Many women notice that around the time of menopause their metabolism seems to change. Weight gathers around the waist, energy levels drop, blood pressure rises, and blood tests show raised cholesterol or changes in blood glucose. After menopause, the risk of developing metabolic syndrome increases and understanding why can help you take control early. Postmenopausal women have 2-3 times higher prevalence of metabolic syndrome compared to premenopausal women. This article explains more about metabolic syndrome and menopause.
The metabolic syndrome is a cluster of the most dangerous heart attack risk factors:
- Diabetes and raised fasting plasma glucose
- Abdominal obesity
- High blood pressure
- High cholesterol.
This syndrome affects 20-25% of adults making them twice as likely to die from and three times more likely to have a stroke or a heart attack when compared to someone without metabolic syndrome. People with metabolic syndrome are five times more likely to become diabetic.
How do you know if you have metabolic syndrome?
Metabolic syndrome isn’t one problem, it’s a cluster of risk factors that tend to appear together. You’re considered to have metabolic syndrome if you meet three or more of the following:
According to the new IDF definition, to have the metabolic syndrome you must have:
- Increased waist size (typically over 80 cm in women) – if your BMI is >30kg/m², central obesity can be assumed and waist circumference does not need to be measured.
Plus any two of the following risk factors
- High blood pressure – systolic BP ≥ 130 or diastolic BP ≥ 85 mm Hg or treatment of previously diagnosed hypertension
- High fasting glucose or insulin resistance – fasting blood glucose of ≥ 5.6 mmol/L or previously diagnosed type 2 diabetes (if above 5.6 mmol/L, an oral glucose tolerance test is recommended)
- Raised triglycerides – ≥ 1.7 mmol/L or on specific treatment for this lipid abnormality
- Low HDL (good) cholesterol – < 1.29 mmol/L in females or on specific treatment for this lipid abnormality
This combination matters because it increases the risk of type 2 diabetes, heart disease, stroke, and fatty liver disease.
What metabolic changes happen at menopause?
Oestrogen protects many metabolic processes, including how the body handles glucose, stores fat, and manages inflammation. When oestrogen levels fall, several changes happen at once:
- Fat shifts to the abdomen. Even if your weight stays stable, body fat redistributes from hips and thighs to the waist. Visceral fat is more metabolically active and drives inflammation and insulin resistance.
- Insulin becomes less effective. This makes the body work harder to keep blood sugar in range, often leading to weight gain and higher fasting glucose.
- Muscle mass declines. Less muscle means a slower metabolism and poorer glucose control.
- Blood pressure tends to rise. Arterial stiffness plus endothelial dysfunction plus changes in the sympathetic nervous system results in higher blood pressure. The risk of hypertension increases in the postmenopausal years as women age.
- A change in blood lipids. A pro-atherogenic lipid profile develops. Increase in total cholesterol, LDL-C (bad cholesterol) and Triglycerides and a decrease in the function of HDL-C (good cholesterol). These changes can result in an increase in plaque in the artery walls.
- Changes in blood vessels. Oestrogen supports healthy blood vessels. It helps keep arteries flexible, reduces inflammation, improves lipid profiles, and enhances nitric oxide (NO) production (which relaxes blood vessels). When oestrogen drops arteries lose elasticity, blood vessels dilate less effectively, inflammatory activity increases and oxidative stress rises. This all results in stiffer, narrower arteries.
What is insulin resistance?
Insulin resistance develops when the body’s cells, mainly in the liver, muscles and fat tissue, stop responding properly to insulin. Insulin is made by the pancreas to help move glucose from the bloodstream into cells. When cells become less responsive, glucose stays in the blood instead of being taken up, so the pancreas releases more insulin to compensate. This leads to hyperinsulinaemia, where insulin levels run chronically high.
Over time, constantly pushing the pancreas to produce excess insulin strains the beta cells. Their function gradually declines, and eventually they can no longer keep up. When the pancreas cannot produce enough insulin to overcome the resistance, blood glucose rises, causing hyperglycaemia and ultimately leading to a diagnosis of type 2 diabetes.
Importantly, harmful changes begin long before diabetes is diagnosed. Persistently high insulin and glucose promote fat build-up inside the liver and muscles, including increased triglycerides, which further worsen insulin resistance and drive the cycle on.
What is central obesity?
Obesity is associated with insulin resistance and the metabolic syndrome. It contributes to hypertension, high serum cholesterol, low HDL-c and hyperglycaemia, and is associated with higher risk of cardiovascular disease. However, where fat is stored matters even more than total weight. Excess fat around the abdomen (easily assessed by measuring waist circumference) is a far better indicator of metabolic syndrome risk than BMI alone.
Can having metabolic syndrome increase the risk of having cardiovascular disease?
Yes, having metabolic syndrome can increase the risk of cardiovascular disease.
What is cardiovascular disease?
Cardiovascular disease (CVD) refers to a broad group of disorders that affect the heart and blood vessels. It includes both congenital or inherited conditions and those that develop later in life, such as coronary heart disease, atrial fibrillation, heart failure, stroke, and vascular dementia.
Coronary heart disease (CHD) is sometimes called ischaemic heart disease (IHD) or coronary artery disease (CAD). It occurs when coronary arteries become narrowed by a build-up of atheroma, a fatty material within their walls.
Every 16 minutes a woman in the UK is admitted to hospital due to a heart attack.
Cardiovascular disease (CVD) represents the leading cause of death and accounts for almost 50% of all deaths in women worldwide. Hypertension, hyperlipidemia and diabetes remain the most crucial risk factors contributing to cardiovascular death in women.
What can you do to your risk of having metabolic syndrome?
You don’t need extreme diets or punishing exercise routines. The foundations are simple.
- Prioritise strength training. Two or three sessions a week is one of the best ways to reverse muscle loss and improve glucose control.
- Increase protein. Helps maintain muscle and reduces hunger.
- Moderate intensity exercise: 150-300 minutes a week
- Choose whole foods most of the time. Vegetables, fruit, whole grains, legumes, lean proteins, nuts, and olive oil support metabolic health. The mediterranean diet is associated with health benefits
- Manage stress and sleep. Poor sleep alone can increase insulin resistance within days.
- Know your numbers. Waist circumference, blood pressure, fasting glucose, and a lipid profile give a clear picture of your metabolic health.
- Secondary prevention. In people for whom lifestyle change is not enough and who are considered to be at high risk for cardiovascular disease drug therapy may be needed to treat the metabolic syndrome.
Is hormone replacement therapy (HRT) helpful?
For many women, yes. Oestrogen has huge benefits for health of your arteries improving vascular function and reducing plaque formation. HRT isn’t a weight-loss treatment, but it can improve insulin sensitivity, reduce abdominal fat gain, and support healthier cholesterol and blood pressure levels. It won’t replace lifestyle changes, but it often makes them more achievable by improving sleep, mood, pain, and energy. The decision to use HRT is individual and should be discussed with a clinician familiar with menopause and cardiometabolic risk.
HRT started in healthy midlife women can reduce the risk of cardiovascular disease.
If you are a woman going through menopause and you would like to discuss this at your appointment with us please let us know. To book a menopause appointment at Rowena Health visit our website booking page.
References
- International Diabetes Federation (2006). METABOLIC SYNDROME. [online] Available at: https://idf.org/media/uploads/2023/05/attachments-30.pdf.
- Our vision is a world where everyone has a healthier heart for longer. UK Cardiovascular Disease Factsheet. (2025). Available at: https://www.bhf.org.uk/-/media/files/for-professionals/research/heart-statistics/bhf-cvd-statistics-uk-factsheet.pdf?rev=0759fdcb1d3248f9b9331c4039e6075c&hash=B0C8BEA1A48B306E4D2FC73C4265FBFA.
- Uddenberg, E.R., Safwan, N., Saadedine, M., Hurtado, M.D., Faubion, S.S. and Shufelt, C.L. (2024). Menopause transition and cardiovascular disease risk. Maturitas, [online] 185, p.107974. doi:https://doi.org/10.1016/j.maturitas.2024.107974.
- Mukherjee, A. and Davis, S.R. (2025). Update on Menopause Hormone Therapy; Current Indications and Unanswered Questions. Clinical Endocrinology. doi:https://doi.org/10.1111/cen.15211.
- I. Lambrinoudaki and Armeni, E. (2023). Understanding of and clinical approach to cardiometabolic transition at the menopause. Climacteric, 27(1), pp.68–74. doi:https://doi.org/10.1080/13697137.2023.2202809.
Written by Dr. Carys Sonnenberg NHS GP and BMS Menopause Specialist. Founder of Rowena Health clinic. December 2025