Menopause is a natural stage in a woman's life when menstrual periods permanently stop, marking the end of her reproductive years. It is diagnosed after a woman has gone 12 consecutive months without a period and typically occurs between the ages of 45 and 55. When menopause occurs before the age of 40, it is known as premature menopause, while menopause occurring between the ages of 40 and 45 is termed early menopause.
A recent study published in The Lancet has highlighted that premature menopause is more common among women living in low- and middle-income countries (LMICs), particularly South Asian women, and is consistently associated with a higher risk of major cardiovascular events across ethnic and income groups.
Considering that cardiovascular disease accounts for nearly 30 per cent of deaths among women each year, causing more than twice as many deaths as all forms of cancer combined, understanding female-specific risk factors has become increasingly important. While cardiovascular disease can affect women of all ages, early onset menopause is emerging as a key indicator that may help identify women at greater risk and enable earlier preventive interventions.
How is early menopause linked to heart disease?
The findings come from the Prospective Urban Rural Epidemiologic (PURE) study, a multinational prospective cohort study that assessed the relationship between the age at menopause and future cardiovascular events. Researchers analysed data from over 1.11 lakh women aged 35 to 70 years across 26 countries and followed them for a median period of 14.6 years.
Women were categorised into three groups: those who experienced premature menopause before the age of 40, those who entered menopause between the ages of 40 and 45, and those who had menopause at age 45 years or later. Researchers then examined the occurrence of major cardiovascular events, including myocardial infarction, stroke and heart failure.
The study found that decreasing age at menopause was associated with a progressively higher risk of cardiovascular disease. Compared with women who underwent menopause at age 45 years or later, women with early menopause had a 14 per cent increased risk of major cardiovascular events, while those with premature menopause had a 27 per cent higher risk, even after adjusting for age and established cardiovascular risk factors.
The associations remained consistent across ethnic groups and country-income categories. Similar trends were also observed for heart attacks and strokes individually.
According to the authors, “Premature menopause was more common in LMICs (lower-middle income countries) and south Asian women and consistently associated with cardiovascular events across country-income group and ethnic groups. This finding suggests that women with premature and early menopause could be a target population for cardiovascular preventative interventions.”
Researchers noted that natural menopause is accompanied by declining ovarian function and lower oestrogen levels. These hormonal changes contribute to adverse lipid profiles, impaired blood vessel function and increased accumulation of abdominal fat, all of which increase the risk of atherosclerosis and cardiovascular disease. Premature menopause results in a prolonged period of low oestrogen exposure, potentially leading to an earlier and more severe loss of cardiovascular protection.
The authors also pointed out that the relationship may be bidirectional. Previous findings from the Framingham Heart Study have shown that elevated cholesterol levels and high blood pressure before menopause are associated with an earlier age of menopause. Another study found that experiencing a cardiovascular event before the age of 35 doubled the risk of early menopause.
Why are South Asian women and women in low- and middle-income countries more vulnerable?
The study found striking regional and ethnic differences in the timing of menopause. Women living in low- and middle-income countries had a 53 per cent higher risk of premature menopause compared with women in high-income countries. Half of the women in LMICs reached menopause by the age of 47.5 years, compared with 50.6 years in high-income countries.
South Asian women were found to have a 34 per cent higher risk of premature menopause than European women. Half of South Asian women reached menopause by age 47.4 years, while the corresponding age among European women was 50.7 years.
Overall, researchers estimated that among postmenopausal women, 9.5 per cent had experienced premature menopause and 15.3 per cent had early menopause. The findings are consistent with previous meta-analyses and population studies.
The authors wrote, “From 26 countries, we estimated that 9.5 per cent of women had premature menopause and 15.3 per cent had early menopause among women post menopause. It is clear that India has a high prevalence of premature or early menopause, with a local study finding one in five women in India aged 40–44 years have gone through menopause.”
Previous meta-analyses involving nearly one million participants have similarly reported increased rates of hyperlipidaemia, coronary heart disease, stroke and overall cardiovascular disease among women with premature or early menopause. Another pooled analysis involving more than 50,000 women found that premature and early menopause increased the risk of coronary heart disease by around 50 per cent .
Despite having a lower prevalence of conventional risk factors such as obesity, diabetes, high blood pressure and abnormal cholesterol levels, women in low- and middle-income countries experienced higher rates of cardiovascular events than women in high-income countries. Researchers suggest that factors such as poor diet, household air pollution, low educational attainment and reduced muscle strength may exert stronger effects on cardiovascular disease in these settings.
The study provides evidence that premature and early menopause represent an additional independent risk factor for women in low-income countries.
Smoking and being underweight were also associated with earlier menopause. Researchers noted that prenatal exposure to maternal smoking and delayed onset of menstruation may further shorten the duration of oestrogen exposure, increasing cardiovascular risk later in life. These factors may be more common in low- and middle-income countries and could partly explain the higher prevalence of premature menopause.
The authors acknowledged certain limitations, including reliance on self-reported menopause status and age, possible recall bias, and the inability to distinguish between natural menopause, surgical menopause and hormone replacement therapy use. However, they noted that the findings were consistent with previous studies conducted across different populations.
Summarising their findings, the researchers concluded, “The higher prevalence of premature and early menopause in LMICs and among south Asian women suggests that this could be important in identifying populations for screening in these regions and inform prevention policies. Future work on the prevention of premature and early menopause is needed and once identified as high risk through premature and early menopause, there is a need for clear messaging to women who are high-risk and their clinicians to aggressively control other modifiable risk factors.”
What doctors want women with early menopause to know
Dr Sanjay Bhat, Senior Consultant – Interventional Cardiology, Aster CMI Hospital, Bengaluru, said growing evidence suggests that premature and early menopause are associated with a higher risk of cardiovascular disease, even after accounting for traditional risk factors such as diabetes, obesity, hypertension, smoking and lifestyle habits.
"The evidence indicates that menopause itself may play an independent role in cardiovascular health," Dr Bhat said. He explained that declining oestrogen levels can adversely affect cholesterol metabolism, blood vessel function, body fat distribution and inflammatory pathways, accelerating the development of atherosclerosis. However, he emphasised that menopause should not be viewed as the sole cause of heart disease but rather as one of several interacting risk factors.
Commenting on why South Asian women and women living in low- and middle-income countries appear to be more vulnerable to premature menopause, Dr Bhat said the reasons are likely multifactorial. He noted that poor nutrition during childhood and adulthood, chronic stress, recurrent infections, environmental pollutants and inadequate access to preventive healthcare may all influence ovarian health and reproductive ageing. Socioeconomic challenges and genetic factors may also contribute.
"Premature menopause is unlikely to result from a single cause. Biological, environmental, nutritional and socioeconomic factors often interact, and lifestyle factors such as physical inactivity, smoking, poor diet and untreated medical conditions can further affect reproductive health," he said.
Dr Bhat stressed that women who experience menopause before the age of 45 should be considered for earlier and more comprehensive cardiovascular risk assessment. He said that while menopause itself does not guarantee future heart disease, it can serve as an important warning sign that warrants closer monitoring.
"Regular checks of blood pressure, cholesterol, blood sugar and body weight can help identify risk factors early. Doctors should also take into account family history, lifestyle habits and a woman's overall cardiovascular profile," he said.
According to Dr Bhat, prevention remains the cornerstone of reducing cardiovascular risk in women with premature menopause. He advised maintaining a balanced diet, engaging in regular physical activity, avoiding tobacco, managing stress and ensuring adequate sleep. Early treatment of conditions such as hypertension, diabetes and high cholesterol can significantly improve long-term outcomes.
"Hormone replacement therapy may also be considered in selected women with premature menopause, provided there are no major contraindications. However, treatment decisions should always be individualised based on age, symptoms and overall health status. Women with additional risk factors such as obesity, diabetes, hypertension or a family history of heart disease stand to benefit the most from early screening and preventive interventions," he added.
This story is done in collaboration with First Check, which is the health journalism vertical of DataLEADS
