Heart Health in Midlife: The Risk Shift Nobody Mentions

Heart disease kills more women than all cancers combined, and the menopause transition is when the risk profile begins to shift. It is rarely the focus of a midlife appointment.

What changes

Across the transition, several markers move in the wrong direction at once: LDL cholesterol and triglycerides tend to rise, HDL becomes less protective, blood pressure often increases, visceral fat accumulates, and arterial stiffness increases.

These are not dramatic changes month to month. Over a decade they compound.

Women are more likely than men to have heart attack symptoms that are not chest pain, and more likely to have those symptoms attributed to anxiety.

Symptoms that present differently

Crushing chest pain is the recognised presentation. Women more often experience unusual fatigue, shortness of breath, nausea, jaw or back or neck pain, or lightheadedness. These are easier to dismiss and easier to have dismissed.

Female-specific risk factors

Standard calculators frequently miss these:

• Preeclampsia or gestational hypertension in any pregnancy
• Gestational diabetes
• Preterm delivery
• Polycystic ovary syndrome
• Early menopause, before 45
• Autoimmune conditions such as lupus or rheumatoid arthritis
• Migraine with aura

If any apply to you, say so explicitly. They change your risk category and they are routinely omitted from the record.

What to track

Blood pressure, a lipid panel including Lp(a) at least once in your life, fasting glucose or HbA1c, and waist circumference. Coronary artery calcium scoring can clarify decisions when risk is intermediate.

What helps

Aerobic exercise, resistance training, blood pressure control, not smoking, sleep, and treating dyslipidaemia when indicated. Timing matters in discussions of hormone therapy and cardiovascular risk, and the picture differs meaningfully depending on age and time since menopause. That is a discussion to have with your own history in front of you.