BEYOND HORMONES (part 2): A Functional Blueprint for Cardiometabolic Health in Menopause

By Hwaida Hannoush, MD FASE 

ADVANCED CARDIOMETABOLIC ASSESSMENT IN MENOPAUSE

A comprehensive functional evaluation includes:

1. Metabolic Markers
• Fasting insulin, HOMA-IR
• Triglyceride-glucose index (TyG)

2. Lipid and Particle Analysis
    • ApoB (superior to LDL-C for predicting             atherogenic particle burden)
    • Lipoprotein(a) [Lp(a)]: Elevated post-menopause and minimally responsive to statins
    • Oxidized LDL (oxLDL)

3. Inflammatory and Immune Biomarkers
    • hs-CRP, fibrinogen , MPO, Lp-PLA2
    • autoimmune markers (ANA, thyroid antibodies)
    • IL-6 and TNF-α (in select high-risk cases)

4. Endocrine and Hormonal Dynamics

    • Estradiol, progesterone, testosterone, and cortisol
    • Full Thyroid panel (TSH, free T3/T4, reverse T3, thyroid antibodies)

5. Vascular Imaging and Function                                                                                                      

    • CAC score: Critical in identifying subclinical plaque in asymptomatic women
    • Coronary CT Angiography with Flow Reserve (FFR-CT):Coronary CT angiography with fractional flow reserve (FFR-CT) is a non-invasive imaging modality that combines high-resolution anatomical visualization of the coronary arteries with computational assessment of blood flow dynamics. It not only evaluates flow-limiting lesions but also characterizes plaque morphology—distinguishing between soft, mixed, and calcified plaque. Identifying high-risk, non-calcified (soft) plaque is critical, as it is more vulnerable to rupture and serves as a powerful predictor of future cardiovascular events.
    • CIMT, EndoPAT: Evaluate endothelial and arterial health

6. Microbiome and Detoxification Assessment

• Stool Analysis assesses microbiota composition, inflammation, and β-glucuronidase activity, a key indicator of estrobolome function. Elevated enzyme levels suggest increased estrogen reactivation, contributing to estrogen dominance. It also identifies dysbiosis and guides microbiome-targeted therapies.

• Complete Hormone Test evaluates estrogen metabolism (2-OH, 4-OH, 16-OH pathways), adrenal function, and cortisol rhythms. Patterns of impaired detoxification may point to gut-liver axis dysfunction, especially when interpreted alongside stool analysis results.

• Organic Acid and Stool Metabolomics detect microbial imbalances, nutrient deficiencies, and cardiometabolic risk markers like TMAO and butyrate. Low butyrate indicates reduced anti-inflammatory capacity and impaired gut barrier function.

7. Oral Health

    • Periodontal disease assessment by biologic or holistic dentists. 

8. Thyroid Health

• Thyroid function optimization to reduce lipid and blood pressure dysregulation

9. Micronutrients: Vitamin D, B-complex, omega-3s, magnesium

10. Autoimmunity & Detoxification: ANA, GGT, homocysteine, albumin-creatinine ratio

11. Genetics: ApoE, MTHFR polymorphisms

12. The Role of Digital Biomarkers: CGM, HRV, and Beyond

In modern integrative cardiology, wearable and digital diagnostics offer real-time, actionable insights. Continuous glucose monitors (CGMs) help identify glycemic variability, postprandial hyperinsulinemia, and reactive hypoglycemia—often missed by fasting glucose or HbA1c alone. In perimenopausal women, CGM data frequently reveals dysregulated glucose metabolism months before overt metabolic syndrome emerges.

Similarly, heart rate variability (HRV) monitoring provides a window into autonomic tone and recovery capacity. Lower HRV correlates with heightened sympathetic activity, impaired vagal tone, and increased cardiovascular event risk [7]. HRV, combined with wearable sleep metrics and fitness trackers, enables dynamic assessment of recovery, stress response, and circadian alignment—key variables during menopausal transition.

Digital data bridges the gap between clinical encounters and daily lived physiology. When integrated with labs, imaging, and patient-reported outcomes, tools like CGM and HRV enable continuous, individualized risk profiling.

KEY THERAPEUTIC PILLARS: FROM MOLECULES TO MOVEMENT

1. Lifestyle and Risk Modification: The Evidence is Clear- A recent study [23] showed that women with high lifestyle adherence (non-smoking, optimal sleep, regular exercise, healthy diet, less sitting) had:

    • 23% lower odds of CVD overall

    • 52% lower odds of CVD if they had premature menopause

    a. Restorative sleep (7–8 hours) is essential for regulating blood pressure, cortisol levels, and cardiometabolic function.

    b. Evidence-based stress management strategies like mindfulness, yoga, breathing exercises, and biofeedback improve heart rate variability and reduce cardiovascular events.

    c. Exercise Prescription

    • Resistance Training: 2–3x/week to counteract sarcopenia and improve insulin sensitivity [12]
    • Zone 2 Cardio: 150 minutes/week for mitochondrial and endothelial health
• VO₂max Tracking: Predictive of cardiovascular and overall mortality

    d. Precision Nutrition

    • Mediterranean diet with added protein (~1 g/lb ideal body weight)
    • Anti-inflammatory foods (omega-3s, polyphenols, fermented fibers)
    • Time-restricted eating and CGM-guided meal timing

3. TARGETED SUPPLEMENTATION

    • CoQ10: Mitochondrial and statin support
    • Omega-3s: Reduce triglycerides and inflammation [16]
    • Magnesium: Supports blood pressure, insulin sensitivity, and HRV
    • Vitamin K2/D3: Prevent arterial calcification while supporting bone health
    • Berberine, curcumin, resveratrol: Modulate insulin, lipids, and inflammation
    • Glycocalyx and nitric oxide support

4. Biodentical Hormone Therapy (BHRT)

• Safest when started within 5–10 years of menopause
• Bioidentical testosterone, estradiol + micronized progesterone preferred
• Lowers Lp(a), improves endothelial function, and reduces central adiposity in select candidates [20]

5. GUT HEALTH OPTIMIZATION: 

• Prebiotic fibers and polyphenols
• Butyrate-producing probiotics
• Phase II liver detox support (glutathione, methylation cofactors)

THE FUNCTIONAL CARDIOLOGY MANDATE 

Cardiovascular disease in women does not begin with symptoms. Up to 90% of asymptomatic individuals show plaque on coronary CT angiography [6]. Early detection—via imaging, digital tracking, and advanced biomarkers—transforms prevention from reactive to proactive.

Digital tools like CGM and HRV quantify real-time physiological stress and recovery. Combined with biometrics (muscle mass, VO₂max, waist-to-hip ratio) and laboratory metrics, they enable longitudinal, precision-based interventions that shift the trajectory of cardiovascular aging.

Conclusion: Precision Prevention as the New Standard

Menopause is not a disease, but a signal to recalibrate care. Functional cardiology reframes this transition as an opportunity for metabolic reprogramming—one rooted in data, physiology, and personalization.

This blueprint—merging functional diagnostics, wearables, imaging, and targeted therapy—provides a comprehensive framework to prevent cardiovascular decline and foster resilience. When implemented early and systematically, it empowers women to reclaim control over their cardiometabolic destiny.

The heart is not merely an organ; it reflects whole-body health. And for women in midlife, it deserves a whole-body, systems-based approach to care.

ABOUT THE AUTHOR

Dr. Hwaida Hannoush is an Internal Medicine provider in Lanham, Maryland. Dr. Hannoush is highly rated in 1 condition. Her top areas of expertise are Alstrom Syndrome, Sickle Cell Disease, Congenital Hemolytic Anemia, and Hemoglobinopathy. Her clinical research consists of co-authoring 11 peer reviewed articles. MediFind looks at clinical research from the past 15 years. She specializes in Women with strong family history of heart disease and those who are high-performers who want clarity, energy, and long-term resilience. (for more information, visit her website @ https://empowered-women-hearts.mn.co/