Heart disease risk rises around menopause. In the years on either side of your final period, LDL cholesterol goes up, body fat increases and shifts toward the abdomen, and blood pressure keeps climbing with age. None of this causes symptoms, which is why it is easy to miss.
The useful response is to check your numbers in midlife and act on what you find. Hormone therapy can be very helpful for menopause symptoms, but it is not a treatment for preventing heart disease.
Key takeaways
- Around menopause, LDL cholesterol rises and body fat increases and shifts toward the abdomen, all without symptoms.
- A cholesterol result from before the transition may be out of date, so it is worth repeating.
- Blood pressure and blood sugar also climb in midlife, though this tracks aging more than menopause itself.
- Menopause before 40 counts as a factor that raises estimated heart risk, so tell your clinician.
- Hormone therapy can help menopause symptoms but is not recommended for preventing heart disease.
Why heart risk rises around menopause
Women on average develop coronary heart disease several years later than men, and their risk increases notably after menopause. For a long time it was unclear whether this was due to menopause itself or simply to getting older.
Studies that followed the same women through the transition have helped separate the two. In a 2020 scientific statement, the American Heart Association reviewed that research and described the menopause transition as a time of accelerating cardiovascular risk, with adverse changes in body composition, cholesterol and measures of blood vessel health.1
The statement calls midlife a critical window for early prevention. That is the practical message: these are the years when a check is most informative.
Cholesterol: the clearest change
The best evidence comes from SWAN, the Study of Women's Health Across the Nation, which examined women every year through menopause. Among 1,054 women who reached natural menopause without using hormone therapy beforehand, total cholesterol, LDL cholesterol and apolipoprotein B all rose substantially within the year before and after the final menstrual period.2
The pattern was similar across ethnic groups, and it matched the timing of menopause and not simply age. The researchers concluded that women have a distinct rise in lipids at this point and that monitoring cholesterol in perimenopause should help prevention.
So a cholesterol result from your early 40s may no longer describe you at 52. If your last panel was before the transition, it is worth repeating. Apolipoprotein B, or ApoB, reflects the number of plaque-forming particles, and our guide to the ApoB test explains when it adds information.
Blood pressure and blood sugar
Blood pressure, glucose and insulin also drift upward in midlife. In SWAN, however, these followed a steady line that fit chronological aging, with no extra jump at the final period.2
That distinction does not make them less important. High blood pressure is one of the strongest drivers of heart attack and stroke in women, and it has no symptoms. Whatever the cause, midlife is when it often first crosses into a range that needs attention. Rising blood sugar and insulin resistance deserve the same watchfulness.
Body fat: where it goes matters
Many women notice their shape changing even when their weight does not move much. SWAN measured this with body scans. At the start of the menopause transition the rate of fat gain doubled and lean mass began to fall, and both trends continued until about two years after the final period.3
Body weight itself rose steadily through the premenopausal years and did not speed up at the transition. In other words, the scale can stay fairly steady while your body composition shifts underneath it.
The American Heart Association statement also describes a move toward fat stored around the abdominal organs, known as visceral fat, which is the kind most closely tied to heart and metabolic risk.1 A waist measurement tells you more about this than weight alone.
Early and premature menopause
Menopause before age 40 is called premature menopause. It can happen naturally or after surgery to remove both ovaries. US cholesterol guidelines count a history of menopause before 40 as a factor that raises a woman's estimated heart risk.
A study of 144,260 postmenopausal women in the UK put numbers on this. After adjusting for standard risk factors and hormone therapy use, natural premature menopause was linked to a 36% higher risk of a group of cardiovascular diseases, and surgical premature menopause to an 87% higher risk. The authors described the increase as small but statistically significant.4
If your periods stopped before 40, or before 45, tell any clinician who is assessing your heart risk. It is a detail that often goes unasked.
Hormone therapy is not a heart prevention treatment
This point is often blurred, so it is worth stating plainly. Hormone therapy is not recommended for the purpose of preventing heart disease.56
The US Preventive Services Task Force recommends against using hormone therapy for the primary prevention of chronic conditions in postmenopausal women.6 The Menopause Society's 2022 position statement describes hormone therapy as the most effective treatment for hot flashes and night sweats, and says the balance of benefit and risk is favorable for treating bothersome symptoms in women who are under 60 or within 10 years of menopause and have no contraindications.
The same statement says the balance appears less favorable for women who start more than 10 years after menopause or after age 60, because of greater absolute risks of coronary heart disease, stroke, blood clots and dementia.5
The decision about hormone therapy belongs with your symptoms, your history and your own clinician. Your heart risk is managed separately, through blood pressure, cholesterol, blood sugar, activity, food and not smoking.
What to check in midlife
| Check | Why now |
|---|---|
| Lipid panel, repeated after the transition | LDL cholesterol and ApoB rise around the final period |
| Blood pressure, including home readings | Climbs with age and causes no symptoms |
| Fasting glucose and A1c | Blood sugar drifts upward in midlife |
| Waist measurement | Fat gain speeds up even when weight does not |
| Your age at menopause, shared with your doctor | Menopause before 40 raises estimated risk |
Your next step
If you are in perimenopause or past menopause and have not had your heart risk looked at since, start with the basics above. Our guide to a heart disease risk assessment explains what a fuller preventive evaluation covers.
You can also answer the three quick questions in the screener on the Cardio Res-Q program page. Perimenopause and menopause are among the risk factors it asks about.
Are You a Candidate for Cardio Res-Q?
Three quick questions about the risk factors we screen for. Your answers stay between you and the clinic.
Frequently asked questions
Does menopause cause heart disease?
Not directly. Menopause brings changes that raise risk, most clearly a rise in LDL cholesterol and a shift in body fat, and these add to the effects of aging. Heart disease still depends on the full set of risk factors, most of which can be measured and managed.
Why did my cholesterol go up when nothing else changed?
This is common. In a large study that tracked women through menopause, total cholesterol, LDL cholesterol and ApoB rose within the year before and after the final period, independent of aging alone. It is a reason to recheck your numbers and discuss them with your clinician, not a sign you did something wrong.
Should I take hormone therapy to protect my heart?
No. Hormone therapy is not recommended for preventing heart disease, and the US Preventive Services Task Force recommends against using it to prevent chronic conditions. It is prescribed for menopause symptoms, and whether it suits you is a separate conversation with your clinician.
I went through menopause before 40. What should I do?
Tell your doctor, because US guidelines treat menopause before 40 as a factor that raises estimated heart risk. It does not mean you will develop heart disease. It means your blood pressure, cholesterol and blood sugar deserve earlier and closer attention.
Related reading
This article is for general education and is not medical advice. Decisions about testing and medication should be made with your clinician. If you have chest pain or other symptoms of a heart attack, call 911.
