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- A new study suggests heart health may begin declining during perimenopause, earlier than previously thought.
- Perimenopausal women were twice as likely to have poorer cardiovascular health scores than premenopausal women.
- Experts say the menopause transition may be a key window to monitor risk factors, such as blood pressure, cholesterol, and blood sugar.
Heart health generally declines after menopause, but new research suggests the changes may start earlier than previously thought. The study, published in the American Heart Association’s journal Circulation, found that women in perimenopause—the transitional stage before menopause—were twice as likely to have low cardiovascular health scores compared to premenopausal women. Here’s what the finding means for your long-term heart health.
What the Study Found
Over the past two decades, growing evidence has shown that menopause is associated with an increased risk of cardiovascular disease—the leading cause of death of women worldwide.
For the new study, researchers wanted to get a clearer picture of women's heart health throughout the menopause transition. They used data from about 9,000 women aged 18 to 80 in the National Health and Nutrition Examination Survey, collected between 2007 and 2020. Participants were classified as pre-, peri-, or post-menopausal based on self-reports of their last menstrual period.
Researchers measured cardiovascular health using eight health and lifestyle factors identified by the American Heart Association to achieve optimal heart health, including diet, physical activity, blood sugar, cholesterol, and body weight. Participants were assigned heart health scores based on the average of all eight factors on a 100-point scale.
The median scores gradually declined with age, but after controlling for age, perimenopausal women were twice as likely to have a low score (less than 50) than premenopausal women. Meanwhile, the odds of postmenopausal women having low scores compared to premenopausal women were not statistically significant.
The perimenopause group was also 76% more likely to have a low cholesterol score and 83% more likely to have a low blood sugar score than premenopausal women.
"The sharpest drop in cardiovascular health isn’t happening after menopause. It’s happening during the transition," Garima Arora, MD, study co-author and cardiologist at the University of Alabama at Birmingham Cardiovascular Institute, told Health.
The study only showed an association—not causation—between perimenopause and declining cardiovascular health. But it establishes perimenopause as a “critical window of opportunity” to identify women whose cardiovascular risk is increasing and intervene before disease develops, said Priya Freaney, MD, cardiologist and director of Women’s Heart Care at Northwestern University, who was not affiliated with the new study.
"The menopausal transition is not just a reproductive milestone—it is a cardiometabolic turning point in a woman’s midlife,” Freaney told Health.
Why Cardiovascular Risk May Rise During Perimenopause
The key change during perimenopause that can affect heart health is a shift in estrogen, the primary female sex hormone. During perimenopause, estrogen levels fluctuate dramatically and generally trend downward. Estrogen plays a protective role for the heart and blood vessels. When estrogen declines, so does that protection.
Estrogen helps keep blood vessels flexible, Arora told Health. When estrogen levels drop, blood vessels can stiffen—an early step toward high blood pressure and atherosclerosis, or plaque buildup in the arteries.
The hormone also plays a role in regulating blood sugar, which means declines in estrogen may contribute to higher blood sugar and an increased risk of type 2 diabetes. Estrogen helps control LDL cholesterol (the "bad" one) and supports HDL cholesterol (the "good" one). Changes in estrogen can throw off that balance, Arora said, potentially increasing cholesterol levels.
Estrogen swings also make your body more likely to store fat around the abdomen, which can increase cardiovascular risk, Arora added. Perimenopausal women experience higher rates of depression and sleep disturbances—both of which are associated with higher cardiovascular risk, Freaney said.
What To Watch For
The “frustrating truth" is that most perimenopausal women won’t have any signs that their cardiovascular risk is in jeopardy, Arora said. “While changes like shifting cholesterol, creeping blood sugar, and less stable blood pressure are building quietly in the background, women can feel completely fine because these shifts simply don't announce themselves,” she explained.
Cardiovascular disease often develops silently over decades, so even women who feel well should monitor their risk factors, Freaney said. Seemingly small changes, like increased belly fat or declines in sleep and energy, can signal a shift in cardiometabolic health and should be taken seriously, Arora noted.
“Ultimately, you should pay attention to anything that feels like your body is just not responding the way it used to regarding diet, exercise, or stress,” she said. “That feeling of the rules changing deserves a real conversation with a provider, not just generic reassurance that it’s part of getting older.”
Some women should be even more proactive, Freaney added, including those with diabetes, hypertension, high cholesterol, obesity, smoking history, premature menopause, or a strong family history of cardiovascular disease.
What To Bring up With Your Doctor
Perimenopause is a crucial time to establish a relationship with a healthcare provider who takes your concerns seriously, Arora said. Make sure to ask for cholesterol, glucose, and blood pressure tests, and discuss any family history of cardiovascular disease or concerns you have.
“Talk about your symptoms honestly, including sleep, mood, energy, weight changes, and ask how they might be connected to your cardiovascular health, not just your menopausal symptoms,” she said. “Those conversations often happen in separate silos and they shouldn’t.”
Cardiovascular risk builds gradually, Freaney noted, so early intervention during perimenopause is key to stopping disease in its tracks, before it gets harder to treat. Try reframing perimenopause not as something to get through, but as a window where the right interventions can shape your cardiovascular health for decades, Arora suggested.
“This isn’t just about damage control," she said. "It’s about opportunity."
