For women, perimenopause and menopause mark a profound physiological transition, one that extends far beyond hot flashes and mood changes. Among the most significant, yet overlooked, shifts is an increased risk to heart health. In fact, cardiovascular disease and stroke are the primary cause of death for women after menopause.

Estrogen has long been recognized as cardioprotective. During the reproductive years, it helps maintain flexible blood vessels, supports healthy cholesterol levels, and has anti-inflammatory effects that help protect the inner lining of blood vessels. Estrogen increases HDL (“good”) cholesterol and helps keep LDL (“bad”) cholesterol in check. It also supports nitric oxide production, which allows blood vessels to relax and dilate.

As estrogen levels fluctuate during perimenopause and decline more permanently after menopause, these protective effects diminish. Cholesterol profiles often shift in a less favorable direction, blood vessels may become stiffer, and inflammation likely increases. One of the most common changes seen during perimenopause and menopause is an increase in LDL cholesterol and triglycerides, along with a potential drop in HDL. Many women continue with usual dietary and exercise habits and yet have very different labs all of a sudden. This often frustrates and confuses women, but is explained by the drop in estrogen levels at this time in life.

Hormonal shifts can influence the nervous system as well. Many women feel constantly stuck in the “fight-or-flight” stress response. This contributes to higher resting heart rates, increased blood pressure, and greater reactivity to daily stressors. Chronic stress alongside chronic low-grade inflammation, which often increases after menopause, play a role in the development of atherosclerosis (plaque buildup in arteries). Blood pressure may also rise due to increased sensitivity to stress hormones. Additionally, insulin resistance becomes more common, which increases the risk of metabolic syndrome and Type 2 diabetes, both of which are strong risk factors for heart disease. Body composition also tends to change. Many women notice an increase in abdominal or visceral fat during this stage of life. This type of fat is metabolically active and releases inflammatory compounds that further contribute to cardiovascular risk.

Sleep disturbances, which are very common in perimenopause and menopause, indirectly affect heart health. Poor sleep is linked to higher blood pressure, impaired glucose regulation, and increased inflammation. The cardiovascular changes associated with perimenopause and menopause are gradual and often silent. Symptoms such as fatigue, shortness of breath or palpitations may be subtle or attributed to aging or stress. This life stage represents a pivotal window for women to be proactive and prioritize heart health.

What may feel like an inevitable cascade of negative health outcomes is often preventable. While hormonal shifts during perimenopause and menopause are unavoidable, their impact on heart health is modifiable. With informed nutrition, stress management, lifestyle strategies and appropriate medical guidance, women can protect cardiovascular health and support longevity for years to come.

Alora Frederick, RDN, LDN, is an integrative and functional dietitian in Waltham, MA. She is currently accepting new patients at Johnson Compounding and Wellness for virtual nutrition appointments. Schedule a free, 15-minute, introductory call at NaturalCompounder.com/Alora.