Perimenopause and cardiometabolic risk: emerging evidence, therapeutic opportunities and unanswered questions

Perimenopause is increasingly recognized as a critical period for cardiometabolic health. During the years surrounding the final menstrual period, adverse changes in lipid profiles, insulin sensitivity, body composition and vascular function accelerate beyond those expected from aging alone, concurrent with the emergence and peak severity of menopause symptoms. Accumulating evidence suggests that vasomotor symptoms and sleep disturbance are associated with adverse cardiometabolic profiles and increased cardiovascular disease risk. Mechanistic data indicate that autonomic dysregulation, inflammation and neuroendocrine systems may represent shared pathways linking symptom burden and cardiometabolic dysfunction. Complementing these findings, prospective studies demonstrate that poor cardiovascular health and metabolic dysfunction may predict subsequent symptom development, suggesting that cardiometabolic health influences the menopause transition experience itself. Together, these findings support a model in which perimenopause represents a physiologic convergence point where symptom burden and cardiometabolic risk intersect, with implications for symptom management and primary prevention. However, major evidence gaps remain, including the absence of interventional studies during perimenopause and uncertainty regarding whether these relationships are causal or therapeutically modifiable. Future research should determine whether targeting cardiometabolic health during this window can improve both cardiovascular outcomes and the symptom experience of the menopause transition.