Women and Heart Disease

Once considered largely a man’s disease, there was a time when doctor’s rarely looked for coronary heart disease (CHD) in women. The reality is that CHD is the leading cause of death for both men and women in the United States and in most developed countries around the world. However, over the past 40 years in the U.S., there has been a striking reduction in CHD deaths in men, but reductions in women have lagged behind. More women than men die of CHD every year, which has been the case for the last 25 years. 

Numerous issues are compounding the problem of detecting and treating CHD in women:
• women have more “atypical” symptoms of CHD compared to men;
• women have more “silent ischemia” — meaning blood flow to the heart is restricted but there is no chest pain — making CHD harder to detect;
• even when women report symptoms, they show less obstructive CHD compared to men with the same degree of symptoms, suggesting a disease pattern that is different than men and — unfortunately — harder to detect;
• once women develop obstructive CHD, they appear to have more adverse outcomes — including a greater risk of dying — compared to men
Given the gender specific differences in the presentation, manifestation, and diagnosis of CHD, it’s important that women learn about these differences so that they can recognize when a heart attack is occurring and get proper, life-saving care as quickly as possible.

Basic Facts
• One in four women dies from CHD, making it the #1 killer of women, regardless of race or ethnicity.
• While more women today understand that CHD is the leading killer of men and women, most women fail to make the connection between risk factors and their personal risk of developing CHD.
• More women (52%) than men (42%) die from a heart attack before reaching the hospital.
• Two-thirds of women who suffer a heart attack never fully recover.
• One in three adult females has some form of cardiovascular disease
• Women who are obese, physically inactive, older than 65 years, of certain ethnicities, have high blood pressure or high cholesterol levels all have a greater risk of developing CHD, as do women with diabetes or pre-diabetes
• Numerous medical tests can help determine whether a person has CHD, but the effectiveness of individual tests varies by sex of the participant
• The relationship of birth control and hormone therapy to CHD is not fully understood and should be discussed with your physician
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Estrogen
One factor that also impacts a woman’s risk of CHD is that of hormones. The hormone estrogen, which is present in women who are ovulating, is considered heart protective when it is produced naturally by the ovaries. Its introduction into the body by artificial means is the subject of much controversy. Women under the age of 35 who are generally healthy and take estrogen-based oral contraceptives or use a birth-control patch are not likely to experience any increased risk of developing CHD.  However, women over the age of 35; women with high blood pressure, diabetes, or high cholesterol; and women who smoke increase their risk of CHD with birth-control pills or the patch (which actually may expose you to more estrogen than the contraceptive pill). 

What’s more, for years, postmenopausal women were prescribed hormones to replace those the ovaries no longer produce to counteract hot flashes and other changes in their bodies as well as protect against endometrial cancer and osteoporosis. Hormone replacement therapy (HRT) can help with some symptoms of menopause, including hot flashes, vaginal dryness, mood swings, and bone loss, but there are risks, too. Beginning in 1991, the Women’s Health Initiative (WHI) was undertaken to look at the most common causes of death, disability, and poor quality of life in postmenopausal women — CHD, cancer, and osteoporosis — and involved nearly 162,000 generally healthy postmenopausal women in a series of trials that looked at hormone replacement therapy, now called postmenopausal hormone therapy (PHT).

Some women received estrogen-only therapy and when compared to women with similar characteristics who took placebo pills, the hormone was shown to increase the risk of blood clots and strokes, make no difference in risk of heart attack or colorectal cancer, had an uncertain impact on breast cancer, and reduced the risk of fracture.  However, when the women taking estrogen plus progestin were compared to a group taking only placebos, PHT increased risk of heart attack, stroke, blood clots, and breast cancer, while reducing the risk of colorectal cancer.  Fewer fractures were seen with the combination therapy as well.

The WHI’s extensive size caused health care professionals to reconsider standard PHT for postmenopausal women.  The thought that PHT protected against CHD was dispelled, and the U.S. Food and Drug Administration (FDA) now states that PHT should not be taken to prevent CHD.  The therapies tested in the WHI are approved for relief from hot flashes and other symptoms of menopause.  However, even though PHT was shown to be effective in combating post-menopausal osteoporosis, it should only be used by women who have a high risk for that disease who cannot take non-estrogen medications.  If PHT is prescribed, the FDA recommends women should take the lowest doses for the shortest amount of time possible to reach treatment goals.

Even though the estrogen-progestin trial was stopped due to the health risks seen, researchers continued to follow the participants to determine whether there were long-term risks to the therapy.  At 3 years, the women who had taken the combination therapy no longer had increased cardiovascular risk over those participants who had taken placebo pills, but the benefits regarding colorectal cancer and fractures also disappeared.

read one of Dr. Steiner's partners articles Women and Heart Disease

Written by Dr. Mark Steiner, Cardiologist in Orlando