When you’re worried about your health, your heart is probably not at the top of your list—but it should be! More women die from heart disease and stroke than all cancers combined. It’s the leading killer of women, and your risk of heart disease spikes in midlife and menopause. But the good news is that it’s highly preventable, and you can significantly reduce your risk of having a heart attack or stroke. But don’t wait.

“If you ask the average 40-year-old woman what her biggest health concern is, she’s likely to say breast cancer,” says Sarah Speck, M.D., one of Seattle’s leading cardiologists and co-founder of POTENTRx, a medical fitness facility that combines medicine, exercise, nutrition, and lifestyle coaching. “Yes, you should get your annual mammograms and Pap tests, but you also need to be aware of the risk factors for heart disease because it’s more likely to kill you.”

Why heart disease increases with menopause

Heart disease occurs when the lining of blood vessels becomes inflamed. Once inflammation starts, the environment is set for cholesterol-related plaque to form in blood vessels. Heart disease isn’t much of a concern during the first half of your life thanks to estrogen. The anti-inflammatory properties of estrogen help to keep women’s blood vessels flexible, reduce plaque, increase good HDL cholesterol, and keep bad LDL cholesterol in check.

A lack of estrogen is one of the reasons that men are nearly twice as likely to have heart disease as women early in life. At age 45, one in five men has heart disease compared to only one in nine women. As estrogen levels fall during perimenopause and into menopause, women lose estrogen’s heart protective benefits, and by age 65, their risk for heart disease is similar to men’s risk—one in three.

But you don’t have to become one of those statistics. “There’s an incredible window there—20 years—where you can do something if you realize that you’re at risk,” says Dr. Speck. Think of your hot flashes and other perimenopause symptoms like warning lights on your car. You wouldn’t ignore them and keep driving, would you? Probably not. More likely, you’d check your owner’s manual to find out what they mean. Consider this guide to be your owner’s manual for heart disease. If you take the time to discover what warning lights (or risk factors) you may have, you can take steps to reverse them and reduce your risk of having a heart attack or stroke.

What’s your risk for heart disease?

The first step to protecting your heart is to know what your personal risk of developing heart disease is as you get older. Some risk factors are uncontrollable, such as age and family history, but knowing if you have any of these uncontrollable risk factors will help you customize your healthy heart plan. While it may seem scary to have uncontrollable risk factors, there are many more risk factors that you have control over and managing those will provide significant protection.

Uncontrollable risk factors of heart disease

  • A prior cardiac event such as a heart attack or stroke
  • Family history of heart disease before the age of 65
  • Age 65 or older
  • Preeclampsia during pregnancy
  • Gestational diabetes
  • Postpartum depression
  • Autoimmune disease
  • Radiation for breast cancer, especially on the left side

The more uncontrollable risk factors you have, the earlier you should start implementing the preventative strategies below.

Controllable risk factors of heart disease

  • Obesity, a body mass index (BMI) of 30 or above
  • Diabetes
  • LDL (bad) cholesterol level above 100
  • HDL (good) cholesterol level below 50
  • Triglycerides level above 150
  • High blood pressure (130/80 or above)
  • Waist circumference 35 inches or larger
  • Fasting blood glucose level above 110
  • Chronic stress
  • Depression
  • Smoking (including e-cigarettes) or exposure to second-hand smoke
  • Sedentary lifestyle

Now that you know the factors that can increase your risk for heart disease, it’s time to take action.

Heart Health Checklist for Midlife and Menopause

These steps will help reduce your heart disease risk no matter which risk factors you have. In addition, they'll help to ease many menopause symptoms, improve your mental health, and lower your risk for other health problems such as diabetes, depression, and cancer. 

1. Partner with a health professional you trust. You want someone who listens to you, understands what you’re going through, and will work with you to address your unique needs. A menopause-certified doctor is specially trained to help you manage symptoms during perimenopause and address long-term health risks like heart disease. They will know what types of screenings you need and create personalized health plans to reduce your individual risk for various conditions, including heart disease.

2. Know and follow your numbers. They include weight, waist circumference, blood pressure, blood sugar, LDL (bad) cholesterol, HDL (good) cholesterol, triglycerides. If your numbers are healthy based on the “controllable risk factors” above, you should talk to your doctor about specific steps you can take to improve them. In addition, it is even more critical that you make the healthy lifestyle changes that follow.

3. Get tested. If you’re over the age of 40 and don’t know your numbers listed in #1, find them out now. You’ll need to get a script from your doctor for the cholesterol and blood sugar tests, but the others you can do on your own. You’ll want to start tracking these numbers even earlier if you have any of the uncontrollable risk factors listed above. You should consult with your doctor about the best timing for you. If you don’t have any other risk factors, and these numbers are normal, repeat the blood tests every three to five years. Track your weight, waist measurement, and blood pressure at least annually.

At menopause, or earlier, if you have certain risk factors, there are three additional tests you should get:

  • Coronary artery calcium screening This heart scan uses specialized x-ray technology to check for calcium deposits in blood vessels, which signals plaque development. If plaque is discovered, you and your doctor should discuss an action plan. If there is no plaque, you should repeat the test every three to five years, depending on your risk factors.
  • Carotid artery IMT (Intima Media Thickness) scan This test scans the wall of the carotid artery that goes to your brain, looking for plaque and abnormal thickening. You should repeat this test every one to five years, depending upon the findings, to see if there is any progression of plaque.
  • High sensitivity cardiac CRP blood test Cardiac C-reactive protein is released when the lining of the blood vessel is inflamed. If your value is above 3, you’re at an increased risk of developing heart disease over the next five to eight years. You should repeat this test every one to three years, depending on your results.

4. Avoid all tobacco. This includes e-cigarettes and second-hand smoke. Smoking causes inflammation that contributes to heart diseases. If you smoke, do everything you can to quit. Nicotine gum or patches may help and do not contribute to heart disease.

5. Manage stress and address depression. Just like stress comes from a variety of sources—your job, your family, the news, traffic—the negative impact it has on your heart occurs in a variety of ways. The hormone cortisol is released when you're stressed, and it can increase cholesterol, triglyceride, blood sugar, and blood pressure levels. It may also contribute to plaque in arteries, impair blood flow to the heart, and make blood stickier and more likely to clot.

In addition, when you’re stressed, it’s harder to practice other healthy behaviors like eating healthy, exercising, and getting to bed early. That’s why it’s so important to find a stress management technique that you can practice consistently. And like there are numerous sources of stress, there are multiple ways to relax, such as walking, meditating, listening to music, taking deep breaths, practicing yoga, and petting your dog or cat. If you still can’t get your stress under control, seek help from your primary care provider, or therapist.

If you’re feeling depressed, get help. Women are two to four times more likely to experience depression during the menopause transition, and being depressed increases your risk for heart trouble.

6. Eat healthy. Based on research, the Mediterranean diet appears to be the best choice for keeping not only your heart healthy, but also your brain. It may also help with hot flashes, prevent breast cancer, boost your mood, and help you live longer. The diet focuses on limiting animal protein to chicken, turkey, and fish, eating two servings of fish a week, eating five servings each of fruits and veggies daily, eating whole grains instead of refined sugars and starches, and consuming heart-healthy olive oil and nuts instead of other fats.

This eating style appears to protect your heart on two fronts. Research has shown that the Mediterranean diet lowers risk for heart disease and heart attacks by up to 30 percent and risk for stroke by up to 17 percent. The diet also influences other risk factors that contribute to heart disease, such as improving cholesterol and blood pressure levels and lowering the risk for diabetes.

7. Move every day. “You don’t have to sweat. You just have to move,” says Dr. Speck. “There’s a 40 percent decrease in cardiovascular risk by just walking three to five hours a week. That is the same reduction in cardiovascular disease risk as taking medication.” You should aim to accumulate 150 minutes of moderate-intensity aerobic activity such as walking, cycling, swimming, or dancing a week. Aerobic, physical activity will also help to boost your mood, keep you mentally sharp, make weight control easier, and reduce your risk for diabetes, hypertension, and other diseases.

Strength training, such as lifting weights, using resistance bands, or doing bodyweight exercises like pushups, provides additional benefits such as keeping you strong, protecting your bones, and easing joint pain. Aim to strength train twice a week.

8. Consider a vitamin D supplement. Vitamin D plays a role in many areas of the body, including bone health, immunity, and mood. It may also help protect your heart by reducing your chances of developing hypertension and diabetes, both risk factors for heart disease. Talk to your doctor about checking your vitamin D levels to see if you might benefit from a supplement. The recommended daily intake of vitamin D is 600 to 1,000 IUs (international units) a day in the form of vitamin D3. Food sources include fatty fish like salmon, tuna, and trout; cremini and portabella mushrooms that have been exposed to sunlight; fortified foods like milk, tofu, yogurt, orange juice, and cereals; and eggs.

9. Familiarize yourself with symptoms of a heart attack and stroke. More women die of heart attacks than men. One reason may be due to women having more subtle signs instead of the classic crushing chest pain or pressure associated with a heart attack. Here are additional symptoms you should pay attention to:

  • Uncomfortable pressure, squeezing, fullness, or pain in the center of the chest that lasts for a few minutes or comes and goes
  • Tightness or pain in one or both arms, back, neck, jaw, shoulder, or abdomen
  • Palpitations with shortness of breath or sweating
  • Breaking out in a cold sweat, nausea, vomiting, lightheadedness, dizziness
  • Symptoms that appear without exertion but during times of stress, such as a family member being in an accident or losing your job 
  • Out of the ordinary fatigue or shortness of breath
  • Feeling of dis-ease

If you experience any of these symptoms, call 9-1-1 immediately. Delaying action may be one of the reasons women are less likely to survive heart attacks. Seconds count, and even subtle symptoms can be deadly.

This advice applies to strokes, too. Stroke is the fourth leading cause of death for women and a cause of serious, long-term disability. A quick way to remember signs of a stroke is to think F-A-S-T:

  • F = face drooping
  • A = arm weakness
  • S = speech difficulty
  • T = time to call 9-1-1

But like a heart attack, stroke symptoms for women may also be atypical or vague, such as fatigue, confusion, or general weakness instead of weakness on just one side. Pay attention to any sudden changes like a severe headache or loss of function like difficulty walking. Treatment for stroke is time-sensitive, so call 9-1-1 immediately. The ambulance crew can alert the hospital to get you treatment faster.

What about HRT and heart health?

When it comes to HRT and heart health, it’s complicated. That’s why hormone replacement therapy isn’t a part of our Heart Health Checklist. While natural estrogen protects your heart, synthetic estrogen can be both helpful and harmful. It all depends on the timing and your personal health history. When HRT is prescribed before or within five years of menopause, usually for symptom management, it may reduce your risk for heart disease and improve other risk factors such as cholesterol. So, if you need symptom relief, it is safe to use HRT during this time frame. However, once you are eight to 10 years past menopause, the one-year mark after your last period, taking estrogen replacement may increase your risk for a stroke or heart attack. HRT is also not an option if you’ve already had a heart attack or stroke.

The complexity of HRT is a good example of why it’s essential to work with a menopause-trained doctor. Other decisions like taking supplements and the timing of screening tests can have similar pros and cons based on your symptoms, risk factors, and lifestyle. Menopause specialists are aware of the latest research in areas affecting women in midlife and menopause, can apply those findings to your personal circumstances, and support you in making lifestyle changes to improve your health.


The information on the Gennev site is never meant to replace the care of a qualified medical professional.  Hormonal shifts throughout menopause can prompt a lot of changes in your body, and simply assuming something is “just menopause” can leave you vulnerable to other possible causes. Always consult with your physician or schedule an appointment with one of Gennev's telemedicine doctors before beginning any new treatment or therapy.



Michele Stanten

February 2, 2022

Medically Reviewed By

Dr. Sarah Speck

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