Menopause represents a pivotal period for evaluating vascular health and mitigating long-term cardiovascular risk in women. This chapter explores the physiological and structural vascular changes that occur during the transition from pre-menopause to menopause, including increased arterial stiffness, carotid intima-media thickness (CIMT), and coronary artery calcium (CAC) deposition. Additionally, functional impairments in endothelial function are highlighted as key contributors to declining vascular health. The transition is further complicated by the emergence or exacerbation of traditional cardiovascular risk factors, such as hypertension, metabolic syndrome, obesity, and overall cardiovascular disease (CVD) burden. Early identification and management during this life stage may offer significant opportunities to reduce the future risk for cardiovascular events.