Heart disease is the No. 1 killer of women in the U.S. and around the world — a threat that’s projected to rise significantly over the next two decades.
In an aim to get ahead of the risk, four major medical organizations — the American Heart Association, the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics and the Society for Maternal-Fetal Medicine — released a coordinated framework for women’s heart health from puberty through menopause.
The groups published the “Female Life Stages” framework on Monday, detailing how female-specific biological changes — periods, pregnancy, perimenopause and menopause — affects girls’ and women’s heart health throughout their lives. The guidelines offer age-specific recommendations for preventing, detecting and managing cardiovascular health in females.
“Heart disease and other forms of cardiovascular disease don’t suddenly become relevant when we become older women,” said Dr. Stacey E. Rosen, former volunteer president of the AHA, who helped write the trio of scientific papers on the subject.
Female healthcare is also often fragmented across different specialties throughout a woman’s lifetime, “which contributes to suboptimal care in girls and women,” the authors of the guidance wrote. Rosen said the new guidelines represent “a paradigm shift in how we look at women’s cardiovascular and brain health.”
“Women experience their healthcare across clinical specialties, but it often is fragmented or disconnected,” said Dr. Sadiya S. Khan, chair of the science advisory group for women’s health at the AHA, who co-authored the guidance. “Specifically, these reports connect the dots for clinicians, for patients and across health domains so that care is holistic and begins in adolescence, recognizing that women’s heart health is uniquely shaped by biological transitions not experienced by men.”
According to the American Heart Association, cardiovascular disease, which includes heart disease and stroke, is the leading cause of death in women, claiming more than 400,000 lives in the U.S. each year. That’s more than breast cancer, lung cancer and chronic lung disease deaths combined. Yet, only about 4 in 10 (41%) women recognize it as their greatest health threat.
Earlier this year, the heart association projected that the percentage of women with at least one type of cardiovascular disease will climb by more than a third, from 10.7% in 2020 to 14.4% in 2050, and nearly 60% of women in the U.S. are forecast to have high blood pressure by 2050.
“These projections underscore the urgency of making cardiovascular health a priority at every stage of a woman’s life,” said Khan. “This new approach gives clinicians across specialties shared guidance to recognize risk earlier, personalize prevention, and act before a heart attack, stroke or heart failure event.”
California Live’s Jessica Vilchis chatted with Nurse Practitioner Barbara Dehn, known as “Nurse Barb,” who shares tips to help you put your heart first. February is national heart health month, a time dedicated to raising awareness about cardiovascular disease, a leading cause of death for women. While the focus on heart health is crucial year-round, this month provides a valuable opportunity to pause, reflect, and take proactive steps to protect our hearts.
Female hearth health stages
The “life stages” in the guidelines emphasize how hormonal health affects cardiovascular health across a woman’s life.
For years, scientists ignored the importance of hormones in women’s heart health because the monthly fluctuations made research more complicated. But estrogen, estradiol and progesterone “impact cells in blood vessels, in the brain, in heart muscle,” Rosen said. They affect cholesterol levels, the stickiness of blood cells, inflammation, blood pressure and the body’s stress response.
“If you appreciate the understanding that these hormones are not just affecting the uterus, ovaries and fallopian tubes but affecting in a rhythmic way every part of the cardiovascular system and brain, you can appreciate why these fluctuations or issues related to these hormones in women have an enormous impact” on heart and brain health, she added.
Stage 1: Perimenarche (Ages 8-15)
This stage represents the transition around the first menstrual period.
The new publications recognize menstrual cycle patterns can offer a look at future heart health. Persistent heavy or irregular menstrual bleeding can serve as early markers of cardiovascular risk, such as polyendocrine metabolic ovarian syndrome (PMOS, formerly known as polycystic ovary syndrome, or PCOS).
Getting a first period before age 10 is linked to a higher risk of heart disease later in life. “That’s not automatically a reason for alarm or medication,” said Dr. Amanda M. Perak, an associate professor of pediatrics and preventive medicine at Northwestern. “It’s a reason to pay a little closer attention to healthy habits and routine checkups.”
By knowing their period history, older teens can be ready to talk with their adult doctor or healthcare professional after they leave a pediatrician’s care. Starting around age 12, eating disorders, which can affect future cardiovascular health, also become more common in girls, Perak said.
“The goal isn’t to worry teens about the chance of a heart attack, which are decades away for nearly all of them,” Perak said. “It’s that the teen years are when patterns get set, and it’s much easier to keep good heart health than to get it back.”
Stage 2: Ovarian Cycle and Pregnancy (Ages 15-44)
Regular ovulatory and hormone cycles are established at this stage, and it’s also when pregnancy typically occurs.
Irregular or heavy bleeding can be an early sign of conditions that raise heart disease risk such as PMOS.
Pregnancy is often seen as a “stress test” for the heart and can reveal important clues about heart health. Conditions like high blood pressure during pregnancy, called preeclampsia, or gestational diabetes aren’t just temporary — they can signal a higher risk for heart disease later in life.
Perinatal depression and anxiety, which affect up to 20% of pregnant women, can increase the risk of having cardiovascular complications. Pregnancy also causes additional stress on your body, which can raise heart disease risks postpartum.
This fall, pediatricians affiliated with Boston Children’s Hospital are rolling out a new questionnaire for kids focused on family history and symptoms, aimed at identifying potential heart risk
Stage 3: Perimenopause (ages 45-51)
Perimenopause is a transitional stage prior to menopause. Fluctuating hormones make menstrual cycles unpredictable, varying in length or skipped some months.
“In general, as those changes are happening, women may experience increases in their low-density lipoprotein (“bad cholesterol”) levels, weight gain and potentially rising blood pressure,” said Dr. Natalie A. Cameron, an internal medicine specialist who is an assistant professor at Northwestern.
During this time, a woman’s estrogen levels begin to drop, which can also increase certain heart disease risk factors. That’s because estrogen helps keep blood vessels relaxed and open. With less estrogen, cholesterol may begin to build up on artery walls, which can increase the risk of heart disease or stroke, as well as the stiffening of blood vessels and arteries.
“We don’t want to make it seem like it’s doom and gloom, but recognize that there are some changes in these phases that can influence cardiovascular risk,” Khan said.
Hormonal changes during this time can also cause shifts in mood and make it more difficult to get a good night’s sleep, both of which influence cardiovascular health, Khan said.
“Hormones can influence your cholesterol and blood sugar and body weight composition. That is not saying that everyone needs to be on hormone therapy to combat that, but we do need to be evaluating those things so we can treat these traditional cardiovascular disease risk factors,” she said.
Stage 4: Postmenopause (age 51 and up)
Women enter this stage after experiencing 12 full months without a period, usually around age 51. Loss of protective estrogen puts them at greater risk of heart issues.
That’s especially important for women who reach menopause before age 45, who have a significantly higher risk of coronary heart disease resulting from plaque buildup in the arteries.
Hot flashes and night sweats are the most common menopause-related symptoms and can last up to 10 years. They also are associated with worse cardiovascular disease risk factor levels.
Each stage of a woman’s life offers “windows of opportunity” to prevent heart disease, said Dr. Esther Kim, director of the Center for Women’s Cardiovascular Health at Atrium Health in North Carolina and author of one of the publications.
“We can go all the way back to adolescence and even childhood and figure out, ‘This person is at risk; we need to keep a closer eye on them,’” said Kim, who is also a professor and chair of cardiovascular medicine at the Wake Forest University School of Medicine in Charlotte.
For women themselves, it comes down to a simple point: by being proactive, women have opportunities to lower their risks.
