Menopause and Cardiovascular Risk: Understanding
the Role of Hormones and Lipids

Shutterstock image #2615768359: A woman shows Holter electrodes attached to her body for daily control of the electrocardiogram. Diagnostics of the heart and cardiovascular diseases.

In the United States alone, cardiovascular disease (CVD) accounts for approximately 1 in every 3 deaths among women, making it the leading cause of female mortality.[1] Yet, many women remain unaware that heart disease, not cancer, is their greatest health risk.

This gap in awareness is primarily because of the long-standing perception that CVD is predominantly a male condition. Most clinical trials have largely included male participants, and the findings were then generalized to women without sufficient sex-specific analysis.

However, as a woman enters midlife and the menopause transition years, her cardiovascular risk begins to rise sharply due to hormonal fluctuations. It is therefore very important to understand the symptoms, risk profiles and treatment options for managing (and preventing) CVD in women.

How Does Menopause Influence Cardiovascular Risk?

For many women, menopause marks a stage during which CVD risk rises significantly, primarily due to declining estrogen levels.[2]

Estrogen directly acts on the cells lining your blood vessels (endothelial cells) and the surrounding smooth muscle to promote vasodilation (widening of blood vessels).[3]  It also helps regulate the vascular response to injury, a process involved in the early development of atherosclerosis.

When estrogen levels decline during perimenopause and post-menopause, vasodilation is reduced, arterial stiffness increases, and greater vascular inflammation contributes to the formation of plaques in arteries and vessels. These vascular changes raise the risk of coronary heart disease, heart attack, and stroke.

In addition, menopause is often accompanied by metabolic and behavioural changes that can further influence cardiovascular risk, such as:[4],[5]

• Reduced satiety and increased appetite

• Disrupted sleep, which can lead to metabolic dysfunction

• Increased insulin resistance, which increases the risk of developing Type II diabetes

• Weight gain, especially around the abdomen (causing increased waist circumference)

• Elevated LDL (bad cholesterol) and decreased HDL (good cholesterol) levels

Together, these changes lead to insulin resistance, dyslipidemia (abnormal cholesterol levels), and chronic low-grade inflammation, all of which contribute to increased CVD risk.

Additionally, if you have a history of conditions such as polycystic ovary syndrome (PCOS) or endometriosis, menopause-related hormonal changes can worsen underlying metabolic issues and inflammation, which may further increase your risk of CVD.

CVD Risk in Menopausal Women with Inherited Cholesterol Risk

Shutterstock image #2678725569: 3d illustration of narrowed blood vessel due to atherosclerosis, Symptoms of high cholesterol in the blood

High levels of lipoprotein(A), or Lp(A), are an independent risk factor for CVD, and what makes it unique is that it’s largely determined by your genetics rather than your lifestyle.[4]

Lp(A) is a cholesterol particle that’s structurally similar to LDL but has an additional protein that makes it more likely to adhere to plaques that can build up inside the walls of arteries. Elevated levels of Lp(A) in the blood can put you at a higher risk of myocardial infarction, stroke, and aortic valve stenosis. Your Lp(A) level is a biomarker that is measured once with a standard blood test. The amount of Lp(A) in your blood is an inherited trait and will generally not change throughout your lifetime. As such, a high Lp(A) is considered a risk factor for CVD.

Similarly, Apo-lipoprotein B (ApoB) is a biomarker that reflects the total number of atherogenic (or plaque-forming) particles in your blood. When both Lp(A) and ApoB levels in your blood are elevated, it indicates a higher concentration of particles that can adhere to the arterial wall, increasing the risk of atherosclerosis, which is a form of cardiovascular disease.

If you know that you have elevated Lp(A) from your family's genetic history, then the significant hormonal changes that occur during the perimenopause transition may further increase your Lp(A) level by as much as 25%.[4]  For this reason, the menopausal transition is considered a risk factor for developing CVD in women. And because Lp(A) is often not routinely included in standard lipids and cholesterol blood tests, many women in mid-life are unaware of this risk factor. Testing for Lp(A) and Apo(B) biomarkers is advisable for women with a family history of cardiovascular disease and/or for women who have disruptive hormonal changes due to a chronic condition like perimenopause, endometriosis, PCOS and thyroid disorders. It is important to discuss the implications of your lipid and cholesterol test results with a physician who is trained in women’s health.* 

How Do You Know If You Have High Lp(A)?

High Lp(A) doesn’t cause symptoms on its own. The only way to know is through a specific blood test that measures Lp(A) levels, which isn’t always included in standard lipid panels.

You might want to discuss Lp(A) testing with your healthcare provider if you have any of the following:

• A family history of early CVD or artheroschlerosis 

• A known diagnosis of hypercholesterolemia

• A history of aortic valve stenosis

• Peripheral arterial disease

Several countries have updated their clinical guidelines since 2025 and now recommend measuring Lp(A) at least once in adulthood, particularly if these risk factors are present.[6]

Generally, Lp(A) levels above 50 mg/dL (125 nmol/L) are considered a risk factor for heart disease. Higher levels mean higher risk. For example, levels above 100 mg/dL (250 nmol/L) are linked to about twice the risk of cardiovascular problems. Because Lp(A) is genetically determined, your level tends to remain relatively stable throughout life. In most cases, a single test is usually sufficient to understand your baseline risk.[6]

Managing Menopause in Women with CVD Risk

Managing menopause when you have existing or elevated CVD risk requires a careful and individualized approach. Your team of healthcare providers, which may include your cardiologist, gynecologist and/or MSCP-certified physician, should work together to address your menopausal symptoms while minimizing your cardiovascular risk.

Hormone Therapy (HT) is considered the first-line treatment for moderate to severe menopausal symptoms, including vasomotor symptoms (hot flashes, night sweats) and mood changes.

The Menopause Society has published its 2022 position statement on Hormone Therapy (HT) and also a 2023 update supporting the “timing hypothesis” for the appropriate use of HT to manage menopausal symptoms and cardiovascular disease risk. For clarity, the “timing hypothesis” suggest that the time of initiating HT use for menopause symptom management is critical. When HT is initiated before the age of 60 years AND within 10 years of reaching menopause to treat vasomotor symptoms (hot flushes, night sweats that can cause disrupted sleep), HT may have a neutral or potentially beneficial effect on cardiovascular health.[7] [8] [9] [10]

HT is generally contraindicated in women with a known high CVD risk, and is not recommended for the primary or secondary prevention of CVD.[8]  Some studies have shown increased risk of stroke and thromboembolism (blood clots) in postmenopausal women of more than 20 years after menopause, or over 70 years of age.[11]  For this reason, HT is prescribed primarily for menopausal symptom relief, but not for prevention of CVD, and women receiving HT should be monitored closely.

The route of estrogen administration can influence both benefits and risks. While oral and transdermal estradiol have been shown to reduce Lp(A) levels by 20-30%, the oral route of administration is associated with higher risks of thromboembolism, blood clots, and possibly breast cancer.[4]

Guidelines from organizations such as the National Lipid Association (NLA) and the American College of Cardiology (ACC) emphasize a risk-based, individualized approach rather than a one-size-fits-all model. Before starting HT, your practitioner may assess factors such as: 

• Blood pressure

• Body weight and overall metabolic health

• Smoking status

• Family history of cardiovascular disease

• Lipid profile (including baseline LDL cholesterol and, in some cases, ApoB or Lp(A))

While elevated Lp(A), ApoB, and high baseline LDL are important risk factors, many practitioners don't view them as absolute contraindications to HT. Instead, they take an individualized approach, particularly for women under 60 or within 10 years of menopause. In these cases, cardiovascular risk factors are weighed alongside overall health, lifestyle, and symptom burden, with decisions made through a shared decision between patient and provider. [12]

Lifestyle changes are the primary interventions for anyone with higher cholesterol and lipid biomarkers. However, they alone aren't sufficient as Lp(A) levels are largely genetically determined. In many cases, patients may require a combination of lifestyle interventions and lipid-lowering medications. Statins are commonly prescribed, even though they have a minimal effect on lowering Lp(A) and may slightly increase it in some individuals.[13]

Additionally, some women experience statin intolerance, which most often manifests as muscle pain (myalgia). In such cases, alternative options may include ezetimibe, a cholesterol absorption inhibitor, and PCSK9 inhibitors, which can further lower LDL cholesterol.[14] [15]

HRT is also generally not recommended in women with specific high-risk cardiovascular conditions, including:

• Established coronary artery disease

• Prior myocardial infarction (heart attack)

• History of ischemic stroke

• Peripheral artery disease

• Venous thromboembolism

• Congenital heart disease

Share Decision-Making Is Recommended

Navigating menopause while considering your cardiovascular health can seem to be complex, especially when the information around hormones, cholesterol, and CVD risk is not always straightforward. There is no ideal one-size-fits-all approach to managing menopause symptoms and CVD risk, as treatment options often involve shared decision-making with your care team.

If you’re experiencing menopausal symptoms or have concerns about your cardiovascular risk, we recommend that you have an open and detailed conversation with your physician who is trained in women’s healthcare and preferably in menopause care. They can guide you on the appropriate next steps and strategies for managing both your menopausal symptoms AND cardiovascular risk.