What You Didn't Know (But Should) About Heart Health

IIllustration by CACTUS Creative Studio.

By Elizabeth Keifer

Heart disease is the number one cause of death in the United States as well as the leading killer of women ages 25 and up. But what most of us know about its symptoms tends to reflect how it manifests in men, explains cardiologist Jayne Morgan — one reason women are more than twice as likely to die after experiencing a heart attack. As we age, the protection women enjoy from heart disease in the form of estrogen starts to fade, increasing our overall risk. We routinely misattribute, neglect, or outright ignore our symptoms, chalking them up to the daily grind, stress, and stage-of-life changes. The “we,” in this case? Both patients and physicians alike. 

What’s more: “Only 22 percent of primary care physicians say they even feel comfortable treating a woman with cardiac symptoms, and 42 percent of cardiologists admit they would feel uncomfortable treating a woman with cardiac symptoms,” adds Morgan. “Which is shocking but makes sense, because most cardiologists are men.” Luckily, physicians like her are sounding the alarm for nuanced, female-focused care and awareness. Here, she shares the facts — and sheds light on how to self-advocate. 

Can we begin by talking about how women’s risk of heart disease evolves with age? 

Prior to menopause, a woman’s risk of heart disease is only half that of a man’s. After menopause, it’s equal to a man’s. And by the time you’re in your seventies, it’s more than that of a man. That’s because estrogen is a cardio-protective factor that we lose as we get older — which starts to happen even before you notice changes in your menstrual cycle. 

I’ve been reporting on women’s health topics for more than a decade and I don’t think I’ve ever had a conversation about heart health through the lens of our reproductive lives. Can you break it down? 

As our estrogen levels drop, our risk of heart disease increases. Menstrual cycles may still be normal, though women may notice changes in their bodies — like putting on weight, feeling more irritable, night sweats, heart palpitations, etcetera.  

By the way, this is also a risky time in a woman’s life where she’s likely to be overdiagnosed with depression or anxiety when she’s actually having hormonal fluctuations. [Physicians] will say: ‘I feel uncomfortable treating women’s cardiac symptoms: They come in with palpitations, then the workup is negative, but they stay symptomatic! I don’t know what to do!’ Well, maybe that’s because we need to look at this with a different lens and have this dialog between gynecology and cardiology. 
In other words, those palpitations might not be a symptom of heart disease; they could be a symptom of changing estrogen levels. But the connection is never made. In fact, you may need to seek out a menopause specialist to talk about if you’re a candidate for menopausal hormone therapy. One, because you’re uncomfortable, and that needs to stop. But also because as we lose estrogen, we lose the protection from heart attacks we’ve enjoyed up until this point in our lives. 

I’ve had some discussions with friends recently about how hard it is to get menopausal hormone therapy — one even said that her doctor called her “vain” for wanting it. What gives? 

There was this study from the 1990s called the Women’s Health Initiative that enrolled thousands of people, drew all these erroneous conclusions about hormone therapy increasing the risk of breast cancer, and overshadowed the way we practice medicine. They had the wrong population in the study — that’s another story — but because of it, we didn’t train [doctors] on hormones. 

That’s another reason to seek out someone with a menopause certification, because that is a physician who has taken the time to learn about and understand it, who isn’t steeped in the results of the Women’s Health Initiative. People like me are taking another look and pushing back.

It is so incredibly frustrating that it’s so hard to get help, or even just information. 

The other thing is that when a woman does present with cardiac symptoms, it’s not unusual to note that she’s already had a prior heart attack of which she was unaware. We’ve got to start talking about what ‘women’s health’ really means, like being included in clinical trials so that information that goes to the FDA isn’t approved for men and then extrapolated to the rest of us as if we’re little men. Not only are we not in the clinical trials, there also aren’t enough clinical trials addressing women specifically. 

So a symptom like palpitations could be a sign of decreasing estrogen, which also signals the loss of that heart protectant. What other symptoms could be signs of a cardiac issue? 

[Compared to men], women’s symptoms may be more of a slow burn. Feeling run down, low energy, jaw pain, chronic back pain: We don’t know these are symptoms, so we chalk them up to stress, running after kids, being busy. Sleep disturbance, multiple awakenings during the night; decreased duration of sleep is a risk factor for heart disease. Especially if you’re in your forties, around menopause, and your estrogen levels are starting to fall. 

We call all of the above ‘atypical’ symptoms, which I hate, because in medical school ‘atypical’ is defined as an aberration. Men, we’re taught, have the ‘main’ symptoms. Except that women make up 51 percent of the population so maybe we’re the ones having the ‘typical’ symptoms. That simple word, ‘atypical,’ makes the signs harder to recognize. Women don’t even know what they are, so we ignore them ourselves. 

Is there anything we might not necessarily consider a risk factor when we reflect on our medical histories, but should be flagged? 

Our pregnancies. Specifically, if they were complicated with preeclampsia, eclampsia, pregnancy-induced hypertension, toxemia, or gestational diabetes. The old treatment for those conditions was just to get you to the end of the pregnancy, because if we can deliver the baby safely, then the disease process just corrected itself. But now we know that if a woman has any of those diagnoses, her lifelong risk for heart disease has increased by twofold, as in twice the risk of a woman who didn’t have any of those complications. 

That woman should be referred to a cardiologist, really as a lifelong maintenance. But that handoff doesn’t happen because folks aren’t aware of it, so we go through our lives without getting preventative care or intervention. Including whether or not you need to be more aggressive in mitigating any of your cardiac risk factors in the future or even be on medication. 

What can we do preventatively? 

Take your symptoms seriously. Exercise. Pay attention to your cholesterol levels and blood pressure. Also, take a hard look at your diet, including artificial sweeteners and aspartame: Not only are people concerned about cancer, but we’re getting increasing data that these ingredients raise the risk of heart disease. They’re also pro-inflammatory, which increases heart disease. It’s not just the little packets. It’s in packaged foods. You’ve got to read the labels. 

Follow Dr. Jayne Morgan on Instagram to learn more about heart health and the intersection of cardiology and gynecology. 

**This interview has been lightly edited for length and clarity.**