Menopause occurs when menstrual cycles cease. In the years before and after menopause, the body undergoes many changes, leading to symptoms that may include hot flashes, emotional changes, and sleep disturbances. But its impact on the body may be even more profound. Medical News Today investigates why menopause might impact cardiovascular health, and how women can maintain a healthy heart as they age.

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How does menopause affect heart health and what are some expert tips to protect it? Image credit: Yana Iskayeva/Getty Images.

Doctors generally hold the belief that cardiovascular disease affects more men than women, but the American Heart Association (AHA) has recently highlighted that heart disease kills more women than all forms of cancer.

Moreover, a woman’s risk of heart disease can increase greatly in the years leading up to, and after menopause, the stage of life after the end of the menstrual cycles.

The periods in the lead-up to, during, and after the cessation of menstrual cycles are referred to as:

  • perimenopause, which may start several years before the last menstrual period and ends 12 months after the last menstrual period
  • menopause, which occurs 12 months after the last menstrual period at an average age of 52 or following surgery, such as removal of the ovaries, that stops menstruation
  • and postmenopause, the years following menopause.

For some people, perimenopause and menopause can pass almost unnoticed, apart from the cessation of menstrual periods. But for most, the time can bring a range of symptoms, which can include:

  • hot flashes
  • irregular periods
  • mood changes
  • night sweats
  • breast tenderness
  • vaginal dryness
  • decreased libido
  • thinning hair and brittle nails.

Many of these symptoms are caused by a reduction in the reproductive hormones, estrogen and progesterone, which accompanies menopause.

While progesterone is thought to have little influence on heart health, the drop in estrogen is likely to contribute to an increased risk of cardiovascular disease.

Deborah Matthew, MD, Chief Medical Advisor at the BHRT Training Academy, and founder of Signature Wellness, told Medical News Today that:

“Estrogen is very protective of heart health for women. Pre-menopausal women, who have plentiful levels of estrogen, have a much lower risk for heart disease and high blood pressure than men. After menopause, when estrogen levels drop, the risk of heart disease in women goes up and becomes higher than in men of the same age.”

Estrogen protects the cardiovascular system in several ways. Robin Noble, MD, a board-certified OB/GYN and Chief Medical Advisor for Let’s Talk Menopause, explained some of them for MNT.

“We do not see much cardiovascular disease in women until after menopause — likely because estrogen has a vasodilatory effect on the vascular [system]. Moreover, estrogen has anti-inflammatory effects, and inflammation and oxidative stress seem to be the primary mechanisms of the development of cardiovascular plaques,” Noble told us.

Once estrogen drops, these cardioprotective effects are lost, increasing a person’s risk of heart disease.

“With decreasing estrogen levels in menopause there can be an increase in cholesterol levels, higher blood pressures, and increase in visceral fat leading to plaque buildup and hardening of the arteries,“ noted Jennifer Wong, MD, a board-certified cardiologist and medical director of Non-Invasive Cardiology at MemorialCare Heart and Vascular Institute at Orange Coast Medical Center in Fountain Valley, CA.

”There can also be increased inflammation which has been associated with increased atherosclerotic plaque, especially unstable plaque. Autonomic changes in menopause can lead to an increase in heart rate and lower heart rate variability,” she added.

According to the AHA, some of the common menopause symptoms — hot flashes, night sweats, depression, sleep disturbances and increased fat around the abdomen — are associated with a higher risk of cardiovascular disease.

In addition, a study from 2023 has linked stress and insomnia following menopause with a higher risk of atrial fibrillation (AFib).

The risk of cardiovascular disease is higher in those who experience early menopause before the age of 40 than in those whose menopause occurs later.

Matthew outlined a range of cardiovascular risks that may increase after menopause. These include:

  • coronary artery disease — estrogen deficiency can promote atherosclerosis, the buildup of plaque in the arteries, increasing the risk of heart attacks
  • high blood pressure (hypertension) — estrogen maintains elasticity of tissues and promotes vasodilation, therefore loss of estrogen can result in higher blood pressure
  • arrhythmias — hormonal fluctuations can influence heart rhythm, potentially leading to palpitations or AFib
  • stroke — risk of stroke is increased due to the higher blood pressure and arterial stiffness
  • heart failure — reduced cardiac efficiency due to a weakened heart muscle may develop, often as a result of untreated high blood pressure or coronary artery disease
  • high cholesterol — estrogen is actually made out of cholesterol, and estrogen deficiency after menopause can cause higher levels of LDL (bad) cholesterol and HDL (good) cholesterol
  • insulin resistance or prediabetes — after menopause, women become more insulin-resistant, which increases prediabetes and diabetes risk, which, in turn, are important risk factors for heart disease and strokes.

Some pre-existing heart conditions can worsen menopause symptoms, and the hormonal changes during menopause can impact pre-existing conditions, as Matthew explained.

“Women with cardiovascular disease can have more severe menopause symptoms, like hot flashes, anxiety and fatigue. The drop in estrogen with menopause can worsen existing cardiovascular conditions like atherosclerosis, high cholesterol and high blood pressure, increasing the risk of heart attacks and strokes,” she told us.

“Menopause, and the characteristic changes associated with menopause, can certainly worsen [cardiovascular disease]. People with obesity may experience more hot flashes, sleep disruption and sleep apnea — a serious condition that should be evaluated and treated.”
— Robin Noble, MD

“Pre-existing cardiovascular disease and other health issues may hinder someone’s ability to pursue some of the healthy lifestyle interventions recommended to mitigate symptoms,” Noble added.

In the years around menopause, people should follow general healthy living advice for maintaining heart health. Noble advised, “Lifestyle modifications that include increased exercise, stress management, healthy eating — with an increase in plant-based foods, whole grains.“

“A green Mediterranean diet, incorporating fish, is likely the healthiest diet — less animal fat and animal proteins, eliminating ultra-processed foods. Intermittent fasting can be a healthy strategy as well,” she told MNT.

As well as a healthy lifestyle, hormone-replacement therapy (HRT) can be an effective way to reduce the risk of heart disease at this time of life.

One study, not yet published in a peer-reviewed journal, suggests that estrogen therapy may have long-term benefits in reducing the risk of heart disease.

In this study, women taking oral conjugated equine estrogens (CEE), the most commonly used estrogen formulation, and those taking CEE plus medroxyprogesterone acetate (MPA) showed improvements in all cardiovascular biomarkers except triglycerides.

They had increased levels of HDL-C (“good” cholesterol), lower LDL-C (“bad” cholesterol), decreased insulin resistance and decreased lipoproteins — all of which may be beneficial to heart health.

“Estrogen replacement, if initiated within 10 years of menopause, is associated with a reduction in the progression of atherosclerosis and reduced risk of death from heart disease (and reduced all-cause mortality). Discussion about hormone therapy must be personalized with a woman’s doctor,” Matthew advised.

One review also suggests that transdermal estrogen (such as gels and patches) may have a greater cardioprotective effect than oral estrogen or estrogen combined with progesterone. However, estrogen alone can increase the risk of endometrial (uterine) cancer, so is generally given only following hysterectomy.

The timing of starting estrogen therapy could also be important. One study from 2016 showed that there was more cardiovascular benefit when HRT was started within 6 years of menopause than when it was started later.

Although the risk of cardiovascular disease rises in women around the time of menopause, there are several measures a person can take to help minimize that risk.

Experts advise following a healthy lifestyle, including a healthy diet and regular physical activity, not smoking, and moderating alcohol consumption.

For many women, hormone therapy will not only help the management of menopause symptoms but can also reduce cardiovascular risk.

However, experts advise that any hormone therapy must be discussed with a clinician to ensure that the most appropriate type is prescribed.

So, although a person’s risk of cardiovascular does rise with the advent of menopause, there are many ways to help keep the heart healthy later in life.