Eating Healthy, Exercising… So Why Are My Cholesterol and A1C Rising?
Why Cholesterol and Insulin Resistance Can Increase During Perimenopause and Menopause
Understanding the connection between hormones, metabolic health, and cardiovascular risk.
Have you noticed your cholesterol creeping up, your blood sugar changing, or your weight shifting toward your midsection—even though your diet and exercise habits haven't changed much?
You're not alone.
Many women entering perimenopause and menopause begin experiencing metabolic changes that seem to appear almost overnight. In my practice, I frequently work with women who are surprised to discover that their cholesterol, LDL, triglycerides, or insulin levels are increasing despite maintaining what they consider a healthy lifestyle.
We often hear about declining estrogen during menopause, especially when discussing hot flashes, sleep disturbances, and mood changes.
But there's another important part of the conversation: How do changing hormones influence our metabolic health, and why might cardiovascular and diabetes risk increase during this stage of life?
Research suggests the answer involves more than estrogen alone.
Menopause Is More Than a Reproductive Transition
Perimenopause is the transitional period leading up to menopause, when reproductive hormones begin fluctuating and menstrual cycles become less predictable.
As women approach menopause, estrogen levels generally decline, but the hormonal changes are more complex than simply losing estrogen.
The relationship between estrogen, testosterone, and sex hormone–binding globulin (SHBG) also changes.
SHBG is a protein that binds to hormones, including testosterone and estrogen, helping regulate how much is available to tissues.
As estrogen declines, the hormonal environment may become relatively more androgen-dominant, even without an actual increase in total testosterone.
Why does this matter?
Because changes in this hormonal balance have been associated with insulin resistance, abdominal fat accumulation, altered cholesterol levels, and metabolic syndrome.
What Does the Research Tell Us?
A landmark 2008 study published in Archives of Internal Medicine, now JAMA Internal Medicine, followed 949 women through the menopausal transition as part of the Study of Women's Health Across the Nation (SWAN).
The researchers wanted to understand whether the development of metabolic syndrome increased during menopause independently of aging and whether changing reproductive hormones contributed to that risk.
Metabolic syndrome is a cluster of risk factors that includes increased waist circumference, elevated blood pressure, elevated blood sugar, high triglycerides, and low HDL cholesterol.
Having at least three of these risk factors increases concern for future cardiovascular disease and type 2 diabetes.
The findings were significant.
By the time women reached their final menstrual period, 13.7% had developed metabolic syndrome.
Researchers also found that the odds of developing metabolic syndrome increased more rapidly during perimenopause than after menopause, even after adjusting for age, body mass index, smoking, and other factors.
Interestingly, higher bioavailable testosterone and lower SHBG were associated with greater metabolic syndrome risk.
The findings suggest that the changing balance of reproductive hormones may contribute to metabolic changes during menopause, rather than chronological aging alone.
Why Does Insulin Resistance Increase During Menopause?
Insulin is a hormone produced by the pancreas that helps glucose move from the bloodstream into cells, where it can be used for energy.
Insulin resistance develops when cells become less responsive to insulin. To compensate, the pancreas may produce more insulin to maintain normal blood glucose levels.
This means a woman can have normal fasting glucose or hemoglobin A1c while already experiencing changes in insulin sensitivity.
Over time, insulin resistance may contribute to elevated blood sugar, increased triglycerides, abdominal fat accumulation, and a greater risk of type 2 diabetes.
Estrogen plays several roles in metabolic regulation, including effects on glucose metabolism, fat distribution, and insulin signaling.
As estrogen declines and body composition changes, women may become more susceptible to insulin resistance.
Newer research from the SWAN cohort also suggests that insulin resistance can increase more rapidly around the final menstrual period, even after accounting for changes in body mass index.
This is one reason I encourage women to look beyond their weight when evaluating metabolic health.
Why Do Cholesterol Levels Change?
Another common concern during perimenopause is an unexpected increase in cholesterol.
Estrogen influences cholesterol metabolism, including how the liver processes and clears circulating lipoproteins.
During the menopause transition, some women experience increases in:
LDL cholesterol, which contributes to atherosclerotic cardiovascular risk
Apolipoprotein B (ApoB), a marker of the number of atherogenic lipoprotein particles
Triglycerides, particularly when insulin resistance is present
Total cholesterol and non-HDL cholesterol
Not every woman experiences the same changes, and cholesterol levels must be interpreted in the context of overall cardiovascular risk.
Nevertheless, these changes deserve attention.
Insulin resistance can also influence lipid metabolism. When insulin signaling becomes impaired, the liver may produce more triglyceride-rich lipoproteins, contributing to an unfavorable lipid profile.
This creates an important connection between reproductive hormone changes, glucose regulation, and cardiovascular health.
It's Not Just About Weight Gain
One of the most frustrating aspects of perimenopause is that body composition can change even when the number on the scale remains relatively stable.
Women may experience a reduction in lean muscle mass, greater accumulation of abdominal fat, and changes in energy expenditure.
Visceral fat—the fat stored around internal organs—is particularly relevant because excess visceral fat is associated with insulin resistance, inflammation, and cardiovascular risk.
This doesn't mean every woman will gain weight or develop metabolic dysfunction during menopause.
It means that preserving muscle, supporting insulin sensitivity, and monitoring cardiovascular risk factors become increasingly important during midlife.
Five Ways to Support Metabolic Health During Perimenopause
The good news is that there are practical steps women can take to support their metabolic health during this transition.
1. Prioritize protein and preserve muscle.
Muscle is an important site for glucose uptake. Including adequate protein throughout the day and participating in regular resistance training can help maintain muscle mass as women age.
2. Increase dietary fiber.
Fiber-rich foods such as vegetables, berries, beans, lentils, oats, nuts, and seeds support digestive health and can help improve cholesterol and blood glucose regulation.
Soluble fiber, particularly from foods such as oats, barley, and legumes, can help lower LDL cholesterol.
3. Choose carbohydrates that support blood sugar balance.
Carbohydrates do not need to be eliminated to support insulin sensitivity.
Instead, emphasize minimally processed, fiber-rich carbohydrate sources and pair them with protein and healthy fats to support balanced meals.
4. Incorporate regular movement.
Resistance training and aerobic activity both support cardiometabolic health.
Walking after meals can also help reduce post-meal glucose spikes.
The goal is consistency, not exhausting workouts.
5. Monitor the markers that matter.
In addition to standard cholesterol testing, discussing appropriate metabolic and cardiovascular assessments with your healthcare provider may provide a more complete picture.
Depending on your individual risk factors, these may include a lipid panel, ApoB, lipoprotein(a), fasting glucose, hemoglobin A1c, blood pressure, and waist circumference.
Fasting insulin is also used in Functional Medicine as an additional reference point to see changes prior to even A1C increases. Its a marker to determine the best overall lifestyle and dietary interventions to course correct prior to insulin resistance happening.
The Bigger Picture: Understanding Your Changing Body
Perimenopause and menopause are natural life transitions, but that doesn't mean the metabolic changes that sometimes accompany them should be overlooked.
The research reminds us that hormonal changes and metabolic health are closely connected.
Declining estrogen, changing androgen balance, body composition, insulin sensitivity, and lipid metabolism can all influence how women experience this stage of life.
Rather than focusing only on weight or a single laboratory marker, I encourage women to take a more comprehensive approach that considers nutrition, physical activity, sleep, stress, metabolic health, and individual cardiovascular risk.
The goal isn't to stop menopause. It's to support your body through the transition and protect your long-term health.
Ready to Better Understand Your Metabolic Health?
At Angie Renee Wellness, I help women navigate the hormonal and metabolic changes of midlife through personalized nutrition and lifestyle strategies.
Whether you're experiencing rising cholesterol, changes in blood sugar, fatigue, or shifting body composition, understanding your individual health picture is an important first step.
Feel your best, live your best.
Research References
Janssen I, Powell LH, Crawford S, Lasley B, Sutton-Tyrrell K. Menopause and the metabolic syndrome: the Study of Women's Health Across the Nation. Arch Intern Med. 2008;168(14):1568-1575. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/414391
Development of insulin resistance in women over the menopause transition. PubMed PMID: 42837175. https://pubmed.ncbi.nlm.nih.gov/42837175/
The cardiometabolic effects of menopause. https://pubmed.ncbi.nlm.nih.gov/42691325/