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Hot flashes and night sweats – they are the hallmark symptoms of menopause.

But there's something else happening to women entering their late 40s and early 50s that they can't see or feel and may not even know about: Their cardiovascular disease risks are rising.

"As women transition through menopause, they experience a lot of changes," said Samar El Khoudary, a professor of epidemiology at the University of Pittsburgh's School of Public Health.

They produce less estrogen. They accumulate more belly fat. Excess abdominal fat is part of a cluster of symptoms that becomes more common after menopause. Known as metabolic syndrome, it is when a person has at least three of the following: abdominal obesity; high triglycerides; low "good" HDL cholesterol; high blood pressure or high blood sugar.

And, "their arteries become more vulnerable to disease, getting thicker and stiffer," said El Khoudary, who chaired the writing committee for a on how the menopause transition affects cardiovascular disease risk. "All of those changes accelerate during menopause."

Heart disease is the leading cause of death for women in the U.S., who typically develop the condition several years later than men. But women are largely unaware of their risk for heart disease, which is more likely to kill them than all forms of cancer combined. According to the most recent , awareness that heart disease is the leading cause of death among women actually fell between 2009 and 2019, particularly among Black, Hispanic and younger women, for whom primary prevention may be most effective.

The decrease in awareness came as knowledge about women's cardiovascular risks increased, El Khoudary said. "Over the last two decades, we've learned a lot about how menopause contributes to heart health," she said.

For example, menopause-related hot flashes and night sweats have been linked to a greater risk for high blood pressure and other cardiovascular risk factors. Research also shows depression during the menopause transition is strongly linked to higher cardiovascular disease risk.

In addition, women who experience natural menopause at a later age have a lower risk of cardiovascular disease and death. Factors that may influence an earlier start to menopause include worse cardiovascular health during reproductive years, cigarette smoking and possibly genetics.

Dr. JoAnn Manson, chief of preventive medicine at Brigham and Women's Hospital and a professor of medicine at Harvard Medical School in Boston, said women would benefit from intensifying cardiovascular prevention efforts in the years leading up to menopause.

"That stage of life is a window of opportunity for making lifestyle changes," said Manson, who also co-authored the 2020 AHA scientific statement that called on health care professionals to consider an aggressive prevention-based approach for women in midlife to decrease the chance of cardiovascular disease in the future.

Research suggests the include not smoking, being physically active, eating a healthy diet, maintaining a healthy weight, getting enough sleep, and keeping cholesterol, blood pressure and blood glucose levels under control. But "very, very few people are good at following all of those," Manson said.

Perhaps the most bang for the buck comes from increasing physical activity, she said. "It is the magic bullet for good health because it reduces the risk for heart disease, stroke, high blood pressure, Type 2 diabetes and cancer and improves bone health, weight control, sleep and mental health. If there were a pill you could take that had all of those benefits, everyone would be clamoring for it."

But not enough people meet federal guidelines for physical activity, which are at least 150 minutes per week of moderate-intensity aerobic exercise, 75 minutes per week of vigorous aerobic exercise or a combination of both.

While it's never too late to add or increase physical activity levels, Manson said, "the earlier you do it in life, the greater the health benefits. Also, maintaining good habits is easier than reversing bad ones."

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