Perimenopause and Heart Health: How Hormonal Changes Raise Cardiovascular Risk

Heart disease is the leading cause of death for women, but most women are never told their risk starts rising during perimenopause, often years before their periods stop. In 2023, heart disease caused 304,970 female deaths in the US, about 1 in every 5. That is more than all cancers combined. And yet only 56% of women know it is their number one killer. What makes perimenopause specifically critical is how sharply the cardiovascular numbers shift. Hypertension affects just 9.8% of premenopausal women but more than doubles to 25.2% during perimenopause. Beginning around two years before the final menstrual period, the rate of visceral fat accumulation doubles, a change driven by the hormonal transition itself, not just aging. After menopause, plaque buildup in women's arteries progresses at roughly double the rate seen in men. And across all major heart health metrics, only about 1 in 5 adult women achieves ideal cardiovascular health scores.

These changes do not begin after menopause. They begin during perimenopause, the transition most women are in right now. The window for prevention is open. Here is what you need to know and what you can do.

TL;DR: In Summary

• Heart disease causes about 1 in 5 female deaths in the U.S. each year, more than all cancers combined.
• Perimenopause usually starts in the mid-to-late 40s and can last 4–10 years.
• During this time, cholesterol, blood pressure, blood sugar, and body fat can all shift in ways that raise heart risk.
• Women who go through menopause before age 45, naturally or by surgery, face a higher baseline risk.
• Early action (lifestyle changes, screening, and working with your doctor) can make a real difference.

What Is Perimenopause and Why Does It Matter for Your Heart?

Perimenopause is the time before your periods stop. It usually begins in your 40s and can last 4 to 10 years. During this time, your body produces less estrogen, causing changes throughout your body.

Estrogen is not just a reproductive hormone. It also protects your blood vessels, helps manage cholesterol, keeps inflammation low, and supports healthy blood sugar levels. When estrogen levels drop, those benefits start to fade.

Dr. Mary Claire Haver, a leading menopause specialist, calls perimenopause “a cardiovascular turning point driven by the loss of estrogen’s protection on arteries.” Research in Circulation, the top American Heart Association journal, confirms that blood vessel function, cholesterol, body composition, and metabolism all shift during this time.

How Does Falling Estrogen Affect Your Blood Vessels?

Think of your blood vessels like flexible rubber hoses. Estrogen helps keep them stretchy and responsive. It does this by stimulating the production of nitric oxide, a chemical that tells blood vessels to relax and widen. As estrogen drops in perimenopause, vessels lose flexibility and become stiffer. This is called arterial stiffness, an early warning sign of future heart problems.

The inner lining of your blood vessels, called the endothelium, also becomes less responsive. When the endothelium does not function well, it is easier for fatty deposits called plaque to build up inside the vessel walls. This process is known as atherosclerosis, and it can eventually lead to a heart attack or stroke.

Why Does Cholesterol Often Get Worse During Perimenopause?

Cholesterol changes during perimenopause because estrogen helps your liver process fats. When estrogen falls, that process becomes less efficient. In your reproductive years, estrogen tends to keep HDL (“good”) cholesterol higher and LDL (“bad”) cholesterol lower. As estrogen declines, LDL often rises and HDL may drop. Triglycerides, another type of blood fat, can also increase.

These shifts matter because LDL cholesterol is more likely to stick to vessel walls and form plaque when levels are high. Stress and inflammation can also make LDL more damaging by causing it to oxidize, which makes it even more likely to build up inside arteries.

Research presented at the European Society of Cardiology confirms that women in the menopause transition show these exact patterns (higher LDL and triglycerides), which may help explain why heart disease rates climb after menopause.

For women who want a more detailed look at their lipid health, advanced testing such as ApoB and Lp(a) levels is increasingly recommended by cardiologists for midlife women. These tests can catch risks that a standard cholesterol panel might miss.

Can Perimenopause Cause High Blood Pressure?

Yes, and this is one of the most underappreciated changes during perimenopause. Because estrogen helps keep blood vessels relaxed, its decline makes them more likely to constrict. This raises blood pressure.

Hormonal swings also increase activity in the sympathetic nervous system (the fight-or-flight system), which raises both heart rate and blood pressure. Sleep disruption, which is very common during perimenopause, adds to this effect by keeping stress hormones elevated overnight.

High blood pressure is the single most modifiable risk factor for heart disease and stroke in midlife women. Getting it checked regularly, including at home as well as at the doctor’s office, gives you the clearest picture of what is actually happening.

What Causes Heart Palpitations During Perimenopause?

Heart palpitations are moments when you suddenly feel your own heartbeat: racing, pounding, fluttering, or skipping. They are very common during perimenopause and can feel alarming, but they are usually not dangerous on their own.

Several things cause them during this transition. Hormonal fluctuations increase sympathetic nervous system activity, making the heart more reactive to stress, caffeine, and poor sleep. Fluctuating cortisol levels, especially at night, can suddenly raise heart rate. Blood sugar dips trigger the release of adrenaline, which speeds up the heart rate. And changing hormone levels can make the heart’s electrical system more likely to produce extra beats, which feel like a “thud” or a “skip.”

Most palpitations in perimenopause are benign. However, atrial fibrillation (AF), an irregular heart rhythm that raises stroke risk, becomes more common during the menopause transition. If your palpitations are frequent, last more than a few minutes, are accompanied by dizziness or chest discomfort, or feel very irregular, see your doctor. A simple ECG can check your heart rhythm.

How Does Poor Sleep During Perimenopause Affect Your Heart?

Sleep problems are one of the most common complaints during perimenopause. Night sweats, racing thoughts, and frequent waking can make restful sleep feel impossible. But this is not just a comfort issue. Poor sleep is a real cardiovascular risk.

A large study followed women ages 42 to 52 for an average of 16 years and measured their heart health using the American Heart Association’s Life’s Essential 8 score. Women who slept fewer than 7 hours or more than 9 hours, woke frequently, or had fragmented sleep had a higher risk of future heart attacks and strokes, independent of other risk factors.

The study also found that only about 20% of midlife women had optimal heart health scores overall, meaning most had multiple risk factors that could be improved.
Poor sleep raises heart risk through several paths: it increases blood pressure by keeping the sympathetic nervous system active overnight, raises inflammatory markers like C-reactive protein, and impairs the body’s ability to manage blood sugar, increasing risk for type 2 diabetes and the vascular damage that comes with it.

How Does Chronic Stress Increase Heart Risk During Perimenopause?

During perimenopause, estrogen levels fluctuate rather than just steadily drop. Because estrogen influences mood-regulating chemicals like serotonin and GABA, these swings can lower your natural stress tolerance, making everyday stressors feel harder to manage.

When stress becomes chronic, cortisol stays elevated. Over time, high cortisol raises blood pressure, promotes the storage of belly fat (visceral fat), worsens insulin resistance, and increases inflammation throughout the body. All of these raise cardiovascular risk.

Depression and anxiety during the menopause transition are also linked to higher heart disease risk, likely because they share the same biological stress pathways. This means mental health during midlife is heart health, and treating one supports the other.

What Role Does Inflammation Play in Heart Risk During Perimenopause?

Inflammation is the body’s response to injury or threat. In small doses, it is helpful. But when it becomes chronic, as it often does during and after perimenopause, it damages blood vessels and accelerates the buildup of plaque.

As estrogen levels fall and visceral fat increases, the body releases more pro-inflammatory cytokines. These damage the endothelium (the inner lining of blood vessels), making it easier for LDL cholesterol to penetrate the vessel wall and form plaque. Endothelial dysfunction, the early breakdown of this lining, is one of the strongest predictors of future cardiovascular events.

In short, inflammation is the bridge between hormonal change and heart disease progression.

Why Does Body Fat Distribution Change, and Why Does It Matter?

Many women notice that during perimenopause, weight seems to shift toward the belly even when overall weight does not change dramatically. This is not just cosmetic. Visceral fat, the fat stored deep around your organs, is metabolically active and raises inflammation, worsens insulin resistance, and increases blood pressure.

A waist circumference greater than 35 inches (88 cm) for women is associated with significantly elevated cardiometabolic risk. This single measurement is a useful and easy way to monitor changes over time.

Can Hormone Therapy (MHT) Protect Your Heart?

This is one of the most common questions women have, and the answer is nuanced. Menopausal hormone therapy (MHT), also called HRT, has been the subject of decades of research, and the current understanding is more positive than it was 20 years ago.

The key finding from recent evidence is called the “timing hypothesis”: MHT appears to be most beneficial for the heart when started within 10 years of menopause or before age 60. When started during this window, estrogen therapy may help maintain endothelial function, improve lipid profiles, and reduce the progression of atherosclerosis.

MHT is not right for everyone. Women with a history of certain cancers, blood clots, or cardiovascular events may not be good candidates. But for many healthy women in early menopause, MHT can be both safe and beneficial for symptoms, bone health, and potentially cardiovascular protection.

If you are considering MHT, have a thorough conversation with a doctor who specializes in menopause. The North American Menopause Society (NAMS) 2022 position statement is the leading clinical guide on this topic.

What Tests Should You Track During Perimenopause?

Getting regular screenings during perimenopause gives you a baseline and helps catch changes early, before they become harder to treat.

Essential screenings:

• Blood pressure: Check at home and at the doctor’s office for the most accurate picture.
• Lipid panel (LDL, HDL, triglycerides, and total cholesterol). Ask about ApoB and Lp(a) if you have other risk factors.
• Fasting blood glucose and/or HbA1c, to check for insulin resistance and early diabetes.
• Waist circumference: A simple proxy for visceral fat. Greater than 35 inches (88 cm) signals elevated risk.
• Optional: C-reactive protein (CRP), an inflammation marker that can add context to your overall risk picture.
• Sleep and stress assessment: tracking sleep quality and stress levels can guide lifestyle changes.

What Can You Do Now to Protect Your Heart?

The lifestyle changes that lower heart risk during perimenopause are not small tweaks. They are genuine cardiovascular interventions. Here is what the evidence supports:

Move Regularly

Aerobic exercise (brisk walking, cycling, or swimming) improves endothelial function and helps blood vessels stay more elastic. Aim for at least 150 minutes of moderate activity per week.

Strength Train

Resistance training helps preserve muscle mass, improves insulin sensitivity, and reduces visceral fat. Even two sessions per week makes a meaningful difference for metabolic health.

Prioritize Sleep

Treat sleep disruption as a health problem, not just an inconvenience. Address night sweats with a cool bedroom, moisture-wicking bedding, or talk to your doctor about options, including MHT. Aim for 7 to 9 hours per night.

Eat to Reduce Inflammation

A diet rich in fiber, omega-3 fats (from fatty fish, flaxseed, walnuts), colorful vegetables, and lean protein helps manage cholesterol, blood sugar, and inflammation. Minimize ultra-processed foods, added sugar, and alcohol. Even moderate drinking has been downgraded as a heart-health recommendation in recent years and disrupts both sleep and hormone metabolism.

Manage Stress Actively

Daily breathwork, resistance training, therapy, and mindfulness all reduce the sympathetic nervous system’s dominance and lower cortisol burden. These are not nice-to-haves. They are tools that directly affect your heart physiology.

Quit Smoking

Smoking dramatically accelerates every cardiovascular risk pathway discussed in this article. If you smoke, quitting is the single most impactful change you can make for your heart health.

Perimenopause is not just a reproductive milestone. It is a biological shift that affects your heart, blood vessels, cholesterol, metabolism, sleep, and stress response, often all at once.

The good news: this is also a window of opportunity. The changes are gradual, and most are modifiable. Regular screenings, evidence-based lifestyle habits, honest conversations with your doctor about risks and options, including MHT, and awareness of the warning signs of heart disease can all make a meaningful difference.

You do not have to wait for symptoms to take your heart health seriously. Start now.

Medical Disclaimer: This article is for educational purposes only and does not constitute medical advice. Always consult a qualified healthcare provider about your personal health, symptoms, and treatment options.