Hot flashes and sleep changes get most of the attention around menopause. Less often discussed is what happens to the heart. Heart disease is the leading cause of death for women in the United States, and the years around menopause are when many of its risk factors start to shift.

This article explains what changes, which numbers are worth watching, and what the evidence says about hormone therapy and the heart.

Why the menopause transition matters

The CDC reports that heart disease is the leading cause of death for women in the United States and was responsible for about 1 in every 5 female deaths in 2023. Only about half of women recognize it as their leading killer.

Women tend to develop coronary heart disease several years later than men, and their risk climbs after menopause. A 2020 American Heart Association scientific statement reviewed two decades of research that followed women through this period. It described adverse changes in body composition, cholesterol and lipoproteins, and blood vessel health during the menopause transition, and called midlife a critical window for prevention.

The National Institute on Aging notes that after menopause, women are more vulnerable to heart disease, stroke and osteoporosis. Menopause is confirmed once a woman has gone 12 months without a period.

What tends to change

Based on the research the AHA reviewed, these are the areas worth watching through your late 40s and 50s:

  • Cholesterol and lipoproteins, which the statement found change in an unfavorable direction during the transition.
  • Body composition, including more fat around the middle. NHLBI notes that fat around the waist carries more risk for heart disease and diabetes than fat on the hips.
  • Blood vessel health, which the statement also found shifts across the transition, and which blood pressure readings help track.
  • Blood sugar, especially if weight is rising.
  • Sleep. Night sweats and broken sleep add their own strain. NHLBI links ongoing sleep deficiency to heart disease and high blood pressure.

Not every woman experiences all of these changes, which is why it helps to track your own numbers rather than rely on averages.

Early menopause as a risk factor

The timing of menopause matters. The 2018 cholesterol guideline from the American Heart Association and American College of Cardiology lists premature menopause, before age 40, among its risk-enhancing factors, along with a history of pre-eclampsia. These factors can tip a borderline decision about starting cholesterol-lowering medicine.

If you went through menopause early, or had high blood pressure or pre-eclampsia in pregnancy, make sure your doctor knows. Those details are easy to leave out of a medical history decades later, and they still count.

Where hormone therapy fits

Hormone therapy is a treatment for menopause symptoms, not a heart medicine. The US Preventive Services Task Force recommends against using hormone therapy to prevent chronic conditions, including heart disease, in postmenopausal women.

For symptoms, the picture is different. The 2022 position statement from the Menopause Society, then called the North American Menopause Society, says hormone therapy remains the most effective treatment for hot flashes and night sweats. For women younger than 60, or within 10 years of menopause, without reasons to avoid it, the statement finds the benefit-risk balance favorable for bothersome symptoms and for preventing bone loss. For women who start more than 10 years after menopause or after 60, it finds the balance less favorable because of higher absolute risks of heart disease, stroke, blood clots and dementia.

The decision is personal and depends on your symptoms, history and preferences. It is worth discussing with a doctor who knows your heart and bone picture as well as your symptoms. The Menopause Society also keeps patient education resources.

What to check in midlife

  • Blood pressure, in the office and at home.
  • A lipid panel, and consider asking about ApoB and lipoprotein(a).
  • A1c or fasting glucose.
  • Waist size and weight trend.
  • Bone health, especially after early menopause. See bone density screening.

If your estimated risk is borderline, a coronary artery calcium score is sometimes used to help decide on treatment, as the 2019 prevention guideline describes.

It helps to bring a short history to your next visit: your age at menopause, any pregnancy complications such as pre-eclampsia or diabetes in pregnancy, and any family history of early heart disease or stroke.

Seeing the whole picture

Menopause care often gets split between a gynecologist, a cardiologist and a primary care doctor, with no one holding all of it. At Legacy Medical, Dr. Shtern follows blood pressure, cholesterol and blood sugar over time, does an ECG in the office as part of the annual executive physical, and coordinates with your other doctors. To talk it through, book a complimentary meet and greet.

This article is general information, not advice for your situation. Members can call the office with questions about their own care.