Many discussions about menopause focus on symptoms like hot flashes and night sweats, but less attention is given to its impact on heart health. According to Dr. Karla Kurrelmeyer, a cardiologist at Houston Methodist who specializes in women’s heart disease, menopause significantly increases the risk of heart attack and stroke.
A 2020 study published in Circulation found that only 56% of women know heart disease is the leading cause of death among women. As more millennials approach perimenopause, awareness remains low; a survey by Wrapp Consulting reports just 12% feel well-informed about menopause.
Dr. Kurrelmeyer explains that menopause officially begins after a year without periods or spotting, typically between ages 45 and 55 in the U.S., with an average onset at age 52. During perimenopause, levels of estrogen and progesterone decrease gradually over five to ten years, leading to changes in cholesterol levels—triglycerides and LDL increase while HDL decreases.
“It doesn’t happen all at once,” Dr. Kurrelmeyer says. “People think when the period stops, then the hormones are gone. That’s not the way it works; the hormones just slowly dip down. All the changes in risk factors that we see are just mirroring what’s happening to those hormone levels. As the levels slowly dip over five to 10 years, we see the effect on the cholesterol panel: The triglycerides go up, the LDL goes up, and the good cholesterol, HDL, goes down.”
She notes that declining hormone levels also raise blood pressure and alter body composition by reducing muscle mass and increasing fat around the midsection—a known risk factor for metabolic syndrome and heart disease.
“When you lose your endogenous hormones, your blood pressure goes up, and it affects your muscle mass,” Dr. Kurrelmeyer says. “As you lose muscle mass, it’s not like you lose weight. You actually put on fat mass, especially around the midsection, which is another risk factor. During menopause, you can easily slip into metabolic syndrome, which also puts you at increased risk for heart disease unless you work really hard with your diet and exercise.”
Metabolic syndrome can lead to insulin resistance and prediabetes or diabetes—both of which further elevate cardiovascular risk.
Early menopause—whether naturally occurring or medically induced before age 40 or 45—moves up this risk timeline by removing years of hormonal protection.
“It increases your risk for future cardiovascular events significantly because you’ve lost 5 to 10 years of the protective effect of estrogen,” Dr. Kurrelmeyer says. “Early menopause is considered a risk enhancer, and a risk enhancer is just that, it elevates your risk, but not to the same degree as a risk factor like diabetes, high blood pressure or high cholesterol. Family history is also a risk enhancer, but enhancers don’t have as high a predictive power as the risk factors do.”
Certain autoimmune diseases such as lupus or rheumatoid arthritis can further increase cardiovascular risks during menopause due to chronic inflammation.
“There are other sex-specific risk enhancers women need to be aware of that elevate their risk,” says Dr. Kurrelmeyer, who adds that these women may want to come in and see a cardiologist earlier. “Autoimmune diseases like lupus, rheumatoid arthritis and psoriasis may cause inflammation levels in your blood to be high, which increases your risk of plaque rupture even if there is a small amount of plaque in the blood vessels in the heart, causing a heart attack.”
Pregnancy complications—including gestational hypertension or diabetes; maternal placental syndromes; small-for-gestational-age infants; or HELLP syndrome—also indicate higher future cardiac risks.
“Pregnancy is like a stress test, right? When women experience conditions like these, it shows that their cardiovascular system has trouble adjusting to their body’s demands,” Dr. Kurrelmeyer says. “If you’ve had one of these pregnancy experiences, it significantly increases your risk for future heart events so you need to come in early for a preventive visit…”
Menopause-related hormonal shifts can also affect heart rhythm by causing palpitations through misfires within the electrical system.
“Though it’s sometimes premature ventricular beats…” Dr. Kurrelmeyer says “…it’s usually just premature atrial beats that will sometimes occur in a row and cause paroxysmal atrial tachycardia… But again usually they’re just a nuisance…”
However she advises seeking care if palpitations accompany chest pain or other concerning symptoms.
Hormone replacement therapy (HRT) remains effective for menopausal symptoms but carries different implications for heart health depending on individual circumstances.
A recent study from The Menopause Society reported improvements in most cardiac biomarkers with certain HRT regimens except triglycerides; conjugated equine estrogens alone provided greater benefit than combined therapy—but HRT may not suit those with existing cardiac issues.
“If a heart scan shows that they’re in the high-risk category for…such as calcium score more than 300…I recommend not taking hormone replacement therapy…” Dr. Kurrelmeyer says “…Based on HERS trial we know…hormone replacement therapy increased risk for more events.”
Women with lower calcium scores may use HRT briefly under medical supervision based on their overall cardiac profile.
To reduce cardiovascular risks during perimenopause Dr. Kurrelmeyer recommends following proven dietary patterns such as the Mediterranean diet along with regular exercise: at least 150 minutes weekly including aerobic activity plus strength training—which helps maintain muscle mass during aging transitions.
“If you’re doing all of these things and having issues it’s crucial to talk with your doctor,” she adds.
She suggests most women should consider seeing a cardiologist after confirming menopause has occurred unless they experienced early loss due to surgery or medical reasons—in which case earlier evaluation may be warranted.
“When women are perimenopausal…” Dr.Kurrelmeyer says “…your cholesterol,blood pressure…may not be at their new levels until menopause has occurred.If you have not had [major vascular event] I suggest waiting …to avoid false sense of security…”
