Cholesterol and Perimenopause: Why Levels Change and What to Do
Find out why cholesterol rises during perimenopause, which tests to get, what the numbers mean, and how to protect your heart health.
Why Cholesterol Changes During Perimenopause
Oestrogen plays a significant role in regulating cholesterol metabolism. It increases HDL (good cholesterol) and helps clear LDL (bad cholesterol) from the blood. When oestrogen falls during perimenopause, this protective effect weakens. Total cholesterol, LDL cholesterol, and triglycerides often rise, while HDL can fall. These changes happen relatively quickly in the menopausal transition and can persist into post-menopause. Many women are surprised to find their cholesterol has shifted noticeably within a few years of perimenopause beginning.
What the Different Cholesterol Numbers Mean
Total cholesterol is a combined figure but gives limited information on its own. LDL cholesterol carries cholesterol to the arteries and, in excess, contributes to plaque formation. HDL carries cholesterol away from the arteries and back to the liver for processing. Triglycerides are fats in the blood that rise with a high-sugar diet, excess alcohol, or insulin resistance. A lipid panel measures all of these. Your doctor may also calculate a non-HDL cholesterol figure or a total cholesterol to HDL ratio, which are more meaningful for cardiovascular risk than total cholesterol alone.
How to Get a Lipid Panel
A fasting lipid panel is available through your GP as a routine blood test. Fasting for nine to twelve hours beforehand gives the most accurate triglyceride and LDL readings. You should be offered a cardiovascular risk assessment in your 40s, and if not, it is worth requesting one. Some surgeries offer this as part of an NHS Health Check for those aged 40 to 74. Private blood testing services can also provide a comprehensive lipid panel if access through the NHS is limited.
What Target Levels to Aim For
In the UK, general cardiovascular risk guidance suggests keeping total cholesterol below 5.0 mmol/L. LDL cholesterol below 3.0 mmol/L is a common target for women without other risk factors, and below 2.0 mmol/L for those with higher risk. HDL above 1.2 mmol/L is considered protective for women. Triglycerides below 1.7 mmol/L is desirable. These are guidelines rather than hard cutoffs, and your overall risk profile, including blood pressure, smoking status, weight, and family history, shapes how your numbers are interpreted.
Lifestyle Changes That Move the Needle
Reducing saturated fat and replacing it with unsaturated fat (olive oil, nuts, avocado, oily fish) has good evidence for lowering LDL. Increasing soluble fibre from oats, lentils, beans, and vegetables supports LDL clearance. Regular aerobic exercise raises HDL meaningfully. Managing body weight, particularly central adiposity that tends to increase in perimenopause, reduces triglycerides and improves the overall lipid profile. Limiting alcohol and reducing refined sugar lowers triglycerides specifically.
HRT and Cholesterol: What to Know
Oestrogen therapy can improve the lipid profile, raising HDL and lowering LDL. Transdermal oestrogen is generally preferred because oral oestrogen can raise triglycerides. The type of progestogen used in combination HRT also matters: micronised progesterone and some newer progestogens are more neutral or positive for lipid profiles than older synthetic progestogens. If your cholesterol has worsened significantly since perimenopause began, discussing HRT with your doctor as part of a cardiovascular protection strategy is worth considering, particularly if you are younger than 60.
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