What role does HDL play in menopause?

During menopause, estrogen decline typically raises LDL cholesterol and often HDL cholesterol. HDL has long been considered 'good' cholesterol because it transports excess cholesterol from arteries to the liver. However, genetic studies (Mendelian randomization) and clinical trials with CETP inhibitors have shown that raising HDL levels alone does not reduce cardiovascular risk. The HDL hypothesis is largely refuted. HDL is better viewed as a risk marker rather than a causal protective factor. For menopausal women, the focus should be on LDL cholesterol, non-HDL cholesterol, and lipoprotein(a), as these better reflect actual risk. Lifestyle interventions like exercise and a Mediterranean diet can raise HDL, but the benefit likely comes from other effects (anti-inflammatory, improved insulin sensitivity). Pharmacological HDL raising is not recommended. Evidence is moderate: observational data show inverse associations, but genetic and interventional studies refute causality.