Cardiovascular Health During the Menopausal Transition

A recent study compared premenopausal, perimenopausal, and postmenopausal women’s cardiovascular health. Perimenopausal women had about twice the odds of having a poor overall score when compared with premenopausal women, after adjusting for age [1].

Menopausal health decline

The menopausal transition, and the associated changes in hormonal levels, especially declining estrogen levels, mark not only the cessation of reproduction but also a general decline in physical and psychosocial health, including a decline in cardiovascular health [2].

In this recent study, the authors focused on changes in women’s cardiovascular health as they go through the menopausal transition. As an indicator of cardiovascular health, they used the American Heart Association’s Life’s Essential 8 (LE8) score across the fertile period (premenopausal stage), the transition stage when menstrual cycles are irregular and hormonal levels fluctuate (perimenopausal stage), and the postmenopausal stage. LE8 is a composite score, ranging from 0 to 100, of eight components that represent various cardiometabolic health-related factors. It includes four self-reported health behaviors (physical activity, diet, smoking status, and sleep duration) and four health factors (blood pressure, blood lipid levels, blood glucose levels, and body mass index [BMI]).

The researchers analyzed data from 9,248 females, aged 18 to 80, who were not pregnant or breastfeeding and who did not have prior cardiovascular disease. This data originated from the National Health and Nutritional Examination Survey cycles 2007 to 2020.

The overall LE8 score worsened, from 72.2 in premenopausal women to 67.3 in perimenopausal women to 64.0 in postmenopausal women, reflecting the effects of chronological and ovarian aging. The diet component scored the lowest, and sleep the highest, across all three groups.

The window of opportunity

An analysis of the results pointed out that perimenopausal women were roughly twice as likely to have a poor LE8 score as premenopausal women were, after adjusting for age. Perimenopausal women had 76% higher chances of poor blood lipid scores and 83% higher chances of poor blood sugar compared to premenopausal women. The same analysis showed that, for postmenopausal women, the likelihood of overall poor LE8 scores appeared to be higher than for premenopausal women, but these results were not statistically significant.

“Our analysis highlights that perimenopause, women’s reproductive transition period to menopause, is the critical time when the increase in cardiovascular risk seems magnified. When we compared women’s LE8 scores to the premenopausal baseline, the perimenopausal group was the first to show a significant jump in the odds of having low heart health,” said Amrita Nayak, M.D., lead author of the study and a research fellow in the division of cardiovascular disease at the University of Alabama at Birmingham.

While perimenopause marks a decline in female cardiometabolic health, it is also an opportunity to intervene. The authors suggest early monitoring of metabolic components to identify cardiometabolic risks and implementing interventions that can reduce the risk of cardiometabolic disease.

“Midlife women should think of the perimenopausal period as a ‘window of opportunity.’ They should be proactive and not wait until they reach menopause to start checking their blood pressure, cholesterol and blood sugar levels,” said Garima Arora, M.D., senior author of the study and a professor of medicine in the division of cardiovascular disease at the University of Alabama at Birmingham.

“Women should talk with their health care team about their reproductive status and any changes they are experiencing. It may be the perfect time to get a baseline for their heart health,” Arora advises.

The major avenue of intervention that the authors see is nutrition, since diet scored poorly across all measured groups. “Nutrition can be a central factor for early and proactive intervention. Focusing on heart-healthy habits early, especially getting regular exercise and following a healthy eating plan like the DASH diet with a focus on lowering salt, can help improve cardiovascular health for perimenopausal women in the years to come,” added Dr. Arora.

Exercise appears to be another promising intervention, as previous studies have suggested that incorporating regular exercise among perimenopausal women helps preserve cardiometabolic health. Such effects were not observed in postmenopausal females. [3,4]

The usual suspect

The authors hypothesize as to why this specific period might be so crucial for female cardiovascular health. The usual suspects in such cases are estrogens, since hormonal changes, especially fluctuations and declines in the levels of estrogens, are one of the main features of menopausal transition [5]. Additionally, estrogens are also known to have cardioprotective effects, including its beneficial impact on lipid profiles, glucose metabolism, and vascular function [6]. Therefore, the researchers hypothesized that perimenopausal fluctuations, rather than menopausal decline in estrogen levels, appear to create a “detrimental and unstable metabolic environment.”

Beyond metabolic effects, the researchers also point to estrogens’ positive effect on the widening of blood vessels, which, when decreased during the perimenopausal transition, can negatively impact blood pressure, further exacerbating cardiovascular health decline.

The next steps

This study agrees with previous reports showing various detrimental metabolic health changes during perimenopause, but it was the first to assess a cardiometabolic score rather than individual elements.

However, this study shows only associations and cannot infer causality. Further longitudinal studies would be needed to investigate it, and such studies should also include a higher number of participants, especially in the perimenopausal stage, to strengthen the evidence.

“Our next step is to follow women over several years to track hormone levels and heart health, which will help clarify the long-term impact of perimenopause and how lifestyle changes can reduce risk,” Arora said. “We hope these findings encourage clinicians to begin screening for high blood pressure, cholesterol and type 2 diabetes earlier in the perimenopausal transition, leading to earlier diagnosis, prevention and intervention at a critical time in women’s lives.”

Literature

[1] Nayak, A., Pampana, A., Gaonkar, M., Bal, H. S., Yerabolu, K., Shetty, N. S., Vekariya, N., Patel, N. P., Li, P., Arora, P., & Arora, G. (2026). Cardiovascular Health Characterization Using Life’s Essential 8 Score in Perimenopausal Women: An Analysis of the National Health and Nutritional Examination Survey. Journal of the American Heart Association, 15(10), e046898.

[2] Hulteen, R. M., Marlatt, K. L., Allerton, T. D., & Lovre, D. (2023). Detrimental Changes in Health during Menopause: The Role of Physical Activity. International journal of sports medicine, 44(6), 389–396.

[3] Mohr, M., Sjúrðarson, T., Skoradal, M. B., Nordsborg, N. B., & Krustrup, P. (2024). Long-term continuous exercise training counteracts the negative impact of the menopause transition on cardiometabolic health in hypertensive women – a 9-year RCT follow-up. Progress in cardiovascular diseases, 85, 54–62.

[4] Nilsson, S., Henriksson, M., Hammar, M., Berin, E., Lawesson, S. S., Ward, L. J., Li, W., & Holm, A. S. (2024). A 2-year follow-up to a randomized controlled trial on resistance training in postmenopausal women: vasomotor symptoms, quality of life and cardiovascular risk markers. BMC women’s health, 24(1), 511.

[5] Santoro, N., Roeca, C., Peters, B. A., & Neal-Perry, G. (2021). The Menopause Transition: Signs, Symptoms, and Management Options. The Journal of clinical endocrinology and metabolism, 106(1), 1–15.

[6] Miller, V. M., & Duckles, S. P. (2008). Vascular actions of estrogens: functional implications. Pharmacological reviews, 60(2), 210–241.