Matters of the heart
- ruchitandon
- Nov 14, 2025
- 4 min read
Updated: Nov 17, 2025
Why women's heart health needs a menopause-focused lens.
Every time I tell a woman that cardiovascular disease is the biggest killer of women, the reaction is the same: disbelief.
And yet it is. Cardiovascular disease kills women at a rate 10 times higher than breast cancer.
Let that sink in.
We’ve long known that oestrogen is protective. But that protection has, paradoxically, bred complacency. Cardiovascular disease in women is under-recognised, underinvestigated, undertreated, and the outcomes are worse than in men (2).
What is cardiovascular disease?
Cardiovascular disease (CVD) is an umbrella term for conditions that affect the heart and the blood vessels. Think of it as plumbing, but biological.
Vessels 101: the housepipe analogy
Imagine the pipework in your house. Now imagine blockages: thickening, narrowing, pressure building. Eventually, something gives. The same can happen in your arteries.
Plaques form inside vessel walls. They:
Reduce blood flow
Damage the vessel lining
Sometimes break off and lodge further downstream
The consequences? Angina, heart attacks, mini-strokes, and strokes; all the result of oxygen-starved tissue
Living compensation
Your arteries are living, elastic tubes with muscle layers that try to compensate. They narrow. They harden. They increase pressure to keep blood flowing. That compensation is what we call high blood pressure.
The heart joins in: it beats faster, harder, and eventually grows larger to keep up. But there’s a limit to how long this system can cope.
Gender differences: smaller parts, bigger problems
Women’s hearts are smaller, with thinner walls and narrower vessels. CVD in women typically involves the microvasculature - the small arteries that don’t always show up on standard scans.
Which means diagnosis is often missed or delayed.
Irrigation analogy, take two
Think of a garden irrigation system. A main pipe can take a 50% blockage and still deliver. But if the tiny drip-feed tubes block, even partially, the plant suffers. Disease within microscopic vessels in women gives less margin for error.
Living consequences
This is why women and men experience cardiovascular disease differently:
Activities
Men typically notice angina and chest pain with physical exercise (greater oxygen demand), and it gets better with rest. Women are more likely to feel chest pain while doing day-to-day activities.
Women are more likely to feel chest pain during mental stress.
Location
Both men and women describe a heart attack as ‘crushing’ chest pain that feels like pressure, but women may also have pain in their neck and throat.
Symptoms
Women commonly experience other symptoms including nausea, vomiting, shortness of breath, abdominal pain, sleep problems, tiredness and lack of energy.
Different risk factors
Some conditions are especially problematic for women:
Diabetes – twice as likely to lead to CVD in women
Autoimmune disease – disproportionately affects women
Mild hypertension – more dangerous for women
Smoking – more harmful for women’s vessels
Stress, anxiety, and depression – under-recognised cardiovascular risks
Metabolic syndrome – a dangerous mix of high glucose, cholesterol, and blood pressure
Obesity
This makes sense when you realise that different diseases affect different-sized vessels. Let’s take diabetes. It is a disease of small vessels, so even though men have a higher prevalence of diabetes than women, it is twice as likely to cause cardiovascular disease in women as in men (3).
Under recognition and systemic bias
Tests to diagnose cardiovascular disease are similar between men and women; the difference is that women experience delays in both diagnosis and treatment.
Women are more likely to be misdiagnosed during heart attacks
They receive fewer referrals, fewer interventions, and less aggressive medication
They're less likely to be prescribed statins or offered high-dose treatment when appropriate
And still, heart disease kills more women than breast cancer, uterine cancer and ovarian cancer combined
Menopause, the silent accelerator
The hormonal shift around menopause is a tipping point for cardiovascular risk. Loss of oestrogen affects:
Blood vessel flexibility
Lipid metabolism
Glucose control
Fat distribution and risk of metabolic syndrome
Inflammation that drives blood vessel damage
These changes can happen without symptoms and warning (4).
What women can do - the midlife essential check
Tests you should ask for when you turn 40 or are experiencing perimenopausal symptoms
Blood tests
Lipid profile: HDL, LDL, cholesterol and triglycerides
HbA1c: a three-month assessment of your blood glucose control
CRP (C reactive protein): a marker of inflammation that contributes to plaque formation
Lipoprotein (a): inherited LDL subtype linked to a higher risk of plaque formation
Thyroid function: even mild hypothyroidism increases risk
Imaging
ECG: rhythm and rate; do this if you have palpitations or a family history
Echocardiogram: visualise heart muscle function
Stress test: if you get symptoms with exercise
Coronary artery calcium scan (CAC): checks for silent plaque build-up
Consider HRT
HRT started within 10 years of menopause can be cardioprotective (5).
Transdermal oestrogen (patch, gel or spray) avoids first pass through the liver (that creates the metabolites that increase the risk of blood clots) and is the preferred route in women with existing cardiovascular risk factors.
Lifestyle beat statins (sometimes)
The best interventions are often free of side effects:
Resistance training (2x/week): lowers BP, improves blood sugar and lipids
Aerobic exercise: improves vessel health and reduces LDL
Sleep: lowers cortisol and blood pressure, improves insulin sensitivity
Stress management: crucial for blood pressure and plaque formation (8)
Find yourself a heart-literate medical team
Push the medics you encounter to consider female-specific treatment.
Cardiovascular health makes up a large part of the health gap between women and men because:
There is a lack of knowledge about the discrepancy in cardiovascular disease in women
A lack of education on the gender bias in medicine in general
Women are underrepresented in cardiovascular research, so they aren’t receiving optimum care (9).
Just as with consideration of HRT, push for sex-specific care. That means:
Symptom diaries
Directly asking: “Is this approach tailored for a woman?”
Getting second opinions when something feels off
Seeking out women’s heart clinics (yes, they exist)
The lowdown
Your heart isn’t failing. The system is.
Women have been left out of cardiovascular research, education, and clinical thinking.
It’s time to catch up. Because midlife heart care isn’t a luxury. It’s your strategy.
If you’re in peri or post-menopause, this is your moment to shift the odds in your favour.
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