Is cardiovascular disease a women's health issue?
Cardiovascular disease is the umbrella term for conditions affecting the heart and blood vessels, including heart attack, stroke and heart failure. It is often thought of as a men's problem, but it is one of the leading causes of death of Australian women. Around 20 women die from coronary heart disease every day — more than twice the number who die from breast cancer.
Despite this, heart disease in women has historically been under-recognised, under-diagnosed and under-treated. For generations, medical research was built largely around men, which means much of what we know about preventing, diagnosing and treating heart disease was defined by data from males. That is starting to change.
This explainer looks at how heart risk can differ for women, why it is often missed, and what is being done about it.
How is women's heart risk different?
Women share the major risk factors for heart disease with men: high blood pressure, high cholesterol, diabetes, smoking, physical inactivity, excess weight and a family history of heart disease. Managing these risk factors matters just as much for women as for men.
Women may also have female-specific risk factors, including:
- Pregnancy complications, such as pre-eclampsia and gestational hypertension, gestational diabetes, preterm birth, and having a smaller baby, which are linked to a higher risk of heart disease later in life.
- Menopause, particularly when it occurs early (before 45 years) or prematurely (before 40 years).
- Some conditions that are more common in women, such as polyendocrine metabolic ovarian syndrome (PMOS, previously known as polycystic ovary syndrome, or PCOS) and certain autoimmune conditions, for example lupus or rheumatoid arthritis.
- Treatments for other illnesses, including some breast cancer therapies, which can affect the heart over time.
Because these factors are not captured by standard heart-disease risk calculators, these tools can underestimate a woman's true risk — which is one reason heart disease in women can go unnoticed until later than it should.
Heart conditions that affect women more
Not every heart problem starts with a blocked artery. Several conditions are far more common in women, and because they do not fit the classic picture they are often missed.
- Coronary microvascular disease
The heart's smallest blood vessels fail to widen properly, so the heart muscle does not get enough blood even though the large arteries look clear on an angiogram. It causes chest pain, breathlessness and fatigue, and is a common reason women are told their tests are normal when something is genuinely wrong. - Spontaneous coronary artery dissection (SCAD)
A tear in the wall of a heart artery that can cause a heart attack. More than nine in ten people affected are women, often younger women without the usual risk factors, and sometimes in the weeks around childbirth. - Takotsubo syndrome, sometimes called broken heart syndrome
The heart muscle suddenly weakens, often after severe emotional or physical stress. It can look exactly like a heart attack, and around nine in ten cases are in women, most of them after menopause. - Heart failure with preserved ejection fraction (HFpEF)
The heart muscle becomes stiff and cannot fill properly. It is more common in women and is often diagnosed late. For a long time there were no proven treatments, though that has begun to change in the past few years.
If you have ongoing chest pain, breathlessness or exhaustion and have been told your arteries are clear, it is reasonable to ask whether the small vessels of the heart have been looked at.
Why is it often missed?
Part of the reason is awareness: when heart disease is seen as a men's condition, the signs are more easily overlooked — by women themselves, and sometimes by those caring for them.
Symptoms play a part too. The most common symptom of a heart attack, for women as for men, is chest pain or discomfort. But women can be more likely to also experience other symptoms — such as shortness of breath, nausea, unusual tiredness, or pain in the jaw, neck or back — and these are more easily mistaken for something less serious. Symptoms of some heart conditions can also be put down to stress, ageing or weight, which can delay diagnosis and treatment.
Care differs too. Australian data show that women having a heart attack take longer to get to hospital, wait longer for treatment once they arrive, are less likely to receive procedures such as angiography and stenting, are less likely to leave hospital on preventive medicines, and are less likely to be referred to cardiac rehabilitation.
Under-representation in research adds to the problem. For decades, women — particularly women of childbearing potential — were excluded from many early clinical studies. One example comes from the United States, whose drug regulator has influenced practice worldwide: in 1977 the Food and Drug Administration (FDA) issued a guideline excluding women of childbearing potential from the early stages of drug trials. It was introduced out of caution following the thalidomide tragedy of the 1950s and 60s — a morning-sickness drug, taken by pregnant women in Australia and elsewhere, that caused severe birth defects — but it was interpreted broadly and kept most women out of drug research. In 1993, the FDA withdrew this restriction and formalised expectations that both women and men be included in drug development and that data be analysed by sex. The same year, the NIH Revitalization Act wrote the inclusion of women and minorities in NIH-funded clinical research into United States federal law.
The consequence was that a generation of medicines, doses and medical devices was tested largely on men, and important differences between the sexes went unstudied — including in cardiovascular disease, where trials focused heavily on men. Representation has improved since the 1990s, but the effects of those gaps are still being felt, and women remain underrepresented in some areas of research today.
Reducing your risk
The encouraging news is that much of the risk of cardiovascular disease can be prevented, and the everyday steps that protect the heart are the same for women as for men: not smoking, staying physically active, eating well, and keeping blood pressure, cholesterol and blood sugar in a healthy range. Our other explainers cover several of these areas in more detail.
There are a few things worth doing that are specific to women:
- Ask your GP for a Heart Health Check from age 45 — or from 30 if you are Aboriginal or Torres Strait Islander, and from 35 if you have diabetes.
- If you have had a pregnancy complication such as pre-eclampsia or gestational diabetes, tell your doctor. This is relevant long after the pregnancy.
- Talk to your doctor about your heart health around menopause.
- If you have been treated for breast cancer, ask whether your treatment has any implications for your heart. (See our Cardiotoxicity explainer)
- If you have chest pain and have been told your arteries are normal, ask about microvascular causes rather than accepting that nothing is wrong.
Most importantly, take heart symptoms seriously and seek help promptly. If you or someone else may be having a heart attack, call 000.