Women face many unique life events, such as pregnancy and menopause, and health challenges that can impact their future heart health.

One such health issue is endometriosis, a condition related to the menstrual cycle. Aside from being incredibly painful, endometriosis is now thought to be linked to an increased risk of heart disease. Research suggests that women who have endometriosis may have a greater long-term risk of developing cardiac disease than women who do not have endometriosis. The increased risk is greatest among women younger than 40.

But how does endometriosis affect the heart? We think it has to do with the changes in estrogen levels that occur naturally and from endometriosis treatment.

What is endometriosis?

Endometriosis is a condition in which endometrium – the tissue that normally lines the inside of the uterus and is shed during a woman’s monthly period – begins to grow outside the uterus. In women with endometriosis, the tissue typically spreads into the pelvic area but in some cases can travel as far as the chest cavity.

The endometrium, no matter where it spreads in the body, is on the same cycle as a woman’s period, which is regulated by the female hormone estrogen. That means the tissue sheds, bleeds, and causes inflammation in any part of the body to which it has attached itself. As you can imagine, it can be incredibly painful. Endometriosis symptoms can range from no symptoms at all to extremely heavy and painful periods, painful bowel movements, painful intercourse, and infertility.

As many as 10 percent of women have endometriosis, though it’s difficult to pinpoint an exact number. Women can be asymptomatic, and the diagnosis usually requires surgery, although there are a few exceptions.

With so many women at risk, researchers want to know whether there is a link between increasedrisk of heart disease and endometriosis itself or if changes in estrogen levels from treatment are to blame.

How does estrogen and endometriosis affect the heart?

We know that endometriosis is associated with inflammation and high cholesterol levels, especially bad cholesterol (LDL). While both of these factors can contribute to heart disease, we think the more important factor is how estrogen affects endometriosis and how treatment methods change the hormonal balance in women’s bodies.

A woman’s ovaries produce estrogen, the female hormone that helps regulate the menstrual cycle and balance other processes in a woman’s body.

Researchers think estrogen helps protect the heart by:

Improving the function of the lining of women’s blood vessels



Controlling cholesterol



Preventing heart disease



As menopause approaches, the ovaries naturally begin to produce less estrogen. During and after menopause, estrogen production stops completely. We think there is about a 10-year period of gradual increase in heart disease risk due to menopause, which may explain why women tend to be diagnosed with heart disease about a decade later than men.

We also know menopause affects body fat distribution. Usually women store fat in the thighs and rear, which is considered protective if the patient is not obese. After menopause, we see women begin to carry more abdominal fat, which is considered dangerous in terms of heart disease risk.

Endometrial tissue is affected by hormonal changes caused by estrogen and progesterone. Endometriosis pain is thought to be due to active bleeding from lesions or producing local irritation and inflammation. Treatment for endometriosis often starts with NSAIDs such as ibuprofen paired with oral contraceptives to help regulate the flow of hormones in the body. If these methods are ineffective to relieve pain, a doctor may prescribe stronger hormone modulating therapy to manage estrogen levels.

If hormone therapy is ineffective, the doctor may recommend a hysterectomy (removal of the uterus) and/or an oophorectomy (removal of the ovaries). Removing the ovaries, which are the “remote control” for the ectopic endometrial tissue, can take away the intense pain and inflammation of endometriosis. However, it also means the body stops producing estrogen, a hormone which has beneficial effects on the heart and blood vessels. This early surgical menopause has been associated with increased risk for heart disease.

Research about endometriosis paired with what we already know about menopause suggests that the connection between endometriosis, estrogen, and heart disease definitely needs to be explored further.

How women with endometriosis can decrease their risk

My specialty is women’s cardiovascular health, so I talk with premenopausal and postmenopausal women every day about decreasing their heart disease risk. What I tell them is similar to what I advise my younger patients who have endometriosis: Try to stay as metabolically healthy as possible.

That means:



Quit smoking



Eat a healthy diet (read the labels on your food and drink)



Exercise regularly



Maintain a healthy weight to prevent Type 2 diabetes and other obesity-related conditions



Control your blood pressure



I advise women right before menopause that they’re about to start experiencing weight gain and a shift in their body fat distribution, so now is an excellent time to incorporate heart-healthy habits and counteract those changes.

Though no patients have asked yet about endometriosis and heart disease, I think this study is important enough for me to change how I approach health-history questions with patients. I usually take a pregnancy history, because pregnancy complications are associated with future risk of cardiovascular disease. If appropriate, we also talk about menopause and hormone therapy.

Now I’m also going to ask whether my patients have endometriosis. This simple question will alert us to women who may be at higher risk for heart disease and prompt us to emphasize early the importance of lifestyle changes. Also, I may advise these women to try the non-surgical treatments before proceeding with surgical menopause.

This is one of those really neat moments as a doctor where we can make an impact and try to prevent disease. Too often in my field, we don’t get the opportunity to identify a young person at higher risk and intervene early enough to make a difference and prevent complications. We typically see patients after they’ve begun experiencing problems and we’re in reactive mode – trying to prevent a first or second heart attack or stroke. That’s why these studies are so important. We can use the information to make an impact early in a woman’s life and prevent heart disease complications.

If you have endometriosis and are concerned about your heart disease risk, request an appointment with a cardiologist or call 214-645-8300.