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  • Writer's pictureEric Goulder, MD, FACC

Heart Talk – February 2024

Protecting Women’s Hearts: A discussion of the Gender- Specific Dynamics of Heart Health 

Cardiovascular Disease, which includes both heart attack and stroke, remains the number one cause of death in Women in the United States. In fact, more women die from heart disease and stroke than the subsequent five causes of death combined! Unfortunately, despite robust public health campaigns, still only 44% of women recognize cardiovascular disease as their greatest health threat. Women (and their healthcare providers) simply do not recognize their risk. 

In 2022, the American Heart Association published a Call to Action for Cardiovascular Disease in Women to increase a sense of urgency when it comes to heart and vascular disease in women. This strong statement from the AHA illuminates the continued gaps in knowledge and care delivery for women with and at risk for cardiovascular disease; issues caused in part by the pervasive lack of representation of women in cardiovascular disease research (38% participation) and the continued false assumption that women are at lower risk for heart disease than men. 

Women’s heart health is of the utmost importance to us. With February being Women’s Heart Month, we are choosing to dive into female specific aspects of cardiovascular disease recognition and prevention as part of our overall goal to continue advocating for optimal women’s healthcare. 


When it comes to heart disease risk in women, there are some things we simply cannot change; these include family history, aging and menopause, genetics, breast cancer with radiation treatment, autoimmune disease and history of pregnancy related complications including gestational diabetes and pre-eclampsia. 

However, there are many risk factors that we DO have control over. These include how we manage stress, how much we move our bodies, if we develop diabetes or insulin resistance, our body weight, waist circumference, oral health, sleep patterns, blood pressure, smoking history and cholesterol levels. These modifiable risk factors are where we need to focus our efforts, and it is never too late!


The complicated nature of heart disease risk in women is likely one of the driving factors behind the belief that men are at higher risk. The truth is, men are at higher risk for cardiovascular disease at an earlier age than women; however, once women hit age 65, the playing field is leveled. One reason for this is as we age, our high levels of protective endogenous (our own) estrogen drop dramatically. Likewise, if a woman has surgically or medically induced menopause at any age, the same physiologic process takes place.

The effect of dropping insulin levels is so dramatic that 10 years after menopause (generally between age 60-65), the protection provided by estrogen early in life is no longer applicable. Where 1 in 9 women have some type of heart disease at age 45, 1 in 3 exhibit disease by age 65 (the same as men). While sex-based risk is equal at this age, women still tend to experience a delay in care and worse outcomes.


One reason women tend to experience a delay in treatment is the different symptoms exhibited by women vs. men during a heart event. In fact, a 2022 study published in the Journal of Therapeutics and Clinical Risk Management demonstrated that 62% of women exhibited no chest pain during an active heart attack, as opposed to only 36% of men. Women are also much more likely to report vague symptoms such as nausea, dizziness, sweating, shortness of breath, anxiety, arm pain or neck/jaw pain. 

In the same 2022 study, 72 percent of women experiencing a heart attack waited more than 90 minutes to call 911, as compared to 54% of men. The absence of traditional “heart attack symptoms” has contributed to the unfortunate fact that a woman’s risk of dying of a heart attack is higher than a male at similar age. 

A 2022 study published in the Journal of the American Heart Association looked at millions of ER visits to determine differences in care delivered to men and women experiencing heart attack symptoms. On average, women waited 11 minutes longer than men to see a healthcare provider and were subsequently less likely to be admitted to the hospital and less likely to receive even basic cardiovascular testing such as an EKG or cardiac enzyme testing. The AHA also notes that women are less likely to receive bystander CPR during a cardiac event due to fear of accusations of inappropriate touching.


The timing of increased risk aligns perfectly with the menopausal transition in women. There are many reasons this may be true: poor sleep, the stress of caregiving for elderly parents, parenting transitions, etc. But one significant reason is the change in estrogen levels. Early in life, women benefit from the protective effects of estrogen on the arteries. Naturally produced estrogen is anti-inflammatory, leading to more “stretchy” and supple, less-inflamed arteries throughout the body. Once natural estrogen levels drop, chronic inflammation can ensue, coupled with less flexible and more unhealthy arterial walls.

Cardiovascular disease occurs when the lining of the arteries become inflamed, allowing for the trapping of lipid particles within the artery wall (plaque). The lack of estrogen in men explains the general increased risk earlier in life. This may seem like a statement of inevitability: menopause leads to heart disease. On the contrary, we encourage you to see this as an incredible opportunity to engage. The gap between the average onset of perimenopause (45) and the onset of increased risk due to lack of estrogen (65) spans twenty years! Those are the years we see as an invitation to set the groundwork for healthy aging. 


  1. Connect with a healthcare provider you trust.

  2. Get your labs tested and follow the results! Perimenopause and menopause are when lipids, inflammation and insulin resistance markers start to rise. If these issues start popping up, address them! 

  3. Get an annual CIMT scan to follow any inflammation or plaque formation within the carotid artery walls and address root causes.

  4. Avoid all nicotine products.

  5. Manage your stress. Engaging in mindfulness and meditation exercises, yoga, gratitude journaling, grounding, exercise, sex and therapy can all help to lower cortisol levels and the effects of chronic stress on overall health.

  6. Take care of your teeth and gums! Brush at least twice daily with an electric toothbrush, floss correctly, use a water pick, see your dentist regularly and have oral pathogens tested.

  7. Test for and treat sleep apnea.

  8. Eat a varied and balanced diet full of whole real foods, ideally tailored to your genetics (ApoE and haptoglobin genotypes).

  9. Move your body! At least 22 minutes/day at a bare minimum, working up to more. For women, resistance exercise is particularly important for longevity, bone strength and insulin sensitivity.

  10. Ensure adequate vitamin D.


If estrogen is so wonderfully protective, what about hormone replacement therapy? The answer is: it’s complicated. In its endogenous form (created by our bodies) estrogen is cardioprotective. However, synthetic estrogen can both help and harm, and the decision to utilize synthetic hormones is highly personal and individualized based on timing, symptoms and personal history. 

Hormone Replacement Therapy initiated before or within five years of menopause for symptom management may reduce the risk for heart disease and could improve some other cardiovascular markers. This window appears to be the safest time to utilize HRT, as HRT utilized 8-10 years after menopause has been associated with increased risk for heart attack and stroke. Additionally, a 2023 study in the Journal of Hypertension found that utilizing hormone replacement therapy may increase the risk of high blood pressure. 

While endogenous estrogen promotes supple, healthy arteries, no studies (on synthetic or bio-identical hormones) have demonstrated restoration of this effect. Women should be placed on HRT only if symptoms warrant the conversation, not simply to protect their hearts. The focus of our efforts for promoting heart health must remain on the modifiable risk factors as discussed above. 


Women are biologically different from men and thus have a different risk profile and timeline for cardiovascular disease. Lack of awareness of the factors that put women at increased risk, as well as the way in which symptoms differ for women, continues to cause delays in both preventive and acute treatment. 

It is our goal to empower women with knowledge about their unique cardiovascular risk factors and tailor lifestyle modifications and medical therapy to the individual. By viewing mid-life as an opportunity to engage and by addressing both modifiable and non-modifiable risk factors we can significantly impact the threat of cardiovascular disease as we age. It is a privilege to work with motivated women. Together we are laying the groundwork for a future where women’s heart health can take center stage in preventive care. 

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