Latest / Heart Health, Reimagined with Dr. Mona Shah, MD / What Menopause Really Does to Your Heart Risk

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What Menopause Really Does to Your Heart Risk · Heart Health, Reimagined with Dr. Mona Shah, MD

• 0:00
  SPEAKER_00: If you are in your 40s and starting perimenopause, in your 50s going through menopause, or you went through menopause 10 or 20 years ago, this matters to you because heart disease is the leading cause of death in women, and menopause can be a major turning point in your cardiovascular risk.
• 0:20
  SPEAKER_00: Here's what many women are never told.
• 0:23
  SPEAKER_00: Your cholesterol can change, your Apo B can rise, your triglycerides can rise, insulin resistance can worsen, and you may gain weight.
• 0:33
  SPEAKER_00: But even more importantly, where your body stores fat can change.
• 0:38
  SPEAKER_00: With more fat beginning to accumulate deep inside the abdomen around your organs, your arteries can become stiffer, your blood pressure can start creeping up, and your sleep may deteriorate.
• 0:54
  SPEAKER_00: Several of these things can happen all at the same time.
• 0:58
  SPEAKER_00: That is what I mean when I say menopause is a cardiovascular and metabolic turning point.
• 1:04
  SPEAKER_00: It means a hormonal environment that has influenced your blood vessels, cholesterol, insulin sensitivity, fat distribution, and metabolism for decades is changing.
• 1:17
  SPEAKER_00: And your cardiovascular risk profile can change with it.
• 1:21
  SPEAKER_00: So today I want to explain what estrogen has actually been doing for you, what changes when estrogen falls, what happens to cholesterol, insulin resistance, visceral fat, and your arteries, and most importantly, what you need to know now, even if menopause happened years ago.
• 1:42
  SPEAKER_00: First, what exactly is menopause?
• 1:45
  SPEAKER_00: Menopause technically means you have gone 12 consecutive months without a menstrual period, assuming, of course, there's not another medical reason for it.
• 1:55
  SPEAKER_00: But the hormonal transition begins years before that.
• 1:59
  SPEAKER_00: During perimenopause, ovarian hormone production becomes more erratic, estrogen can fluctuate significantly, and ovulation becomes less consistent.
• 2:10
  SPEAKER_00: Progesterone levels decline because ovulation is happening less frequently, and eventually estrogen levels fall substantially as ovarian function declines.
• 2:23
  SPEAKER_00: Now this matters because estrogen is much more than a reproductive hormone.
• 2:29
  SPEAKER_00: Estrogen receptors are found throughout your body, including in your blood vessels, your liver, your skeletal muscle, and fat tissue.
• 2:39
  SPEAKER_00: Estrogen influences how your body processes cholesterol, affects insulin sensitivity, affects where fat is stored, and has important effects on the lining of your blood vessels.
• 2:52
  SPEAKER_00: Remember that lining, we've talked about it before.
• 2:55
  SPEAKER_00: It's called the endothelium.
• 2:57
  SPEAKER_00: Think of the endothelium as the active protective lining inside your arteries.
• 3:03
  SPEAKER_00: A healthy endothelium helps your blood vessels relax and expand appropriately, helps regulate inflammation and clotting, and helps maintain healthy blood flow.
• 3:16
  SPEAKER_00: Estrogen helps support nitric oxide signaling, which is one of the ways blood vessels relax and dilate.
• 3:23
  SPEAKER_00: So when estrogen declines, some of those vascular and metabolic effects decline with it.
• 3:29
  SPEAKER_00: Progesterone also has effects on blood vessels and inflammation, but the evidence is much stronger for estrogen and the overall menopausal hormonal transition than it is for progesterone loss by itself.
• 3:43
  SPEAKER_00: That doesn't mean estrogen was completely protecting you from heart disease and then suddenly disappeared.
• 3:50
  SPEAKER_00: Atherosclerosis, aka plaque buildup in the arteries, builds over decades, but the environment in which that plaque develops can become less favorable.
• 4:02
  SPEAKER_00: That is why this period matters.
• 4:06
  SPEAKER_00: How much does cardiovascular risk really change?
• 4:10
  SPEAKER_00: The American Heart Association has specifically identified the menopausal transition as an important period when cardiovascular risk factors can accelerate.
• 4:20
  SPEAKER_00: And in the Framingham Heart Study, one of the largest-running cardiovascular studies we have, postmenopausal women had more than twice the age-adjusted cardiovascular risk compared with women of the same age who had not yet gone through menopause.
• 4:37
  SPEAKER_00: But here's the important part.
• 4:39
  SPEAKER_00: When researchers accounted for things like cholesterol, diabetes, blood pressure, and other cardiovascular risk factors, much of that excess risk was explained.
• 4:51
  SPEAKER_00: To me, that's really the point.
• 4:53
  SPEAKER_00: Menopause does not simply flip a switch and create heart disease, it changes many of the things that ultimately drive heart disease.
• 5:03
  SPEAKER_00: This is exactly why I keep saying cardiovascular prevention can't come down to just one thing.
• 5:10
  SPEAKER_00: A normal LDL alone doesn't tell me enough.
• 5:13
  SPEAKER_00: A normal A1C alone doesn't tell me enough.
• 5:16
  SPEAKER_00: A normal weight certainly doesn't tell me enough.
• 5:18
  SPEAKER_00: You have to look at everything together.
• 5:21
  SPEAKER_00: I'm Dr.
• 5:22
  SPEAKER_00: Mona Shaw, a holistic cardiologist focused on prevention and looking at the whole picture.
• 5:28
  SPEAKER_00: And if you like this kind of approach, every week I talk about topics related to prevention, including heart scans, labs, lifestyle, diet, and much more.
• 5:38
  SPEAKER_00: Subscribe if that's what you're here for.
• 5:42
  SPEAKER_00: Now let's get into exactly what changes.
• 5:44
  SPEAKER_00: Let's start with cholesterol.
• 5:46
  SPEAKER_00: One of the clearest changes we see around menopause is in cholesterol and lipoproteins.
• 5:52
  SPEAKER_00: LDL cholesterol tends to rise, Apo B tends to rise, and triglycerides can rise.
• 5:59
  SPEAKER_00: Some of these changes appear to accelerate particularly around late perimenopause and the first few years after the final menstrual period.
• 6:09
  SPEAKER_00: In the Swan study, one of the largest studies following women through this transition, women in early postmenopause had about twice the odds of having an LDL of 130 or higher compared with women who are still premenopausal.
• 6:25
  SPEAKER_00: Now, when I say triglycerides, I mean fats circulating in your bloodstream.
• 6:30
  SPEAKER_00: When I say LDL, I'm talking about cholesterol carried inside one group of particles that can contribute to plaque.
• 6:37
  SPEAKER_00: And when I say APOB, I am talking about the number of plaque-forming particles circulating in your blood.
• 6:45
  SPEAKER_00: That is why I care so much about APOB.
• 6:47
  SPEAKER_00: You can have LDL that does not look terrible and still have more APOB particles than I want.
• 6:53
  SPEAKER_00: I have an entire separate video explaining APOB and why I use it.
• 6:57
  SPEAKER_00: But one of the biggest changes is visceral fat.
• 7:01
  SPEAKER_00: And I want to spend more time on this because I think this is one of the most important and most misunderstood changes around menopause.
• 7:10
  SPEAKER_00: A woman may tell me, my weight has only gone up five pounds, or I weigh almost the same, but my body looks completely different.
• 7:20
  SPEAKER_00: That is very common.
• 7:21
  SPEAKER_00: Yes, many women absolutely do gain weight around menopause.
• 7:26
  SPEAKER_00: Aging, lower activity, loss of muscle, sleep disruption, hormonal changes, and metabolic changes all can contribute.
• 7:35
  SPEAKER_00: But menopause also appears to change where your body prefers to store fat.
• 7:40
  SPEAKER_00: Instead of storing as much fat underneath the skin, around the hips and thighs, women tend to accumulate more centrally.
• 7:49
  SPEAKER_00: And some of that is visceral fat.
• 7:52
  SPEAKER_00: Visceral fat is not simply the soft fat you can pinch under your skin.
• 7:56
  SPEAKER_00: It is fat stored deep inside the abdomen around your internal organs.
• 8:01
  SPEAKER_00: Metabolically, visceral fat behaves very differently, and research has shown significant increases in abdominal and visceral fat during menopausal transition.
• 8:14
  SPEAKER_00: Even when overall weight doesn't change dramatically.
• 8:18
  SPEAKER_00: Why do I care so much about visceral fat?
• 8:20
  SPEAKER_00: Because visceral fat is biologically active.
• 8:24
  SPEAKER_00: It releases inflammatory signaling molecules and is strongly associated with insulin resistance.
• 8:31
  SPEAKER_00: Insulin resistance meaning your cells are no longer responding to insulin as efficiently.
• 8:36
  SPEAKER_00: So your pancreas has to produce more and more insulin to keep your blood sugar normal.
• 8:43
  SPEAKER_00: And this is critical.
• 8:45
  SPEAKER_00: You can have normal fasting glucose and a normal A1C and still be insulin resistant.
• 8:52
  SPEAKER_00: That is why I do not rely on glucose on A1C only.
• 8:56
  SPEAKER_00: In my own practice, depending on the patient, I will also look at insulin resistance markers because I want to know the whole metabolic picture.
• 9:04
  SPEAKER_00: I have an entire video on insulin resistance because this is one of the most commonly missed pieces of cardiovascular prevention.
• 9:12
  SPEAKER_00: I'll link it in the comments below.
• 9:15
  SPEAKER_00: Visceral fat is also associated with an unhealthy cholesterol pattern.
• 9:20
  SPEAKER_00: What does that even mean?
• 9:21
  SPEAKER_00: It can mean higher triglycerides, more APOB containing particles, changes in HDL, which is your good cholesterol, that helps clear excess cholesterol out of your arteries, and overall a more plaque-promoting pattern in the blood.
• 9:39
  SPEAKER_00: Visceral fat also promotes inflammation.
• 9:42
  SPEAKER_00: Depending on the patient, I may look at inflammatory markers such as high sensitivity CRP or HSCRP as one more piece of the cardiovascular picture.
• 9:54
  SPEAKER_00: Not because one inflammatory marker in isolation tells me the whole story, but because I'm trying to understand the overall environment in which plaque may develop.
• 10:05
  SPEAKER_00: Visceral fat is also associated with endothelial dysfunction.
• 10:10
  SPEAKER_00: Remember, the endothelial is a lining inside your arteries.
• 10:14
  SPEAKER_00: Endothelial dysfunction means that lining isn't doing its job as well as it should.
• 10:20
  SPEAKER_00: The artery doesn't relax and dilate normally.
• 10:24
  SPEAKER_00: Inflammatory signaling increases and the blood vessel environment becomes less healthy.
• 10:30
  SPEAKER_00: Over years, that combination of insulin resistance, inflammation, abnormal cholesterol particles, and vascular dysfunction can create a much more favorable environment for plaque buildup or atherosclerosis.
• 10:46
  SPEAKER_00: So please don't judge your cardiovascular health by the bathroom scale alone.
• 10:51
  SPEAKER_00: You may weigh exactly the same as you did 10 years ago and have a completely different amount of muscle, visceral fat, and metabolic risk.
• 11:01
  SPEAKER_00: There's also evidence that vascular function itself changes through menopause.
• 11:06
  SPEAKER_00: Endothelial function declines, and arteries can become stiffer.
• 11:11
  SPEAKER_00: In the Swan Heart study, arterial stiffness increased by about 7.5% within just one year of the final menstrual period, compared with less than 1% a year before that, roughly an eight-fold jump in the pace of change.
• 11:27
  SPEAKER_00: And it wasn't explained by traditional cardiovascular risk factors.
• 11:31
  SPEAKER_00: Why does that matter?
• 11:32
  SPEAKER_00: A stiffer artery makes your heart work harder with every single beat.
• 11:37
  SPEAKER_00: And arterial stiffness itself is linked to higher blood pressure and future cardiovascular risk.
• 11:43
  SPEAKER_00: That does not mean your arteries suddenly became more blocked.
• 11:47
  SPEAKER_00: Arterial stiffness is different from plaque buildup and means the artery is losing some of its normal elasticity and flexibility.
• 11:55
  SPEAKER_00: But it's another reason this period matters.
• 11:59
  SPEAKER_00: Blood pressure tends to rise as women move through midlife, but this is yet another area where I don't want to oversimplify.
• 12:07
  SPEAKER_00: A lot of the blood pressure rise appears related to aging, body weight, visceral fat, and metabolic changes rather than just losing estrogen.
• 12:16
  SPEAKER_00: So, regardless of the mechanism, know your blood pressure.
• 12:20
  SPEAKER_00: Don't assume that because your blood pressure was 110 over 70 when you were 42, it's still there when you're 57 or 67.
• 12:29
  SPEAKER_00: Resistance training is another place where I think women have been underserved.
• 12:34
  SPEAKER_00: And it's not primarily about looking toned, although that's nice.
• 12:39
  SPEAKER_00: Muscle is metabolically active tissue.
• 12:42
  SPEAKER_00: It helps dispose of glucose, supports insulin sensitivity and your bones, and helps you preserve strength as you age.
• 12:51
  SPEAKER_00: Maintaining muscle can help counter some of the unfavorable body composition changes we see with aging and menopause.
• 12:59
  SPEAKER_00: Research consistently shows that resistance training can preserve or increase lean mass, while aerobic exercise improves cardiovascular fitness and helps reduce body fat.
• 13:11
  SPEAKER_00: Ideally, I want women doing both.
• 13:14
  SPEAKER_00: Walking is fantastic, but walking alone is not your complete exercise prescription.
• 13:20
  SPEAKER_00: And I have an entire video on exercise and cardiovascular health, and I'll link it below in the comments.
• 13:26
  SPEAKER_00: What about sleep?
• 13:28
  SPEAKER_00: Sleep often deteriorates during perimenopause and menopause.
• 13:32
  SPEAKER_00: Hot flashes, night sweats, insomnia, mood changes, and sometimes even sleep apnea can all set in.
• 13:40
  SPEAKER_00: Poor sleep can worsen insulin resistance, affect blood pressure, and affect appetite and weight regulation.
• 13:48
  SPEAKER_00: Observational studies have linked persistent insomnia symptoms in midlife women with later, higher cardiovascular risk that does not prove insomnia causes events, but sleep belongs in the cardiovascular prevention plan.
• 14:05
  SPEAKER_00: It is not just about a wellness issue.
• 14:08
  SPEAKER_00: And what about men?
• 14:09
  SPEAKER_00: Men also experience age-related hormonal changes, including declining testosterone levels, and those hormonal changes can be associated with changes in body composition, insulin sensitivity, and cardiovascular health.
• 14:23
  SPEAKER_00: But that transition is physiologically different from menopause.
• 14:27
  SPEAKER_00: Women experience a much more distinct loss of ovarian function and a substantial decline in estrogen.
• 14:35
  SPEAKER_00: So I don't want to turn this video into a testosterone discussion, but I do have an upcoming video specifically on hormone replacement in both men and women and what we actually know about cardiovascular risk.
• 14:50
  SPEAKER_00: That is where I'm going to get into estrogen, testosterone, progesterone, timing, who may benefit, who may not, and what the heart data actually shows.
• 15:01
  SPEAKER_00: There's one group where menopause itself becomes an especially important cardiovascular risk marker.
• 15:07
  SPEAKER_00: Women who go through menopause unusually early.
• 15:11
  SPEAKER_00: In a pooled analysis of more than 300,000 women across 15 studies compared with menopause around age 50 to 51, menopause before age 40 was associated with about a 55% higher cardiovascular risk.
• 15:30
  SPEAKER_00: Menopause between 40 and 44 was associated with about a 30% higher risk.
• 15:36
  SPEAKER_00: And menopause between 45 and 49 was associated with about a 12% higher risk.
• 15:42
  SPEAKER_00: So if you had premature or early menopause, please make sure your doctor knows that belongs in your cardiovascular history.
• 15:51
  SPEAKER_00: So what do I want women to actually know?
• 15:54
  SPEAKER_00: Whether you're entering menopause now or went through it 15 years ago, know your numbers.
• 16:00
  SPEAKER_00: And I mean all of them.
• 16:02
  SPEAKER_00: Your blood pressure, LDL, APOB, triglycerides, Elipoprotein A at least once, fasting glucose, A1C, your insulin resistance markers, and inflammation markers when appropriate.
• 16:17
  SPEAKER_00: Know your waist circumference and body composition, not just your weight, and know your family history.
• 16:23
  SPEAKER_00: Tell your doctor if you had premature menopause, pre-eclampsia, or gestational hypertension, or gestational diabetes.
• 16:32
  SPEAKER_00: Those all belong in your cardiovascular history.
• 16:36
  SPEAKER_00: And please don't automatically assume that every new symptom is just menopause.
• 16:42
  SPEAKER_00: New exertional chest pressure, windedness, a significant unexplained decline in exercise tolerance, fainting, or even new sustained palpitations, which is skipping of your heartbeat, deserve evaluation.
• 16:58
  SPEAKER_00: So if you remember one thing from this video, remember this.
• 17:03
  SPEAKER_00: Menopause can be a major turning point for your heart.
• 17:07
  SPEAKER_00: As estrogen declines, your metabolic and vascular environment changes.
• 17:13
  SPEAKER_00: You may accumulate more visceral fat, insulin resistance may worsen, LDL and APOB rise, triglycerides may rise, your arteries can become stiffer, and your blood pressure and sleep can both start to shift.
• 17:28
  SPEAKER_00: Those changes can influence what happens to your arteries over the next 10, 20, or 30 years.
• 17:35
  SPEAKER_00: The answer is not to fear menopause.
• 17:37
  SPEAKER_00: The answer is to recognize what is changing and intervene early.
• 17:42
  SPEAKER_00: And I'll say this too: menopause isn't only a list of risks to manage.
• 17:48
  SPEAKER_00: For a lot of women, this stage of life also opens doors, more time and focus for yourself.
• 17:54
  SPEAKER_00: Often after years spent raising a family or building a career, a real chance to reinvest in your own health and your own goals.
• 18:03
  SPEAKER_00: I want you walking into this stage informed, not afraid, and using that shift toward focusing on yourself as part of the motivation to take your cardiovascular health seriously too.
• 18:16
  SPEAKER_00: I know the next question many of you are going to ask: if estrogen was doing all of these things, should I replace it?
• 18:23
  SPEAKER_00: What about progesterone?
• 18:25
  SPEAKER_00: What about testosterone?
• 18:26
  SPEAKER_00: What about testosterone in men?
• 18:28
  SPEAKER_00: Does timing matter?
• 18:30
  SPEAKER_00: Does oral versus transdermal estrogen matter?
• 18:33
  SPEAKER_00: Who may benefit?
• 18:34
  SPEAKER_00: Who should not take hormones?
• 18:36
  SPEAKER_00: And does hormone replacement actually prevent heart disease?
• 18:40
  SPEAKER_00: I have an entire upcoming video devoted specifically to hormone replacement in both men and women and cardiovascular risk because that subject deserves its own discussion.
• 18:52
  SPEAKER_00: For now, I want you to leave with this.
• 18:55
  SPEAKER_00: Know your numbers, know your insulin resistance, and know your inflammation.
• 19:00
  SPEAKER_00: Pay attention to visceral fat and muscle, not simply your weight.
• 19:04
  SPEAKER_00: Protect your sleep and maintain your fitness.
• 19:08
  SPEAKER_00: Use this stage of life as an opportunity to change your cardiovascular trajectory before disease becomes an event.
• 19:20
  SPEAKER_00: If you want to go deeper on it, watch my video on why your A1C can still be normal, even when your insulin resistance.
• 19:28
  SPEAKER_00: I break it all down there.
• 19:31
  SPEAKER_00: It's showing up on your screen now.
• 19:33
  SPEAKER_00: And I'll see you in the next one.