Heart Health Across a Woman’s Lifetime: New Guidance Links Hormones, Mind and Cardiovascular Risk

A trio of scientific publications released today in the journal Circulation by the American Heart Association, together with the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine, lays out a female-specific, life-course approach to preventing and managing cardiovascular disease. The documents argue that fluctuating hormones, mental health and well-being, and the health of the heart and brain are tightly interconnected, and that these connections should become a routine part of clinical care beginning in adolescence rather than emerging only in later life.

“Women experience their healthcare across clinical specialties, but it often is fragmented or disconnected. Specifically, these reports connect the dots for clinicians, for patients, and across health domains so that care is holistic and begins in adolescence,” said Dr. Sadiya Khan, chair of the writing group and the Magerstadt Professor of Cardiovascular Epidemiology at Northwestern University’s Feinberg School of Medicine in Chicago. The joint effort is described by its authors as a paradigm shift in how women’s cardiovascular and brain health are viewed, offering pediatricians, primary care clinicians, endocrinologists, obstetricians, gynecologists and cardiologists a unified approach to cardiovascular concerns specific to women.

“Heart disease and other forms of cardiovascular disease don’t suddenly become relevant when we become older women,” said Dr. Stacey E. Rosen, immediate past volunteer president of the American Heart Association, who helped write the reports. The publications divide a woman’s life into distinct stages, each of which offers chances for early detection, risk factor identification and treatment. Dr. Esther S.H. Kim, director of the Center for Women’s Cardiovascular Health at Atrium Health in Charlotte, North Carolina, called each stage a “window of opportunity” to prevent heart disease. “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 professor and chair of cardiovascular medicine at Wake Forest University School of Medicine.

A central theme of the series is the role of hormonal health in cardiovascular disease across a woman’s life. Rosen noted that for years scientists overlooked the importance of hormones in women’s heart health because monthly fluctuations made research more complicated. Yet estrogen, estradiol and progesterone affect cells in blood vessels, in the brain and in heart muscle, influencing 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, Rosen said.

The reports also stress that while the most common cardiovascular problem in women is the same as in men — plaque buildup that narrows arteries — women are more likely to experience other serious conditions. Kim contrasted the classic image of heart disease, a middle-aged or older man with obvious risk factors, with the possibility that a woman’s heart disease may look different: microvascular coronary disease, which affects the small blood vessels of the heart; heart failure with preserved ejection fraction, in which the heart contracts normally but fails to relax properly between beats; or spontaneous coronary artery dissection, in which a heart artery suddenly tears. These conditions require specific diagnostic tests, Kim said, and if clinicians do not think of the disease processes, they will not order the right tests and the diseases will be missed. She urged women to know the symptoms of cardiovascular disease, to talk about them, and to be persistent if they feel their doctor is not listening.

Adolescence emerges as a critical turning point in the new guidance. “Heart health for women doesn’t start at menopause,” said Dr. Amanda M. Perak, an associate professor of pediatrics and preventive medicine at Northwestern and a pediatric cardiologist at Ann & Robert H. Lurie Children’s Hospital of Chicago, who worked on all three publications. “Puberty is a big turning point.” Menstrual cycle details offer a window into future heart health: a first period before age 10 is linked to a higher risk of heart disease later in life, which Perak said is not automatically a reason for alarm or medication but a reason to pay closer attention to healthy habits and routine checkups. Irregular periods, especially alongside stubborn deep acne or unusually extra facial or body hair growth, can signal polyendocrine metabolic ovarian syndrome, previously known as polycystic ovary syndrome or PCOS, which has been linked to problems regulating blood sugar, diabetes and heart disease later on. Because some irregularity is expected in the first one to three years after a girl’s first period, Perak emphasized that what matters is a pattern that persists. Knowing their period history can also help older teens communicate with adult clinicians after leaving pediatric care. “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.”

In early adulthood, the reports urge women to recognize that they can be at risk for cardiovascular disease. Kim described working with older women referred for testing that measures plaque buildup in the heart’s arteries who were “shocked out of their minds” to see abnormal scores — outcomes she suggested might have been prevented if those women had been aware of cholesterol problems, family history issues or the need for healthy habits at an earlier age. At every phase of life, women can ask their clinicians how to optimize their heart health, said Dr. Natalie A. Cameron, an internal medicine specialist and assistant professor at Northwestern who led the writing team for one of the documents and contributed to the other two. The answer at every phase includes the basics known as Life’s Essential 8: maintaining healthy weight, blood pressure, blood sugar and cholesterol levels; eating a healthy diet; getting enough physical activity and quality sleep; and avoiding tobacco. Cameron also suggested questions about what constitutes a normal period, since abnormalities at this age can signal higher cardiovascular risk; how contraceptive options affect heart health, given that some are better for women with heart disease or cardiovascular risk factors; and whether specific tests or medication adjustments are needed before a planned pregnancy. The reports emphasize the importance of good cardiovascular health before pregnancy, yet 9 out of 10 women ages 20 to 44 have less-than-ideal heart health when they become pregnant.

Pregnancy itself is often described as a stress test for the heart. High blood pressure in pregnancy, gestational diabetes and preterm birth are linked to a higher risk of heart disease later in life, Cameron said, and the first year after a pregnancy is a very critical time for controlling and monitoring those risks. However, many women face challenges that prevent them from obtaining follow-up care during this period. Mental health threads through every life stage in the new framework. Mood changes, including symptoms of anxiety and depression, can be related to hormonal fluctuations, and anxiety or depression may influence lifestyle choices such as exercising less or eating less healthy foods. Starting around age 12, eating disorders, which can affect future cardiovascular health, become more common in girls, Perak said. By age 17, girls are twice as likely as boys to be diagnosed with depression, and teens with depression are more likely to develop obesity later, while teens with obesity are more likely to develop depression. Women with established cardiovascular disease are more likely to have depression and anxiety, Rosen said, while depression and anxiety can in turn harm cardiovascular health. The series calls for making mental health and well-being screening a routine part of a woman’s care.

In the years before menopause, hormones fluctuate, and Cameron noted that women may in general experience increases in low-density lipoprotein, or “bad” cholesterol, weight gain and potentially rising blood pressure. It is also a time when years of unhealthy lifestyle choices may start to catch up and overt heart disease may emerge. But Rosen rejected the idea of surrendering to something inevitable: “The answer is an absolute, positive, emphatic no. It’s never too late to make healthy changes.” The years around menopause are a good time for a woman and her healthcare team to discuss whether she is at risk for heart disease, what she can do about it and what tests she should have. Cameron stressed the importance of knowing your numbers and monitoring them with a clinician at annual visits, or more often when actively managing blood pressure or cholesterol levels. After menopause, which marks the end of a woman’s periods, a woman with an average life span still has roughly 40% of her life ahead of her. Rosen suggested discussing how to predict risk — a doctor may use a risk calculator such as the American Heart Association’s PREVENT equations to guide care — how to address essential risk factors, and what else can be done to make the next decades as healthy as possible. Sleep, often a concern during menopause, is one such topic, and Rosen encouraged anyone with problems to ask whether evaluation or treatment options are warranted. She noted that her own mother, 87, was just put on cholesterol-lowering medications, a decision she heartily endorsed: “It’s always about opportunities.”

Because women’s healthcare is fragmented — over a lifetime a woman may see a pediatrician, primary care doctor, obstetrician/gynecologist, cardiologist and psychologist, with communication not guaranteed and health records not always transferring — the publications spell out the need for unified care. Women can also take an active role in organizing their own health journey, Rosen said, comparing medical history tracking to the paperwork one would bring to an accountant before tax season, whether in a notepad or a digital folder. Cameron suggested asking whether clinicians can see each other’s medical notes and whether they have talked; some of her patients have provided phone numbers to help her connect with clinicians outside her healthcare system. Rosen added that women caring for sick parents or children can be “a lioness” about preventive care on behalf of others, and reminded women that they are worthy of doing that work for themselves. The stakes are considerable: cardiovascular disease, which includes heart disease and stroke, is the leading cause of death in women, claiming more than 400,000 lives in the United States each year — more than breast cancer, lung cancer and chronic lung disease combined — yet only about 4 in 10 women recognize it as their greatest health threat. Through its Go Red for Women initiative, the American Heart Association aims to empower women to take charge of their heart health at every stage of life. “We don’t want heart attacks and strokes to happen,” Cameron said. By being proactive, women have opportunities to lower their risks.

Subject of Research: A life-course approach to women's cardiovascular health linking hormones, mental health and care across life stages

Article Title: Why every stage of life matters for a woman’s heart health

Article References: Why every stage of life matters for a woman’s heart health. Original publication (Bibliographic details unavailable.)

Image Credits: AI Generated

DOI: Not provided

Keywords: women's heart health, cardiovascular disease, American Heart Association, hormones, menopause, pregnancy, menstrual health, PCOS, mental health, Life's Essential 8, Circulation, preventive cardiology