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Heart Health in Midlife: Navigating the 2026 Lipid Guidelines

For women, midlife is a critical physiological “crossroad.” Beyond the familiar flushes and irritability, longterm risk of developing heart disease takes an up-kick at menopause. Heart disease remains the leading cause of death for women globally, yet it is frequently under-detected and its risk factors left untreated.

The 2026 American College of Cardiology (ACC) and the American Heart Association (AHA) guidelines represent a shift in recommendations. We are moving away from the binary “good vs. bad” cholesterol labels and toward a more precise understanding of unhealthy lipoprotein particles, cumulative lifetime risk, and the unique biological history of women.

Blood lipids – more than “good and bad” cholesterol

Lipoproteins and ApoB

Your blood is watery, but fats (cholesterol and triglycerides) are oily. To travel through your bloodstream, they must be packaged into “submarines” called lipoproteins.

This is a sophisticated recycling and delivery system:

• From Gut to Liver: After a meal, large particles (chylomicrons) carry fats from your gut to your liver.

• From Liver to Body: The liver repackages these into VLDL and LDL particles to deliver energy to your cells.

• Back to the Liver: Cleanup particles (HDL) pick up excess cholesterol to take back to the liver for disposal.

Every unhealthy particle that can cause plaque carries exactly one Apolipoprotein B (ApoB) molecule. Measuring ApoB gives a more accurate count of the total number of “submarines” with damage potential in your blood than just measuring the amount of cholesterol inside them. If your ApoB is high, your risk is high—even if your standard LDL-C looks “normal.”

Lipoprotein (a)

High Lp(a) is considered a key, often overlooked inherited cause of early cardiovascular disease, affecting roughly 20-25% of people. You only need to measure it once to know if you have this risk. Current drug treatments are not effective at lowering Lp(a) so control of all other risk factors eg lifestyle, stop smoking, lower APO B etc is vital.

Triglycerides and Insulin Resistance

Triglycerides are the most common type of fat in your body, used for energy. However, high levels are a major driver of atherosclerotic cardiovascular disease (ASCVD). High triglycerides are often a “red flag” for insulin resistance, frequently exacerbated by a diet high in refined carbohydrates and sugars. When insulin resistance is present, your liver produces more VLDL particles. These interact with other lipoproteins to create smaller, denser LDL particles that are more likely to get embedded in the artery wall, especially when inflammation (hsCRP) is present to “prime” the vessel lining.

Calculating your personal risk

The 2026 guidelines highlight the PREVENT-ASCVD Calculator. The US risk tool has been expanded to include people as young as 30, and to offer a 10 year and 30 year risk. This is valuable because young people will naturally have a low 5 year risk, clouding decisions to treat high lipids and missing the opportunity to prevent ASCVD longterm. An extended version included American zip codes, but adding these is optional. (The area you live in can give clues to socioeconomic disadvantage which is a risk factor for heart disease).

The Australian CVD Risk Calculator is based on the previous PREVENT equations and whilst including local postcodes, it only predicts a 5 year risk.

There is no harm in calculating both – don’t be confused if they differ, these are only estimates.

Note: If you already have Type 2 Diabetes, Chronic Kidney Disease, or existing heart disease, these calculators are not valid for you. You are already considered high-risk, and the guidelines recommend intensive treatment regardless of what a “score” says.

Risk Enhancers

A key pillar of the new guidelines is that a “low” or “intermediate” score on a risk calculator is not the final word. Risk enhancers are clinical factors that may justify starting Lipid-Lowering Therapy (LLT) even if your calculated risk seems low.

If you have any of the following, the benefit of starting treatment (like a statin) is likely much higher:

• Family History: A first-degree relative with premature heart disease (Men < 55y; Women < 65y).

• Primary Hypercholesterolaemia: LDL-C consistently greater than 4.1 mmol/L.

• Metabolic Syndrome: Increased waist circumference, high triglycerides (>1.7 mmol/L), low HDL, or high blood pressure.

• Chronic Kidney Disease: (eGFR 15–59 mL/min).

• Chronic Inflammatory Conditions: Psoriasis, Rheumatoid Arthritis, Lupus, or HIV.

• Female-Specific Factors: See below.

• High-Risk Biomarkers: Persistently elevated triglycerides (TG > 2.0 mmol/L), hsCRP > 2.0 mg/L, or a high Lp(a) level.

Female-Specific Risks

One of the most empowering aspects of the new guidelines is the formal recognition of female-specific “risk enhancers.” If you have experienced any of the following, your “true” heart risk is likely higher than a standard calculator suggests:

• Adverse Pregnancy Outcomes (APOs): A history of pre-eclampsia, gestational diabetes, or preterm birth is now recognised as a “failed stress test” for the heart. These conditions increase your risk of heart disease decades later.

• Premature Menopause: If you entered menopause before age 40, your heart has lost the protective effects of oestrogen much earlier than average, significantly increasing your cardiovascular risk.

• Inflammatory Conditions: Women are disproportionately affected by autoimmune diseases like Lupus or Rheumatoid Arthritis. These cause chronic inflammation (reflected in high hsCRP), which the guidelines now list as a major reason to consider starting statins earlier.

The Role of Coronary Artery Calcium Scores

If your risk remains uncertain, and the decision to use LLT is uncertain, a Coronary Artery Calcium (CAC) scan is recommended.

A CAC score of zero is excellent news, but it does not mean there is no plaque. It simply means there is no calcified (hardened) plaque. You could still have “soft” or “fatty” plaque that hasn’t hardened yet. This is why we still manage lifestyle and lipids even with a zero score—we want to prevent that soft plaque from ever forming or calcifying.

Lipid Lowering Therapy

There are various medications that can lower your lipids. These can be combined if necessary. Your risk and blood lipid levels determine what your target for LLKT should be. These targets are lower in the 2026 guidelines, reflecting the value in having lipids “lower for longer” to prevent the build up of plaque and the subsequent risk of heart disease, stroke, renal disease and peripheral vascular disease.

Most people can not typically “eat their way” to lower lipids. Much of the cholesterol in your body is made by your liver.

• Statins: First-line treatment. They lower liver cholesterol production and have various other impacts.

• Ezetimibe: Blocks cholesterol absorption in the gut.

• PCSK9 Inhibitors: Injectables that supercharge the liver’s ability to clear LDL particles.

• Bempedoic Acid: Lowers liver cholesterol production and inflammation.

On the basis that cholesterol is such an important compound in the brain, a common concern for women is whether lowering lipids affects cognitive function. The 2026 guidelines are firm: LLT does not cause dementia. In fact, by protecting the small blood vessels in the brain from plaque buildup, these treatments often help prevent vascular dementia and cognitive decline.

Targets (Australian Units)

• LDL-C: < 2.6 mmol/L (If you are intermediate risk) or < 1.8 mmol/L (if you are high risk).

• ApoB: < 80 mg/dL (or ~0.8 g/L).

• Inflammation: Check hsCRP; if > 2.0 mg/L, risk is enhanced.

• Triglycerides:  < 1.7 mmol/L; if high, discuss insulin resistance and diet.

 

Summary Checklist for your next GP Visit:

1. Calculate the PREVENT score: What is my 5/10/30-year heart risk?

2. Lp(a) Test: Have I had my “one-in-a-lifetime” genetic cholesterol check?

3. Reproductive History: Ensure your GP knows about any pregnancy complications or early menopause.

4. hsCRP: Check your inflammation levels.

5. CAC Scan: If there’s any doubt, “see” the plaque before deciding on treatment.

At Viv Health, we believe that midlife is not the beginning of the end, but the start of a “second act.” By following these new guidelines and advocating for your heart health today, you are ensuring that your second act is a long, healthy, and vibrant one.

 

Reference

2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Dyslipidemia: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation March 2026

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Key Take Aways

Heart disease kills the most women globally

Atherosclerotic heart disease can be prevented

Know your risk

Lipid lowering treatment keeps damaging lipids lower for longer 

 

Other resources

Australian CVD Risk Calculator

US PREVENT Calculator

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As we navigate through and beyond menopause, we often focus on major health concerns such as heart health, dementia or bone density, but there are other (preventable) conditions that can really interfere with life – shingles being one of them. If you’ve ever had chickenpox, the herpes zoster virus never actually left your body; it’s simply been “sleeping” in your nerve tissues. Shingles occurs when that virus reactivates, often triggered by stress or the natural ageing of the immune system. Even if you have had the chicken pox vaccination (which most midlife women have not), there is still a chance, albeit very small, of getting mild shingles.

Shingles can occur anywhere on the body — most commonly the chest, back, abdomen, or less often the limbs or genitals. It typically affects one side only and follows a nerve distribution (a dermatome).

About shingles

Early symptoms (1-5 days before the rash appears)

• Burning, tingling, stabbing, or electric-shock pain

• Deep aching in a band-like area

• Skin sensitivity (even clothing can hurt)

• Itching or numbness

• Mild fever, headache, or fatigue

The pain is usually localised to one side and does not cross the midline

Rash phase

• Red patch that develops into clusters of small fluid-filled blisters

• Blisters follow a stripe or band pattern

• Rash stays on one side of the body

• New blisters may appear for 3–5 days

• Blisters crust over after 7–10 days

• Heals over 2–4 weeks

• Pain continues through the rash phase and can be severe even if the rash looks mild.

Whilst shingles most commonly affects the torso, it can affect the face. The prodrome still occurs 1-3 days before the rash appears- pain, sensitivity, even fever and headache.The rash can occur across the forehead, cheek, scalp, nose, ear or mouth.

Eye involvement (urgent)

When shingles affects the ophthalmic branch of the trigeminal nerve (called Herpes zoster ophthalmicus) symptoms may include:

• Red eye

• Eye pain

• Blurred vision

• Sensitivity to light

• Rash on the tip of the nose (a warning sign called Hutchinson’s sign)

If you suspect shingles is affecting your eye, go to an Emergency Department or see an ophthalmologist that day. Shingles in the eye can cause permanent scarring and vision loss.

Ear involvement

If shingles affects facial and ear nerves (known as Ramsay Hunt syndrome), symptoms may include painful rash in or around the ear; hearing loss; dizziness; facial weakness or paralysis on one side; and altered taste. This can resemble Bell’s palsy but includes pain and rash.

Can you “catch” shingles?

You cannot “catch” shingles from someone else, but if you have an active rash, you can pass the virus to others as chickenpox. The virus is contained in the fluid of the blisters and is spread through direct skin-to-skin contact or contaminated surfaces (like towels). You remain contagious from the moment the first blister appears until the very last one has completely crusted and scabbed over. To protect others—especially pregnant women, newborns, and the immunocompromised—keep the rash strictly covered with clothing or a bandage and maintain meticulous hand hygiene.

What to do if you suspect shingles

Time is of the essence. Shingles is treated with antiviral medication, which is most effective when started within 72 hours of the rash appearing. Keep the lesions covered and see your GP as soon as you can (that day). If shingles is involving the eye, this is a medical emergency – go to the ED and raise your concern about ophthalmic shingles as soon as you can.

Shingles vaccine

The current vaccine used in Australia is Shingrix, a non-live vaccine. It is incredibly effective, offering about 97% protection for those in their 50s and 60s. Even a decade later, protection remains high (around 80%).

It is a two-dose course (spaced 2–6 months apart). Common side effects include a sore arm at the injection site, fatigue, muscle aches, or a mild fever for 24–48 hours.

In Australia, the National Immunisation Program (NIP) provides the vaccine for free to everyone aged 65 years and over; First Nations people aged 50 years and over; immunocompromised adults (18+) with specific medical conditions.

If you are a healthy woman in your 50s, you can still access Shingrix privately via your GP or pharmacist. While costs vary, expect to pay approximately $280–$300 per dose (roughly $600 for the full course). Whilst this is a considerable financial investment, it may save a severely painful few weeks, prolonged pain from post-herpetic neuralgia or in some instances, damage to vision.

 

 

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Key Take Aways

Shingles is a painful rash that occurs on one side of the body.

It occurs following a reactivation of herpes zoster infection (past chicken pox).

Antiviral medication taken early can lessen the severity.

Shingrix vaccine can drastically reduce your chances of have shingles.

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Musculoskeletal pain is one of the most common symptoms of menopause.

Arthritis, frozen shoulder, hip “bursitis”, muscle loss, aches and pains and osteoporosis are all more common during and after menopause. Whilst the role of oestrogen and other hormones seem important, current evidence does not point to MHT being helpful in preventing or treating conditions other than osteoporosis.

Learn more about current understanding in this video.

 

 

 

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Other resources

 

Wright VJ, Schwartzman JD, Itinoche R, Wittstein J. The musculoskeletal syndrome of menopause. Climacteric. 2024 Oct;27(5):466-472.

Overton R, Amini P, Chew A, et al. The effect of hormone replacement therapy on musculoskeletal pain in menopausal women: A systematic review and meta-analysis. Post Reproductive Health. 2025[/vc_column_text][/vc_column][/vc_row]

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A new international consensus statement has been released to help clinicians and breast cancer survivors better understand when menopausal hormone therapy (MHT) may be considered after breast cancer, and how to make safe, individualised decisions.

Many women experience significant menopausal symptoms after breast cancer treatment. Hot flushes, night sweats, sleep disruption, joint pain, sexual health changes and brain fog can profoundly impact quality of life. While lifestyle measures and non-hormone treatments can help, they are not always effective.

Systemic MHT remains the most effective option for vasomotor and other symptoms — but for breast cancer survivors, it has traditionally been contra-indicated because it may increase the risk of recurrence. Importantly, this risk is not the same for every woman. It depends on tumour biology, stage at diagnosis, and how long it has been since treatment.

The new consensus statement acknowledges that some women may choose to accept a small increase in risk in exchange for major quality-of-life improvements. The document aims to support clinicians and patients in making informed, shared decisions, rather than applying blanket prohibitions.

What determines the risk of using MHT after breast cancer?

The panel emphasises that three biological factors strongly influence recurrence risk — and therefore the potential impact of HRT:

1. Oestrogen receptor (ER) status

• ER-positive cancer is more likely to be stimulated by oestrogen.

• Because of this, women with ER+ tumours have a higher theoretical risk of a small cancer growing if exposed to systemic MHT.

• Risk is highest for those with strongly ER+/PR+ disease.

2. Cancer stage & pathology

• Larger tumours, lymph node involvement, and high-risk features (such as high grade) increase baseline recurrence risk.

• When baseline risk is higher, even a small relative increase from HRT can result in a more meaningful absolute increase — and this should be part of the discussion.

3. Time since diagnosis

• Recurrence risk is highest in the first 3–5 years after treatment.

• As time passes without recurrence, absolute risk generally decreases.

• However, ER+ cancers have a well-recognised risk of late recurrence, so time alone does not remove risk — it simply changes the conversation.

• Some cancer recurrences can switch receptor status.

Understanding these factors allows clinicians to estimate a woman’s individual baseline risk and explain how much HRT might change that risk in absolute numbers, not just percentages — a key part of informed consent.

What Does the consensus statement recommend?

A 25-member multidisciplinary panel reviewed the best available evidence on vaginal oestrogen, systemic MHT, and testosterone after breast cancer.

Their key recommendations:

1. Using vaginal oestrogen is acceptable 

Local vaginal oestrogen can be used to treat genitourinary symptoms (dryness, discomfort, UTIs). Systemic absorption is extremely low, and it is considered safe for most survivors after an informed discussion with their oncology team.

2. Systemic MHT may be considered (off-label in specific cases)

Systemic MHT is not routinely recommended, but it is not absolutely prohibited.
It may be offered off-label when:

• symptoms are severe,

• non-hormonal therapies have been ineffective,

• and the individual’s risk–benefit profile is acceptable based on tumour stage, ER status, and time since treatment.

Some women will decide that even a small increase in recurrence risk is not acceptable. Others may prioritise symptom relief and quality of life.

3. Shared decision-making is essential

Decisions must consider:

1. The woman’s symptoms and the impact on daily life

2. Her individual estimated recurrence risk, based on tumour biology, pathology and years since diagnosis

3. Her preferences, values and treatment goals.

This process should be clinician-guided, documented, and ideally involve the oncologist or multidisciplinary breast team.

For years, discussions about MHT after breast cancer have been oversimplified. This consensus statement recognises the complexity — and the importance of patient autonomy, quality of life, and personalised risk assessment.

It encourages clinicians to:

• give clear, honest information

• calculate absolute (not just relative) risk

• acknowledge the woman’s values and priorities

• support her in making an informed choice

The panel hopes doctors and patients will use this framework to guide safe, collaborative decision-making.

Read the paper here

 

 

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Key Take Aways

Using MHT after a breast cancer diagnosis is nuanced and requires shared-decision making

Vaginal oestrogen is considered safe

Receptor status, stage and time since diagnosis impact baseline risk.

 

Other resources

Menopausal hormone therapy for breast cancer patients: what is the current evidence?

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Creatine : a potential supplement for women in midlife

Midlife women are the largest consumers of supplements, most of which are not proven to be beneficial in the absence of deficiency. Creatine, however, may be a supplement worth taking. (More research to be done!)

Creatine has long been associated with male athletes and bodybuilding, but this is rapidly changing. High-quality research now shows emerging benefits for women, especially during midlife, when maintaining muscle, bone, mood and cognitive health becomes increasingly important.

What does creatine do?

Creatine is a naturally occurring compound made from three amino acids (glycine, arginine, methionine). The brain and body each produce around 1–3 g per day, and a further 1-3 g comes from food—mainly meat and fish.

Its primary role is to help rapidly regenerate ATP, the “quick energy” molecule your cells use for almost every high-intensity or high-demand task. Although 95% of creatine is stored in skeletal muscle, the brain also relies on creatine, especially during periods of stress or increased metabolic demand.

Because women typically have ~70–80% lower intramuscular creatine stores than men—and these stores decline with age—the potential upside of supplementation is even greater.

Why creatine matters more in midlife

1. Muscle strength & lean mass

Midlife is when women experience accelerated loss of muscle mass and strength. Studies consistently find that creatine combined with resistance training improves:

• muscle strength

• power

• lean body mass

• training quality.

Women respond at least as well as men—sometimes better—because they start with lower baseline stores.

 

2. Brain health, cognition & “brain fog”

Creatine supports brain energy metabolism and has shown benefits particularly when the brain is under stress, including:

• sleep deprivation

• concussion or mild TBI (traumatic brain injury)

• high cognitive load

• mood disorders

• intense physical stress.

Studies show improved cognitive performance under these conditions. Although research specifically on everyday “brain fog” is presently absent, creatine may benefit mood disorders, sleep disturbance and plausibly brain fog.

There is also early data supporting creatine as an adjunctive therapy for depression, with improved mood scores and enhanced SSRI response.

3. Bone health

Creatine may support bone density by improving:

• muscle strength → higher mechanical load on bone

• cellular energy in osteoblasts

• performance during weight-bearing exercise.

Creatine alone is not a bone medication—but it amplifies the bone-building effect of resistance training.

Dosage recommendations for women in midlife

The first ~5 g/day of supplemented creatine is preferentially absorbed by muscle—especially in women who exercise regularly.

This means less creatine is available to cross the blood–brain barrier, which is why brain-focused dosing is typically higher.

For muscle, bone & general health

5 g/day of creatine monohydrate.

This is safe, effective, and well studied.

For brain, mood & cognitive support

10 g/day, divided into 1–2 doses.

Why more?

• The first ~5 g saturates skeletal muscle.

• Additional creatine increases availability to the brain.

• Higher doses have been used safely in research examining concussion, sleep deprivation, and depression.

Take consistently for 4–6 weeks, then continue long-term at 5–10 g/day depending on training load and goals.

Types of creatine

The most studied and reliable form is creatine monohydrate.
Other forms (HCl, buffered, ethyl-ester) have no proven advantage and are often more expensive.

Choose a product that is:

• third-party tested

• plain powder

• free of fillers or additives

Do you still need to exercise?

Yes!
Creatine works best when paired with:

• resistance training (2–4 days per week)

• weight-bearing activity

• high-intensity short bursts

It’s not a magic powder—it’s an amplifier.

Safety & potential side effects

Creatine is one of the safest and most researched supplements in sports and clinical nutrition.

Common, mild side effects:

• temporary water retention (1–1.5 kg)

• mild bloating in some women

• slight stomach upset if taken on an empty stomach

• cramping is rare (usually dehydration-related).

Creatine does not harm kidneys in healthy individuals (elevated creatinine, commonly used as a measure of kidney function, is due to increased creatine metabolism). Those with exisiting kidney disease should seek medical advice.

Long-term use (even 5–10 years) has been shown to be very safe.

Reference list

Smith-Ryan AE et al., Creatine Supplementation in Women’s Health: A Lifespan Perspective. Nutrients. 2021. PMCID: PMC7998865. PubMed Central

Smith-Ryan, A. E., et al (2025). Creatine in women’s health: bridging the gap from menstruation through pregnancy to menopause. Journal of the International Society of Sports Nutrition

Kreider RB et al., Safety and efficacy of creatine supplementation in exercise. JISSN (review). (JISSN summary of daily needs ~1–3 g/day). BioMed Central

Avgerinos KI et al., Effects of creatine supplementation on cognitive function (systematic review). (and related reviews on brain). Frontiers+1

Lyoo IK et al., Randomized, double-blind trial: Creatine augmentation for SSRI treatment in women with MDD. 2012. PubMed Central

Bakian AV et al., Dietary creatine intake and depression risk among U.S. adults. 2020 (observational analysis). Nature

Roschel, H., Gualano, B., Ostojic, S. M., & Rawson, E. S. (2021). Creatine Supplementation and Brain Health. Nutrients, 13(2), 586. Nutrients

 

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Key Take Aways

Creatine is used by brain and muscle for generating energy

It has long-known benefits for exercise but emerging benefits for cognition and depression, especially in “stressed” brains

The brain may need 10g daily, (more that the 5g daily commonly recommended for muscles)

Creatine is very safe

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Hot flushes are more than an inconvenience – associations with heart and brain health are now emerging.

For a long time, hot flushes and night sweats were seen mainly as a quality-of-life issue. They can certainly disrupt sleep, cause embarrassment, and make day-to-day life difficult. But in recent years, researchers have been asking whether vasomotor symptoms (VMS) might also be a signal of something more — whether they tell us about a woman’s risk of cardiovascular disease or changes in brain health. The evidence is still evolving, but the message is clear enough to take seriously: persistent or frequent flushes are not just uncomfortable, they may also be a red flag for future health risks.

In cardiovascular research, studies such as the SWAN Heart cohort in the United States have found that women who experience frequent hot flushes across the menopause transition are more likely to show early signs of heart and blood vessel disease. These women had greater coronary artery calcification and poorer endothelial function — in other words, changes in the blood vessels that are known to predict cardiovascular events. Even day-to-day blood pressure monitoring shows that flushes can coincide with higher readings, and while those rises may be small, sustained differences over years add up. It is important to be clear: no study has yet shown that a hot flush directly causes a heart attack. Rather, they seem to travel together, which makes hot flushes a useful clinical cue to check other risks carefully.

When it comes to the brain, a similar story is unfolding. Researchers who measure flushes with physiologic monitors — rather than just self-report — have shown that women with more flushes at night tend to have more white-matter hyperintensities on MRI scans. These are small changes in the brain’s wiring that are associated with later cognitive decline. Laboratory work has also shown that on days when flushes are frequent, verbal memory and attention can be subtly worse. None of this proves that hot flushes cause dementia, but it does suggest that women with heavy symptom burdens deserve careful attention to brain as well as heart health.

Some women are particularly vulnerable. Those who go through early or surgical menopause, without oestrogen replacement, face higher long-term cardiovascular and cognitive risks. Carriers of the APOE ε4 gene variant — the most common genetic risk factor for Alzheimer’s disease — also have higher baseline risk. Intriguingly, some observational studies suggest that APOE ε4 carriers who start menopausal hormone therapy (MHT) earlier may perform better on memory tests, but this remains an area of research rather than clinical guidance. It would not be appropriate to recommend genetic testing or to prescribe MHT solely on this basis, but it is one example of how personalised risk may matter in the future.

For now, the more important message is that many of the key risks are modifiable.

Every woman with significant VMS deserves a proper cardiovascular check-up — in Australia, that means a Heart Health Check with calculation of five-year risk using the Australian CVD Risk Calculator, and tailored advice about blood pressure, lipids and diabetes screening. These checks should also consider history of pregnancy complications such as pre-eclampsia or gestational diabetes, which add to lifetime risk. Lifestyle changes still do much of the heavy lifting: regular physical activity, a plant-rich Mediterranean-style diet, adequate sleep, limiting alcohol, and quitting smoking or vaping if relevant. These strategies reduce cardiovascular and dementia risk (and often improve the severity of hot flushes themselves). Screening for sleep apnoea and mood problems is also worthwhile, as both can worsen symptoms and overall cardiometabolic risk.

On the treatment front, MHT remains the most effective option for bothersome hot flushes and night sweats. For women under 60 or within about ten years of menopause, the benefits usually outweigh the risks when therapy is tailored to the individual. For women who are older, or further from menopause, MHT is not automatically ruled out, but it requires more careful consideration. At these ages, risks related to blood clots, stroke, and dementia appear to be higher, and decisions should be made case by case, with attention to personal history and preferences. Several non-hormonal medications, including SSRIs, SNRIs, gabapentin, clonidine, and the newer neurokinin-3 receptor antagonist fezolinetant (approved in Australia in 2024), can all reduce hot flushes. The choice depends on other medical conditions and what each woman feels comfortable with.

Where the science is strong is in showing that hot flushes line up with changes in the heart and brain. Where the science is still thin is understanding the nature of that relationship (is it correlation, causation or a common mechanism underlying both), in proving whether treating the flushes themselves reduces those long-term risks and furthermore, if using hormonal or non-hormonal treatments makes any difference. We do not yet know the threshold at which flush frequency becomes dangerous, nor whether all women are equally affected. Genes such as APOE probably play a role, but they are not the whole story.

So, if you are experiencing frequent or persistent hot flushes, the safest path is not to worry, but to act. Check your personal risk, seek information about all treatment options and focus on your healthiest self across diet, exercise, and medications. That way, you are not only improving your quality of life now, but also protecting your heart and brain health in the decades ahead.

 

References

1. El Khoudary SR, et al. Vasomotor Symptoms and Cardiovascular Events in the Study of Women’s Health Across the Nation Heart Study. Journal of the American Heart Association. 2021.

2. Thurston RC, et al. Hot Flashes and Subclinical Cardiovascular Disease: Findings from the SWAN Heart Study. Circulation. 2008.

3. Daube JR, et al. Objective Hot Flashes Are Associated With White Matter Hyperintensities in Midlife Women. Neurology. 2022.

4. Maki PM, et al. Physiologic Hot Flashes Are Associated With Poorer Verbal Memory Performance. Menopause. 2008.

5. The North American Menopause Society (NAMS). The 2022 Hormone Therapy Position Statement of The North American Menopause Society. Menopause. 2022.

6. Saleh RN, et al. APOE ε4 Genotype, Menopausal Hormone Therapy, and Cognitive Performance in Midlife Women: EPAD Cohort Findings. Alzheimer’s Research & Therapy. 2023.

7. National Heart Foundation of Australia and Australian Chronic Disease Prevention Alliance. Australian Guideline for Assessing and Managing Cardiovascular Disease Risk. Medical Journal of Australia. 2023.

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Key Take Aways

Hot flushes and night sweats are associated with an increased risk of heart and brain disease.

Mechanistic links, outcomes if hot flushes are treated and wether MHT reduces risk remain unknown.

MHT is still not recommended for heart and brain health unless you experience menopause under 45 years of age.

 

Other resources

Australian CVD Risk Calculator

NOTE – this calculator estimates 5 year risk.

CVD is a longterm health problem. To reduce your 20 year risk, take action on modifiable risk factors now, even if your 5 year risk is low.

 

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Understanding Australia’s Pharmaceutical System (2025)

Australia has a unique and highly structured pharmaceutical system designed to make medications affordable and accessible. If you’ve ever wondered about the difference between private and PBS prescriptions, or why some medicines require special approval, here’s a quick guide.

The PBS: Making Medicines Affordable

The Pharmaceutical Benefits Scheme (PBS) is a government program that subsidises the cost of many prescription medicines. This means patients pay only a portion of the medicine’s full cost, and the government covers the rest. The amount you pay depends on whether you have a concession card.

• Concession card holders (such as Pensioner Concession Card or Health Care Card holders) currently pay $7.70 per PBS-listed medicine (as of 2025), with free medications once they reach the Safety Net threshold.

• General patients pay up to $31.60 per medicine, with similar protections after reaching their threshold.

Private Prescriptions vs. PBS Prescriptions

Not all medicines are covered by the PBS. If a medicine isn’t listed, or you don’t meet PBS criteria, it may be issued as a private prescription. In this case, you’ll pay the full cost of the medication, which can vary widely.

Authority Scripts: What Are They?

Some medications on the PBS require Authority approval—usually for higher-cost drugs or those needing strict eligibility criteria. These scripts may require prior approval from Medicare (via phone or online), although many now qualify for ‘streamlined authority’, making the process easier.

60-Day Prescribing: Increasing Convenience

In 2023, the Australian Government began rolling out 60-day dispensing for certain long-term medications—such as those for high blood pressure, high cholesterol, and diabetes. This allows eligible patients to receive two months’ supply with one script—reducing pharmacy visits and co-payments. However, not all medications qualify, and it depends on clinical suitability (you must be already stable using the medication) and doctor discretion.

Multiple Packs and Dispensing Limits

In some cases, prescribers can request multiple packs to be dispensed at once—especially for patients travelling or with special needs. This usually requires an authority script and documented justification.

Your Health Fund

While the Pharmaceutical Benefits Scheme (PBS) keeps medicine costs low for many Australians, private health insurance can also help reduce out-of-pocket costs—particularly for non-PBS (private) prescriptions. Some extras cover policies include benefits for prescription medications not subsidised by the PBS, such as certain types of menopausal hormone therapy (MHT), dermatology treatments, or compounded medications. These rebates vary between insurers and depend on your level of cover, annual limits, and whether the medication is legally prescribed by a registered healthcare provider. It’s important to check your policy details or speak with your insurer to see if you’re eligible for reimbursement on private prescriptions, as PBS-listed medicines are not typically claimable through private health funds.

Australia’s pharmaceutical system offers strong protections against high medication costs, especially for those with chronic illness or low income. Knowing the difference between PBS and private prescriptions, understanding authority requirements, and making use of new initiatives like 60-day dispensing can help you get the most out of the system.

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Key Take Aways

Many forms of MHT are now available on the PBS and some are also eligible for 60 day prescribing.

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The menopause transition can really play havoc with your mood.

 

In this interview, Dr Juliet Tait, a GP with special interests in menopause and mental health, shares helpful information about-

• mental health
• mental illness
• how to maintain the best mental health
• what happens during perimenopause.

She also shares her personal perimenopausal mental health challenges.

 

Watch the video here

 

Feel free to share it with women you care about!

 

 

 

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Iron deficiency and its associated symptoms are common, particularly during perimenopause. These symptoms often overlap with those caused by hormonal changes, making accurate diagnosis important.

The role of iron

Iron is vital for many physiological functions, including:

• Oxygen transport: Iron is a key component of haemoglobin, the protein in red blood cells responsible for carrying oxygen from the lungs to the rest of the body.

• Energy production: Iron supports cellular processes that produce energy.

• Immune function: Adequate iron is necessary for maintaining a healthy immune system.

• Muscle health: Iron is required to produce myoglobin, a protein that stores oxygen in muscle cells.

• Metabolic processes: Iron is involved in various enzymatic reactions throughout the body.

The body carefully regulates iron levels, as both deficiency and excess can be harmful.

Causes of iron deficiency

Iron deficiency can result from inadequate intake, such as from a diet low in iron-rich foods or increased loss, due to heavy menstrual bleeding, gastrointestinal blood loss, intense physical exercise, or certain medical conditions.

Importantly, iron deficiency can occur with or without anaemia (a low haemoglobin level). Many symptoms may be present even when haemoglobin is within the normal range.

Symptoms

Common symptoms include:

• Fatigue

• Headaches

• Brain fog

• Sleep disturbances

• Mood changes

• Hair thinning or loss

• Restless leg syndrome

If anaemia develops, additional symptoms such as palpitations and shortness of breath on exertion may also appear. These symptoms can easily be mistaken for those of perimenopause or menopause, highlighting the importance of proper evaluation.

Diagnosis

Diagnosis typically involves a blood test to measure:

• Ferritin, the protein that reflects iron stores. In symptomatic individuals or those with ongoing losses, aiming for a ferritin level in the mid-normal range may be more appropriate than simply avoiding the lower limit.

• Full blood count, to check haemoglobin levels.

• Transferrin saturation, particularly useful when ferritin levels may be falsely elevated due to inflammation, infection, or obesity.

Ferritin tests may need to be repeated if results are unclear or confounded by other conditions.

Treatment

Managing iron deficiency involves two key strategies:

1. Addressing the underlying cause of iron loss, such as:

   • Treating heavy menstrual bleeding using hormonal therapies (e.g., combined oral contraceptive pill, progestogen-releasing intrauterine device, or short-term high dose cyclic progestogens).

   • Investigating and managing other sources of loss (e.g., gastrointestinal bleeding including early bowel cancer, coeliac disease, urinary losses, or high physical activity levels).

2. Replenishing iron levels through:

   • Dietary changes.

   • Oral iron supplements.

   • Iron infusions, in cases of very low ferritin or poor response to oral supplementation.

Dietary iron

The recommended daily intake (RDI) of iron for menstruating women aged 31–50 is 18 mg per day in Australia. This requirement reflects ongoing iron losses from menstruation and is significantly higher than that of men (8 mg/day) or postmenopausal women (8 mg/day).

Iron in the diet is found in two forms: haem iron, found in animal products, is efficiently absorbed (about 15–35%) and non-haem iron, from plant sources, is less efficiently absorbed (about 2–20%) and more affected by other dietary factors.

Haem iron sources (higher absorption)

• Red meat (e.g. beef, lamb): ~2.5–3.0 mg per 100g

• Poultry (e.g. chicken, turkey): ~1.0–1.5 mg per 100g

• Fish and shellfish (e.g. sardines, mussels): ~1.0–2.0 mg per 100g

• Eggs: contain ~0.6–1.2 mg of iron per egg (mostly non-haem iron)

Non-haem iron sources (lower absorption)

Although some plant foods contain a high total iron content, the bioavailability is much lower than from animal sources.

Examples:

• Lentils, chickpeas, beans: ~2.0–3.5 mg per cup (cooked)

• Tofu: ~3.0 mg per 100g

• Fortified breakfast cereals: up to 7.0 mg per serve

• Nuts and seeds (e.g. pumpkin seeds, cashews): ~2.5 mg per 30g

• Leafy greens (e.g. spinach): ~3.6 mg per 100g—but with limited absorption due to oxalates

For example, 100g of cooked beef may provide 3.0mg of iron toward your daily intake requirements but only deliver 0.5–0.6 mg of absorbable iron, while the same amount of spinach may provide only 0.1 mg, despite similar total iron content.

Enhancing iron absorption can be achieved by pairing meals with vitamin C-rich foods (e.g. capsicum, citrus, tomatoes) to improve non-haem iron absorption; avoiding tea, coffee, calcium-rich foods, or antacids within 1–2 hours of iron-rich meals; combining haem and non-haem sources to maximise absorption of plant-based iron.

Iron supplementation

For those who need iron supplementation, several oral preparations are available in Australia:

• Ferrous sulfate (e.g. Ferrograd-C): commonly used, contains 325 mg (105 mg elemental iron)

• Ferrous fumarate (e.g. Ferro-F-Tab): 200 mg (65 mg elemental iron)

• Iron polymaltose complex (e.g. Maltofer): a gentler alternative with fewer GI side effects; 100 mg elemental iron per tablet

Common side effects of iron tablets include nausea, constipation, dark stools, and abdominal discomfort. To reduce side effects start with one tablet every second day and gradually increase to daily dosing if tolerated, take tablets on an empty stomach for best absorption, but if stomach upset occurs, taking them with food is acceptable, avoid taking with calcium-rich foods or antacids.

Iron supplementation is typically required for 3–6 months, depending on the severity of the deficiency and response to treatment. Even after symptoms improve, treatment should continue until iron stores (ferritin) return to a normal range.

A rise in ferritin and haemoglobin is usually seen within 4–8 weeks, but full replenishment of iron stores can take up to 6 months. Blood tests should be repeated after 8–12 weeks to assess response and adjust treatment if needed.

Iron infusions

Iron infusions are intravenous treatments used to rapidly replenish iron stores. They are typically administered as ferric carboxymaltose (e.g. Ferinject) or iron polymaltose.

Indications include:

• Severe iron deficiency (especially with anaemia) where oral iron is not tolerated or effective.

• Chronic conditions (e.g. inflammatory bowel disease) affecting absorption.

• Ongoing heavy menstrual bleeding with poor response to oral therapy.

• Severe iron deficiency when rapid correction is needed.

Iron infusions are usually administered in a clinic setting over 15–60 minutes. They are generally well tolerated but can occasionally cause allergic reactions, skin staining (if leakage occurs), or delayed flu-like symptoms.

Correcting iron deficiency can alleviate symptoms that are often misattributed to hormonal changes, especially during perimenopause.

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Key Take Aways

Heavy, frequent periods can result in iron deficiency

Symptoms of iron deficiency can mimic those of perimenopause and menopause

Menstruating perimenopausal women need 18mg of iron/day whereas postmenopausal women only need 8mg/day

 

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