For many women, age 40 is when they really start to settle into themselves. Their career is set, perhaps they’ve started a family and they know themselves better than ever. Life is good.
It’s also a time of subtle changes as hormonal shifts start to happen. Levels of estrogen and progesterone start fluctuating, which affects every body system, but especially the heart and cardiovascular system.
Estrogen protects the heart(1) and cardiovascular system, which means younger women have lower risk of heart attacks compared to men of the same age. However, as estrogen levels start to decline in perimenopause, women's cardiovascular risk profile rises.
Unfortunately, most women have no idea these profound changes are happening. And many clinicians are unaware too, because traditional cardiac care and training centers the male experience. This leads to women’s particular risks and symptoms being misunderstood and overlooked. And this gap is one of the big reasons that cardiovascular disease is the No.1 killer of women(2) in the US, accounting for one in three deaths.
That’s why on the unPAUSED podcast, research cardiologist Dr. Jayne Morgan asserted that menopause isn’t just a time of hormonal change; this transition needs to be reframed as “a cardiology red flag.” She noted that women are “more likely to be admitted to hospitals for heart failure and three times as likely to die.” Until the medical community starts seeing menopause as a serious potential cardiac risk factor, it’s critical for women to understand the changes that start around age 40 and what to do to protect their long-term health.
After menopause several significant changes occur that can affect women’s heart health. Researchers believe that the decline in estradiol, the active form of estrogen, underlies all of these shifts:
- Estrogen keeps the blood vessels supple and flexible. As the hormone levels fall, the lining of the blood vessels, called the endothelium, starts to stiffen which in turn causes blood pressure to creep up(3) in menopausal women. Hypertension is considered a modifiable heart disease risk factor.
Changes in body composition
After menopause, weight gain tends to settle around the belly(4) due to lower estrogen levels. It’s often metabolically active visceral fat that surrounds the organs.- Insulin resistance is when the body stops responding to insulin, leading to elevated blood sugar, and an increased risk for pre diabetes or type 2 diabetes. An estimated 88% of people in the US have insulin resistance(5), and many are unaware. After menopause, the low estrogen can drive elevated risk of insulin resistance(6) and systemic inflammation.
- Researchers have found that the ratios of cholesterol shift(7) in the wrong direction after the menopause transition: LDL (the troubling cholesterol) rises, while HDL (the good cholesterol) declines.
Getting regular health screenings and knowing your numbers is an important part of protecting your cardiovascular health. However, even if you’re staying on top of those, there’s one significant risk for heart disease that standard tests overlook: your level of Lipoprotein a, often known as Lp(a). This lipid circulates in the blood, but unlike LDL, HDL and triglycerides, Lp(a) isn’t included in typical cholesterol screenings. It’s usually checked just once when you’re in your 20s; an estimated 20% have levels high enough to raise cardiac risk.
Fortunately, a growing number of researchers are sounding the alarm on the dangers of ignoring this marker. Lp(a) is considered by cardiac researchers to be a significantly dangerous and underrecognized risk factor for heart attack and stroke, one that many doctors and members of the general public remain unaware of. Unfortunately that's too late for many women. Women are “more likely to be admitted to hospitals for heart failure and three times as likely to die,” Dr. Morgan shared on the unPAUSED podcast. This type of cholesterol is often determined by your genes, and conventional wisdom has held that Lp(a) stays pretty much static for decades, unaffected by diet or exercise habits. But recent studies show perimenopausal women can experience a steep rise in Lp(a)(8) that can signal plaque in the arteries, so it’s wise to request an Lp(a) screening in your late 30s.
Numerous studies have found Lp(a) levels can vary by ethnicity(9). Women of Sub-Saharan African ancestry(10) can have Lp(a) levels two to three times higher than those of European descent. People of Chinese heritage tend to have lower levels compared to Europeans, while analyses for people of Hispanic background are inconsistent. A level above 50 ng/dL raises risk for heart attack artery plaque and all cause mortality, according to the National Lipid Association. However a 2024 analysis led by researchers from Stanford University found that 31% of Mexican patients and 63% of Black patients(11) had levels over 50 ng/dL, raising their 10-year risk of a cardiac event. For those patients, 30 ng/dL is a more useful cut off.
While menopausal cardiac changes are serious, lifestyle shapes risk. Lifestyle factors play a crucial role in heart disease prevention, with the vast majority of cases being potentially avoidable rather than inevitable.
Many women think a heart attack starts with crushing chest pain or pain down the left arm. While that may be true for men, women have different symptoms, and knowing them can save your life. Typical symptoms for women are fatigue, nausea and jaw pain, so pay attention to your body. And since women are likely to be dismissed in the emergency room, it’s crucial to insist on an EKG to document what’s happening with your heart.
Numerous studies show that women on menopausal hormone therapy can lower their risk of cardiovascular disease(12) and all cause mortality if it’s started at the right time. Some studies show oral estradiol can be more effective in lowering Lp(a)(13) and other cholesterol compared to transdermal forms. However, oral estradiol poses different risks from transdermal forms, so women should have a risk-benefit conversation with their menopause-trained clinician.
People like to joke about hot flashes, but they aren’t funny or benign. They’re distress signals from your cardiovascular system. Silently suffering through hot flashes and night sweats means you’re at increased risk for heart attack or stroke. Options for hot-flash relief include transdermal, oral or vaginal systemic estradiol such as Femring or non-hormonal hot flash treatments like fezolinetant and SSRIs. Hormone therapy is just one facet in a comprehensive lifestyle strategy to keep blood pressure and insulin resistance in check.
Regular exercise stimulates the production of nitric oxide(14), which keeps the endothelium healthy and flexible. Movement can also help whittle away menopausal belly fat when paired with the right approaches to nutrition and sleep. Guidelines recommend resistance exercise two to three times a week, balance training and 150 minutes of cardio exercise. A 20-minute walk after meals will go a long way towards keeping blood sugar levels stable and restoring insulin sensitivity—even a 10-minute walk(15) is effective. An anti-inflammatory Mediterranean eating plan(16) centers on fresh produce that’s full of nutrients, healthy fats like olive oil, beans, fish and small amounts of red meat. Prioritize getting adequate protein and fiber every day, adding a supplement like Fiber GDX if you find you’re falling short. Science tells us that this eating pattern can lower blood pressure(17), reduce inflammation, and help reverse the metabolic effects of polycystic ovary syndrome and insulin resistance. Eating better also means avoiding sweet drinks, ultraprocessed foods and too many simple carbohydrates.Prioritize Sleep and Stress Management Sleep is when your body restores and repairs itself. Creating a sleep regimen that ensures you’re getting at least 7.5 to 8 hours of sound sleep is vital for a healthy heart. It also ensures that levels of the stress hormone cortisol stay balanced. Managing stress is important too, so find an activity that helps you to relieve stress such as yoga(18) or spending time in nature(19), which has been shown to help lower cortisol, blood pressure and inflammation(20) while increasing immune function. With a combination of knowledge and lifestyle strategies, women can keep their hearts healthy for decades to come.
