Evidence check: HDL in the context of menopause

HDL cholesterol levels often shift during menopause: estrogen decline can lower HDL or alter subclass distribution (less large, protective HDL2). However, the HDL-raising hypothesis has been largely refuted by CETP inhibitor trials and Mendelian randomization – HDL is a risk marker, not a causal protective factor. More relevant are HDL functionality (cholesterol efflux capacity) and the full lipid panel (LDL, triglycerides, Lp(a)). The 2025 ESC/EAS guidelines emphasize LDL reduction and universal Lp(a) screening, not HDL elevation. For menopausal women, this means: HDL in the normal range is fine, but isolated HDL boosting via lifestyle (e.g., alcohol, estrogen) is not cardioprotective. Focus should be on overall lipid profile, blood pressure, glucose, and lifestyle (exercise, Mediterranean diet). Evidence: human-moderate (observational studies, no RCTs for HDL raising).