Cardiovascular health in midlife was discussed during a plenary symposium at the Menopause Society 2025 Annual Meeting. Garima Sharma, MD, discussed sex-specific risk factors associated with cardiovascular disease (CVD) in midlife, including the menopause transition (MT), which we focus on here. Currently CVD in women remains understudied, under-recognized, underdiagnosed, and undertreated; and under-represented in clinical trials.
CVD risk factors include diabetes, hypertension, hyperlipidemia, smoking, a family history of CVD, weight gain, sleep disorders in midlife, premature ovarian failure, and premature menopause, both natural and surgical.
Dr. Sharma said improving CV competencies during MT requires multi-disciplinary scalable, integrative, and collaborative approaches involving specialists in sleep medicine, behavioral health, oncological, gynecologic, urologic care, and CV care focused on cardiometabolic health, diet, and nutrition.
Erin Donnelly Michos, MD, discussed primary prevention of CVD in women, reviewing the contributions of blood pressure (BP), lipids, and diabetes. The majority of women at midlife and beyond have hypertension, which is undertreated and controlled in only about 1 in 4, yet confers a greater relative risk for myocardial infarction for women vs men. Declining estrogen during MT influences BP in multiple ways. Lowering systolic BP reduces major cardiovascular events similarly in women and men.
Dr. Michos said all lipid fractions get worse in most women at menopause, including increased total cholesterol, low-density lipoprotein cholesterol (LDL-C), and triglycerides, and decreased high density (HD) L-C. Cholesterol matters as much or more for women as for men. LDL-C. is a causal agent for atherosclerotic CVD pathogenesis, and a primary target for CVD prevention. High HDL-C cannot counteract high LDL-C and is never a reason not to treat a patient with lipid-lowering therapy who would qualify based on LDL- and apolipoprotein B-related risk.
Statins as well as non-statin therapies show similar benefit for women and men in lowering LDL-C, yet women are less likely to be treated with lipid management in both primary and secondary prevention of CVD because their risk may be underestimated.
Early menopause is associated with an increased risk of diabetes. Diabetes confers a greater relative CVD risk in women, which should be managed along with other CV risk factors. Cardiorenal protective sodium-glucose transport-2 (SGLT2) inhibitors benefit women as much as men, as do glucagon-like peptide-1 receptor agonists (GLP1-RA), which reduce stroke as well as CV events.
Lifestyle is the foundation of all preventive efforts. High risk individuals may also need pharmacotherapy plus lifestyle to reduce their risk of CVD, the leading cause of mortality in women. Randomized clinical trials across therapeutics for BP, lipids, and diabetes indicate women benefit as much as men do for CV risk reduction; 90% of attributable risk for myocardial infarction is due to modifiable risk factors.
“The best intervention is prevention,” Dr Michos said.. She concluded, “Atherosclerosis represents a clinical paradox: it is potentially the most preventable or treatable chronic disease, yet it remains the greatest cause of disability and death throughout the world. This does not have to be the case. We need to treat risk factors and focus on prevention.”
Dr. Lederman has no conflicts of interest to report.
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