What does menopause do to your risk of cardiovascular disease?

Menopause is more than a hormonal change: it is a period in which the risk of cardiovascular disease increases noticeably. Fat shifts toward the abdomen, insulin sensitivity declines, and the cholesterol profile worsens. These are well-known risk factors, and they deteriorate during menopause more rapidly than normal ageing alone would explain. Women develop coronary artery disease on average somewhat later than men, but menopause erodes part of that time advantage.

The earlier menopause begins, the greater this risk. Women who enter menopause before the age of 40 have a demonstrably higher risk of coronary artery disease, heart failure, and stroke than women who reach menopause later. In women who had both ovaries surgically removed before the age of 40, that risk is considerably greater still. Hot flushes and sleep problems, by the way, are not merely troublesome symptoms: women with such complaints also tend to have a less favourable cardiovascular risk profile on average.

Hormone therapy is a widely used option, but its safety depends strongly on the type and the timing of initiation. Oral combination therapy with oestrogen and progestogen increases the risk of blood clots and ischaemic heart disease. Tibolone, a synthetic compound sometimes prescribed for menopausal symptoms, shows a clearly elevated risk of myocardial infarction and ischaemic stroke in a large Swedish register study. These are serious signals that you should discuss with your doctor before starting hormone therapy.

There are also cautious indications that hormone therapy with oestradiol and progesterone, started shortly after the onset of menopause, may have a protective effect on the heart. This is the so-called 'timing hypothesis': the protection appears to apply only when treatment is started early, not when it is begun years after menopause. The evidence for this is still limited, but it does identify the timing of initiation as a decisive factor.

Regarding lifestyle, the DASH diet and the Mediterranean diet favourably influence cholesterol and improve vascular function. Data specific to women going through menopause are still scarce, but there is no indication that these diets would be less suitable for this group.