The Heart Risk Hiding Behind Your Hot Flashes

We have done a remarkable job teaching women to fear breast cancer and to get screened for it, and I wouldn’t take back a single pink ribbon that gets worn each October. Those ribbons show what years of steady awareness can do for women’s health, and I’d love to see that same energy go toward a second color — red.

In 2023, 42,213 women in the United States died of breast cancer. That same year, heart disease killed 304,970 women, about seven times as many, causing roughly one in every five female deaths. But only about half of women know heart disease is their leading killer.

I’m the daughter of a cardiologist who grew up to become an OB-GYN, and I still came to this information late. I wrote about my own wake-up call earlier this year, when I finally understood that my pregnancy complications belonged in my cardiac history. That piece covered the clues pregnancy leaves behind. This one is about the clues that show up later, in the years around your last period, when most women are still seeing a gynecologist and very few are seeing a cardiologist.

For years, the rise in heart risk after midlife got chalked up to plain old aging. A new review in Obstetrics & Gynecology makes the case that menopause does its own work on the heart, separate from the birthdays. It also points out that gynecologists are often the main doctors women see in midlife, which puts us in a good position to notice when something is amiss. Here are a few important things I want every patient to think about.

What happens to cholesterol around your last period

LDL, the cholesterol most closely tied to clogged arteries, climbs during the menopause transition. So does apolipoprotein B, or ApoB, a protein that sits on every LDL particle and its plaque-forming cousins, which makes it a way of counting how many of those particles are in your blood. The sharpest increases happen right around the final period, a pattern that points to menopause rather than age. That means your cholesterol can rise because of menopause, even when your diet and habits haven’t changed.

HDL earned its reputation as the “good” cholesterol. Its job is cleanup: It picks up extra cholesterol from artery walls and carries it back to the liver to be cleared, which is why a higher HDL number has always been reassuring. Around menopause, HDL levels often go up while each particle gets worse at the job. Picture a house that suddenly has more vacuums, each with weaker suction. Higher HDL after menopause has even been linked to more early plaque in the arteries. After your final period, more HDL doesn’t automatically mean more protection, and that is news to a lot of women.

Fat moves before the scale does

Most of the weight women gain in midlife tracks with age. Menopause changes where that weight goes and what it’s made of. As the transition begins, the rate of fat gain doubles and muscle starts to decline. Visceral fat, the deep fat packed around the organs, builds fastest in the two years leading up to the final period, at about 8 percent a year, then keeps rising at a slower pace afterward. More of it is linked to thicker artery walls.

Your scale can hold perfectly steady while your heart risk shifts underneath it. A waist measurement says more about this kind of change than BMI does, so ask for one at your next visit.

Hot flashes, sleepless nights, and your heart

Hot flashes are usually treated as a nuisance, a quality-of-life problem, and they absolutely are one. They may also be telling you something about your heart.

Women with hot flashes tend to have higher blood pressure over the years, and high blood pressure is a major risk factor for heart disease. That helps explain why women with menopausal symptoms, hot flashes included, have a higher risk of coronary heart disease. Hot flashes have also been linked to arteries that don’t relax and widen as easily, and to more calcium buildup in the aorta, the body’s main artery, even when blood pressure and cholesterol are taken into account.

Sleep belongs in this conversation too. Women whose insomnia stuck around through midlife had a 71 percent higher risk of heart attack, stroke, heart failure, and other heart events, even after accounting for hot flashes and depression. If you’re lying awake at 3 a.m. night after night, bring it up at your appointment and make sure it gets taken seriously as part of your heart health.

The age you reached menopause counts

Age at menopause is one of the most useful heart questions a doctor can ask — and, unfortunately, one that’s asked least. Compared with menopause at 50 or 51, reaching menopause before 40 raises the risk of cardiovascular disease by about 55 percent, and menopause between 40 and 44 raises it by about 30 percent. Having both ovaries removed before 40 carries even more risk than reaching menopause that early on its own. Early menopause belongs on the list of female-specific heart risk factors, alongside pregnancy complications, PMOS, and autoimmune disease, and the American Heart Association has called the menopause transition a window for early prevention.

Many of the risk calculators doctors use lean heavily on age, so a 47-year-old can look low-risk on paper while several of these clues stack up. The American Heart Association’s newer PREVENT tool also estimates risk over 30 years, which gives women in their 40s and 50s a more realistic picture.

Menopause hormone therapy

Menopause hormone therapy is the most effective treatment we have for hot flashes, and for healthy women who start it before 60 or within 10 years of their last period, the benefits generally outweigh the risks. It isn’t prescribed to prevent heart disease. Your heart health does help decide which form makes the most sense, and estrogen through the skin is often preferred over a pill for women with some heart risk. Patches have been hard to find lately, so it helps to know that estrogen gels and the vaginal ring that delivers estrogen throughout the body are options too.

Women at high heart risk, or who have had a heart attack, stroke, or blood clot, have generally been advised against systemic estrogen. Even then, it’s a conversation worth having with your doctor before anyone decides for you. Decades of misinformation have left many women convinced they aren’t candidates, and far more women can safely consider hormone therapy than currently believe they can.

What you can ask for at your next appointment

You don’t need a cardiologist to get started. Most of this fits into a regular gynecology or primary care visit.

• Tell your doctor how old you were at your last period (or your best guess, if a hysterectomy or hormonal IUD makes that hard to pin down), and whether your ovaries were removed.

• Bring up hot flashes, night sweats, and trouble sleeping, and ask whether anyone is connecting them to your heart health.

• Ask for a cholesterol panel during the transition instead of relying on one from years ago, and ask whether ApoB testing makes sense for you.

• Keep an eye on your blood pressure over time, not only the reading at today’s visit. A home cuff helps.

• Ask for a waist measurement.

• Share your pregnancy history, especially high blood pressure in pregnancy, preeclampsia, or preterm delivery.

• Ask for a PREVENT risk estimate, and what your doctor plans to do with the number.

Keep the pink ribbons. Just make some room for red, too.

Sarah Berg, MD, is a board-certified OB-GYN and certified menopause practitioner who spent over a decade in clinical practice caring for women across all stages of life. She now focuses on evidence-based education and storytelling that helps women understand their bodies, prioritize preventative care, and navigate midlife health with clarity and confidence. Learn more at Selfority.

The post The Heart Risk Hiding Behind Your Hot Flashes appeared first on Katie Couric Media.