Menopause Is Not Just Hot Flushes: A Bone and Heart Health Plan After 45

Hot flushes are the most talked-about symptom of the menopause, yet two other changes progress silently in the body at this time: bone loss and an increase in cardiovascular risk. According to the Türk Jinekoloji ve Obstetrik Derneği (TJOD, the Turkish Society of Obstetrics and Gynaecology), the age of menopause in Türkiye is around 47–49 ¹; it is diagnosed retrospectively, once periods have been absent for one year ^1,2. The stage before this is called perimenopause (the transition leading up to the menopause); symptoms such as irregular periods, hot flushes and sleep problems often begin here ².

This article approaches the menopause not as a disease, but as a natural checkpoint for planning the future of a woman’s health. The Lancet’s 2024 series on menopause likewise proposes approaching menopause not as a hormone deficiency, but within an “empowerment model” in which women gain information, confidence and decision-making authority ³. Healthy ageing (longevity) is not a promise either; it is the name for this approach of recognising risks early and protecting quality of life. The plan below can serve as a framework for every menopause consultation.

Bone: silent loss speeds up with the menopause

According to the North American Menopause Society (NAMS) 2021 statement on osteoporosis, bone loss begins 1–3 years before the menopause and continues at a rate of about 2% a year for 5–10 years; this postmenopausal (after the menopause) loss, caused by the fall in oestrogen, is the main cause of osteoporosis (commonly called ‘bone thinning’) ⁴. According to an estimate cited in the statement, a 50-year-old white woman in the US has about a 40% risk of an osteoporosis-related fracture over the rest of her life ⁴; a figure specific to Türkiye is not given in this article. Older age, genetic predisposition, smoking, a slight build and certain diseases and medicines that affect bone increase the risk ⁴.

Fractures may be associated not only with pain but also with a serious burden of illness and with loss of life ⁴. For this reason, NAMS recommends assessing fracture risk factors in all postmenopausal women, together with these basic measures: adequate intake of protein, calcium and vitamin D, regular physical activity, stopping smoking and avoiding excess alcohol ⁴. The risk assessment determines who should have a bone density scan (DXA); for women with low bone density and additional risk factors, there are treatments that prevent bone loss, and the decision is made together with the patient ⁴. Menopausal hormone therapy (MHT) has also been shown to prevent bone loss and fractures ⁵.

Heart: the window when risk accelerates

Cardiovascular disease is the leading cause of death in women, and the risk rises markedly after the menopause ⁶. The American Heart Association (AHA) 2020 scientific statement, drawing on studies that followed women through the menopause transition over many years, makes an important distinction: this increase is not simply a result of ageing; declining function of the ovaries contributes in its own right ⁶. Adverse changes in body fat distribution, blood fats (lipids and lipoproteins) and measures of blood vessel health have been documented during the transition ⁶.

The same statement describes midlife as a “critical window” in which early intervention to reduce cardiovascular risk can take place; in practice, this call for monitoring means reviewing blood pressure, blood fats, blood sugar and waist circumference at the menopause consultation ⁶. The International Menopause Society (IMS) 2024 White Paper notes that a higher rate of cardiovascular disease has been reported in women who have severe hot flushes; whether this link is causal is not yet known, but severe hot flushes can be regarded as an occasion to review cardiovascular risk ⁷. An important limit: MHT is not used to prevent heart disease ^5,8.

Where does hormone therapy fit in the plan?

The NAMS 2022 position statement finds MHT more effective than other options for hot flushes and genitourinary syndrome of menopause (vaginal dryness and urinary symptoms at the menopause) ⁵. According to the statement, for women who are under 60 or within the first 10 years after the onset of menopause and who have no contraindications, the benefit–risk balance is favourable for treating bothersome hot flushes and preventing bone loss ⁵. If treatment is started after the age of 60 or more than 10 years after the menopause, the balance is less favourable, because the absolute risks of coronary heart disease, stroke, blood clots in the veins (venous thromboembolism) and dementia are increased ⁵.

The distinction matters: MHT is a treatment option for symptoms, not a shield against chronic disease. In 2022 the US Preventive Services Task Force (USPSTF) issued a recommendation against using MHT for the primary prevention of chronic conditions, and stated that this recommendation does not cover the treatment of symptoms such as hot flushes ⁸. The 2024 follow-up of the KEEPS study also showed that 4 years of treatment given at the onset of menopause brought neither benefit nor harm to memory and thinking about 10 years after treatment ended ⁹. For women who do not wish to, or cannot, use hormones, there are also non-hormonal options supported by high-quality evidence; suitability is determined at the consultation ¹⁰.

The change the scales do not show

When the body composition of 1,246 women was measured over several years in the SWAN follow-up study, a striking picture emerged: once the menopause transition began, the rate of increase in fat mass doubled, lean (muscle) mass began to fall, and this change continued until 2 years after the final period, then stopped ¹¹. Total body weight, however, did not show any acceleration during the transition ¹¹. In other words, even if the scales stay the same, the balance of fat and muscle inside the body may have changed; weight monitoring is an incomplete measure at this stage.

This finding supports the view that the aim at menopause is not to lower the number on the scales, but to preserve muscle mass and look after metabolic health; the adequate protein intake and regular physical activity recommended for bone ⁴ are common ground here too. Sleep is also part of the plan: 40–56% of women in perimenopause and postmenopause report difficulty sleeping (31% in the late reproductive stage before the menopause), and many hot flushes coincide with awakenings on sleep recordings ¹². Raising sleep problems at the consultation, rather than dismissing them as “something that comes with age”, opens the door to a holistic assessment of symptoms.

How is the plan put together?

When the statements and studies discussed in this article are read together, six areas stand out in the menopause consultation: bone health ⁴, heart and metabolism ⁶, cognitive function ^5,9, sexual and urinary health ⁵, sleep ¹² and body composition ¹¹. This is not a guideline scheme but a framework proposed by this article. An individual symptom plan is added on top of these; which option is suitable is decided together, based on your age, the time since the menopause, your personal and family risk profile and your preferences ^3,5. The plan is not made once and then finished; as NAMS emphasises, decisions are reviewed again at regular intervals throughout postmenopausal life ^4,5.

One special situation deserves a separate mention: when the ovaries stop working before the age of 40, this is called premature ovarian insufficiency (POI), and the joint 2024 guideline of ESHRE, ASRM and IMS strongly recommends that these women, whether or not they have symptoms, continue hormone therapy at least until the age of natural menopause, to reduce risks to bone, heart and general health ¹³. The menopause is neither an end nor a disease; it is a stage in which, with accurate information and timely steps, you can shape your health in the years ahead. If you have symptoms, please consult an obstetrics and gynaecology specialist.