Kelly Officer, 49, eats a vegan diet and shuns most processed foods. So, after a recent routine blood test revealed that she had high cholesterol, “I was shocked and upset,” she says, “since it never has been [high] in the past.”
Officer is not alone. As women enter menopause, cholestrol levels jump—by an average of 10-15%, or about 10 to 20 milligrams per deciliter. (A healthy adult cholesterol range is 125-200 milligrams per deciliter, according to the National Library of Medicine.)
This change often goes unnoticed amidst physical symptoms and the general busyness of those years. But, says Dr. Erin Michos, director of women’s cardiovascular health at Johns Hopkins Medicine, “we need women to get screened and know their numbers.” High cholesterol is a leading risk factor for heart disease, which kills more women in the U.S. than any other cause, including all forms of cancer combined. And the longer someone lives with high cholesterol, the greater the odds that it will build up in their arteries and cause a heart attack or stroke.
Many factors around midlife conspire to push cholesterol levels up, such as a sedentary lifestyle, less healthful diet, and weight gain. But the one that stands out as a clear driver of this shift is the sudden, unavoidable drop in estrogen levels at menopause. Unlike other issues that begin in perimenopause—mood changes, hot flashes, fatigue—the rise in cholesterol tends to happen fairly suddenly, typically in the year before through the year after menopause.
Researchers are learning more about how and why this change happens, how better to screen for it, and the best treatments for women. But the first step is to acknowledge it. “This is a normal transition,” Michos says. And menopause marks an essential time for women to check in on their health.
Read More: How to Lower Your Cholesterol Naturally
The big cholesterol change
Before women go through menopause, which typically arrives around age 51 in the U.S., they tend to have healthier cholesterol profiles and lower rates of cardiovascular disease than their male counterparts. But with the onset of menopause, that advantage drops off. By the time people reach their 60s and 70s, the rates of cardiovascular disease are almost even between sexes, with women surpassing men in this risk by their 80s. And women who go through menopause early are at an even higher risk sooner.
Estrogen’s protective effect on cholesterol is apparent even before menopause, as cholestrol levels rise and fall slightly with estrogen level fluctuations throughout each menstrual cycle. Researchers are still teasing out the details about how estrogen influences cholesterol, but much of it can be traced back to the liver, where estrogen receptors help to dictate a person’s lipid profile.
The resulting patterns are clear: Once the body stops making as much estrogen, overall lipid profiles turn more harmful. Levels of “bad” cholesterol (low-density lipoproteins, or LDL) and triglycerides rise, and “good” cholesterol (high-density lipoproteins, or HDL) falters.
Even the remaining HDL might become less protective, says Samar El Khoudary, an associate professor at the University of Pittsburgh School of Public Health. Her research has shown that although HDL is a marker of decreased risk for heart disease before menopause, the opposite might be true after menopause. So it’s not just the quantity and balance of these particles, but also that “the quality of these particles changes as women transition through menopause,” she says.
Test and assess
The only way to determine cholesterol levels around menopause is to test for them. But predicting the timing is difficult. Menopause is usually only apparent once it’s over and a person has already gone a year without a period.
Current recommendations suggest most people at low risk for cardiovascular disease have their cholesterol checked every five years, starting at age 20. (Even children and adolescents should have baseline cholesterol screenings.) Experts advise additional testing if there is a family history of high cholesterol or there has been a substantial health change, such as abdominal weight gain, periods of high stress, or menopause.
Regular tests are important because heart disease risk goes up the longer high cholesterol remains untreated. And cholesterol can be a quiet killer: “If you don’t check, you don’t know,” says Dr. Samia Mora, a cardiovascular specialist and director of the Center for Lipid Metabolomics at Brigham and Women’s Hospital and associate professor at Harvard Medical School.
Of course, not all women who go through menopause develop high cholesterol. If someone’s baseline cholesterol has been healthy, and if their other risk factors for heart disease are low, an average rise in cholesterol levels is usually not immediately worrying.
But additional testing might be warranted if cholesterol levels or other cardiovascular disease risk factors (such as family history, high blood pressure, diabetes, obesity, and smoking) are high. Other tests that doctors might recommend include a coronary calcium scan that measures the amount of plaque buildup in the arteries around the heart or a check of lipoprotein (a), which is a form of LDL that can reveal more about cardiovascular risks.
El Khoudary and others say that doctors should also start looking beyond standard lipid panels for more details about a person’s cholesterol, including particles’ size, shape, and composition. Research has found that, for example, smaller particles of LDL are more harmful than larger ones. Such tests exist—El Khoudary and others use them in research—but they are harder to get through standard clinician visits. She says incorporating these details into care could be even more helpful for women as they transition through menopause and shape their health for the next decades of life.
Treating is succeeding
For women whose cholesterol rises to unhealthy levels during menopause, lifestyle adjustments are usually the first recommendation. “We can’t avoid aging, we cannot avoid our genetics, but we can change our lifestyle to counteract these effects,” Mora says.
Diet alone can impact cholesterol by 20 to 30 milligrams per deciliter. Even when diet alone cannot get someone into a healthy range, Michos likes to remind patients that their cholesterol would likely be even more harmful without the extra effort. And she sees plenty of women going through menopause who, even with vegan diets, ultimately need cholesterol-reducing medication.
Statins are the standard pharmaceutical treatment for people with high cholesterol, including those in menopause. But women are less likely to go on statins, due to a combination of health care providers being less likely to recommend them and women being less likely to agree to take them. This trend is unfortunate because women can get a greater benefit from statins than men do, says Dr. Patricia Best, a cardiologist at Mayo Clinic and the Women’s Heart Clinic and an associate professor at Mayo Clinic College of Medicine and Science.
Best sees people get discouraged when their lifestyle efforts fail to generate healthy cholesterol levels—and many then avoid medications because taking them makes them feel like they’ve failed. “It’s really important to understand that sometimes even if you do everything right, you’re still going to end up needing a medication,” Best says. That is not failure, she says. Starting on medication to manage high cholesterol is a success: “The most important thing is to keep yourself healthy over the long haul.”
Experts also warn that the way many doctors calculate the need for statins or other cholesterol treatment is based on a 10-year risk of a major event like a heart attack or stroke. But, particularly for women in midlife, these risk-scoring systems do not capture the lifetime risk and the years of accumulating risk leading up to that point. “You don’t want to wait until 65 to start instituting all of these preventive [measures] that are going to help for quality of life throughout the rest of her years,” Mora says.
If a drop in estrogen prompts an increase in cholesterol, what about adding estrogen back into the body, such as with hormone replacement therapy? Typically taken as synthetic estrogen pills, hormone replacement therapy is frequently prescribed for hot flashes and other menopause symptoms. And many women who do take it see an improvement in cholesterol levels. However, it’s not recommended solely as a cholesterol drug, in part because estrogen also increases the risk for blood clots.
As with much of health, the best bet is prevention, which includes having a healthy lifestyle for as many years as possible. “It’s not just how high your cholesterol is now, but how long it has been high,” Mora says. “All of the years exposed to high cholesterol are cumulative. On the plus side, lifestyle interventions are also cumulative.”
Read More: What to Know About High Cholesterol in Kids
How—and why—to prioritize cholesterol
Menopause often coincides with a potentially stressful and busy time in women’s lives, when their careers are still in full swing, and they may be providing care for their offspring as well as their parents. Amid these pressures, women often put their own health aside, foregoing exercise and healthy food—and missing routine health care, including cholesterol checks.
But healthy habits during this period are particularly important, Best says. “A little bit more exercise, a little bit more thoughtfulness [about] diet can really make a huge difference—because it’s during the next decade that women are at a marked increased risk of heart disease.”
The hard truth is that with the inevitable metabolic shifts during middle age, what used to work to stay healthy might not cut it anymore, Best says. “Your body is changing, so you have to adapt.”
When a shift in hormones is coupled with weight gain, “that’s your one-two punch” that can lead to a high cholesterol reading—often for the first time in a woman’s life, Best says. This pattern has become even more familiar in the past couple of years. For example, although Officer used to exercise regularly, since the pandemic disrupted her previous routines, she says that healthy habit fell by the wayside, and she has now put on extra weight.
To help combat menopause-related cholesterol shifts, women don’t need to start running marathons or even going fully vegan, Mora says. She recommends a heart-healthy diet, such as a Mediterranean diet, with plenty of fruits, vegetables, and whole grains and low amounts of processed foods and refined carbohydrates. Other often-overlooked lifestyle adjustments, she says, including getting enough sleep and managing stress—which can help not just cholesterol but overall cardiovascular and metabolic health.
Mora, who is around menopause age herself, tries to follow smart lifestyle habits about 80-90% of the time. This means she eats lots of fruits and nuts and takes the stairs instead of the elevator—but still eats the occasional dark chocolate bar. “We get overwhelmed with trying to change everything at once,” Mora says. “All you need to do is institute a moderate amount of healthful lifestyle behaviors that you do consistently most of the time.”
Best agrees that trying to make healthy decisions all the time can be daunting. She’s 53, the mother of two children, and married, and she holds multiple positions at the Mayo Clinic as well as with other professional groups. “So I fully understand my patients when they’re like, ‘Are you kidding me? How am I going to fit that in?’”
Best has been folding healthy activities into her daily life, such as cooking as a family or walking with her husband. Not only are these good for her own health, she says, “but it’s good for everyone else in the family.”
Despite these efforts—and her own clinical expertise—even Best’s cholesterol went up during menopause. “It’s always disappointing,” she says. She didn’t lose her resolve though. “Gaining weight and having worse cholesterol are expected, but you can also fight through all of those things.”
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