As women transition through perimenopause, there’s often a renewed focus on hormone balance, bone strength, and weight management. But one silent risk frequently goes overlooked until it’s too late: coronary artery disease (CAD). It remains the leading cause of death for women, and midlife is a crucial window for early prevention.

Emerging research is reshaping how we screen for heart disease, now offering smarter, more precise tools than simply checking a standard cholesterol panel. Leading the way in next-generation heart screening are:  Apolipoprotein B (ApoB) and Lipoprotein(a).  When paired with coronary artery calcium (CAC) scoring,  they are helping identify hidden cardiovascular risk before symptoms strike.

What Is Coronary Artery Disease and Why Should You Care?

Coronary artery disease happens when plaque builds up in the arteries that supply blood to your heart. Over time, this narrowing can trigger heart attacks or other serious complications. During perimenopause, shifts in estrogen levels can accelerate metabolic and inflammatory changes that make arteries more vulnerable.

Traditional cholesterol tests, like LDL (“bad” cholesterol), only tell part of the story. Many women with “normal” cholesterol still go on to have cardiac events.  Around 72% of women having their first heart attack have LDL‑C levels considered “normal” by conventional screening cutoffs (<130 mg/dL). It's not just how much cholesterol you carry, but how many atherogenic particles (i.e. the "problematic" particles) are circulating in your bloodstream.

ApoB: A Better Predictor of Risk

A recent large-scale study published in the European Heart Journal showed that Apolipoprotein B (ApoB) is a structural protein present in every artery-clogging particle like LDL, VLDL, and IDL; and, is a more precise marker of cardiovascular risk than LDL cholesterol alone.

For every standard deviation increase in ApoB-containing particles (ApoB), there was a 33% higher risk of developing coronary artery disease, regardless of the type or size of the particles.

Because each atherogenic lipoprotein carries one molecule of ApoB, testing ApoB gives a direct count of the number of damaging particles, not just their cholesterol cargo.

Lipoprotein(a): The Underestimated Threat

The study also confirmed that Lipoprotein(a), a genetically determined LDL-like particle with a unique “sticky” protein called apolipoprotein “little a”, is an independent risk factor for coronary artery disease.

High Lp(a) levels:

• Promote plaque formation
• Interfere with normal clot breakdown
• Aren’t significantly changed by diet or lifestyle, usually...(I have actually seen changes in this value with lifestyle adjustments).

And it's useful to know that: Lp(a) is not part of standard cholesterol testing, yet it may account for a substantial portion of unexplained cardiovascular events in women.

Many cardiologists now recommend testing Lp(a) at least once in your lifetime.  Especially if you have a personal or family history of heart disease, even in the absence of high cholesterol.

Seriously worth consideration (in my opinion): CAC Scoring

One of the most powerful tools for visualizing your risk, in particular if labs are borderline, is the coronary artery calcium (CAC) score. This low-dose CT scan measures calcium deposits in your coronary arteries, revealing early plaque build-up years before symptoms appear. This number should be ZERO...in a perfect world.

Why it’s so helpful in perimenopause:

• Clarifies risk when cholesterol is “normal” 
• Avoids over treatment in women with zero plaque 
•  Helps to guide discussions on statins, hormone therapy, and lifestyle intensity 

If your ApoB or Lp(a) is elevated, a CAC score can tell you whether it’s causing real arterial damage-- or if you still have time to prevent it. 

So, What Should You Do?

Here’s how to translate this research into action:

Step 1: Go Beyond the Standard Lipid Panel

Ask your doctor for:

• Apolipoprotein B 
• Lipoprotein(a) (once in a lifetime, or perhaps more often if elevated)

These can usually be ordered through major labs and are often covered by insurance.

Step 2: Consider a CAC Score

If you’re 40–65, have risk factors (like high ApoB, family history, or metabolic syndrome), and aren’t sure whether you need medication, this test can offer another metric for consideration. A score of zero is incredibly reassuring. A high score might prompt more aggressive interventions.

Step 3: Address what you have control over

Heart disease prevention in midlife is not just about numbers--it’s about what those numbers reflect:

• Insulin resistance 
• Chronic inflammation 
• Hormonal decline 
• Oxidative stress 

Integrative and functional strategies to support cardiovascular health during perimenopause include:

• Anti-inflammatory diets (like the Mediterranean or D.A.S.H diets)
• Magnesium 
• Omega-3 supplementation (with monitoring of blood levels in order to optimize dosing)
• Targeted support for estrogen metabolism 
• Regular exercise (being sedentary is just as bad as smoking)
• Stress management and quality sleep 
• Guided use of hormone therapy, if appropriate 

The Takeaway

Perimenopause is a pivotal time to take stock of your heart health—before problems emerge. Relying on LDL alone might miss hidden risk. The future of screening lies in particle-based markers like ApoB and Lp(a), and imaging tools like CAC scoring that show us what’s really going on inside your arteries.

Knowing your numbers is powerful..but knowing which numbers to look at and why is even more important.

Wellness always,

Dr. Lynd

Clearly, this post is for general information only!  This is not medical advice. No physician/patient relationship is formed. Utilizing any of this information is at the reader's own risk.   This content is not a substitute for personalized medical advice, diagnosis or treatment. Seek advice from your personal professional provider who knows you and your current medical needs.

Need help interpreting your ApoB, Lp(a), or CAC results? At Integrative Menopause MD, we use advanced cardiometabolic screening and personalized strategies to reduce risk and support you through midlife transitions. Reach out for a consultation tailored to your body, your labs, and your future.