Heart and Vascular Health in the Menopause

What changes at the menopause?

Oestrogen is not only a reproductive hormone; it acts directly on the blood vessel wall. When its level falls:

• Blood vessels become less elastic. Oestrogen protects the inner lining of the vessel and prevents plaque from forming. Once that protection is gone, vascular resistance rises — where the ovaries have been removed, this change becomes measurable within a month.
• The cholesterol profile worsens. Total cholesterol, "bad" cholesterol (LDL) and triglycerides rise; "good" cholesterol (HDL) falls.
• Blood becomes more prone to clotting.
• Blood pressure rises. By the age of 60, more than half of women have high blood pressure.
• Fat distribution shifts. Even if weight stays the same, fat moves from the hips to the abdomen.

How much does risk rise in early menopause?

An early menopause leaves the heart unprotected at exactly the age when that protection matters most:

• With ovarian insufficiency before 40, the risk of cardiovascular death rises 2.38-fold and overall cardiovascular disease risk 1.61-fold.
• Heart attack risk rises 1.40-fold, ischaemic stroke 1.24-fold and heart failure 1.39-fold.
• In early menopause between 40 and 45, overall cardiovascular risk rises 1.18-fold.
• Surgical menopause is more severe: where early menopause occurs spontaneously the increase is 1.36-fold, but where the ovaries are removed it rises to 1.87-fold. In women whose ovaries are removed before 45 and who do not take hormone therapy, coronary heart disease risk increases threefold.

Each additional year before the menopause reduces heart failure risk by about 4%. Conversely, in early menopause each year spent without oestrogen adds a little more risk — independently of age, smoking and weight.

What monitoring is recommended?

• At diagnosis: blood pressure, weight and body mass index, cholesterol profile and glucose status are assessed.
• At least once a year: blood pressure, weight and smoking status are reviewed.
• Cholesterol and glucose tests: the interval is set individually — baseline values, the presence of metabolic syndrome and overall risk determine it.

Hormone therapy and timing

The effect of hormone therapy on the heart depends on when it is started. This is the most widely misunderstood part of the subject.

When started early

Where treatment begins within the first 10 years of the menopause or before the age of 60, the findings are:

• In the Danish trial, coronary heart disease, heart failure and cardiovascular deaths fell by about 50%.
• In the 2023 Cochrane analysis, coronary heart disease risk fell by 48% and all-cause mortality by 30%.
• Another trial showed that treatment started early in the menopause slowed thickening of the carotid artery, and that this protective effect disappeared entirely when treatment began more than 10 years after the menopause.

When started late

In women more than 10 years past the menopause or over 60, starting oral hormone therapy for the first time does not provide cardiac protection and may increase the risk of clots and stroke.

By mouth or through the skin?

The route of administration makes a difference to clotting. Oestrogen taken by mouth passes through the liver and stimulates the clotting system, increasing the risk of venous clots 2- to 4-fold. Forms applied to the skin (gel, spray, patch) bypass that first pass and leave clotting markers unchanged: in large studies the clot risk ratio was 1.58 for oral use but 0.93 for use through the skin — that is, no increase.

For that reason, use through the skin is considered first in women with high blood pressure, lipid disorders or diabetes. Which route suits you is decided during a consultation — see menopoz tedavisi.

The part lifestyle plays

• A Mediterranean pattern of eating: built on vegetables, fruit, pulses, nuts, olive oil and fish; it improves waist size, blood pressure, lipids and insulin resistance.
• Weight: losing only 5-10% of total body weight is enough to reverse disturbances driven by insulin resistance.
• Activity: at least 150 minutes a week of moderate aerobic activity (brisk walking, cycling, swimming) plus two strength sessions. Women with low physical fitness have 4.7 times the risk of heart disease.
• Smoking: it both brings the menopause forward and raises coronary risk. Stopping is the single most effective step in this whole picture.