📈 How Menopause Raises Heart Disease Risk

First let’s take a moment to acknowledge that the frustration is real. You eat well. You’re active. Maybe even super fit. And at some point, as you travel through the menopause transition, you get your routine labs and wellness report, and its got a bunch of red flags. Elevated LDL. Elevated A1c. Maybe elevated blood pressure. Lots of stuff trending in the wrong direction, seemingly out of the blue that doesn’t make sense.

It kind of sucks (which I’m saying from experience). But it’s important to recognize that being fit doesn’t protect us from heart disease–especially once we enter menopausal territory. The journal Menopause recently published a heart disease explainer, recognizing menopause as an independent cardiovascular risk factor, and explaining how menopause drives worsening cardiometabolic risk (lipids, visceral fat, insulin resistance, blood pressure, vascular health) beyond what we’d expect from aging alone.

The paper also argues that this is a critical window for aggressive prevention. Here’s what to know. 

⬇️ We Lose Cardiometabolic Protection as Estrogen Declines

Estradiol helps keep vessels flexible, supports mitochondrial health, improves lipid handling, and modulates the renin–angiotensin–aldosterone system (RAAS, the hormone network your body uses to control blood pressure); all of that shifts unfavorably when levels drop. As estradiol falls, our cardiovascular disease risk accelerates in our late perimenopause and early postmenopausal years. Some common changes women see include:

• Atherogenic lipids: blood lipids tend to shift in a more heart disease–promoting direction, with increases in total cholesterol, LDL, triglycerides, and apoB, alongside a drop in HDL (the “protective” cholesterol).

• Body composition: there’s a tendency to store more fat deep in the abdomen and around organs (visceral and ectopic fat, including around the heart), which can double or more during the menopause transition—even if body weight or BMI doesn’t change much.

• Glucose/insulin: insulin resistance becomes more common, raising the risk for metabolic syndrome. These changes are especially noticeable from late premenopause through perimenopause, though some increases in fasting glucose and insulin are also part of normal aging.

• Vascular function: blood vessels lose some of their flexibility and function more quickly, leading to greater arterial stiffness and progression of atherosclerosis, as estrogen’s protective (vasodilatory and anti-inflammatory) effects decline.

• Blood pressure: rates of high blood pressure rise during the transition, driven by both aging and hormone-related changes in the blood vessels.

The Menopause paper leans into lifestyle interventions to help–structured exercise, diet, weight management–to help prevent or blunt these changes. Anyone who has 10 or 30 years of training logs will find this advice frustrating. For women in early menopause, hormone therapy can be very helpful, improving lipids and other risk factors. The picture is less clear for women going through menopause on the average timeline (and anyone who has been in the menopause space for a while knows that this is a topic of fierce debate). At this point, The Menopause Society doesn’t recommend hormone therapy for the primary or secondary prevention of cardiovascular disease.

That said, vasomotor symptoms such as hot flashes and night sweats are linked to an increased risk of cardiovascular disease, as are poor sleep and chronic stress. So, if you’ve got symptoms, it makes sense that addressing them is likely good for your heart health. Speaking for myself, hormone therapy did nothing for my lipids or glucose/A1c levels. My blood pressure is good, and my visceral fat is very low, but it’s hard to say if that’s all the exercise, genetics, or estrogen (or all of the above). 

Which is a long way of saying that even if you’re doing everything right, you may need more assistance to stay on top of your cardiovascular disease risk once you hit the transition. It’s definitely been an ongoing journey (odyssey?) for me. Red yeast rice and berberine worked like a charm for a while (note: I was working with a doctor, not just DIYing it)…until they didn’t. Seems at this point on the journey, I just need something stronger/different. 

So, we’re working on what levers to pull to bring my lipids back into a healthier zone. The good news is that there are many potential pharmaceutical options, so if I don’t tolerate one, there are others to try. I’m also going to explore some other dietary approaches (though I’ve pulled lots of those levers already). 

The bottom line is that heart disease is still the number one killer of women. We lose our natural protection during the menopause transition. And depending on your genetics and personal circumstances, it may take more work to stay on top of your risk factors. But since heart disease is also very preventable, it’s 100% work worth doing.