The hidden heart hazard every woman over 40 needs to know about

While most discussion of menopause focuses on the obvious signs — hot flashes, trouble sleeping, and the end of menstruation and fertility — it’s even more important to pay attention to the insidious changes happening behind the scenes.

And that starts with the heart.

Heart disease is the leading cause of death in women in the United States. And risk of heart disease rises sharply around menopause. We’ve known that for years, but we haven’t known precisely why.

But now a new study just published in the Journal of the American Heart Association points to a hidden culprit.

As women go through menopause, they go through numerous cardiovascular transformations. The vascular system undergoes an overhaul and they see shifts in triglycerides and other types of blood fats. Together, these are thought to contribute to the increase in heart disease risks after menopause.

But this new study points to yet another unseen change that may be the most dangerous of all…

The stealth fat that leads to disastrous effects 

I’ve been warning people for years about the hazards of fatty liver. But this new research shows “fatty heart” may be an even bigger concern for women leading up to, during, and after menopause.

During menopause, the composition of body fat changes. That includes an increase in fat surrounding the heart. Previous studies have found links between “heart fat” and heart disease risk. It’s linked to coronary artery disease, cardiovascular events, and even death from all causes.

The Journal of the American Heart Association study takes that research further, exposing one particular type of heart fat that has, until now, gone largely ignored.

This fat, called paracardial fat, is one of two distinct types of fat around the heart. The other type is called epicardial fat. Until now, doctors, researchers, and even health writers have been conflating the two — talking just about “heart fat.”

But it turns out that the two types of fat are completely different beasts. And if we learn to treat them as such, we might be able to make serious strides in tackling heart disease risk after menopause.

Epicardial fat directly covers the heart. It serves a function — providing energy to the heart.

But paracardial fat — the one we’re going to focus on today — does not serve any function. It is located in pockets around the heart.

Both paracardial and epicardial fat increase in volume after menopause. But only paracardial fat is linked with declining levels of the hormone estradiol (a type of estrogen). Estradiol levels naturally drop during menopause. In this study, the women who saw the largest drops in estradiol levels during the 5 years of follow up had 20 percent more paracardial fat than those with the smallest decline. That suggests that menopause — and specifically the hormonal shifts associated with it — is behind the increase in paracardial fat.

And the researchers found that increases in paracardial fat were associated with increased risk of coronary artery calcification, as well as the extent of the calcification.

Coronary artery calcification is a big problem for heart health. It’s the result of calcium buildup in the blood vessels that deliver blood to the heart. Blood vessels that have this calcium buildup become hard and narrow over time, limiting blood supply (and therefore nutrients and oxygen) to the heart. Which is why it’s linked with major adverse cardiac events.

So what can be done about it? Well, the authors of this study have an idea. They speculate that, because of the estradiol link, hormone replacement therapy might have an effect on dangerous paracardial fat. Of course, there are some pretty big caveats with this advice…

The only kind of HRT I recommend

As you probably know, hormone replacement therapy is a popular way of replenishing women’s estrogen levels during and after menopause. But it’s also hugely controversial — and with good reason.

While synthetic hormone replacement is a boon to pharmaceutical companies, it’s been a disaster from a public health perspective. In fact, in the early 2000s, the National Institutes of Health determined that one type of hormone replacement therapy (Prempro) caused breast cancer in otherwise healthy women. The effect was so clear and so devastating that the study investigating the connection was halted early to avoid putting more women at risk.

That has turned a lot of people off hormone replacement completely. But in my opinion, that’s throwing out the baby with the bathwater.

The fact is there is a safer way to replace hormones lost during menopause. It’s called bioidentical hormone replacement therapy, and it’s designed to precisely match the amounts and types of hormones your body would naturally produce.

I’ve prescribed it to my patients for years, with great success. I’ve seen it restore health and vitality to women who feel their youth slipping away. It has addressed their complaints about hot flashes, vaginal dryness, and other symptoms of menopause.

And it’s far safer than synthetic hormone replacement. Still, it does come with a few caveats …

First, before starting anyone on hormone replacement therapy, I order a blood test to look at overall hormone levels. That way, I know what we’re actually trying to replace rather than just loading women up on some standard dose. Then, based on their individual needs, I design an individualized cream that they can have made at a compounding pharmacy. And I never include estrone (the so-called “bad” estrogen that can cause all sorts of problems). Throughout treatment, I follow up with additional blood tests to make sure we’re seeing the changes we expect — and none of the changes we don’t.

The second caveat — and it’s a big one — is that no one who has had an estrogen-related cancer should use hormone replacement therapy of any sort. Neither should people with genetic markers for estrogen-related cancers (BRCA, for instance). For these women, risks of HRT far outweigh the benefits. They already have much higher risk of developing breast cancer, and adding more estrogen to the mix can be like throwing fuel on a fire.

Given that hormone replacement therapy is not a fit for everyone — and the fact that there’s no proof that it’s a fix for fatty heart — it’s important to look at other ways to address the problem. The good news is, recent research shows there’s a simple, safe way to do just that.

The perfectly safe way to reduce heart fat 

A recent analysis of several different studies found that heart fat can be reduced significantly with diet — with or without exercise. In obese women, weight-loss interventions had a remarkable effect on heart fat, decreasing it by 17 percent!

If you’re going through menopause, and especially if you’re overweight, it’s time to take charge of your diet. Stick with a diet of whole, unprocessed foods, grass-fed and finished meats, organic produce, and foods with monounsaturated fatty acids. That’s the basic dietary advice I give to everyone.

But I also have some recommendations specifically for women going through this major transition. During menopause, your body has different needs than it does at any other time. You’re prone to weight gain and a shifting of fat in the body. Including, as the study I’ve been telling you about found, increased paracardial fat. So you need specific guidelines, which I’ve outlined in my hot-off-the-presses book, The A-List Diet. 

This book is the result of years of research, learning, and trial and error. Before putting pen to page, I made sure it works…And it does. It’s revolutionary, really.

It fills in the missing link that has prevented some people from losing weight and getting healthier on other low-carb diets. I’ve used it to get my A-list clients red-carpet ready — including women going through menopause — and they’ve been wowed by the results.

The best part of it is that it’s fully tailored to where you are right now. Today. That means if you’re a post-menopausal woman with stubborn belly fat, you won’t be following recommendations designed for a 22-year-old guy trying to tone his pecs. It’s the closest I can come to meeting with you personally and designing your own meal plan.

So if you haven’t already picked up a copy, please, do yourself — and your heart — a favor and visit and order one today.



I know I just told you about a review that found diet — with or without exercise — can curb heart fat. But you know I’m not going to let you off the hook that easily. Regardless of what that analysis found, the evidence is clear: Exercise is absolutely essential both for healthy weight and for heart health.

So keep at it (or start exercising today if you don’t already). Find an activity you love and do it. Move your body every day if you want your heart to carry you through menopause and into the healthy, vibrant, and beautiful decades ahead.

“Postmenopausal women with greater paracardial fat have more coronary artery calcification than premenopausal women: The Study of Women’s Health Across the Nation (SWAN) Cardiovascular Fat Ancillary Study.” Journal of the American Heart Association. 2017;6:e004545.

“Cardiovascular fat, menopause, and sex hormones in women: the SWAN Cardiovascular Fat Ancillary Study.” J Clin Endocrinol Metab. 2015;100:3304-3312

“Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial.” JAMA. 2002;288:321-333.

“Comparison of reducing epicardial fat by exercise, diet or bariatric surgery weight loss strategies: a systematic review and meta‐analysis.” Obes Rev. 2015;16:406-415.