9.0% had metabolic syndrome. Menorrhagia was strongly associated with age, black race, and private insurance.

The proportion of obesity, contraceptive use, PCOS, infertility, anemia, NSAIDs, and leiomyoma uterus was higher in menorrhagia hospitalizations than in the regular menstrual cycle group. Among hospitalizations of women aged ≤40 years, the researchers observed significant associations between menorrhagia and an increased likelihood of cardiovascular disease outcomes, including major adverse cardiovascular events (OR 1.6), coronary heart disease (OR, 1.7), stroke (OR, 2.0), heart failure (OR, 1.5), and atrial fibrillations or arrhythmias (OR, 1.8). Sensitivity analyses yielded similar results.

In contrast, menorrhagia did not show robust associations with cardiovascular disease events among hospitalized women aged above 40 years. Menorrhagia without irregular menstruation was robustly related to diabetes, heart failure, atrial fibrillation, and MACE events. Menorrhagia with irregular menstruation showed strong relationships with atrial fibrillation and coronary heart disease outcomes among young female hospitalizations.

The mediation analysis showed direct associations between menorrhagia and major adverse cardiovascular events after accounting for metabolic syndrome (OR, 1.5), adiposity (OR, 1.4), hypertension (OR, 1.4), diabetes (OR, 1.5), and anemia (OR, 1.5). Anticoagulant use (OR, 5.3), black race/ethnicity (OR, 2.1), insulin use (OR, 2.5), contraceptive/hormone use (OR, 1.9), adiposity (OR, 1.8), metabolic syndrome (OR, 1.8), smoking use (OR, 1.7), anemia (OR, 1.3), and alcohol use (OR, 1.1) were associated with increased odds of MACE events in addition to menorrhagia (OR, 1.3).

Hormonal imbalance in menorrhagia patients can cause cardiac abnormalities such as hypoxia, inflammation, and impaired hemostasis. Menstrual repair and hypoxia are affected by decreased hypoxia-inducible factor-alpha (HIF-α) expression, vascular smooth muscle proliferation, and transforming growth factor-beta 1 (TGF-β1). Reducing environmental exposure can help with menstruation issues and cardiovascular disease risk.

The study found an association between menorrhagia and cardiovascular disease events in young girls in the United States, regardless of adiposity, metabolic syndrome, hormone usage, anemia, or uterine fibroids. Regular examinations and screenings for menstrual disorders, particularly menorrhagia, can aid in stratifying and managing cardiovascular disease risk. Menorrhagia should be diagnosed early and managed optimally to minimize adverse outcomes. Future research should consider the age of onset and evaluate its long-term influence on cardiovascular disease outcomes.

Journal reference:
Pooja Toshniwal Paharia

Written by

Pooja Toshniwal Paharia

Pooja Toshniwal Paharia is an oral and maxillofacial physician and radiologist based in Pune, India. Her academic background is in Oral Medicine and Radiology. She has extensive experience in research and evidence-based clinical-radiological diagnosis and management of oral lesions and conditions and associated maxillofacial disorders.

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