Abstract Background Epidemiological studies have shown a higher risk of cardiovascular mortality associated with early menopause, but the relation between menopausal age and extent of coronary artery disease after menopause is unknown. We assessed the relation between menopausal age and extent of coronary disease in post-menopausal women with an acute coronary syndrome. Methods A prospective study was conducted in patients > 55 years-old undergoing coronary angiography for an acute coronary syndrome. Enrolment was stratified by sex (women/men ratio 2:1) and age (55–64, 65–74, 75-85 and >85 years). Women were administered menopause questionnaires during admission. An independent core lab quantified coronary artery disease extent using the Gensini Score , which classifies both significant (>50%) and non-significant lesions. Linear correlation was used to appraise the association between the Gensini score and menopausal age. Results We enrolled 675 patients, 249 men and 426 women (mean age 74 years). The mean Gensini score was 60±36 in men vs 50±32 in women (p<0.001), being higher among men at any age. The median menopausal age of women was 50 years. Risk factors and age at first acute coronary syndrome were identical among women below and above the median menopausal age. The Gensini score in women showed a weak association with age R=0.127; p=0.0129, but not with menopausal age R=0.063; p=0.228. At multivariable analysis, ejection fraction, female sex and ST elevation myocardial infarction were independent predictors of the Gensini score in the overall population Conclusions Menopausal age was not associated with the extent of coronary artery disease. Age at first acute coronary syndrome presentation, risk factors and prior cardiovascular events were not affected by menopausal age. (The LADIES ACS study: NCT01997307)