Changes in heart health begin in perimenopause


“Don’t it always seem to go, that you don’t know what you’ve got ‘til it’s gone.” Samar R. El Khoudary, PhD, MPH, used Joni Mitchell’s popular song lyrics to introduce the crowd to her session, “Health is Where the Heart Is,” which addressed the connection between heart health and menopause.

Samar R El Khoudary, PhD, MPH, BPharm, FAHA, is Vice Chair and Associate Professor of Epidemiology at the Epidemiology and Translational Science Institute at the University of Pittsburgh in Pennsylvania. Khoudary’s research focuses on cardiovascular disease in midlife women.

The menopause transition has been linked to adverse changes that are critical to heart health. These include body fat distribution, lipids and lipoproteins, and vascular health measures. Surprisingly, guidelines for cardiovascular disease management do not recommend hormone therapy, but focus primarily on a healthy lifestyle.

Khoudary presented additional heart health-related statistics her and her team found during research.

“Our heart is not just a place where we store feelings and emotion. Our heart works without stopping,” Khoudary began. “When we are in our 39 to 50 [year] age range, obesity enters your life, blood pressure, glucose, cholesterol. As we get older, these risk factors accumulate.”1

The American Heart Association defined 7 risk factors that people can improve through lifestyle changes to help achieve ideal cardiovascular health, which Khoudary noted and referenced throughout her session. The factors to monitor were glucose, cholesterol, blood pressure, body mass index (BMI), physical activity, diet, and any smoking habit.2

According to Khoudary, a healthy lifestyle can prevent a substantial majority of heart diseases in women. Healthy lifestyle metrics include physical activity, not smoking, weight control, and a healthy diet (e.g., high in fiber, whole grain, fruits and vegetables, fish, low in saturated and trans-fat). According to the National Health and Nutrition Examination Survey from 2007 to 2008 and 2011 to 2012, only 21% of females 20 years or older have 5 or fewer healthy lifestyle metrics at ideal levels (n=84, 129, 14 years of follow-up).3

“Metabolic syndrome is a constellation of cardiovascular risk factors,” said Khoudary, “and women experience increased risk in these constellations.”

Research was able to show that women also accumulate visceral fat in their abdomen, she said. “During midlife, women have more fat around their heart itself and the vessels. This fat has a more dramatic impact than the visceral because of its close anatomical location,” she stated.

The same goes for lipids. “In a study of women’s health across the nation, researchers saw significant rise in bad cholesterol within one year of menopause, and, in a follow-up work, we were able to show that this increase is not benign. It’s actually increased carotid plaque,” Khoudary said.

“The particles themselves are not as they used to be. During the menopausal transition, women are at higher risk of vascular vulnerability, [with a] change in the different layout of the vessels. The lumen becomes wider, the wall becomes thicker, and the stiffness increases,” she said.

Favorable cardiovascular health at a young age extended survival by 4.5 to 7 years, according to a 40-year follow-up of the Chicago Heart Association study.4

“We have the data. We know the tools,” she said. “But what’s shocking here is that, when you look at data from the American Heart Association, only 21% of females older than or equal to 20 years have at least 5 of these together.”

The Chicago Heart Association project analyzed 25,000 participants aged 18 to 74 years and followed them for more than 14 years. “The research showed us that favorable cardiovascular health at a younger age extended survival by almost 4 years,” Khoudary pointed out.4

“As a practitioner, heart health matters,” Khoudary said. “Our heart is precious. It keeps us enjoying this beautiful life, and we should not take [it] for granted."


  1. El Khoudary, S. R. 2021 September 21. Health is Where the Heart Is. North American Menopause Society Annual Meeting, Washington, D.C.
  2. My Life Check | Life’s Simple 7. Published 2018. Accessed September 21, 2021.
  3. NHANES - National Health and Nutrition Examination Survey Homepage. Published 2021. Accessed September 21, 2021.
  4. Allen NB, Zhao L, Liu L, et al. Favorable Cardiovascular Health, Compression of Morbidity, and Healthcare Costs. Circulation. 2017;135(18):1693-1701. doi:10.1161/circulationaha.116.026252
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