Heart Health in Perimenopause — What to Know Now

Estrogen is a powerful cardioprotective hormone. It helps blood vessels stay flexible and dilated, promotes healthy HDL cholesterol levels, reduces LDL oxidation (which is what makes LDL dangerous), lowers inflammatory markers, and helps regulate blood pressure. Before menopause, women have significantly lower rates of heart disease than men of the same age — and estrogen is a major reason why.

During perimenopause, as estrogen levels become erratic and ultimately decline, these protective effects diminish. Blood vessels become stiffer and less responsive, LDL cholesterol rises (often dramatically — some women see a 10-15% increase in total cholesterol during the transition), HDL cholesterol may decline, triglycerides increase, and inflammatory markers like C-reactive protein rise.

Simultaneously, perimenopause brings metabolic changes that compound cardiovascular risk: increased visceral fat (which is metabolically inflammatory), rising insulin resistance, and shifts toward a more atherogenic (artery-clogging) lipid profile. Blood pressure often begins to rise during perimenopause as well, partly due to increased arterial stiffness and partly due to changes in the renin-angiotensin system that estrogen had been modulating.

The net result is that the 10-year period surrounding menopause is when women's cardiovascular risk profile shifts most dramatically. A woman who had normal cholesterol, blood pressure, and blood sugar in her 30s may have clinically significant changes by her late 40s or early 50s — and these changes can happen faster than many women or their doctors expect.

Perimenopause is the time to establish a thorough cardiovascular baseline if you haven't already. The key numbers to know and track include blood pressure (optimal is below 120/80 mmHg; anything consistently above 130/80 is now classified as hypertension), lipid panel (total cholesterol, LDL, HDL, triglycerides — with specific attention to whether your numbers have changed from prior readings), fasting glucose and HbA1c (which screens for insulin resistance and prediabetes), and waist circumference (abdominal obesity is a stronger cardiovascular risk factor in women than BMI).

Beyond these basics, some providers recommend additional markers for a more comprehensive picture. Lipoprotein(a) or Lp(a) is a genetically determined lipid particle that independently increases cardiovascular risk — it's a one-time test since it doesn't change significantly over time. High-sensitivity C-reactive protein (hs-CRP) measures systemic inflammation, which rises during perimenopause and is an independent cardiovascular risk predictor. A coronary artery calcium (CAC) score can detect subclinical atherosclerosis before symptoms develop.

The critical point is that cardiovascular risk in women has historically been undertreated because risk calculators were developed primarily using data from men. Standard 10-year risk calculators often underestimate risk in younger women and don't account for female-specific risk factors like preeclampsia history, gestational diabetes, PCOS, premature menopause, or autoimmune conditions. If you have any of these, your lifetime cardiovascular risk may be higher than standard tools suggest.

Request a comprehensive cardiovascular screening during perimenopause and establish regular follow-up — these numbers can change quickly during the hormonal transition.

Heart palpitations — the sensation of your heart racing, pounding, fluttering, or skipping beats — are a common and often alarming perimenopause symptom. They're typically caused by estrogen's effects on cardiac electrical conduction and autonomic nervous system regulation. As estrogen fluctuates, it can increase sensitivity to catecholamines (adrenaline-like hormones), alter the electrical timing of heartbeats, and amplify the cardiovascular response to stress.

Most perimenopausal palpitations are benign. They often co-occur with hot flashes (the same autonomic nervous system activation that dilates blood vessels also speeds the heart), anxiety episodes, caffeine intake, or during the luteal phase of the menstrual cycle when hormones are in flux. Isolated premature atrial contractions (PACs) and premature ventricular contractions (PVCs) — the "skipped beat" sensation — are extremely common and usually harmless.

However, palpitations should be evaluated if they are prolonged (lasting minutes rather than seconds), associated with dizziness, lightheadedness, or fainting, accompanied by chest pain or shortness of breath, or if you notice a very rapid or irregular heart rhythm. These can indicate atrial fibrillation, supraventricular tachycardia, or other arrhythmias that become more prevalent during and after the menopausal transition.

A basic cardiac evaluation typically includes an ECG (electrocardiogram), thyroid function tests (hyperthyroidism can cause palpitations), and sometimes a Holter monitor (a portable ECG worn for 24-48 hours to capture intermittent rhythm disturbances). If palpitations are frequent and distressing but benign, reducing caffeine and alcohol, managing stress, and treating underlying perimenopausal symptoms (particularly with hormone therapy) often help.

The relationship between hormone therapy and cardiovascular health has been one of the most debated topics in women's health. The current evidence, informed by reanalyses of the Women's Health Initiative and subsequent studies, supports a nuanced view known as the "timing hypothesis" — the cardiovascular effect of HT depends critically on when it's started relative to menopause.

For women who start hormone therapy during perimenopause or within 10 years of their last period (the "window of opportunity"), estrogen appears to maintain and even improve cardiovascular health. It preserves arterial flexibility, maintains healthy endothelial function, and helps sustain a favorable lipid profile. Multiple observational studies and the WHI reanalysis show that women who start HT in this window have a lower risk of coronary heart disease and all-cause mortality compared to those who don't use HT.

Starting HT after age 60 or more than 10 years after menopause, particularly oral estrogen, carries a higher cardiovascular risk — likely because estrogen has different effects on healthy blood vessels versus arteries that already have established atherosclerosis. In older arteries with plaque, estrogen may promote plaque instability.

Transdermal estrogen (patches, gels) is generally considered the safest delivery method for cardiovascular health because it avoids the first-pass liver metabolism that increases clotting factors and triglycerides. Micronized progesterone is preferred over synthetic progestins (like medroxyprogesterone acetate) because it has a neutral-to-positive cardiovascular profile. The bottom line: for symptomatic perimenopausal women without contraindications, timely initiation of HT is generally cardiovascular-neutral to beneficial.

The perimenopausal years are a critical window for establishing cardiovascular protective habits, because the metabolic and vascular changes happening now set the trajectory for the decades ahead. The most impactful interventions are those that address the specific risk factors that emerge during this transition.

Regular aerobic exercise is perhaps the single most powerful cardiovascular protector. The American Heart Association recommends at least 150 minutes per week of moderate-intensity aerobic activity (brisk walking, cycling, swimming) or 75 minutes of vigorous activity (running, HIIT). Exercise improves arterial flexibility, lowers blood pressure, raises HDL cholesterol, improves insulin sensitivity, and reduces visceral fat — addressing nearly every cardiovascular risk factor that worsens during perimenopause.

Dietary changes matter enormously. A Mediterranean-style diet — rich in olive oil, fish, nuts, legumes, fruits, vegetables, and whole grains, and low in processed foods and refined sugar — has the strongest evidence base for cardiovascular protection. Reducing sodium intake helps manage the blood pressure increases common in perimenopause. Omega-3 fatty acids from fish or supplements reduce triglycerides and inflammation.

Manage stress actively. Chronic stress elevates cortisol, blood pressure, and inflammatory markers, all of which accelerate cardiovascular damage. Perimenopause itself is a stressor — both biologically and psychologically — so deliberate stress management (exercise, meditation, therapy, social connection) isn't optional, it's cardiovascular medicine.

Don't smoke, and if you do, this is the most important time to quit. Smoking interacts synergistically with declining estrogen to accelerate arterial damage. Finally, know your numbers and advocate for comprehensive cardiovascular screening — women's heart disease remains underdiagnosed because its presentation often differs from men's.

Yes, and this difference contributes to delayed diagnosis and poorer outcomes for women. While chest pain or pressure is still the most common symptom in both sexes, women are more likely than men to experience atypical symptoms — and in some cases, to have a heart attack without classic chest pain at all.

Women's heart attack symptoms more frequently include shortness of breath (sometimes the primary or only symptom), nausea or vomiting, pain in the jaw, neck, upper back, or between the shoulder blades, unusual fatigue (sometimes described as extreme exhaustion that comes on suddenly, days before the event), lightheadedness or dizziness, and a sense of impending doom or severe anxiety. These symptoms can be vague, gradual in onset, and easily attributed to stress, indigestion, or — during perimenopause — hormonal changes.

This atypical presentation, combined with the misconception that heart disease is primarily a male problem, leads to significant diagnostic delays. Studies show that women wait longer to seek care, are less likely to be given aspirin or ECGs in the emergency department, and experience longer times from symptom onset to diagnosis and treatment. Women under 55 are particularly vulnerable to delayed diagnosis because neither they nor their providers expect heart disease.

The key takeaway for perimenopausal women is to know these atypical symptoms and take them seriously. If you experience any combination of these symptoms that is new, unexplained, or severe — especially during exertion — don't assume it's hormonal. Call 911 or your local emergency number. It's far better to be evaluated and reassured than to delay care for a potentially life-threatening event.