Her LDL cholesterol was normal. Menopause pushed it to high-risk levels: What women need to change

A 45-year-old patient of mine had borderline high LDL cholesterol — the so-called “bad” cholesterol — at around 130 mg/dL. With aggressive lifestyle changes, she managed to bring it down to 100 mg/dL at first and then lower. A few years later, following menopause, she came to see me again as her LDL shot up to a high 170 mg/dL. This time, I had to put her on cholesterol-lowering medication alongside lifestyle changes, including regular exercise, better sleep, weight management and diet.

The case illustrates a concern that can catch women off guard: bad cholesterol levels can change significantly around menopause, even when there has been no previous diagnosis of heart disease. Women often do not realise that menopause can be an important turning point for their heart health, a key message from a new series of three scientific papers published in Circulation. Developed through a collaboration involving the American Heart Association, the American Academy of Paediatrics, the American College of Obstetricians and Gynaecologists, and the Society for Maternal-Fetal Medicine, this is the first time that experts are calling for a more comprehensive approach to women’s cardiovascular health through all life stages, from adolescence through pregnancy, menopause and beyond.

The research highlights how hormonal changes, reproductive health, mental well-being and cardiovascular risks are interconnected.

Heart health is a lifelong responsibility, not a menopause milestone

The research advocates for cardiovascular risk assessment throughout a woman’s life, rather than treating heart disease as a concern that begins in later years. Women should know their blood pressure, cholesterol and blood sugar levels well before menopause and take corrective measures. These should continue to be monitored as they age, with follow-up tailored to their individual risk.

Hormonal health can offer early clues to future heart disease

The research highlights links between hormonal health and cardiovascular risk, including the significance of menstrual patterns and conditions such as polycystic ovary syndrome (PCOS), also referred to in the new publications as polyendocrine metabolic ovarian syndrome. An early first period — before age 10 — has been associated with a higher risk of heart disease later in life. Persistent irregular periods, particularly when accompanied by severe acne or unusual facial or body hair growth, may indicate an underlying hormonal or metabolic condition that warrants assessment.

Women with PCOS may face an increased risk of insulin resistance, abnormal blood sugar and diabetes, inflammation, LDL alongside other cardiovascular risk factors. The condition should therefore prompt long-term monitoring and preventive care, rather than being viewed solely as a reproductive health issue. A systematic review and meta-analysis involving more than 346,000 women found that irregular, infrequent or absent periods were associated with a 29% higher relative risk of cardiovascular disease.

Menopause can bring a significant rise in LDL cholesterol

The findings show that women may experience rising LDL cholesterol, weight gain and increasing blood pressure during the years leading up to menopause. These changes can increase cardiovascular risk. So, women should not assume that earlier normal cholesterol results will remain unchanged. A lipid profile around the menopause transition can help identify changes and guide decisions about lifestyle measures or medication.

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Lifestyle changes that matter

Build consistent physical activity into everyday life. Prioritise sleep. Menopause-related sleep disruption can make healthy routines harder to maintain. Good sleep hygiene and appropriate evaluation of persistent sleep problems are important. Pay attention to changes in weight and abdominal fat. I recommend a low-carbohydrate dietary approach. Repeat testing and clinical review can help determine whether lifestyle changes are sufficient.

Where LDL cholesterol remains high or overall cardiovascular risk warrants it, statins or other cholesterol-lowering medicines may be appropriate. The decision should be based on the woman’s individual risk profile and clinical assessment, not menopause alone.

Contraceptive pills and hormone replacement therapy need individual assessment

Hormonal treatments, including oral contraceptive pills (OCPs) and hormone replacement therapy (HRT), are another important part of the discussion. Oral contraceptives containing estrogen can influence the liver’s production of clotting proteins, increasing the tendency for blood clots to form; they may also raise blood pressure, increasing the risk of stroke and, in susceptible women, heart attack. HRT can increase the risk of blood clots.

These treatments should not be regarded as universally safe or universally unsuitable. Their benefits and risks depend on the indication, formulation, dose, route of administration and the woman’s medical history — including her cardiovascular and blood-clotting risk factors.

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Mental health and sleep deserve a place in heart care

The research also highlights the relationship between mental well-being and cardiovascular health. Anxiety, depression, hormonal fluctuations and sleep disturbances can affect one another and influence behaviours such as exercise and eating. Women have heavily disrupted sleep patterns, which may make it harder to maintain healthy routines.

A woman may see a gynaecologist for menstrual problems, an obstetrician during pregnancy and a physician or cardiologist later in life. If relevant information is not shared for a coordinated approach, early warning signs may be missed.

The most important message for women is simple: Know your numbers, take warning signs seriously, and make heart health part of routine care at every stage of life.

(The author is lead cardiologist and medical director, Sparsh Hospital, Bengaluru)