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Heart Disease is the #1
Killer of Women


If breast cancer scares you, heart disease should scare you even more...

The most recent statistics show that breast cancer causes approximately 40,000 deaths in women each year, but heart disease causes 500,000!


It can be more challenging to diagnose heart disease in women because:

  • They often do not have the 'typical' symptoms.

  • They are more likely to have hard-to-recognize types of heart disease, such as coronary microvascular disease or variant angina.

  • Doctors fail to identify the early signs of a developing heart condition.


Another major problem is that many health care providers do not understand the vital role that hormones play in heart health even though the scientific research has proven there to be substantial differences in heart health before and after menopause.

This article will provide you with additional information on signs and symptoms of heart disease in women, risk factors, and tips on prevention. Special attention will be given to hormones and the use of HRT in menopausal heart disease prevention.

Symptoms can be Subtle

Approximately one in four female deaths in the United States every year is a direct consequence of heart disease. One of the main obstacles to early intervention is that the symptoms are often subtle. Therefore, it is essential to know what some of the most common symptoms are and not dismiss them. Here are some of them:


  • Shortness of breath

  • General fatigue

  • Chest pain (pressure, sharp, dull, or heavy pain)

  • Abdominal pain

  • Nausea

  • Neck, throat, or jaw pain

  • A tingling or painful sensation in one or both arms

  • Upper back pain

  • Dizziness

  • Weakness

  • Sweating and change in skin color



Other symptoms of heart disease are more common in women than in men. These include:

  • Insomnia

  • Swelling in the legs and feet

  • Heart palpitations (the feeling of the heart beating very fast)

  • Weight gain

  • Wheezing

  • Coughing

  • Indigestion and heartburn

  • Fainting 


Much More Than Genetics


Many people mistakenly believe most health problems are genetic. But in fact, less than 5% of all chronic diseases are hereditary. Most of the risk factors are directly tied to lifestyle. Chronic stress, sleep deprivation, unhealthy eating habits, sedentary lifestyle, and smoking are some of the most common culprits. Diabetic and/or obese women as well as those who have an autoimmune disease, high blood pressure, depression, high triglycerides are also at increased risk. But, another extremely important and often overlooked risk factor is hormone deficiencies, especially estrogen.


Years of scientific research have shown that menopause and changing estrogen levels play a central role in women’s cardiovascular system. So, let’s take a more detailed look at the connection between estrogen and heart health.

Estrogen & Heart Health

There is a lot of evidence that endogenous estrogen protects heart health in women before menopause. Before they reach menopause, women have a lower risk of high blood pressure (hypertension) and heart disease compared to men of the same age. Why? because estrogen does some really important things when it comes to protecting a woman's cardiovascular system.


Here's the short list:

  • It improves the elasticity of all tissues, including the blood vessels.

  • It improves blood flow by dilating blood vessels

  • It protects the blood vessels from age-related damage by absorbing free radicals. 

  • Estrogen also has a positive effect on blood cholesterol levels. In premenopausal women, the so-called good cholesterol (HDL) levels are higher, and bad cholesterol (LDL) levels are lower than in men of the same age.

  • It improves blood sugar control.

  • It promotes the growth of new blood vessels.

  • It prevents platelets from clumping together thus reducing the risk of clotting.

  • It prevents cholesterol plaque from sticking to the inside of arteries.









Once women become menopausal, their risk of heart disease increases significantly. This is especially true in women who've had their ovaries removed. In fact, women who go into menopause early because of surgical removal of their ovaries are at even higher risk. One study found that women who underwent hysterectomy with ovarian conservation at or before age 35 had an increased risk of congestive heart failure (4.6-fold increase) and coronary artery disease (2.5-fold increase).

The lack of endogenous estrogen makes the walls of blood vessels less elastic and increases blood fibrinogen (the substance that helps blood clotting) levels. That translates into a higher risk of plaque, blood clot formation, and high blood pressure. Good cholesterol (HDL) levels drop while bad cholesterol (LDL) levels, levels of inflammation, and blood sugar rise. These underlying physiologic changes are compounded by the weight gain, sleep disturbances, and increased sensitivity to stress many menopausal women experience.


Hormone Replacement Therapy & Heart Health









It wasn't so long ago that doctors frequently prescribed hormone replacement therapy (HRT) for relief from menopausal symptoms. Unfortunately, due to flawed data from a large 2001 Women's Health Initiative Study, HRT got a very bad (and undeserved) reputation. Doctors quit prescribing HRT and fearful women abruptly stopped using it. 

What's really sad is that in 2013, the authors of the WHI study published another paper in which they claimed certain aspects of their 2001 study were flawed and likely produced 'false' results...but it seems that even ten years later, doctors still haven't read that study! So, unfortunately, they continue to withhold HRT despite evidence of many benefits, including possibly reducing the risk of heart disease.

To be fair, a lot of confusion surrounds the topic of HRT because both doctors and patients have a lot of misunderstandings and misconceptions. HRT is not all the same. How it's given (oral vs. topical), the doses in which its given, the source from where it comes (i.e. premarin comes from pregnant horse urine), and whether or not it's properly balanced and monitored determine its safety. Another thing to keep in mind is that the progestins prescribed by conventional doctors is the same as the progesterone naturally made in the body. Nothing could be further from the truth!

The benefits of HRTgo way beyond the relief of menopause symptoms. In addition to its cardiovascular benefits, it also favorably impacts other health issues commonly associated with menopause, such as Alzheimer's Disease, osteoporosis, and diabetes. It also lowers the risk of colon cancer.

Many major medical organizations continue to take a cautionary stance on using HRT to prevent cardiovascular disease. For example, The American Heart Association admits that the loss of natural estrogen may contribute to a higher risk of heart disease in women after menopause, they currently do not recommend postmenopausal hormone replacement therapy as a means of reducing this risk. The American College of Obstetricians and Gynecologists agrees that HRT may not be the primary method of heart disease prevention in postmenopausal women. But, it supports the evidence that women in early menopause with good health and no history of heart disease may experience cardiovascular benefits from a properly dosed and monitored HRT.

One study correctly points out that:

"Subsequent publications of the more complete data from WHI have shown no significant increase in CHD, and a tendency to a reduction in those initiating HRT below age 60 years. This is important because other therapeutic strategies for the primary prevention of CHD, such as aspirin and statins, are not of proven benefit in women, in contrast to men. Subsequent WHI findings have not shown a clear increase in breast cancer, and any potential increase from HRT is similar to that seen with many lifestyle factors and other commonly used medications."

The Bottom Line?

Since cardiovascular disease remains the #1 killer of women in this country, doctors and patients need to be educated about the risk factors and symptoms and implement all possible preventative measures. This should include hormone optimization with HRT in menopausal women (as long as they don't have a history of pre-existing heart disease).  Women should also remain vigilant in proactively modifying their risk factors. This includes maintaining a healthy weight, reducing stress, engaging in regular physical activity, and making sleep a priority.

When it comes to HRT, the key is for women to work with an experienced healthcare provider who thoroughly understands how to safely prescribe HRT.  


  • Westerman S, Wenger NK. Women and heart disease, the underrecognized burden: sex differences, biases, and unmet clinical and research challenges. Clin Sci (Lond). 2016;130(8):551-563. doi:10.1042/CS20150586

  • DiNardo D, McNeil M. Update on Women's Heart Disease. J Womens Health (Larchmt). 2020;29(8):1028-1031. doi:10.1089/jwh.2020.8486

  • Fortini F, Vieceli Dalla Sega F, Caliceti C, et al. Estrogen-mediated protection against coronary heart disease: The role of the Notch pathway. J Steroid Biochem Mol Biol. 2019;189:87-100. doi:10.1016/j.jsbmb.2019.02.008

  • Newson L. Menopause and cardiovascular disease. Post Reprod Health. 2018;24(1):44-49. doi:10.1177/2053369117749675

  • Naftolin F, Friedenthal J, Nachtigall R, Nachtigall L. Cardiovascular health and the menopausal woman: the role of estrogen and when to begin and end hormone treatment. F1000Res. 2019;8:F1000 Faculty Rev-1576. Published 2019 Sep 3. doi:10.12688/f1000research.15548.1

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