Have you noticed how everything hits women all at the same time? Just when you thought you had all the checks and balances perfectly aligned in midlife, here comes the menopausal transition to upset your equilibrium.
This Women’s Health Month, Dr Zoë Astroulakis, Cardiology Consultant at New Victoria Hospital, explores how the menopause affects heart health and why reassessing cardiovascular risk around this time is so important for long-term wellbeing.
Dr Astroulakis is one of only 6% of the UK’s female Consultant Cardiologists who have chosen to specialise in intervention for coronary heart disease (ischaemic heart disease). She has spent almost 25 years treating acute heart attacks as well as performing coronary stenting procedures for angina – experience that has shaped her focus on risk reduction and prevention. This is particularly relevant for women around the menopause.
Menopause: a major health transition
The average age at which women in the UK enter menopause, defined as no menstrual period for 12 consecutive months, is 51.
For some women, the menopause passes with relatively few symptoms. For others, it can be profoundly disruptive, affecting sleep, mood, cognition and physical health. Symptoms often begin 5-10 years before the menopause, resulting from the stuttering decline in production of ovarian oestrogen in response to hormones like FSH.
Until very recently, the menopause received little attention beyond primary care and gynaecology, as it was not routinely taught at medical school. Historically, women have also been under-represented in clinical trials, with outcomes and results extrapolated from data collated from male counterparts and a “one-size fits all” medical approach.
Encouragingly, the tide has turned, with well-conducted research now attracting funding, and scientists really getting to grips with how widespread the effects of oestrogen in the body appear to be, with almost all cell lines having oestrogen receptors.
As women are now living longer, given the advances in medical care over the previous generations, many will spend a third of their lives in the post-menopausal phase, making it vital to understand how the menopause influences long-term health, particularly the heart.
Menopause and heart disease: closing the risk gap
Heart attacks and strokes remain the leading cause of death in the UK, and whilst women are relatively protected before the menopause, the decline in the cardioprotective oestrogen means that thereafter cardiovascular risk rises sharply. Menopausal women not only catch up with men but also often experience worse outcomes, partly because heart disease in women is still under-recognised and sometimes misattributed to anxiety or stress.
There are currently no studies showing that hormone replacement therapy (HRT) directly reduces the future risk of cardiovascular illness. However, we do see cardiovascular health benefits if HRT is started for symptoms within the first 10 years. So the decisions around HRT, should always be tailored to each individual woman and her symptoms in discussion with her primary care physician or a British Menopause Society-accredited specialist.
“As a Cardiologist, it’s not my role to advise on starting HRT, but I am passionate about the empowerment of women to finally be heard, not to suffer the often quite disorienting symptoms of the menopause, and am frustrated at the number of times I have heard women complain they have been dismissed as “anxious”, “depressed” or “overwrought” and sent off with a prescription of anti-depressants or sleeping tablets.
The myth that women don’t suffer from coronary artery disease has now officially been debunked, and I am absolutely dedicated to raising the issue of women’s heart health, especially around the time of the transition to the menopause.” Dr Zoë Astroulakis, MBBS, BSc. Hons, FRCP(UK), PhD, Cardiology Consultant
Your 40s are a critical window for heart health
The NHS offers health checks for all over-40s, assessing blood pressure, weight and BMI, smoking status, cholesterol and glucose control (HbA1c measure). However, many women assume that if these are “acceptable” once, no further action is needed. Dr Astroulakis describes the 40s as a decade for requesting a “cardiac MOT” – a time to pause, reassess risk, and make targeted lifestyle changes to preserve your cardiovascular health.
How menopause influences cardiac risk factors
Cholesterol (lipids)
The decrease in ovarian oestrogen at the time of the menopause is associated with a 15-25% increase in blood cholesterol, with an unfavourable increase in the harmful “bad” LDL-cholesterol and triglycerides, as well as a reduction in the healthier “good” HDL-cholesterol.
LDL-cholesterol is taken up into the walls of the arteries, leading to atherosclerotic plaques which, if stable, may simply enlarge over the years until they obstruct blood flow and cause chest pain (angina), or may rupture, leading to the formation of a blood clot which blocks the artery, causing a heart attack (myocardial infarction).
While statins remain the mainstay of drug treatment used to achieve very low LDL-cholesterol levels in coronary artery disease patients, diet, exercise and lifestyle changes can also help reduce LDL-cholesterol and triglyceride levels and boost your HDL-cholesterol levels.
Recently, many long-held myths surrounding how to eat to lower blood cholesterol have been challenged and dispelled, and the science continues to evolve. With new findings emerging all the time, and not always in agreement, keeping up with the expanding array of “healthy food facts” can be challenging, even for clinicians. Reassuringly though, the message is not to “fat-free” your lifestyle, but rather to:
reduce your consumption of red meat, butter and saturated fats,
increase your legumes, beans, pulses and soluble fibre, such as beta-glucan-rich foods,
consider porridge oats or chia seeds for breakfast, and
add healthy fats, like nuts, avocados, polyunsaturated fats and olive oil, to your regular diet.
While emerging research into areas such as the gut microbiome is fascinating and may shape future guidance, Dr Astroulakis stresses that women do not need to chase every new diet trend. Focusing on well-established, evidence-based dietary patterns remains one of the most effective ways to protect heart health during and after the menopausal transition.
Blood pressure
Hypertension (high blood pressure) is one of the most important risk factors for cardiovascular disease, and one of the easiest to miss. Often symptom-free, it can develop quietly over time, which is why occasional checks at home can be so valuable.
Blood pressure naturally fluctuates from minute to minute, but when it stays persistently elevated, this places extra strain on the heart and blood vessels. With age, arteries gradually become stiffer. Around the menopause, this process may be accelerated by the loss of oestrogen, which normally helps blood vessels stay flexible, though it is difficult to tease this out from the other risk factors like smoking, excess alcohol consumption, or low physical activity and obesity.
Blood sugar
Type 2 diabetes is defined by high blood sugars and the body’s inability to handle glucose through a relative resistance to insulin produced by the pancreas. In contrast to Type 1 diabetes, it is lifestyle related. After the menopause, women enter a more insulin-resistant phase with higher blood glucose levels, as measured by the glycosylated haemoglobin (HbA1c).
The diagnosis of type 2 diabetes is a huge shot across the bows, as this significantly increases the risk of heart attacks, stroke, heart failure, peripheral vascular disease and death. The good news is that a return to normal blood glucose levels can be achieved by a change in diet and exercise.
Weight
Many women notice that after the menopause, weight gain is common – particularly around the waist and hips – even when eating and exercising as before. While the exact relationship between falling oestrogen levels and weight gain is complex, oestrogen is known to influence how and where fat is stored, as well as how it is metabolised.
Rather than focusing on numbers alone, this stage of life offers a useful moment to reassess weight, body composition and lifestyle habits. Small, realistic changes can have a meaningful impact not only on cardiovascular risk, but also on energy levels, joint health and overall wellbeing.
Smoking
If you are still smoking – STOP.
You are accelerating your way to a heart attack, and that message simply can’t be sugar-coated. Amongst multiple other harmful effects, smoking will thicken your blood, making a blood clot more likely. It also inflames the walls of the arteries, leading to them narrowing; it increases your heart rate and the deposition of LDL-cholesterol in your artery walls – all of which makes the perfect milieu for a sudden heart attack.
Stopping smoking at any age leads to rapid and measurable improvements in cardiovascular risk. Even for long-term smokers, quitting is one of the most powerful steps toward protecting the heart.
Exercise
Regular physical activity is essential for heart health at every stage of life but becomes especially important around the menopause. Exercise supports strong bones and muscle mass, reducing the risk of falls and fractures, while also protecting the cardiovascular system.
Beyond the physical benefits, exercise improves mood, reduces stress and supports better sleep – issues many women struggle with during the menopausal transition. Over time, it helps lower resting heart rate and blood pressure, improves cholesterol balance (reducing LDL and increasing HDL), and supports healthier blood sugar control.
Current guidance recommends at least 150 min of moderate weekly activity, comparable to 75 min of vigorous intensity, split into 30-minute sessions. British Heart Foundation recommends that moderate exercise includes any activities that leave you feeling warm and mildly breathless (e.g., a fast walk), whereas intense exercise should leave you feeling hot, sweaty and more breathless (though you can still talk).
New research suggests that combining regular muscle‑strengthening exercise (heavy lifting) with short bursts of higher‑intensity aerobic activity can be particularly helpful for heart health in midlife and beyond. Current guidance often encourages to aim for at least two sessions of strength or resistance training each week, alongside one or two sessions of interval‑style exercise that alternate brief periods of harder effort with easier recovery.
For those who have become more sedentary, the message is not about perfection or intensity, but consistency. Finding something enjoyable and sustainable, and gradually moving away from a sedentary lifestyle, can make a profound difference to long-term heart health, especially once you hit your 40s.
Key takeaways for women approaching the menopause
- Declining ovarian oestrogen levels are associated with changes in cholesterol, blood pressure, blood sugar and weight that increase cardiovascular risk.
Heart disease risk rises rapidly after the menopause.
Your 40s and early 50s are the time to review your cardiovascular health and modify your risk factors.
Small, sustained lifestyle changes can have lasting benefits.
Lipid profiles can be significantly improved by:
reducing saturated fat,
increasing fibre (particularly beta-glucans),
eating more legumes, nuts and healthy fats, and
taking regular exercise.
When to seek reassurance or specialist advice
If you feel well but would like a clearer picture of your cardiovascular risk during or after the menopausal transition, Cardiac Screening at New Victoria Hospital offers a proactive, consultant-led assessment.
If you are experiencing symptoms, have existing cardiovascular concerns, or would like personalised advice from a specialist, please request an appointment with our Consultant Cardiologists on 020 8949 9020 or complete our online form:
