Cardiovascular Disease Risk Increases With Menopause: What You Need to Know

When we talk about menopause, we usually talk about hot flashes, sleep, mood changes, weight, and vaginal symptoms. But there's another conversation I want every woman to have as she moves through midlife: what's happening to your cardiovascular health?

Heart disease is the leading cause of death in women. And while menopause itself isn't a disease, the menopause transition is an important time to pay attention to cardiovascular risk. This isn’t meant to scare you. Knowing your risk can be empowering, because there’s a lot you can do about it.

Why does heart risk change around menopause?

Cardiovascular risk rises with age, but the menopause transition adds its own changes that can affect that risk. Around menopause, we often see LDL cholesterol increase, blood pressure rise, and body composition shift toward more abdominal fat. Insulin resistance can also become more pronounced, increasing the risk of type 2 diabetes. At the same time, arteries become less flexible as we get older. Declining estrogen contributes to this loss of flexibility, but aging itself also plays a major role.

These changes don't happen in exactly the same way or at exactly the same time for every woman. And I don't want to oversimplify this by saying that the loss of estrogen is solely responsible for the increase in heart disease risk.

Instead, I think of menopause as a window of opportunity to reassess your cardiovascular health.

This is particularly important if you have other risk factors, such as high blood pressure, elevated LDL cholesterol, diabetes, smoking, low physical activity, or a strong family history of cardiovascular disease.

The timing of menopause matters, too. Women who experience menopause at a younger age may have a different cardiovascular risk profile and deserve particular attention to prevention.

How do we figure out your heart risk?

This is one of the most useful conversations you can have with your healthcare provider.

We don't determine your heart disease risk based on menopause alone. We look at the whole picture.

That includes things like:

• Your age

• Blood pressure

• LDL and HDL cholesterol

• Smoking status

• Diabetes or blood glucose levels

• Family history

• Your overall health and other medical conditions

  
  

One tool commonly used to put some of these factors together is the ASCVD risk calculator.

ASCVD stands for atherosclerotic cardiovascular disease. In simple terms, this refers to cardiovascular disease caused by plaque buildup in the arteries, which can eventually lead to a heart attack or stroke. Newer versions of this calculator (the AHA PREVENT equations) are now recommended in some U.S. guidelines, but the idea is the same: combine your risk factors into a single number.

The ASCVD risk calculation estimates your risk of having a cardiovascular event over the next 10 years.

But here's something important: the number isn't a diagnosis, and it isn't a treatment plan.

It's a starting point.

If your risk is clearly low, we may focus on lifestyle and monitoring your risk factors over time. If your risk is clearly high, medication such as a statin may make sense.

The more difficult situation is often the woman in the middle. Maybe your cholesterol is elevated, but your overall risk isn't particularly high. Or perhaps you have a strong family history that isn't fully captured by the calculator.

That's when we sometimes need another piece of information.

What is a CAC score?

CAC stands for coronary artery calcium.

A CAC score comes from a specialized CT scan that looks for calcium in the arteries supplying the heart. Calcium is a marker of calcified atherosclerotic plaque in the coronary arteries.

So while your cholesterol tells us about one of your risk factors, a CAC scan can tell us whether there is evidence of calcified plaque in your coronary arteries.

A CAC score of zero means that no calcified plaque was detected. In the appropriate patient, that's reassuring and is associated with a relatively low short-term cardiovascular risk. A score above zero means calcium is present, which tells us that coronary atherosclerosis is already present.

The higher the score, generally, the greater the concern. And once you're on treatment, CAC scores can still go up over time even when therapy is working. That's because the test mainly shows calcified plaque that may become more dense as it stabilizes.

But a CAC scan isn't something every woman needs simply because she has reached menopause.

When might a CAC scan be useful?

I think of CAC as a tie-breaker, rather than a routine screening test.

For example, let's say we've calculated your ASCVD risk and we're somewhere in the range where the decision about starting a statin isn't obvious. You have some risk factors, but you're not clearly high-risk.

In that situation, a CAC score may give us additional information.

A score of zero may support the decision to defer statin therapy in some appropriately selected patients, while a higher score may make the benefit of treatment much clearer.

CAC can also sometimes be helpful when other pieces of the picture don't quite line up. Perhaps you have a strong family history of premature heart disease, or your cholesterol is higher than we'd like but your calculated risk is otherwise relatively low.

The important thing is that the CAC score doesn't replace the rest of your risk assessment. It adds another piece of information when the treatment decision isn't clear.

This is a conversation to have with your healthcare provider. A CAC scan has limitations and isn't appropriate for everyone.

What can you do to protect your heart?

Once we know your risk, the next question is the one I really care about:

What can we do about it?

Some of the most important things are surprisingly unglamorous.

Move your body

Regular physical activity is one of the most effective ways to improve cardiovascular health.

Aerobic exercise helps cardiovascular fitness, while resistance training becomes increasingly important as we age because maintaining muscle supports metabolic health, strength, and independence.

You don't have to become an endurance athlete. Walking, cycling, swimming, hiking, dancing, strength training, or whatever activity you enjoy and can do consistently all count.

Know your numbers

Keep track of your blood pressure, cholesterol, and blood glucose.

These numbers can change during midlife, and catching a trend early gives you more opportunities to do something about it.

Don't smoke

If you smoke, quitting is one of the most important things you can do for your cardiovascular health.

Eat for your overall health

A Mediterranean-style eating pattern, with plenty of vegetables, fruit, whole grains, legumes, lean protein, and healthy fats, is a good foundation for cardiovascular health.

This isn't about eating perfectly. Your overall pattern matters much more than whether you occasionally eat a cookie or have dinner out.

Take sleep seriously

Poor sleep is common during menopause, but that doesn't mean you have to simply accept years of terrible sleep as part of getting older.

Sleep problems can affect blood pressure, metabolism, mood, and overall health. If you're consistently struggling with sleep, it's worth figuring out why and treating the problem.

Address chronic stress

"Just reduce your stress" isn't particularly helpful advice when you have a demanding job, family responsibilities, or a life that is simply busy.

But chronic stress can affect blood pressure, sleep, physical activity, and other behaviors that influence cardiovascular health.

Finding something that helps you manage stress, whether that's exercise, time outside, mindfulness, breathing exercises, therapy, or something else that works for you, is worthwhile.

What if lifestyle changes aren't enough?

If your LDL cholesterol, blood pressure, blood sugar, or overall cardiovascular risk is high enough, medications can be an important part of prevention. Taking a statin or blood-pressure medication isn't a failure of lifestyle. Sometimes it's simply another tool we use to reduce your risk.

What about menopausal hormone therapy?

This is a question I hear frequently: "If estrogen changes cardiovascular risk, should I take hormone therapy to protect my heart?"

The answer is no. MHT should not be prescribed specifically to prevent cardiovascular disease.

But that's very different MHT may be an appropriate treatment for bothersome menopausal symptoms like hot flashes when the individual benefits outweigh the risks. In this age and timing window, the cardiovascular risk calculus is generally more favorable. After about age 60 or more than 10 years past menopause, that risk calculus tends to shift, and the potential for harm increases.

The decision to use MHT should be based on your symptoms, age, timing relative to menopause, medical history, and individual risks and benefits, rather than on the idea that it will prevent heart disease.

I've written more about this in Can Menopause Hormone Therapy (MHT) Protect You From Heart Disease? Here's the Truth.

What about heart palpitations?

Now let's talk about another question I hear all the time: "Why does my heart suddenly feel like it's racing?"

Palpitations are the sensation of being aware of your heartbeat. You may feel your heart beating faster than usual, pounding, fluttering, or seeming to skip a beat.

Palpitations are common during perimenopause, and hormonal fluctuations may play a role. They're often due to extra beats or brief runs of faster rhythm that are uncomfortable but not dangerous.

And they can be incredibly unsettling.

A woman will sometimes tell me, "I know I'm probably fine, but every time it happens I think something is wrong with my heart."

The good news is that palpitations during the menopause transition are often not dangerous. But we shouldn't automatically assume that every episode of a racing or irregular heartbeat is "just menopause."

Caffeine, alcohol, dehydration, stress, thyroid problems, low blood sugar, medications, and other medical conditions can also cause or worsen palpitations.

That's why the pattern matters.

If your palpitations are new, persistent, becoming more frequent or severe, or lasting more than a few minutes, talk with your healthcare provider. Depending on what you're experiencing, they may want to check your blood pressure, thyroid function, blood counts, electrolytes, or heart rhythm, or use a heart monitor to see what is happening during an episode.

When should I worry about chest symptoms?

Palpitations are usually benign, but some heart-related symptoms should never be ignored.

If palpitations occur along with chest pain or pressure, shortness of breath, sweating, significant dizziness, or feeling faint, seek urgent medical attention.

And please know the warning signs of a heart attack.

The classic picture of a heart attack is often portrayed as someone clutching their chest. Women can certainly have that symptom, but heart attacks can also cause discomfort in the arms, back, neck, jaw, or stomach. Shortness of breath, nausea or vomiting, cold sweating, and lightheadedness can also occur. Women are more likely than men to have "atypical" symptoms like shortness of breath, nausea, or back or jaw discomfort, sometimes without classic crushing chest pain.

If you have symptoms that could represent a heart attack, call 911 rather than waiting to see if they go away or trying to drive yourself to the hospital.

The bottom line: protecting your heart during menopause

Menopause is a good time to stop treating cardiovascular health as something you'll worry about later.

That doesn't mean menopause suddenly makes you high-risk for heart disease. It means midlife is an important opportunity to look at the factors that actually determine your risk and do something about the ones you can change.

At a routine visit, I want to know your blood pressure. I want to know your cholesterol and blood sugar. I want to know whether you smoke, how active you are, how you're sleeping, and whether there is a family history that changes the picture.

Sometimes that's all we need.

Sometimes we'll calculate your ASCVD risk. Sometimes, when the answer isn't clear, we'll have a conversation about whether a CAC score would add useful information.

And sometimes the most important thing we do is identify a risk factor early enough to do something about it.

Your heart doesn't need you to be perfect. It needs you to pay attention.