Cholesterol and Menopause: Levels, Management and HRT

Cholesterol plays an important role in the body’s production of cells, vitamins, and steroid hormones. Made in the liver, the waxy, fat-like substance is transported through the blood by lipoproteins, including low-density lipoprotein (LDL) and high-density lipoprotein (HDL). The body also gets cholesterol from dietary sources.⁽¹⁾⁽²⁾

What is considered a healthy cholesterol level is different for everyone, depending on factors such as age, sex, past medical history, and medication use. On average, a healthy LDL cholesterol level for women aged 20 and older is less than 100 milligrams per deciliter (mg/dL), while a healthy HDL level is 60 mg/dL or higher.⁽³⁾

While high levels of HDL, or “good” cholesterol, may help protect against cardiovascular issues, elevated LDL, or “bad” cholesterol, can increase the risk of arterial plaque buildup and heart disease. Women become more susceptible to cardiovascular disease following menopause. Experts believe this may be due to fluctuations in sex steroid hormones, which are known to influence cholesterol levels.⁽⁴⁾ 

This article will explain how changes in hormones can affect cholesterol levels throughout different stages of menopause and how women can manage high cholesterol to support heart health later in life.

The Role of Hormones in Cholesterol Levels During Menopause

Estrogen levels fluctuate and steadily decline during menopause. As the primary sex steroid hormone in women, estrogen helps balance the body’s lipoprotein levels. It also regulates the metabolization of cholesterol in the liver. Higher estrogen levels during a woman’s reproductive years contribute to increased HDL cholesterol levels.⁽⁴⁾⁽⁵⁾Estrogen may also influence reverse cholesterol transport, a metabolic process in which excess cholesterol is circulated back to the liver, converted into bile, and expelled from the body as waste. These actions may explain estrogen’s potential protective effects against cardiovascular disease.⁽⁴⁾

Because of the relationship between estrogen and cholesterol, hormonal changes during menopause may affect women’s lipoprotein levels. Results from a scientific review published in Menopause showed that postmenopausal women had higher total cholesterol and LDL cholesterol levels compared to premenopausal women, potentially increasing their risk of heart disease and stroke.⁽⁶⁾

How Different Stages of Menopause Affect Cholesterol Levels

Cholesterol levels can vary depending on the stage of menopause. Here’s how lipoprotein levels may change from perimenopause to postmenopause.

Perimenopause and Its Impact on Cholesterol Levels

Perimenopause is the time in a woman’s life when irregularities in menstruation begin to occur as hormone levels start to fluctuate. Also called the menopause transition, perimenopause lasts an average of four years until a woman has not had a period for 12 consecutive months. As women enter the menopause transition, cholesterol levels may gradually change over time.

Researchers from a study published in the American Journal of Epidemiology looked at the link between lipid changes and women’s menopause status.⁽⁷⁾ The categories for menopausal status included premenopause, early perimenopause, late perimenopause, early postmenopause, and late postmenopause.

The research findings revealed that although cholesterol levels increased slightly, they remained similar in premenopausal and early perimenopausal women. However, total cholesterol and LDL cholesterol levels were highest during late perimenopause and early postmenopause. HDL cholesterol levels also peaked during late perimenopause. While higher HDL levels generally support heart health, some research indicates that HDL quality may change over the course of the menopause transition, potentially reducing its protective effects.⁽⁸⁾

Postmenopausal Changes in Cholesterol

Cholesterol levels may continue to change as postmenopausal women age. A study found that postmenopausal women had higher total and LDL cholesterol levels and lower HDL cholesterol levels compared to perimenopausal women.⁽⁹⁾ Another study found that postmenopausal women who were six or more years past menopause had lower HDL cholesterol and higher LDL cholesterol than those who had experienced menopause less than two years prior.⁽¹⁰⁾

Changes in cholesterol levels can put postmenopausal women at greater risk for cardiovascular disease. Some research suggests that plaque builds up more quickly in postmenopausal women than in men, potentially due to an imbalance of estrogen and testosterone that occurs during menopause. This imbalance can cause changes in blood clotting and fat storage, making women more vulnerable to heart problems.⁽¹¹⁾ 

Other Contributing Factors to Higher Cholesterol During Menopause

In addition to hormone fluctuations, certain menopausal symptoms may also contribute to cholesterol changes during menopause:

• Weight Gain: Abdominal weight gain is common during menopause. Increased body weight can raise LDL cholesterol and decrease HDL cholesterol.⁽⁵⁾

• Sleep Disturbances: Many women experience sleep loss during menopause due to disruptive vasomotor symptoms. Poor sleep can raise cholesterol levels and increase the risk of metabolic disorders.⁽¹²⁾

• Stress: Menopause is a life event that can heighten women’s stress levels. Increased stress is a common psychological symptom experienced during menopause that can trigger excess cholesterol production.⁽¹³⁾

• Low Energy: Menopausal women may feel their energy levels drop as they age. This may lead to reduced physical activity, which can increase the risk of high cholesterol.

Lipid changes may also be influenced by the following factors:⁽¹³⁾

• Genetics: People with a family history of high cholesterol are more prone to the condition.

• Aging: As the metabolism slows down with age, high cholesterol becomes more common in individuals aged 40 to 59.

• Smoking: Smoking has been linked to lower HDL cholesterol levels in women. It can also increase LDL cholesterol.

• Medications: Some adults take more medications as they age. Among other drugs, certain heart and blood pressure medications can cause abnormal lipid levels.

• Health Conditions: Conditions such as sleep apnea, diabetes, and polycystic ovary syndrome (PCOS) are associated with high cholesterol.

Signs of High Cholesterol 

People with high cholesterol are typically asymptomatic. However, individuals with a family history of extremely high LDL cholesterol levels, known as familial hypercholesterolemia, may experience the following symptoms:⁽¹⁴⁾

• Fatty Skin Bumps: Medically referred to as xanthomas, these yellow or orange bumps may develop under the skin’s surface due to an accumulation of fat. These bumps often appear on the buttocks, knees, hands, and other areas of the body.

• Corneal Arcus: This is an eye condition in which a gray or white ring develops around the cornea. 

A blood test (lipid panel) can determine whether a person has high cholesterol. Recommendations for testing frequency vary, but women aged 55 to 65 are generally advised to be tested annually or every two years. Younger adults may be tested every five years.⁽³⁾

How to Manage Cholesterol During Menopause

Women can take steps to manage their cholesterol during menopause. The following healthy habits and treatment options may help lower high cholesterol levels:⁽⁵⁾

• Making Dietary Adjustments: Eating plenty of fruits, vegetables, whole grains, and fish can help keep cholesterol levels within a healthy range. It’s also recommended to limit LDL-raising foods like red meat, dairy, and those containing artificial sweeteners.

• Getting Weekly Exercise: Activities like walking, bicycling, and even gardening can help lower cholesterol. Adults are recommended to get at least 150 minutes of moderate to vigorous aerobic exercise every week.

• Maintaining a Healthy Weight: High cholesterol has been linked to obesity and being overweight. Maintaining a healthy weight through a balanced diet, regular exercise, and quality sleep can help with weight management and maintenance.

• Reducing Stress Levels: Practicing mindfulness and self-care strategies during menopause may help manage stress and support healthy cholesterol levels.

• Monitoring Cholesterol Levels: While diet, exercise, weight management, and stress reduction are all important for heart health, some postmenopausal women may still develop high cholesterol. It’s recommended that women work with their healthcare provider to regularly monitor cholesterol levels, particularly during the menopause transition.

• Taking Medications: In addition to implementing healthy lifestyle changes, a doctor may prescribe medication to help lower cholesterol.

Hormone Replacement Therapy (HRT) and Cholesterol

Hormone replacement therapy (HRT) may help improve total, LDL, and HDL cholesterol levels in postmenopausal women.⁽¹⁵⁾ While studies have produced varied results, HRT may also provide cardiovascular benefits. Women who begin using HRT before the age of 60 or within 10 years of reaching menopause have a lower risk of cardiovascular disease compared to women who don’t use HRT.⁽¹⁶⁾ However, HRT is currently not recommended as a preventive treatment method.

While rare, HRT is associated with risks such as blood clots, stroke, and breast cancer.⁽¹⁶⁾ Specific forms of HRT, such as low-dose estrogen, transdermal HRT, and the addition of micronized progesterone for patients with a uterus, may help reduce the risk of certain adverse effects.⁽¹⁵⁾ However, HRT may not be recommended for women with certain health conditions, such as cardiovascular or blood clotting disorders, due to a higher risk of complications.

HRT is considered a safe and effective treatment for menopausal symptoms. A doctor will assess its suitability on a case-by-case basis, considering factors such as a patient’s age, medical history, and age since menopause, along with other individualized considerations.

The Importance of Monitoring Cholesterol During Menopause

Cardiovascular disease is the leading cause of death among women in the United States.⁽¹⁶⁾ Women have higher levels of estrogen during their reproductive years, which may lower their risk for cardiovascular disease. However, as hormone levels fluctuate during menopause, it becomes increasingly important to keep an eye on factors that can impact heart health, such as high cholesterol.

Women approaching menopause should consult with their doctor about HRT options and treatment and management strategies for high cholesterol. Taking proactive steps can help maintain cardiovascular health throughout menopause and beyond.