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Women’s heart health at midlife

Cardiovascular disease is the #1 cause of death in women. Heart disease in women looks different than heart disease in men.

Optimize heart health at midlife

Many heart health factors are within your control. Knowing them, and your personal risks, can help you optimize your heart health at midlife. Here you’ll find:
  • How heart health changes at midlife
  • What you can monitor and manage
  • Online calculators to assess your risk
  • Conditions that raise your risk (e.g., chronic diseases, pregnancy complications)
  • Routine tests to ask for
  • How heart disease shows up differently in women
You can find the full transcript of this interview here.
IN HEALTHCARE SETTINGS

Women’s heart symptoms are often overlooked, so know the risks and advocate for yourself:

  • Less likely to be referred for cardiac testing
  • More likely to be sent home from the ER during a heart event
  • Worse outcomes after a first heart attack, partly due to delayed diagnosis

Cardiovascular risk factors change during the menopausal transition.

Unfavorable changes in cholesterol profiles

During perimenopause, cholesterol levels often shift in a direction that increases the risk of heart disease.

  • Increase in “Bad” Cholesterol: There is a rise in three specific types—LDL, Lp(a), and ApoB. High levels of these cholesterols can lead to plaque build-up in the arteries.

  • Decrease in “Good” Cholesterol: Levels of HDL (“good” cholesterol) typically decline.

    Note: Newer research suggests that HDL may become less cardioprotective after menopause, meaning this specific decrease might not be as negative as previously believed.

Shifts in body composition and fat distribution

The way the body stores fat changes significantly during midlife.

  • Loss of Lean Mass: There is a general shift away from lean body mass toward a higher percentage of overall fat mass.

  • Subcutaneous to Visceral Fat: Instead of storing fat right under the skin (subcutaneous), the body begins predominantly storing it deep inside the abdomen around internal organs (visceral fat).

  • Why it matters: Visceral fat is associated with increased inflammation, insulin resistance, high blood pressure, high cholesterol, and a greater overall risk of heart disease.

Changes in blood pressure (Hypertension)

Blood pressure often changes during the menopause transition, though the data surrounding this link is more mixed.

  • The Risk: High blood pressure (medically known as hypertension) is a major driver of heart disease.

  • Normal: A reading less than 130/80 mmHg is generally considered optimal.

    High: If either the top number (systolic) is 130 or higher, or the bottom number (diastolic) is 80 or higher, the reading is considered elevated or high.

Assess your personal risk factors

These things increase your heart disease risk, and you should mention them to your healthcare provider if they don’t ask:
  1. preeclampsia during pregnancy
  2. an autoimmune disease
  3. diabetes
RISK CALCULATORS
Recommendations from WLB advisor, Dr. Emily Lau

  • PREVENT

    Prevent is the newest risk calculator that estimates both 10- and 30-year risk of all CVD, atherosclerotic CVD, or HF.

  • Pooled ASCVD Risk Calculator (PCE 2013)

    Pooled Cohort Equations (PCE) risk predicts 10-year risk for a first atherosclerotic cardiovascular disease (ASCVD) event

Heart-healthy behaviors in perimenopause

Making heart-healthy changes to your lifestyle helps lower the risk for heart disease, stroke and other major health problems. Read Life’s Essential 8 from the American Heart Association to learn the steps you can take to live a healthier lifestyle.

Monitor your blood pressure.

Buy a cuff to check at home. You don’t need to overdo it, but checking once a month starting at age 35 or 40 isn’t a bad idea.

Exercise regularly.

  • 150 minutes per week of moderate-intensity aerobic activity or 75 minutes per week of vigorous aerobic activity or a combination of both
  • Add moderate to high intensity muscle-strengthening activity (e.g. resistance or weights) on at least 2 days per week
  • Less time sitting (even light-intensity activity can offset some of the risks of being sedentary)
  • Gain even more benefits by being active at least 300 minutes (5 hours) per week
  • Increase the amount and intensity of exercise gradually over time

Eat a heart-healthy diet.

This is what Dr. Lau shares with her patients:

  • Wide variety of fruits and vegetables
  • Whole grains and products made up mostly of whole grains
  • Healthy sources of protein (plants, nuts, fish/seafood, low-fat or fat-free dairy, lean meat and poultry)
  • Olive and avocado oils
  • Minimally processed foods
  • Minimize intake of added sugars
  • Foods prepared with little or no salt

Limit your alcohol intake.

If you smoke, create a plan to quit.

Heart disease in women is different from men

Men often have large artery blockages, but women more often have:
  • Disease of smaller blood vessels (called microvascular disease)
  • Spasm of coronary arteries: this would show up with symptoms like a heart attack but more episodic
  • Plaque that erodes (i.e. the surface lining of an artery peels off) rather than plaque that ruptures (where the cap cracks). In both cases the body notices this as a foreign substance and forms a clot which can impede blood flow and lead to heart attack or stroke.

Signs of heart disease in women: when to seek medical care

Heart attacks show up differently in women. Here are the signs:
  • Chest pressure, tightness, or burning (not always severe pain)
  • Shortness of breath
  • Extreme fatigue (sometimes days or weeks beforehand)
  • Nausea, vomiting, or indigestion
  • Jaw, neck, shoulder, or upper back pain
  • Dizziness or lightheadedness
  • A general feeling that “something isn’t right”
When to schedule a general assessment with a cardiologist:
  • If you use one of the assessment tools above and your estimated risk of developing heart disease in 10 years is intermediate, mention this to your health care provider and ask for Lp(a) and ApoB tests.
  • If you have risk factors for heart disease
  • If you notice chest pain with exercise
  • If you notice an increase in your blood pressure over time

Tests and measurements used to assess heart health

Lipid panel to measure cholesterol levels

LDL and HDL included, Lp(a) and ApoB tests are not included on a routine lipid panel

Blood pressure

If you track yours at home monthly, you will know if you get an unusually high reading at a health care visit.

Electrocardiogram (ECG / EKG) to measure heart rhythm

  • Measures heart rhythm and electrical activity
  • Can show prior heart attacks, rhythm issues, or active ischemia
  • Quick and non-invasive

Heart ultrasound (echocardiogram) to show structure and function

  • Shows heart structure, pumping function, and valves
  • Can identify heart failure, valve disease, or prior damage
  • No radiation

Exercise stress test (with or without imaging)

  • Heart monitored while walking on a treadmill or cycling
  • Looks for signs of reduced blood flow during exertion
  • Your healthcare provider may suggest imaging is which would require an IV to use a nuclear tracer while the test is performed.

Coronary artery calcium (CAC) scan to measure calcium buildup

  • CT scan that measures calcium buildup in coronary arteries, which reflects plaque
  • Helps identify early atherosclerosis, even without symptoms
  • Especially useful when risk is “borderline” or unclear
  • Does not require contrast dye
  • Takes about 10 minutes
  • Low radiation exposure (roughly similar to a mammogram)
  • Many imaging centers and hospitals allow self-pay CAC scans, sometimes without a referral, though some still require a clinician’s order.
  • Typical out-of-pocket cost
    • Usually $75–$300
    • Many centers offer a flat, cash price
  • Important caveats about scheduling your own CSC and paying out-of-pocket
    • A zero score doesn’t mean zero risk, especially for:
      • Younger people
      • Women with microvascular disease
      • It doesn’t assess soft (non-calcified) plaque
      • Results should ideally be reviewed with a healthcare provider to decide next steps

Cardiac catheterization (angiography)

  • Invasive test (gold standard)
  • Usually reserved for:
    • High-risk findings
    • Ongoing chest pain
    • Suspected significant blockages

Treatment, tailored to you

Choosing the right treatment comes down to your personal health history, current medications, and individual preferences.

When it comes to women’s cardiovascular care, keep in mind:

  • The Prescription Gap: Women are often less likely to be prescribed preventive heart medications, despite having a similar or higher risk.
  • Different Side Effects: How your body responds to a medication can vary significantly based on biological sex.
  • Hormonal Transitions: Major life shifts, like menopause, can alter your medication needs over time.
  • Pregnancy History: Your past pregnancies play a critical role in determining which treatments are safest and most effective today.