Estrogen does many important jobs in the body beyond regulating the reproductive cycle. It helps manage cholesterol and blood sugar, supports blood flow, keeps muscles and bones strong, and may also help with concentration.

During perimenopause, estrogen levels rise and fall unevenly. After menopause, estrogen levels drop much more. These changes can affect many parts of the body, including the heart and blood vessels. Here is what to know about protecting your heart during and after menopause.

Heart disease is the leading cause of death in women. Menopause may be one of several factors that increase the risk of heart disease.

Estrogen is believed to protect heart health in younger women, but that protection fades as estrogen levels lower in perimenopause.

Starting your period at age 10 or younger or reaching menopause at age 40 or younger also seems to increase the risk of cardiovascular disease later in life.

The menopause transition doesn’t directly cause heart disease, but it can lead to changes that put stress on blood vessels, the heart, and other organs.

If low estrogen raises the risk of heart disease, you might think hormone replacement therapy (HRT) could lower that risk. Doctors used to believe this too, but a long-term study by the Women’s Health Initiative (WHI) suggests that HRT may actually increase the risk of cardiovascular disease in some women.

In that study, some postmenopausal women who received HRT were more likely to experience heart disease, stroke, and blood clots. HRT also increased the risk of breast cancer and dementia in women who received estrogen and progestin (a critical combination for preventing endometrial cancer in women with a uterus).

In the WHI study, estrogen-only therapy, which is only used for women without a uterus, had a different set of risks than combined estrogen-progestin therapy, but it was not risk-free. The type and formulation of estrogen and progestin also matter, so the risks are not the same for every hormone therapy.

HRT can also help manage some perimenopausal symptoms, such as hot flashes, insomnia, and vaginal dryness. It can also reduce the risk of osteoporosis, a condition that makes bones weak and brittle.

Although doctors no longer recommend HRT solely to prevent heart disease, it can be a safe and effective menopause treatment for some women. Your healthcare provider will consider your age, medical history, and overall health before recommending HRT, and they’ll regularly monitor your health during treatment.

​​High cholesterol means there is too much cholesterol in the blood. Over time, cholesterol can help form plaque in the arteries. This buildup can narrow and harden the arteries, raising the risk of atherosclerosis, high blood pressure, heart attack, and stroke.

Cholesterol comes from animal-based foods, but the body also makes it in the liver. Cholesterol levels can change before, during, and after perimenopause.

Cholesterol levels often worsen during late perimenopause and early postmenopause, around the time periods stop for good. In particular, total cholesterol and LDL “bad” cholesterol may rise. Hot flashes and night sweats may also be associated with a higher risk of heart and metabolic problems.

HDL, or “good” cholesterol, may be less helpful for predicting heart health during the menopause transition. Earlier in life, higher HDL levels are usually linked to a lower risk of heart disease. But during perimenopause and after menopause, changes in hormones and metabolism may affect how HDL works, so higher levels may not protect the heart in the same way.

Your healthcare provider can help you monitor your cholesterol levels and recommend ways to reduce them if they get too high.

It’s common for blood pressure to increase with age, but menopause may also play a role in raising blood pressure levels. Some women experience a sharp increase in blood pressure in the year after menopause, while others experience a slight decline or no change. Researchers don’t know how to explain these variations yet.

Possible risk factors include older age and lower follicle-stimulating hormone levels, as well as hot flashes and night sweats. Doctors recommend frequently monitoring blood pressure during perimenopause.

Your healthcare provider can explain the various treatment options for lowering high blood pressure. If it goes untreated, high blood pressure can weaken your heart, damage organs, and increase the risk of heart attack and stroke.

Poor-quality sleep, short sleep durations, sleep disturbances, and insomnia may increase your risk of hardened arteries after menopause. Poor sleep doesn’t seem to affect the cardiovascular health of premenopausal women.

Depression is more common during perimenopause and is linked to worse heart health. Early evidence also suggests that depression in midlife women may be tied to early signs of atherosclerosis.

It’s also important to be aware of hot flashes, cold sweats, night sweats, and heart palpitations during perimenopause. If these symptoms are frequent, long-lasting, or severe, they may be a sign of poor heart health.

There are many other steps you can take to protect your heart. The American Heart Association recommends the following:

• Smoking cessation
• Limiting foods high in saturated fat and added sugar
• Staying physically active
• Maintaining a healthy body weight
• Getting healthy sleep
• Taking extra steps to control blood sugar, cholesterol, and blood pressure

Research shows these lifestyle changes can help prevent weight gain and lower LDL cholesterol, triglycerides, blood pressure, blood sugar, and insulin.

One long-term study confirmed that women who followed lifestyle changes for 14 years had a significantly smaller risk of heart attack, unstable angina (sudden chest pain), and other heart-related issues.

Managing ongoing stress may also improve heart health. Studies link stress to an increased risk of high blood pressure and cardiovascular disease in perimenopausal women.

Better sleep, a healthy diet, and more physical activity may help lower stress. Learning other ways to cope can also help.

Talk to a healthcare provider if you need help making any of these lifestyle changes. Prescription medication may make it easier to quit smoking, manage body weight, fall asleep and stay asleep, and manage stress, as well as lower cholesterol, blood pressure, and blood glucose.

Midlife is an important time for women to focus on preventing heart disease through lifestyle changes and close monitoring. Attend regular checkups with your healthcare provider for heart disease screening, and discuss your risk factors and how to address them.

Learn how to recognize a heart attack and what to do if you have one. Heart attacks can feel different in women and men. Women may experience any of these symptoms:

• Pain, tightness, squeezing, or pressure in the jaw, throat, neck, one or both arms, chest, upper back, or upper abdomen
• Chest pain, though it tends to feel more subtle than the crushing type of pain described by men
• A numb or tingling sensation in the left arm
• Shortness of breath or difficulty breathing unrelated to physical activity
• Nausea or vomiting
• Indigestion, heartburn, or upset stomach
• Extreme fatigue
• Severe, unexplained anxiety
• Sweating, including a cold sweat
• Fainting

If you think you might be having a heart attack, or if you are not sure, call 911 right away. Then do the following:

• Take aspirin if a dispatcher or your healthcare provider has told you to do so.
• Take nitroglycerin if you have a prescription.
• Sit down, stay as calm as you can, and wait for help. Do not drive yourself to the hospital.

Menopause is a time of change. You may lose the protective effect of estrogen, but you can keep your heart healthy in other ways. Talk to your doctor about what’s right for you.