Prevalences of subclinical carotid atherosclerosis, metabolic risk factors and obesity were assessed in 313 postmenopausal women by means of clinical, biochemical and ultrasound characterization and their associations were studied, women with cardiovascular disease or diabetes being excluded from the study. The results revealed that metabolic syndrome and body mass index (BMI) were strongly associated, whereas only the metabolic syndrome - and not body mass index - was associated with early subclinical carotid atherosclerosis. Similarly, increases in BMI (normal to obese via overweight) were not associated with carotid atherosclerosis whereas increases in metabolic status (normal to metabolic syndrome) conferred an approximately threefold adjusted odds of carotid atherosclerosis. Control of metabolic risk factors may thus be more important than weight loss for the prevention of cardiovascular disease in postmenopausal women.