Cardiovascular Risk Across the Menopause Transition

Contents

1. A statement on the transition
2. Menopause versus age
3. Body fat and good cholesterol
4. When menopause arrives
5. Symptoms as markers
6. Hormone therapy and timing
7. A short glossary

Menopause related concerns are part of the gynecologic experience of Candace Cooley, and the cardiovascular side of the transition is usually measured in years of life rather than in any one laboratory value. The American Heart Association and The Menopause Society noted in 2026 that many women spend about 40 percent of their lives after menopause, that about 6,000 women in the United States reach it each day, and that cardiovascular disease is the leading cause of death in women. They stress that menopause does not cause heart disease, but that the factors tied to it often shift in midlife. By the time women reach menopause, about 90 percent have at least one risk factor for heart disease, yet only 4 in 10 women see heart disease as their greatest health threat.²

A statement on the transition

In 2020 the American Heart Association published a scientific statement on the years before the final period. Its news release describes a transition that for many women begins in the late 40s to mid 50s, when the ovaries make less estrogen, a hormone that may protect the heart. The same drop can follow surgery that removes the ovaries. The writers add that the association’s guidance for women dated from 2011 and did not include the newer data. It also found that only 7.2 percent of women in the transition met physical activity guidelines and fewer than 20 percent kept a consistently healthy diet, and its vice chair noted that randomized trials of lifestyle changes, cholesterol lowering drugs and hormone therapy had rarely enrolled women during the transition itself.¹ Limited trial data, Medscape adds, suggest that a combined lifestyle program in these years can prevent weight gain and lower blood pressure, triglycerides and glucose.³

Menopause versus age

Separating menopause from aging is the core problem. Medscape’s report on the statement explains that rises in LDL cholesterol, apolipoprotein B, metabolic syndrome risk and vascular remodeling at midlife are driven more by the transition, while rises in blood pressure, insulin and glucose are more likely the work of age.³ The National Institute on Aging reports a similar split in the long running SWAN study, and adds that arterial stiffness rose significantly within one year of the final period, beyond what age and risk factors predicted. SWAN enrolled 3,302 women aged 42 to 52 from five racial and ethnic groups and followed them yearly, which is what allows age and ovarian change to be pulled apart.⁴

Figure

Menopause and the heart in numbers

women in the United States entering menopause each day

6,000

of many women's lives spent after menopause

About 40%

of women with at least one heart disease risk factor by menopause

About 90%

women who recognize heart disease as their greatest health threat

4 in 10

Body fat and good cholesterol

The statement singles out two less obvious changes. Fat around the abdomen and the organs increases during the transition and is tied to higher death rates from all causes, even at a normal body mass index. And HDL cholesterol, usually called the good cholesterol, appears to reverse its association with heart risk over the transition, so a high level may not mean the same thing at every stage of life.¹ Lean muscle also declines more steeply in these years.³

When menopause arrives

Timing carries information. An earlier natural menopause generally marks greater cardiovascular risk, and so does removal of both ovaries before menopause.³ The institute describes a SWAN substudy in which longer menstrual cycles beginning five years before the final period were associated with thicker artery walls later, which suggests cycle length could serve as an early signal.⁴ The years leading up to the final period are described in perimenopause.

Symptoms as markers

Hot flashes and night sweats are associated with worse risk factor levels, and depression and poor sleep, both common in these years, have been linked to heart disease in some studies.¹ CNN reported in 2023 on research by a University of Pittsburgh team that tied frequent or persistent hot flashes in early menopause to a higher risk of heart attack, stroke and heart failure, and a newer study of 276 women that linked objectively measured daytime hot flashes to higher C reactive protein. A Menopause Society medical director quoted there frames the flashes as a marker of risk, not a cause.⁵ The 2026 heart association material adds that an estimated 1 in 4 women may develop atrial fibrillation after menopause, based on a study of more than 83,000 women, and that menopause and aging can speed chronic kidney disease, itself a contributor to heart disease and stroke.² The symptoms themselves are covered in vasomotor symptoms.

Hormone therapy and timing

Hormone therapy has been studied as a way to offset the loss of estrogen. Medscape reports data suggesting that starting it before 60 or within ten years of menopause is associated with lower cardiovascular risk.³ A 2024 meta analysis in PubMed Central of 33 randomized trials found no overall change in deaths or cardiovascular events, higher risks of stroke and venous thromboembolism, and fewer deaths and events when therapy began within ten years of menopause.⁶ The 2020 release adds that, in some studies, the benefits for most women in early menopause, including less type 2 diabetes and protection against bone loss, seem to outweigh the risks.¹ The institute describes KEEPS, a trial of more than 700 women at low cardiovascular risk within three years of their last period, which recorded no major adverse cardiovascular events with therapy; it also notes that the Preventive Services Task Force does not recommend hormones to prevent chronic disease.⁴ See menopause hormone therapy and the Women’s Health Initiative.

Figure

Hormone therapy and the cardiovascular system

randomized trials pooled

33

postmenopausal women included

44,639

risk ratio for stroke with hormone therapy

1.23

risk ratio for venous thromboembolism

1.86

A short glossary

Menopause. The point twelve months after the last period, as the institute defines it.⁴

Metabolic syndrome. Three or more of abdominal obesity, high triglycerides, low HDL cholesterol, high blood pressure and high blood sugar.¹

Visceral fat. Fat that sits around the organs rather than under the skin.¹

C reactive protein. A blood marker of inflammation used to estimate heart disease and stroke risk.⁵

Flow mediated dilation. How far an artery widens with blood flow, a measure of vessel health.⁶

How these numbers apply to one woman is a matter for her own clinician.