Hot flushes, mood swings, bones and sleep. That's probably what most women think about, and talk about, when it comes to perimenopause or postmenopause. Cardiovascular health rarely makes the list, and it is the one with the largest numbers behind it. In 2024 around 20,200 Australian women died of cardiovascular disease, accounting for almost one in every four female deaths.
I know that is a jarring and confronting number, and likely one that has touched someone close to almost everyone reading this. However, it is important to talk about, because cardiovascular risk responds to a change in lifestyle or behaviour better than almost anything else in midlife health, and the years where it responds best are the years that pass most women without it being mentioned.
That window starts earlier than people expect. Not after menopause, but in the years before it.
And if you are already postmenopausal, the same changes still work. The transition is when risk climbs fastest, which makes it the highest-value time to act. After it, blood pressure, blood fats and visceral fat all still respond to what you do, and bringing them down decreases your risk.
A quick word on the words (because I am an absolute stickler for detail)
Menopause itself is one day. It's the date of your final period, and you can only confirm it in hindsight, 12 months later.
The years of hormonal change leading up to that day are perimenopause, also called the menopause transition. Everything after that day is postmenopause.
That distinction matters here, because the cardiovascular change happens during the transition. Which is the part most women are still in when they're told it's probably nothing.
What the transition does, separate from getting older
In 2020 the American Heart Association (AHA) published a scientific statement on this, and the central finding is the part that gets missed. The menopause transition itself, independent of chronological ageing, is associated with accelerating cardiovascular risk.
That phrase, independent of chronological ageing, separates two things that normally get lumped together and called getting older. Some of what happens to women's hearts in their 50s is ageing, and it would happen anyway. The rest is tied to the transition, which means it's tied to where you are in your own hormonal change rather than to how old you are.
So two women the same age can be in completely different places. One is 48 and two years into the transition, and the cardiovascular changes have already started. The other is 48 and has not entered it, so they're yet to encounter these changes. Same age, different risk, and the age is the part that tells you nothing.
What actually shifts
Three things change together through the transition.
Body fat redistributes. It moves from the hips and thighs toward the abdomen, and specifically to visceral fat around the organs. This happens in women whose weight on the scales doesn't change at all, which is why it's so easy to miss. A tape measure around your waist picks it up where the scales will not.
The fats in your blood change. Cholesterol rises, and the mix of it shifts in a less favourable direction. The statement also notes something counterintuitive. A higher level of good cholesterol, the HDL on your blood test, doesn't reliably mean lower risk in women at every life stage.
The blood vessels themselves change. Arteries stiffen, and the lining that controls how they widen and narrow stops working as well. Both are measurable, and both shift through the transition.
Why it gets missed
The window where risk accelerates is roughly the late 40s to mid 50s. For most women that's while periods are still happening, often while they're irregular, and often while the fatigue and the broken sleep and the weight that won't shift are all being put down to a busy decade.
It's also the window where prevention counts for the most. The AHA statement is explicit that this is the time for early intervention, so waiting until you're postmenopausal means missing the years with the most to give.
What to do with this
It's important to say that a rising risk is not the same as something having gone wrong. It means the odds have moved, and those are years you can still act in.
The practical version is to know your numbers through your 40s rather than after. Book a GP appointment and ask for three things: your blood pressure, a lipid panel, which is the blood test for cholesterol and other fats, and your results from last time so you can see which way they are moving.
That third one rarely gets handed over unless you ask for it, and it is the most useful. A single cholesterol reading tells you where you are. Two readings a few years apart tell you where you are heading, which is the thing you can actually act on.
The two changes that do the most
Blood pressure and blood fats have a significant impact on cardiovascular health. And how much you move and what you eat have a big effect on those numbers. Both physical activity and diet are more effective in this window than at almost any other point, because the fat redistribution, the blood fat changes and the vessel changes are still in progress rather than finished.
The AHA statement reports that among women going through the transition, a mere 7.2% meet the physical activity guidelines, and fewer than 20% maintain a healthy diet. So the two changes with the most to offer are the two being made least.
If you are in that 7.2%, good on you. Almost no one else in this window is.
Guidelines like these get quoted constantly. Most of the women I've worked with have heard the numbers and still couldn't tell you what they mean for them, which is a failure of how they get communicated rather than anything else.
So I'm giving them their own issues over the next few weeks, the dietary guidelines and this one, and working through what they actually look like in a real week.
If this post prompts one thing, make it the appointment.
Often when someone reads something about heart health, the next move is to buy fish oil. Whether that does anything, and for whom, is the next post.
The timing argument here is the same one as bone loss, which also runs on your last period rather than your birthday. Two different systems, one window.
The takeaway
Cardiovascular risk starts climbing during the transition rather than after menopause, and the window runs from roughly the late 40s to the mid 50s. Your age does not tell you where you are in it. Know your blood pressure and blood fats through your 40s, ask for your previous results so you can see which way they are moving, and use a tape measure rather than the scales.
About this series
This post is part of Is This Just Getting Older?, a collaboration running through October with eight of us working with women in health, performance and wellbeing. Menopause, nutrition, fibre, snacks, movement, energy, self-compassion and sleep, one topic at a time, leading up to World Menopause Day on 18 October.
There is a Midlife Health and Wellbeing Pack being given away across the campaign, worth more than $3,000, with consultations, books, coaching sessions and a month of Greenher Daily in it.
To enter: follow all eight of us, then like the giveaway post and leave a comment saying one thing you wish more people understood about midlife health. Every account and the post are on one page here. Entries close 18 October.
The science behind this post:
- Australian Institute of Health and Welfare. Heart, stroke and vascular disease: Australian facts. Deaths from cardiovascular disease, 2024. aihw.gov.au
- El Khoudary SR, Aggarwal B, Beckie TM, et al. Menopause transition and cardiovascular disease risk: implications for timing of early prevention. A scientific statement from the American Heart Association. Circulation. 2020;142(25):e506-e532. Read the statement