Heart Attacks in Women
Perhaps you’ve heard by now that in women, heart attacks often “look” different than they do in men. While chest pain is still the most common symptom, occurring in approximately 87–90% of cases, women are significantly more likely to experience additional or accompanying symptoms.
These can include nausea, indigestion, unusual fatigue, shortness of breath, palpitations, pain in the jaw, neck, back, shoulders, or arms, and vomiting. These symptoms are more likely to be subtle, intermittent, or dismissed as stress, anxiety, or gastrointestinal issues.
This creates a dangerous situation.
Many women delay seeking care because they don’t want to seem dramatic or hypochondriacal, or because their symptoms don’t match the classic image of a heart attack.
Compounding this is the well-documented tendency for women’s health concerns, especially pain and nonspecific symptoms, to be minimized or dismissed within the medical system. When symptoms are labeled as “atypical,” women are more likely to be sent home without appropriate cardiac testing.
These delays matter: women, particularly those under 65, experience higher mortality rates in the year following a first heart attack compared to men, in part because diagnosis and treatment are delayed.
Heart Health for Women Over 40
As women move through perimenopause and into menopause, cardiovascular risk begins to rise sharply.
One of the key drivers of this shift is the natural decline in estrogen. Estrogen plays a critical role in maintaining vascular health. It helps the lining of blood vessels, known as the endothelium, remain flexible, relaxed, and protected from inflammation. When estrogen declines, the vessels produce less nitric oxide, a compound that helps them widen, and more endothelin-1, which makes them tighten.
When estrogen levels fall, this balance changes.
Blood vessels become stiffer and less responsive, blood flow is reduced, and inflammation increases. Over time, this environment accelerates the buildup of atherosclerotic plaque and raises the risk of hypertension, coronary artery disease, and heart attacks.
Importantly, research shows that these changes do not begin abruptly after menopause; declines in endothelial function can start as early as perimenopause and continue to worsen for years afterward, even in women who are otherwise healthy.
The loss of estrogen also affects multiple metabolic pathways tied to cardiovascular health.
Cholesterol profiles often become less favorable, with increases in LDL cholesterol and triglycerides and decreases in protective HDL cholesterol.
Insulin resistance becomes more common, visceral (abdominal) fat accumulates, and arteries remodel in ways that make them thicker and less elastic.
Hormonal changes can also activate systems such as the renin-angiotensin-aldosterone system, which plays a role in blood pressure regulation, further increasing cardiovascular strain.
Although estrogen is clearly protective during the reproductive years, hormone therapy later in life has produced mixed results in clinical trials. One explanation is the “timing hypothesis,” which suggests that estrogen is most beneficial when introduced earlier in the menopausal transition, before significant vascular aging and plaque formation have occurred. Once blood vessels have already stiffened or developed atherosclerosis, estrogen may no longer provide the same protective effects.
So yes, this can feel sobering. A natural and inevitable hormonal transition is associated with a cascade of changes that increase cardiovascular risk. The good news is that much of this risk can be identified early and addressed proactively.
One of the most powerful tools we have is appropriate testing.
When assessing cardiovascular risk in women, especially during midlife, the following labs are particularly helpful:
- A lipid panel, ideally with particle size or ApoB, to better assess cholesterol-related risk
- Lipoprotein(a), a genetically driven risk marker that often goes undetected with standard screening
- Hemoglobin A1c and fasting insulin, to evaluate blood sugar control and insulin resistance
- High-sensitivity C-reactive protein (hs-CRP), a marker of chronic inflammation
- A full thyroid panel, as thyroid function significantly influences lipid metabolism and heart health
For women over 50, or earlier in the presence of risk factors, a coronary artery calcium (CAC) score can provide valuable information about the presence of subclinical plaque and help guide prevention strategies when traditional risk calculators fall short.
Cardiovascular disease remains the leading cause of death in women, but it is not inevitable.
Understanding how women’s symptoms present, how hormonal transitions affect the heart, and which tools truly assess risk allows women to advocate for themselves and take meaningful steps toward protecting their long-term health.
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Dr. Jennifer Potter, ND
Naturopathic Doctor San Jose
408-356-1364
Dr. Jennifer Potter, ND provides natural healthcare solutions for families and individuals, focusing on perimenopause/menopause, autoimmune conditions, fatigue, and immune support. She is deeply committed to her patient’s well being, prioritizes patient education and combines natural and conventional therapies to deliver personalized care. Outside of her practice, she enjoys time with her two kids, reading fiction, and crocheting.
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References
Symptoms of Infarction in Women: Is There a Real Difference Compared to Men? A Systematic Review of the Literature With Meta-Analysis. Cardeillac M, Lefebvre F, Baicry F, et al. Journal of Clinical Medicine. 2022;11(5):1319. doi:10.3390/jcm11051319.
Cardiovascular Risk in Perimenopausal Women. Stevenson JC, Tsiligiannis S, Panay N. Current Vascular Pharmacology. 2019;17(6):591-594. doi:10.2174/1570161116666181002145340.
Cardiovascular Disease Risk Factors in Women: The Impact of Race and Ethnicity: A Scientific Statement From the American Heart Association. Mehta LS, Velarde GP, Lewey J, et al. Circulation. 2023;147(19):1471-1487. doi:10.1161/CIR.0000000000001139.
Menopause: A Cardiometabolic Transition. Nappi RE, Chedraui P, Lambrinoudaki I, Simoncini T. The Lancet. Diabetes & Endocrinology. 2022;10(6):442-456.
doi:10.1016/S2213-8587(22)00076-6.
Aging Women and Their Endothelium: Probing the Relative Role of Estrogen on Vasodilator Function.
Somani YB, Pawelczyk JA, De Souza MJ, Kris-Etherton PM, Proctor DN. American Journal of Physiology. Heart and Circulatory Physiology. 2019;317(2):H395-H404.
doi:10.1152/ajpheart.00430.2018.
