Why Estrogen Protects the Heart (and Why It’s Not a Prescription)

Hello friends❣️

Welcome to the February 3rd edition of Menopaussible—bringing you the news you can use and the ⚡ energy ⚡ you need to support your menopause journey.

I'm Maria Caracci Ciccolella—mindset coach and menopause advocate.
​(Connect with me ​IG​ or ​​LinkedIn​​!)

We have arrived in February which is American Heart ♥️ Health Awareness Month, an important designation as only 44% of women recognize cardiovascular disease as their leading health threat—responsible for nearly 1 in 3 deaths.

Heart disease has a different profile in women than in men, and the risk for the disease increases with the onset of menopause—largely because women lose the cardioprotective benefits associated with estradiol (estrogen). Which of course begs the question—if estrogen has cardioprotective benefits, why then, is menopause hormone therapy (MHT) not prescribed as a preventative measure?

We’re here to tackle that question below—let’s dive in shall we?

Estrogen’s Role in Our Heart Health

Among its varied duties within the body, estrogen takes on some key responsibilities when it comes to heart health:

For one, it regulates blood vessel pliability, helping blood vessels relax and expand to accommodate blood flow. As estrogen levels decline—and alongside the aging process—blood vessels become stiffer, which may cause blood pressure to rise, leading to hypertension (high blood pressure). Hypertension in turn, can drive artery wall damage, allowing for arterial plaques, which are mostly cholesterol (LDL), to build up.

Also significantly, it helps with cholesterol management, regulating cholesterol by assisting in the metabolism of fats in the liver, while also clearing cholesterol from tissues in your body, which is then excreted in waste. This process is disrupted with the withdrawal of estrogen, leading LDL (“bad”) cholesterol to increase and HDL (“good”) cholesterol to decline.

So if estrogen is keeping these two risk factors in check, why wouldn’t we preventatively prescribe it?

Two reasons explain this:

• The decline of estrogen, while a significant change maker, isn’t the only variable at play
• Data does not (yet) exist supporting such a measure

Aging & Lifestyle Factors Also Matter

As much as I like to repeat the mantra: I am my energy, not my age, there is no denying the chronological progression of the body.

Time marches on as do cellular changes which add to increased risk—among them, stiffening of arterial walls and heart valves, thickening of the heart walls and a reduction in the heart’s ability to heal itself. Aging also has a hand in the body’s weight gain trajectory, which combined with body composition changes (thank you also to menopause) can be a compounding factor to our increased heart risk.

Lifestyle also significantly contributes: notably, levels of inactivity, dietary patterns, chronic stress, sleep disruption, and usage of nicotine, alcohol or narcotics.

While menopause might appear to be the main reason heart disease risk increases, it’s actually just the last factor in a more complex picture.

The Data is Not (Yet) There

As this newsletter has highlighted before, women’s health research is still woefully full of gaps that need to be filled. One of those gaps: the long-term study of menopause hormone therapy initiated during perimenopause/early menopause and cardiovascular benefit.

Existing studies that have looked at the question of MHT and cardiovascular benefit have been focused largely among postmenopausal women, notably the Women’s Health Initiative where the average participant was in her 60s and many started MHT after being in menopause for 10 years. (In that study, hormone therapy was shown to increase cardiovascular risk, and subsequent data analysis of the various age cohorts gave rise to the timing theory, which suggested that the benefits of MHT diminished as one moved further away from the moment of menopause.)

Two studies that do exist and offer a window into MHT’s protective possibility include The Danish Osteoporosis Prevention Study (DOPS) and The KEEPS Trial (Kronos Early Estrogen Prevention Study)—though limitations exist in each:

• The participants in DOPS knew they were taking hormones, which introduced a bias
• In KEEPs, lower doses were used and the participants were younger and had healthier baselines—factors that impacted the findings

Thus, without solid data, FDA guidelines continue to recommend that MHT be prescribed for the treatment of moderate-to-severe symptoms, preventing osteoporosis, and premature menopause—NOT cardiovascular prevention.

Set Your Heart on Heart-Healthy Actions

While the exploration of this question grinds on, women still have plenty of options for not simply reducing their cardiovascular risk but improving their overall cardiovascular health.

​
​Know Your Numbers

Take a proactive stance in your healthcare management with your physician to understand existing or potential risk factors, and to identify strategies and solutions that promote your long-term health. Get a read on your:

• Blood pressure
• Cholesterol (especially LDL and, if possible, Apo B)
• Blood sugar/A1c
• Waist circumference (visceral fat indicator)
  ​

Understand Your Personal Risk

Also understand how certain personal factors may come into play, to arrive at your complete risk picture. Factors that can impact your risk include:

• Age at menopause: Women experiencing early menopause (before age 40) have 27% higher risk of metabolic syndrome and need more aggressive screening and monitoring
• Family history: Combined with menopause-related changes, this amplifies your risk
• Accumulated lifestyle factors: Decades of dietary patterns, activity levels, stress exposure, and sleep quality all interact with hormonal changes

Lean into the Fundamentals (Because They Still Matter!) 🌟

Plant + Protein-Forward Eating: Continue prioritizing fiber (25–30g daily) through colorful produce and legumes; eat lean proteins, omega-3 rich seafood, and healthy fats

Strength-Based Movement: Preserve and build lean muscle mass during this transition as one of your most powerful tools to help reduce visceral fat gain that can impact metabolic and cardiovascular health

Prioritize Sleep: Create relaxing routines and tools that help promote 7–8 hours of sleep at night—especially important as sleep disruption during menopause can independently affect cardiovascular risk

Manage Stress: Keep using those accessible relaxation tools—chronic stress influences atherosclerosis development and affects blood pressure and cholesterol

Limit alcohol and don’t smoke: These become even more important during the transition

This is the Time to Show Yourself Some Love

I often say that the menopause experience is loud for a reason—these symptoms call our attention to ourselves and the silent shifts that can take place as a result. Menopause is the opportunity to recalibrate and to take care. And while there is no research yet that establishes MHT as the silver bullet for ongoing cardiovascular health, there IS a tremendous body of research supporting the things we can control—the fundamentals above—giving us not just the knowledge, but the power to take heart disease out of that #1 slot.

In other heart-related news:

Women Need Less Exercise Than Men for Heart Protection!
​A UK Biobank study published in Nature Cardiovascular Research found that women achieve greater cardiovascular benefits from less exercise than men. Women who exercised 250 minutes per week (roughly 4 total hours) reduced their heart disease risk by 30%, while men needed 530 minutes—more than double—to achieve the same benefit. Among participants who met the standard 150 minutes per week guideline, women saw a 22% lower heart disease risk compared to 17% for men.

Women’s CVD Risk Models Still Inadequate, Conference Highlights
​Sessions from the 2025 American Society for Preventive Cardiology Congress emphasized that current cardiovascular risk prediction models continue to have significant limitations when it comes to female-specific risk factors. The published highlights underscored the need for better integration of pregnancy-related conditions, menopause status, and other women-specific factors into the clinical risk assessment tools used in practice.