Cardiovascular Disease in Menopause: Confronting the Monolithic Health Curve

Among the many significant disparities in research on women’s health, the range of risks associated with the menopausal transition have been largely ignored. In recent years, however, emerging research has begun to shed light on these issues, including the elevated risk for cardiovascular disease (CVD) associated with perimenopause and menopause.

Increased CVD Risk Linked to Menopause

“After menopause, the incidence of heart disease increases in women at a faster pace compared to men,” said obstetrician-gynecologist Nanette F. Santoro, MD, professor and the E. Stewart Taylor Chair in the Divisions of Reproductive Endocrinology and Infertility and Reproductive Sciences at the University of Colorado Anschutz in Aurora.^1,2

The Study of Women’s Health Across the Nation (SWAN) showed that “in the late menopause transition, which is the approximately 2-year interval of time when a woman is having skipped menses but not long enough to define her as menopause, there are steep changes in low-density lipoprotein cholesterol (LDL-C), visceral adipose tissue, fat mass, and lean body mass, prevalence of metabolic syndrome, carotid intimal medial thickness, and depression,” Dr Santoro explained.³  

We tend to assume that menopause marks a change in a woman’s health status and that her health status does not change after that — and this is a hazardous assumption.

“All of these conditions increase a woman’s risk for CVD, and they all seem to accelerate briefly before menopause is completely defined,” she continued.⁴ “Once it’s been 1 to 2 years after the last menstrual period, these changes continue but in a more benign fashion,” underscoring the importance of recognizing and addressing these risk factors.

Regarding potential mechanisms involved in the menopause-CVD connection, “It is possible that the changes associated with estrogen ups and downs help to precipitate this rapid CVD risk accumulation,” Dr Santoro said. “The menopause transition itself may be stressful enough to account for some of these changes, and there may be an interaction — at least in some women — with age-related changes and with estrogen changes associated with menopause.”

In a plenary session at ENDO 2025, Dr Santoro described a “monolithic health curve” in reference to women in menopause.⁵ “We tend to assume that menopause marks a change in a woman’s health status and that her health status does not change after that — and this is a hazardous assumption,” she told Endocrinology Advisor. 

She pointed to recent multi-omics data from Stanford University identifying 2 periods of accelerated aging — around 44 and 60 years of age — among both men and women.⁶

“In women, these aging ‘nodes’ were completely independent of menopause, so a woman’s risk profile for diseases, including CVD, may well be influenced by what her aging ‘clock’ is doing,” she said. “In other words, an overfocus on menopause and estrogen can cause a clinician to miss other important signs.”

Clinical Recommendations

“Most women deserve a deep dive into their health status at around age 45, which is an ideal opportunity to kick off a discussion about optimal lifestyle,” Dr Santoro advised. “Many women will have some symptoms of menopause at that age, although they are generally mild, and they are often interested in taking better care of themselves and preparing for the transition.”

She cited the American Heart Association’s “Life’s Essential 8” as a solid starting point and added that patients with increasing CV risk factors and a family history of heart disease could benefit from a preventive cardiology consultation.⁷ She also emphasized the need to screen for and treat depression among women of this age group, given its association with heart disease and the increase in depressive symptoms during the menopause transition.³

In addition, a greater frequency of hot flashes has been linked to a higher CVD risk later in life as well as worse endothelial function and more signs of subclinical heart disease.^8,9

“The frequent hot flashes may be a ‘tag’ that these are the women to keep an eye out for and to try to manage their CVD risks proactively,” Dr Santoro said. “It is not known if treating the hot flashes will prevent CVD later in life, but it’s a study worth undertaking.”

Along with asking patients about vasomotor symptoms, mood changes, and other indicators of increased CVD risk, it is important for clinicians to understand the lipid panel for this age group, advised Lily N. Dastmalchi, DO, a cardiologist with Inova Health System and assistant professor of clinical medicine at the University of Virginia School of Medicine in Charlottesville. “Changes in the lipid profile during the menopausal transition include increased apolipoprotein B (apoB) and LDL-C, and high-density lipoprotein cholesterol (HDL-C) loses its protective effect.”¹⁰

Dr Santoro emphasized the importance of “getting the right treatments to the right people, because Black women, Hispanic women, and Indigenous women all report worse menopausal symptoms than White women,¹¹ and yet they remain undertreated by a larger margin than White women.”^12-14

Misleading and Risky Marketing

In her ENDO 2025 presentation, Dr Santoro cautioned about the growing market targeting women with menopause-related products that overfocus on the role of hormones and menopause in aging among women.⁵

“The ‘feminine forever’ concept, which is being repackaged for the 2020s to convince women that they need hormones, creates the narrative that aging is all about menopause and menopause is all about aging, and if you ‘undo’ menopause by giving women back estrogen, you can make it all go away,” she said. “It would be nice if that were true.”

Dr Dastmalchi noted that social media content often presents hormone therapy as a “panacea to all woes that occur during this life stage.” Among other concerning trends, she cited specialized clinics where women can receive “pellets that administer a small dose of hormone over time. These are not tested and are incredibly dangerous.”^15,16

Additionally, although testosterone is generally believed to decrease during menopause, some evidence suggests that levels of free testosterone increase due to a reduction in sex hormone binding globulin (SHBG), Dr Dastmalchi said.¹⁷

“Some women are put on testosterone for ‘libido’ benefit, and it is not FDA-approved for women, so a microdose must be given via a prepared gel and paid for out-of-pocket,” she continued. “The potential side effects from elevated testosterone levels include clitoromegaly and deepening of the voice, which are irreversible.”¹⁶

Dr Dastmalchi added that supplement companies promote various products targeting women in this age group, such as herbal powders and creatine to address “adrenal fatigue” and brain fog, for example. ^18,19 “Therefore, it’s important to ask patients what they are taking and being aware of the potential risks and indications.”

Ongoing Gaps in Menopause Care

Greater clinician education is among the myriad ongoing needs to improve the care and outcomes of menopausal women.

“We need to educate the next generation of clinicians on the importance of menopause on women’s cardiovascular health, mental health, and overall health outcomes,” Dr Dastmalchi stated. “Medical students and specialized training programs should be aware of the importance of this life stage and how to care for women during this time.”

Dr Santoro suggested that all medical specialties caring for women in midlife and beyond should be educated on evidence-based menopausal medicine. “The guidelines have changed remarkably little over the past 10 to 20 years, and yet treatment for menopausal symptoms is inadequate and women do not feel well served,” she said. “This creates a vacuum that sends them off into evidence-free zones, and that is a priority for change.”

Among topics that warrant further investigation in menopausal women, Dr Dastmalchi noted the need for research on the cardiovascular benefits of early hormone therapy and the optimal time to start lipid-lowering therapy for CVD risk reduction.

“Research into the earlier stages of the transition, how menopause and aging interact, and how to best set women up for a healthy lifespan are important priorities,” according to Dr Santoro. “Women live longer than men but spend more years with chronic conditions that impair their quality of life, and we need to get ahead of that. There is lots of work to be done.”

This article originally appeared on Endocrinology Advisor