Heart Disease in Women: More Than Just Cholesterol
Heart disease is the leading cause of death in women.
Approximately 44% of women in the United States are living with some form of heart disease.
Most cardiovascular disease in women occurs after the age of 55, often after menopause. However, this does not necessarily mean there is a direct relationship between lower hormone levels and heart disease. That part is a little more complicated. Because apparently, our hormones couldn't just leave quietly—they had to make everything complicated on the way out.
Today, let’s talk about the risk factors associated with heart disease.
There are the traditional risk factors that most of us have heard about, as well as some emerging, less well-known factors. Let’s start with the familiar ones.
1. Diabetes
Diabetes is commonly diagnosed with a hemoglobin A1c (a measure of average blood sugar over approximately three months) of 6.5% or higher, or with two separate fasting blood glucose tests showing a level of 126 mg/dL or higher.
Symptoms of diabetes can include fatigue, blurred vision, increased urination, increased thirst, increased hunger, slow-healing wounds, and tingling or numbness in the fingers or toes. But—and this is important—some people have no symptoms at all, and diabetes is discovered incidentally on routine blood work.
In women, diabetes has an especially strong impact on the earlier development of heart disease and on the risk of death from cardiovascular disease.
Importantly, women are often diagnosed with diabetes at later stages and may receive less aggressive treatment than men.
This highlights an important point: women need to advocate for themselves.
Ask questions. Speak up. And if you feel like something isn't right, don't be afraid to say so.
Your life may depend on it.
2. Weight
I have already discussed how obesity is a complex condition and that diet and exercise, while important, are not always enough (https://www.rx4trauma.com/post/understanding-obesity-without-shame).
If only it were as simple as “eat less and exercise more.” Wouldn't that make everyone's lives considerably easier?
As women age, they lose muscle mass at a rate of approximately 3–8% per decade after age 30. And we all know that muscle burns more calories than fat, so as we lose muscle, our metabolism can slow, making weight management more difficult.
Equally important is where the fat is stored.
Before menopause, estrogen tends to direct fat storage toward the hips and thighs. After menopause, fat distribution shifts more toward the abdomen. This central, or abdominal, obesity is associated with an increased risk of cardiovascular disease.
Menopausal women also tend to have more visceral fat—the fat stored around the internal organs—which is metabolically more active and associated with greater health risks. Younger women tend to have more subcutaneous fat, which is the fat stored just underneath the skin.
So, apparently, even our fat changes its mind after menopause.
We have also talked about the shortcomings of BMI when it comes to looking at the whole picture. Another option is to look at waist circumference. A larger waist circumference (over 35 inches) is associated with an increased risk of cardiovascular disease.
In other words, sometimes the tape measure can tell us something the scale can't.
3. Smoking
Cigarette smoking is a leading preventable cause of disease, death, and disability in the United States. More than 16 million Americans live with a smoking-related disease.
Studies involving nearly two million women show that female smokers have a 25% greater relative risk of coronary heart disease events compared with male smokers.
Smoking also has anti-estrogen effects. Estrogen helps protect blood vessels and supports healthy lipid metabolism, so smoking may interfere with some of these protective effects.
This is one area where I don't have a funny comment.
Smoking is bad for your heart (among many other things).
Period. End of sentence. Stomp it out.
4. High Blood Pressure
Current treatment guidelines for hypertension are the same for men and women, but high blood pressure does not affect the sexes in exactly the same way.
Women tend to experience a steeper rise in blood pressure beginning in midlife and may be more susceptible to organ damage from hypertension, including effects on the heart, kidneys, and brain.
A significant percentage of women over age 60 have hypertension, and hypertension becomes increasingly common during and after the menopausal transition.
And because high blood pressure is often called a “silent” condition, you can't necessarily tell what's happening just because you feel fine.
Your blood pressure does not care if you feel fantastic.
The decrease in estrogen that occurs during menopause may contribute to changes in blood vessels and increased arterial stiffness, which can contribute to higher blood pressure.
This is not to say that estrogen is a treatment for high blood pressure.
It is not.
But the role of hormone replacement therapy in cardiovascular health continues to be studied very carefully.
5. High Cholesterol
Cholesterol levels in women change throughout life and can even fluctuate during the menstrual cycle. These changes are not solely related to diet and exercise. Genetics. Tobacco. Alcohol.
Birth control pills (among other medicines) may affect triglycerides, HDL (“good”) cholesterol, and LDL (“bad”) cholesterol, depending on the formulation and dose of estrogen. During menopause, hormonal changes cause LDL and very-low-density lipoprotein (VLDL) cholesterol levels tend to rise.
Studies also suggest that women are less likely than men to be offered treatment for the same cholesterol abnormalities. Women are also more likely to stop cholesterol medications because of side effects such as muscle pain. So again- advocate for yourself. If you are having side effects from medications, have an honest discussion with your doctor and talk about alternatives.
So, once again, your cholesterol is not simply a reflection of whether you ate a salad yesterday.
Which—if you're asking—I did not. Oops.
6. Age
What goes up and never goes down?
You guessed it.
Your age.
Unfortunately, there is no medication, supplement, diet, exercise program, or expensive skincare product that can stop this particular risk factor.
The increase in heart disease risk after menopause is steeper in women than in men of the same age.
The average age of a woman's first heart attack is around 70, although it varies considerably from person to person.
Remember to put that in your calendar for future reference.
As our population ages, the burden of heart disease grows. The economic cost of cardiovascular disease in the United States is enormous (500 billion dollars) and is projected to continue increasing (1 trillion dollars by 2035).
That's a lot of money.
That's also a lot of pairs of shoes.
Researchers continue to study the role of hormone replacement therapy (HRT) in cardiovascular health. Some studies suggest benefits, while others show potential risks. Current recommendations generally support considering hormone therapy for symptom management in appropriate women who are younger than 60 or within 10 years of menopause, assuming there are no contraindications. Starting hormone therapy later may carry greater cardiovascular risks.
And this is where things get complicated again.
Hormones aren't simply “good” or “bad” for your heart. Timing, age, individual health history, the reason for taking them, and the type and route of hormone therapy all matter.
So if someone tells you they have discovered the one simple answer to menopause, hormones, and heart disease, I would ask more questions.
Heart disease in women is influenced by biology, hormones, lifestyle, age, and the ways women experience and receive medical care. Understanding these risk factors is an important first step toward prevention.
And perhaps the biggest takeaway is this:
You don't have to wait until something goes wrong to start paying attention to your heart.
Know your numbers. Know your risk factors. Ask questions. And advocate for yourself.
Because your heart deserves at least as much attention as your cholesterol gets every time you look at a piece of cheesecake.
In the next blog, we’ll move beyond the traditional risk factors and explore some of the lesser-known and emerging contributors to heart disease in women—including pregnancy-related conditions, autoimmune diseases, stress, sleep, and other factors that deserve far more attention than they often receive.
Because, as it turns out, there is a lot more to women's heart health than cholesterol, blood pressure, and being told to “lose a few pounds.”
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