Menopause and heart disease: why risk rises and what to do

Heart disease risk rises after menopause, partly because of age and partly because the transition itself shifts cholesterol, body fat and blood vessel health in an unfavorable direction. Heart disease is the leading cause of death for US women, yet most of the risk factors behind it can be measured in your 40s and treated long before they cause harm. The practical move is to know your numbers now and act on the ones that are drifting.

Why risk rises around menopause

For decades, doctors noticed that women develop coronary heart disease several years later than men and wondered whether menopause was the turning point. Long-term studies that followed women through the transition, such as the Study of Women’s Health Across the Nation (SWAN), allowed researchers to separate the effect of getting older from the effect of the ovaries winding down.

The American Heart Association’s 2020 scientific statement summarized what they found. Across the menopause transition, women show distinct changes in sex hormones along with adverse shifts in:

• Cholesterol and other lipids. LDL cholesterol and apolipoprotein B rise most steeply around the final menstrual period. Our guide to cholesterol changes in perimenopause gives the figures.
• Body composition. Fat mass tends to rise and lean mass to fall, even when the scale barely moves.
• Vascular health. Measures of blood vessel health change for the worse.

The statement’s conclusion is that midlife is a time of accelerating risk and therefore a critical window for early prevention. It also noted that the most recent sex-specific AHA prevention guidelines, from 2011, did not reflect this research.

The numbers

According to the CDC, heart disease caused the deaths of 304,970 US women in 2023, about 1 in every 5 female deaths. Only about 56% of women recognize it as their leading cause of death.

The age at which menopause happens matters. In a UK Biobank analysis of 144,260 postmenopausal women followed for a median of 7 years, cardiovascular events (a composite including coronary disease, heart failure, atrial fibrillation, stroke and blood clots) occurred at these rates:

Group	Events per 1,000 women per year	Adjusted hazard ratio
No premature menopause	5.70	1.00 (reference)
Natural menopause before 40	8.78	1.36
Surgical menopause (both ovaries removed) before 40	11.27	1.87

The hazard ratios were adjusted for conventional risk factors and hormone therapy use. The authors called the increase small but statistically significant. If this applies to you, see our guide to premature ovarian insufficiency.

Checks worth doing in your 40s and 50s

What to measure	Why it matters
Blood pressure	Nearly half of US women have high blood pressure; see blood pressure in midlife women
Lipid panel	LDL cholesterol rises around the final period
Lipoprotein(a), once	Largely inherited; the 2026 cholesterol guideline recommends measuring it at least once in every adult
A1C or fasting glucose	Diabetes raises heart risk
Weight and waist	Body fat tends to rise across the transition
10-year risk estimate	Combines the above to guide treatment

Risk calculators have changed. The 2026 ACC/AHA dyslipidemia guideline replaced the older Pooled Cohort Equations with the AHA’s PREVENT equations, which estimate 10-year and 30-year risk for adults aged 30 to 79 and include kidney function. The guideline sorts 10-year risk into low (under 3%), borderline (3% to under 5%), intermediate (5% to under 10%) and high (10% or more).

Women’s history counts. The same guideline asks clinicians to record reproductive risk markers, including premature or early menopause, preeclampsia, gestational diabetes, gestational hypertension and preterm delivery. These can tip a borderline decision toward treatment. If the decision is still unclear, a coronary artery calcium scan can help reclassify risk in women 45 and older.

What lowers risk

The AHA’s Life’s Essential 8 framework lists the eight factors that best capture heart health: diet, physical activity, nicotine exposure, sleep, body mass index, blood lipids, blood glucose and blood pressure. Each is scored from 0 to 100, and the average gives an overall cardiovascular health score. It is a useful checklist because every item can be changed.

The CDC’s practical version for women:

• Know your blood pressure and check it regularly.
• Get tested for diabetes and have cholesterol and triglycerides checked.
• Quit smoking.
• Get at least 150 minutes of physical activity a week; strength training counts toward a healthy body composition.
• Choose foods that help manage weight; a Mediterranean-style pattern is well studied.
• Limit alcohol to one drink a day or less.
• Find healthy ways to manage stress.

Sleep is now part of the AHA’s definition of heart health, which matters in a life stage when night sweats and early waking are common.

When lifestyle is not enough, medications are effective. Statins lower LDL cholesterol, and blood pressure drugs lower stroke and heart attack risk. The thresholds for starting them depend mainly on your calculated risk, with factors such as early menopause used to refine borderline cases.

Where hormone therapy fits

Hormone therapy treats hot flashes and night sweats; it is not a heart medicine. The Menopause Society’s 2022 position statement says it is not approved for primary or secondary prevention of cardiovascular disease.

Timing shapes the picture. For healthy women under 60 or within 10 years of menopause, the statement says the favorable effects of hormone therapy on coronary heart disease and all-cause mortality should be weighed against rare increases in breast cancer, blood clots and stroke. For women who start more than 10 years after menopause or after 60, the balance is less favorable because absolute risks of coronary heart disease, stroke, blood clots and dementia are higher. Women with prior heart disease, stroke or blood clots generally should not use systemic hormone therapy.

For the full picture, read is hormone therapy safe?.

When to see a clinician

Call 911 for chest pain or pressure, or for upper back or neck pain, indigestion, nausea, extreme fatigue, dizziness or shortness of breath that comes on suddenly. Women can have heart attack symptoms other than chest pain.

Book a visit if you have not had your blood pressure, cholesterol and blood sugar checked in the past few years, if your periods stopped before 45, if you had preeclampsia or gestational diabetes, or if a close relative had early heart disease. Ask your clinician to calculate your 10-year risk and explain what would change it. Racing or skipped beats are common in perimenopause and usually harmless, but palpitations with fainting or chest pain need prompt care.

Bring a list of your numbers and your reproductive history. You can search for a menopause-literate clinician in our directory.