Menopausal estrogen decline is associated with higher low-density lipoprotein (LDL) cholesterol.
Dr. Matthew Nudy is an assistant professor of medicine and public health sciences at Penn State College of Medicine. He presented 'The cardiovascular consequences of estrogen avoidance' at The Menopause Society 2026 Annual Meeting, held October 20 to 24, 2026, in San Diego, California. His talk was part of the 'Presidential Symposium: The toll of estrogen avoidance.' He reviewed the effects of estrogen loss and hormone therapy on lipids, subclinical vascular disease, and cardiovascular outcomes.
Data from the Study of Women's Health Across the Nation (SWAN) show LDL cholesterol rising around the final menstrual period, with greater estradiol decline associated with higher levels. In the Women's Health Initiative (WHI) trials, conjugated equine estrogen lowered LDL cholesterol. 'We see that conjugated equine estrogen brings LDL concentrations down to premenopausal levels,' Dr. Nudy said.
Asked how this compares with a statin, he said, 'We typically expect more LDL lowering with a statin medication. But what we did find is that estrogen has effects on other cardiovascular biomarkers as well.'
What arterial calcification may reveal about cardiovascular risk in women
A coronary artery calcium (CAC) score reflects calcified coronary plaque in asymptomatic patients. In a WHI ancillary study of more than 1000 postmenopausal women followed for about 8 years, higher CAC scores were associated with more cardiac events and higher cardiovascular and all-cause mortality. In the WHI estrogen-alone trial, women aged 50 to 59 years who received estrogen had lower CAC scores than those who received placebo.
Medium-sized arteries in the breast can also calcify, a finding called breast arterial calcification that is visible on screening mammography. In a study that used artificial intelligence to grade its severity, more severe calcification was associated with more major adverse cardiovascular events.
Why timing may shape the cardiovascular effects of hormone therapy
In KEEPS, hormone therapy did not slow CAC progression in recently menopausal women. In ELITE, estradiol slowed carotid intima-media thickness progression in women within 6 years of menopause, but not in women 10 or more years past menopause.
Observational data from Finland associated estradiol-based hormone therapy with lower coronary heart disease and stroke mortality, and stopping therapy with higher cardiovascular mortality in the following year. Dr. Nudy cautioned that these associations do not establish hormone therapy for cardiovascular prevention. A meta-analysis of randomized trials showed reduced coronary heart disease when therapy began within 10 years of menopause, but not later.
'Hormone therapy lowers LDL cholesterol, but its effects on subclinical atherosclerosis range between beneficial and neutral,' Dr. Nudy concluded. Cardiovascular effects vary with age and timing of initiation. He advised individualizing hormone therapy for symptom relief, because cardiovascular prevention alone is not an indication.
Abbreviations: LDL, low-density lipoprotein; WHI, Women's Health Initiative; CAC, coronary artery calcium.