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Cardiovascular disease is the leading cause of death among women, but fewer than half recognize it as their biggest health threat, said Dr. Sadiya S. Khan, lead author of a new set of guidelines for assessing women’s cardiovascular risk.
Research increasingly shows that the risk of stroke, heart disease and other cardiovascular problems is associated with hormonal changes that occur over the course of women’s lives, from their first period to their last.
“There is clearly a trend there,” said Khan, the Magerstadt professor of cardiovascular epidemiology at Northwestern University Feinberg School of Medicine.
The new guidelines, published Oct. 26 in the journal Circulation by experts from the American Heart Association, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine, aim to make that pattern clearer, so women and their doctors know what to look for at each stage.
“Organizing care around these stages creates natural checkpoints to detect risks early, rather than leaving decades of a woman’s life unattended,” said Dr. Nisha Parikh, system director of Northwell Health’s Women’s Cardiology Program, who was not involved in the report.
The guidelines should be “empowering rather than frightening,” Khan said. Understanding the risk can help women now and help them to prepare for what comes next.
It’s never too early to think about heart health, said study co-author Dr. Tamara Hannon, a professor of pediatrics at Indiana University School of Medicine. Parents can help their children develop habits that will benefit their heart health for the rest of their lives. Encouraging a healthy diet — including plenty of fruits, vegetables and whole grains, and limiting ultra-processed foods, animal-based fats, and juices and other sugary drinks — is not only good for the developing body, but actually the norm as children grow.
A healthy diet reduces the risk of obesity and type 2 diabetes, both associated with cardiovascular disease.
Hannon also emphasized viewing daily physical activity as a life skill (rather than a weight loss technique) and promoting good sleep, as both are essential for cardiovascular health.
Make sure your child’s pediatrician monitors their growth, she said, because poor or excessive growth can indicate hormonal imbalances that could affect their cardiovascular health. And if there is a family history of high cholesterol, heart disease or heart attack before the age of 50, be sure to have your cholesterol levels checked. Plaque can accumulate in the blood vessels early on and “wear and tear on the blood vessels in the heart can start to add up,” Hannon said. High cholesterol in children can be treated with diet, exercise and medication (statins) if needed.
Doctors may not pay attention to a healthy 18-year-old’s cholesterol levels, “but that cholesterol is going to affect her in 20 or 30 years,” said co-author Dr. Afshan B. Hameed, a clinical professor of obstetrics, gynecology and cardiology at the University of California, Irvine. A recent European study found “silent atherosclerosis,” or early buildup of cholesterol plaques in blood vessels, in 1 in 13 people aged 18 to 29.
Adolescence is also a good time to check for markers of diabetes risk, such as blood pressure, blood sugar and A1c. Nearly one-third of adolescents and teens have prediabetes (which can develop into diabetes), research has found. According to the U.S. Centers for Disease Control and Prevention, people with diabetes are twice as likely as those without it to have heart disease — and the longer you’ve had diabetes, the greater the risk.
The onset of menstruation before age 10 is associated with a higher risk of cardiovascular disease in adulthood, the report said. Doctors aren’t sure what the connection is, but weight may play a role, as a higher body mass index, or BMI, and earlier periods often go hand in hand. Girls who menstruate earlier are also at greater risk of developing eating disorders, which can damage the heart.
Earlier periods may indicate polyendocrine metabolic ovarian syndrome, or PMS (formerly called PCOS), a hormonal condition that can increase cardiovascular risk in adulthood. Irregular or heavy periods are also symptoms, so it’s important for girls to talk to their doctor about what they’re experiencing.
“It’s normal to have somewhat irregular periods for the first six years after your period. It’s not normal to have excessive bleeding to the point of missing school or having your period more often than every 28 days,” Hannon said. “This trend may be a sign of increased risk of cardiovascular disease.”
If painful periods or depressed mood cause difficulty sleeping or prevent girls from participating in sports or other physical activities, it may also influence their heart health.
Whether you’ve only been menstruating for a few years or are familiar with Aunt Flow, it’s crucial to watch out for irregular cycles, cycle changes, or heavy bleeding. Keep in mind that what feels normal to you may be “heavy” by clinical standards; a typical sign of heavy menstrual bleeding is going through a pad or tampon every hour for multiple hours.
Khan acknowledged that while there are “research gaps” that need to be filled, doctors know there is a link between irregular periods and higher cardiovascular risk. “It may be because of PMOS or other factors,” she said, but either way, it warrants attention.
An estimated 10 to 13 percent of women suffer from PMS, which can lead to increased visceral fat and insulin resistance, increasing the risk of cardiovascular disease, according to the report. This condition is often misdiagnosed – or ignored altogether. Women with PMS have a four times higher risk of heart attack and stroke, Hameed said.
Mood problems can disrupt sleep, which is crucial for the cardiovascular system, and prevent girls and women from engaging in other heart-healthy behaviors, like eating well and exercising regularly. These issues also may reflect major hormonal fluctuations that, themselves, can significantly affect cardiovascular disease risk.
Hameed seemed pregnant to be on a treadmill for nine months. This stress can cause an otherwise healthy woman to develop cardiomyopathy (weakening of the heart muscles) or develop previously undiagnosed cardiovascular disease. Cardiovascular disease is the leading cause of death during pregnancy and for the first year after giving birth, she said.
If you’re pregnant or have given birth within the last year and you’re experiencing shortness of breath, chest pain, extreme fatigue, swelling in your legs, or just not feeling up to your usual energy levels, it could be due to the stress of pregnancy or having a new baby – or it could be a sign of cardiovascular disease. “Don’t underestimate your symptoms,” Hameed said. Talk to your doctor.
What happens during pregnancy can predict future cardiovascular health as well. Women who have complications during pregnancy – such as high blood pressure, gestational diabetes, a stunted baby or premature delivery – are at higher risk of developing cardiovascular disease later.
Estrogen protects the heart and blood vessels, and during perimenopause – about four to seven years before a woman stops menstruating – estrogen begins to decline. These hormonal shifts can have an enormous impact on health and well-being — and specifically on cardiovascular health. For example, “bad” LDL cholesterol may rise, arteries stiffen and fat can accumulate around organs.
Women should raise their concerns with their doctors – and doctors should be on the lookout too. With vigilance, perimenopause presents an opportunity to prevent a heart attack, stroke or coronary artery disease, Hameed said.
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