Heart Health and Bone Density: Critical Considerations for Women with Diabetes in Menopause

Heart disease is one of the biggest health threats to postmenopausal women. Menopause can have a significant impact on heart disease risk in women due to several factors, including changes in hormones, increases in blood pressure, and weight gain – all changes that often happen organically as we age.
The decline in estrogen levels during menopause can lead to changes in lipid profiles. Our LDL (“bad cholesterol”) is a fat that circulates in our blood and delivers cholesterol cells to the remainder of the body. This type of cholesterol increases with menopause. Our HDL (“good cholesterol”) is the “scavenger” cholesterol and helps to carry and remove other forms of cholesterol from your bloodstream and take it to your liver. The rise in LDL and decrease in HDL cholesterol are one means that heart disease risk is elevated as we grow older and especially with menopause.
Menopause is often associated with higher blood pressure, which is a major risk factor for heart disease. The higher blood pressure causes your heart and blood vessels to work harder, which can affect this delicate system. A woman’s risk of heart disease, heart attack, and stroke all increase with age.
Many women experience weight gain during menopause, which can contribute to obesity-related heart disease risks. Cortisol, our stress hormone, is increased due to stress and lack of sleep, all of which increase as we age. This causes the deposition of bodily fat (adipose tissue), particularly in the abdomen, which further exacerbates the difficulty of managing blood glucoses.
So you can see how important it is to monitor blood pressure and cholesterol and weight during this ever-changing time. Regular monitoring of cholesterol, blood pressure, and triglycerides is crucial, especially for individuals at higher risk of heart disease, such as postmenopausal women, people with diabetes, or those with a family history of cardiovascular conditions. Here are the general recommendations for monitoring these key cardiovascular risk factors:
Cholesterol Monitoring
- Total Cholesterol:
- Ideal level: Less than 200 mg/dL (5.2 mmol/L).
- Low-Density Lipoprotein (LDL) Cholesterol (“Bad” Cholesterol):
- For people at low risk: Less than 100 mg/dL (2.6 mmol/L).
- For people at high risk (e.g., diabetes, cardiovascular disease): Less than 70 mg/dL (1.8 mmol/L).
- High-Density Lipoprotein (HDL) Cholesterol (“Good” Cholesterol):
- For women: 50 mg/dL (1.3 mmol/L) or higher.
- For men: 40 mg/dL (1.0 mmol/L) or higher.
- Action: Monitoring should take place annually or more frequently for people with risk factors like diabetes, heart disease, or a family history of high cholesterol. If cholesterol levels are high, dietary changes, regular exercise, weight management, and medications (e.g., statins) may be recommended.
Blood Pressure Monitoring
- Target Blood Pressure:
- Normal: Less than 120/80 mm Hg.
- Elevated: Systolic pressure (top number) between 120-129 mm Hg and diastolic pressure (bottom number) less than 80 mm Hg.
- High Blood Pressure (Hypertension):
- Stage 1: 130-139/80-89 mm Hg.
- Stage 2: 140/90 mm Hg or higher.
- Frequency:
- At least once a year for adults with normal blood pressure (less than 120/80 mm Hg).
- More frequently (e.g., every 6 months) for people with elevated or high blood pressure or those at higher risk of heart disease.
- Home monitoring is also recommended for those diagnosed with high blood pressure to track progress and treatment effectiveness.
- Action: If blood pressure is high, lifestyle modifications (reduced salt intake, regular exercise, weight loss) and medications (e.g., ACE inhibitors, beta-blockers) may be prescribed.
Triglycerides Monitoring
- Ideal Triglyceride Levels:
- Normal: Less than 150 mg/dL (1.7 mmol/L).
- Borderline High: 150-199 mg/dL (1.7-2.2 mmol/L).
- High: 200-499 mg/dL (2.3-5.6 mmol/L).
- Very High: 500 mg/dL or more (5.7 mmol/L or higher).
- Frequency:
- Typically checked as part of a fasting lipid panel every 4-6 years if normal, or more frequently if there are risk factors for heart disease, such as diabetes, obesity, or a personal or family history of high triglycerides or cardiovascular disease.
- Annual or biannual monitoring may be recommended for people with elevated triglycerides or those undergoing treatment for high triglycerides.
- Action: If triglycerides are elevated, lifestyle interventions such as a heart-healthy eating plan (low in sugars and refined carbohydrates), weight loss, exercise, and sometimes medications (e.g., fibrates, omega-3 fatty acids, or statins) are recommended.
Now, let’s turn to osteoporosis. Menopause increases a woman’s risk of osteoporosis primarily due to the decline in estrogen levels. Estrogen is a hormone that plays a key role in maintaining bone density by inhibiting the activity of osteoclasts, which are cells that break down bone tissue. When estrogen levels drop during menopause, this protective effect is diminished, leading to an imbalance where bone breakdown outpaces bone formation.
How does menopause specifically contribute to the increased risk of osteoporosis?
Estrogen helps maintain bone density by promoting calcium absorption and reducing the activity of bone-resorbing cells. After menopause, the significant drop in estrogen leads to accelerated bone loss, especially in the first few years after menopause. With lower estrogen levels, osteoclasts become more active, resulting in increased bone resorption (breakdown), while bone formation by osteoblasts (cells that build bone) doesn’t keep pace. This lack of balance with breakdown and formation leads to overall bone loss. Over time, this imbalance leads to a decrease in bone mineral density, which makes bones more porous, fragile, and prone to fractures. The most common sites of osteoporotic fractures are the spine, hips, and wrists. Women who experience a rapid loss of bone mass during and after menopause are more susceptible to fragility fractures—breaks that occur from minimal trauma, such as a fall from standing height.
Women with diabetes who are in menopause face an increased risk of both heart disease and osteoporosis due to the combined effects of hormonal changes from menopause and the metabolic complications associated with diabetes. Here’s how these factors interact:
Increased Risk of Heart Disease
- Decline in Estrogen: During menopause, the natural decline in estrogen, which has a protective effect on the cardiovascular system, makes women more vulnerable to heart disease. As we have said, estrogen helps regulate cholesterol levels, maintaining higher levels of HDL (good cholesterol) and lower levels of LDL (bad cholesterol). When estrogen levels drop, this balance is disturbed, increasing the risk of atherosclerosis (hardening of the arteries), high blood pressure, and other cardiovascular issues.
- Diabetes’ Impact on Heart Health: Women with diabetes already have a higher risk of developing cardiovascular disease due to elevated blood glucose levels, which can damage blood vessels and contribute to plaque formation in the arteries. In women with diabetes, this risk is compounded during menopause. Above-range blood glucose levels increase inflammation and insulin resistance, both of which can accelerate the progression of heart disease. Women with diabetes in menopause are more likely to develop conditions such as heart attacks, stroke, and heart failure at a younger age than women without diabetes.
- Insulin Resistance: Menopause can worsen insulin resistance, a common issue in diabetes, further elevating blood glucose levels and raising cardiovascular risk. Additionally, the weight gain often associated with menopause, particularly abdominal fat, increases the likelihood of developing metabolic syndrome—a cluster of conditions that raises the risk of heart disease.
Summary of Combined Risks:
- Heart Disease: Menopause lowers estrogen, raising cholesterol and increasing heart disease risk, while diabetes compounds this with high blood glucose, inflammation, and insulin resistance.
- Osteoporosis: Menopause accelerates bone loss due to low estrogen, and diabetes adds to this through poor bone quality, high glucose levels, and potential medication side effects.
Together, these risks highlight the need for careful management of both menopause and diabetes through lifestyle changes, medications, and regular monitoring to reduce the risks of both heart disease and osteoporosis. In all cases, maintaining a healthy eating plan (low in saturated fats, sugars, and processed foods), regular physical activity, weight management, and avoiding smoking are essential components of reducing these cardiovascular risk factors.
Regular follow-ups with healthcare providers are critical to adjusting treatment and ensuring that these risk factors remain within healthy ranges.
Preventing osteoporosis, particularly in postmenopausal women and those at risk, involves adopting strategies to strengthen bones and minimize bone loss. The following are key prevention strategies:
Adequate Calcium Intake
- Daily recommendations:
- Women 50 and younger: 1,000 mg/day.
- Women over 50: 1,200 mg/day.
Sources of calcium include:
- Dairy products (milk, yogurt, cheese).
- Leafy green vegetables (kale, broccoli).
- Calcium-fortified foods (orange juice, plant-based milks, cereals).
- Supplements may be necessary if dietary intake is insufficient, but it’s better to get calcium from food when possible.
Vitamin D
- Vitamin D is essential for calcium absorption in the body and helps maintain bone health.
Daily recommendations:
- Adults up to age 70: 600 IU/day.
- Adults over 70: 800 IU/day.
Sources of vitamin D include:
- Sun exposure (about 10-30 minutes of sunlight several times a week, depending on skin type and geographic location).
- Fatty fish (salmon, tuna), fortified foods, egg yolks, and supplements if necessary.
Weight-Bearing and Muscle-Strengthening Exercises
- Weight-bearing exercises (help build and maintain bone density):
- Activities like walking, jogging, hiking, stair climbing, dancing, and tennis.
- Muscle-strengthening exercises (improve balance and muscle support for bones):
- Weightlifting, resistance training, and exercises using resistance bands or body weight.
- Aim for at least 30 minutes of weight-bearing activity most days of the week and strength training exercises two to three times a week.
Avoid Smoking and Excessive Alcohol
- Smoking: Smoking is harmful to bone health, as it reduces calcium absorption and decreases estrogen levels in women, speeding up bone loss.
- Alcohol: Excessive alcohol (more than two drinks per day for women and three for men) can interfere with the body’s calcium balance and affect bone formation, leading to increased fracture risk.
Limit Caffeine and Sodium
- Caffeine: Excessive caffeine intake can decrease calcium absorption and contribute to bone loss. Limit consumption to 1-2 cups of coffee or tea per day.
- Sodium: A high-sodium diet increases calcium loss through urine. Reducing processed and salty foods can help minimize this effect.
In a postmenopausal woman with Calcium or Vitamin D deficiency, supplements may be prescribed by her provider to ensure she does not remain deficient. Maintaining good cardiovascular health in the menopausal and postmenopausal time period may involve a delicate interplay between reduction in risk factors, choice of lifestyle factors, and dietary choices and, if necessary, supplementation as needed. The goal is to optimize the restoration of essential nutrients required to help the body utilize all of the above strategies to optimize health during this transitional time.
About the Author
Dr. Mala Freeman-Kwaku, lead physician at Arboretum Gynecology, has over 22 years of experience specializing in gynecologic care, including treating uterine fibroids, heavy menstrual bleeding, and menopausal symptoms. A graduate of the University of Virginia and Georgetown University Medical Center, she transitioned from a group practice to create a more intimate healthcare environment, successfully rebranding her practice while maintaining patient loyalty. Skilled in hysteroscopy and advanced procedures like the Sonata fibroid ablation, she shares her expertise as a speaker for Gynesonics and through her private consulting firm, MFK Advising Group, LLC. Dr. Freeman-Kwaku is married with four children, enjoys traveling, and remains active in her church and community.
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