Cardiologist with 20 years of experience explains why women in their 40s might experience changes in cholesterol

Women are often told that fluctuating cholesterol is caused by their diet. However, Dr Bhojraj explains why it might have more to do with hormones.

For many women, the 40s mark a period of quiet but profound change as the body transitions into perimenopause and eventually menopause. While these years are often associated with shifts in reproductive health, the impact of hormonal fluctuations extends far beyond that. Changes in hormones – particularly oestrogen – can influence multiple systems in the body, including metabolism, brain function, and crucially, heart health. As these internal shifts unfold, they may alter cardiovascular risk in ways that aren’t always immediately obvious, even when diet and lifestyle remain unchanged.

Dr Sanjay Bhojraj, an interventional cardiologist and functional medicine expert with over 20 years of experience, is shedding light on why women in their 40s may experience sudden changes in cholesterol levels despite no shifts in diet or lifestyle. In a March 12 episode of The Trusted Pharmacist, hosted by Steve Hoffart, he explains how declining oestrogen during perimenopause and menopause can significantly impact heart health.

Cholesterol jump in 40s

He explains, “Thousands of times in my career I would have a woman in her 40s and this was before I was functionally minded. We would see that LDL was always 80 or 90 – perfect, no meds, doing great – and then you'd see this little bump and I would always say – of course doctors excel at gaslighting patients – we're like you must have done something different or you must have done something wrong, what are you doing in your life, etc. It was never about your biology, it was always about behaviour.”

What’s really happening?

Dr Bhojraj explains that these changes may, in fact, be hormone-induced. During perimenopause, the female body experiences a decline in oestrogen – a hormone that plays a crucial cardioprotective role, quietly safeguarding the arteries for decades. As this natural protection begins to wane, cardiovascular risk can rise, even in the absence of any significant changes in diet or lifestyle.

The cardiologist notes, “Most women are told cholesterol goes up because of diet. But there’s another reason almost nobody talks about. During perimenopause, oestrogen begins to decline…and that hormone has been quietly protecting your arteries for decades. When that protection fades, cardiovascular risk can start climbing – even if your lifestyle hasn’t changed.”

Dr Bhojraj illustrates this with a simple analogy: imagine pulling up a blanket – as you adjust it, your toes are left exposed. He explains that a similar process unfolds in the body when oestrogen levels decline. As this protective “cover” gradually recedes, its cardioprotective effects begin to wane bit by bit, leaving the heart and blood vessels more vulnerable.

The cardiologist elaborates, “Really what's happening is that oestrogen dip in perimenopause is now getting rid of some of that risk. It's like when you have a blanket and it starts to creep up and now your toes are exposed to the cold, right? So now your toes are exposed as the oestrogen retreats to cardiovascular risk.”

The role of hormone replacement therapy

Dr Bhojraj emphasises that menopause isn’t only about visible symptoms like hot flashes or hair fall – it also brings a less obvious but significant rise in cardiovascular risk due to declining oestrogen levels. This is why he suggests that hormone replacement therapy may be an option worth considering, as it can help restore oestrogen levels and potentially support heart health.

He explains, “That's a really important time to have that conversation about hormone replacement. Most people just think it's about hot flashes, as you mentioned, or hair falling out or whatever. But hormone replacement truly is cardioprotective.”

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