Top Things to Know: Menopause Transition and Cardiovascular Disease Risk: Implications for Timing of Early Prevention

Published: November 30, 2020

  1. Earlier age at natural menopause is a marker for greater CVD risk. Risk factors of early age at natural menopause include short menstrual cycle length, low parity, smoking, and worse cardiovascular risk profile during reproductive life. Black people and individuals of Hispanic race or ethnicity are also at higher risk of early age at natural menopause.
  2. Perimenopause commences with the onset of intermenstrual cycle irregularities and extends 12 months after menopause; it’s identified as a period of vulnerability accompanied by significant alterations in several cardio-metabolic and vascular health parameters strongly linked to higher CVD risk.
  3. During midlife, women experience increases in LDL-C, metabolic syndrome risk, and vascular remodeling, which are likely driven by the menopause transition (MT) more than chronological age itself.
  4. Novel data show a reversal in the associations of HDL-C with CVD risk over the MT, suggesting higher HDL-C levels may not consistently reflect good cardiovascular (CV) health in all epochs of life in women.
  5. Increases in abdominal visceral fat and decreases in lean skeletal muscle mass are more pronounced during the MT. Paracardial fat is higher after menopause and linked to greater risk of coronary artery calcium. This fat depot could be regulated by estradiol level and influenced by hormone therapy.
  6. Vasomotor symptoms, a hallmark of the MT, are associated with worse CVD risk factor levels and measures of subclinical atherosclerosis. The associations between vasomotor symptoms and CVD risk may depend on the timing of these symptoms during the MT (e.g. early onset).
  7. Limited data exist on the current status of ideal CV health behaviors (such as applying AHA Life's Simple 7) in women during the MT. Only 7.2% of women traversing menopause meet physical activity guidelines and fewer than 20% of those women consistently maintain a healthy diet.
  8. Data for primary and secondary prevention of atherosclerotic CV disease and on the utility of lipid-lowering interventions remains limited for women traversing menopause and requires further study so evidence-based recommendations can be developed.
  9. Research data increasingly support potential CV benefits of certain hormone therapy formulations when started in early, but not late, menopause. More research is needed to assess the role of other hormone therapy formulations, route of administration, and duration on cardio-metabolic health in women, including those traversing menopause.
  10. Despite substantial observational evidence demonstrating accelerated CV risk during the MT, randomized clinical trials of lifestyle and behavioral interventions have not adequately represented this high-risk population.


El Khoudary SR, Aggarwal B, Beckie TM, Hodis HN, Johnson AE, Langer RD, Limacher MC, Manson JE, Stefanick ML, Allison MA; on behalf of the American Heart Association Prevention Science Committee of the Council on Epidemiology and Prevention; and Council on Cardiovascular and Stroke Nursing. Menopause transition and cardiovascular disease risk: implications for timing of early prevention: a scientific statement from the American Heart Association [published online ahead of print November 30, 2020]. Circulation. doi: 10.1161/CIR.0000000000000912.