Did you know that heart disease is the leading cause of death among women? It's a surprisingly overlooked fact, but it's true that heart disease is responsible for one in three deaths, killing more women than all cancers combined. In other words, heart disease far outstrips breast cancer as a killer of women, despite the latter having a much higher public profile as a feared Bogeyman.
Treatment and prevention of heart disease in women was the subject of a recent (Sept 2024) online talk to the Harley Street At Home1 group by Dr Suzanne Steinbaum, a leading American cardiologist specialising in women's heart health2. According to her, since the 1980s more women have been dying of the condition than men. Part of the reason, she says, is a high rate of missed diagnoses in women, the result of a 'male algorithm' bias to testing that spots heart disease in men, but not in women.
The difference between men and women
Almost all the early research into heart disease was carried out on men, work that found in general that their heart disease presented as an effect, such as a blockage or at least a significant narrowing, in one of the major cardiac arteries – those blood vessels supplying oxygenated blood to the heart's own muscles, enabling the heart to pump blood around the body. Block either of those arteries and the cardiac muscles can no longer function properly and the heart fails to pump effectively.
Diagnostic tests were developed that could readily identify such major blockages and narrowings, including exercise stress tests, echocardiograms and angiograms. These in turn led to effective treatments, such as the insertion of stents (tubes) to hold narrowing tubes open, and heart bypass surgery in which a section of blood vessel is taken from another part of the body and is used literally to bypass the blocked/restricted cardiac artery.
The diagnostic tests are highly effective in men, and yet rarely work in women. How can this be? 'I can give you a hypothetical description of a typical scenario.' says Dr Steinbaum. 'A women who is, say 50 years old, goes to her doctor complaining of mild chest pains, palpitations, lack of energy and light-headedness. These are all symptoms of heart disease, so the doctor refers her to a cardiologist, who then performs the standard cardiac tests. They all come back normal. The cardiologist says to the woman 'You're fine, there's no problem, go home. Improve your diet, get more sleep, exercise, reduce your stress levels.”
'A year later,' continues Dr Steinbaum, 'she comes back to her doctor still complaining of the same symptoms. The doctor again refers her to a cardiologist who does the same standard tests and gets the same all-clear. “You're fine, there's no problem, go home...” etc. This cycle may be repeated several times until evenutally, one day, this woman has a heart attack. 'How did we not see this coming?' the cardiologists will ask.
Female heart disease
According to Dr Steinbaum, it has only started to become clear in quite recent years that heart disease in men and women is very different. While – as just described – in men it attacks just one spot in a major cardiac blood vessel, in women it affects mostly the heart's microvasculature, damaging a large number of the smaller blood vessels that branch off from the main cardiac arteries, feeding blood to every nook and cranny of the heart's muscles. Such a large number of 'mini' blockages and restrictions remain invisible to the standard tests, giving results indicating that the heart's function is quite normal when in fact it is anything but. The outcome, as already mentioned, is a large number of missed early-stage diagnoses in women.
So if the standard 'male algorithm' tests don't work on women, what's the way forward? 'The damage that leads to heart disease in women typically starts at menopause.' says Dr Steinbaum. 'In younger women estrogen circulating in the blood helps to keep the walls of the cardiac blood vessels supple and soft, enabling the blood to flow through the vessels smoothly.
'With menopause that supply of estrogen suddenly stops, and this leads to the blood vessels stiffening.' she says. As a result, the flowing blood is more likely to cause damage, usually little tears, to the blood vessels' internal walls, damage that is not fully repaired, leading to the build-up of what is called plaque around the damaged areas – partially successful damage repair that effectively begins the process of narrowing the blood vessel and disrupting the flow of blood.
So how can we treat this? One cannot really go putting hundreds of stents into or bypass grafts around multiple small blood vessels. Is there an effective treatment for heart disease in women?
Moving forward with female heart disease treatment
One of the most obvious treatments of symptoms is to use vasodilators, drugs that cause the blood vessels to enlarge, thus helping to overcome any obstruction.
However, according to Dr Steinbaum, prevention seems to be the best form of defence. 'Fortunately,' she says '80% of heart disease is preventable. When it comes to heart disease, for women there is a fork in the road, and that fork is the menopause.' As she explained, one branch takes you down the road of doing nothing and just letting things happen, while the other fork is the path where you take steps to protect your heart and to maintain its health.
So women should take care of their heart health, before and during menopause, to prevent damage to their cardiac blood vessels occurring in the first place. The problem is motivating women to to do this, especially at time in their life (ie the menopause) when they might not be feeling at their best. Dr Steinbaum quoted a survey in which 90% of women asked realised that heart disease is a major issue for women. And yet, only 13% of them felt it was a problem likely to affect them. They were in denial: it was a problem for everyone else but not them!
One way to help improve motivation is to talk about heart health instead of heart disease, something that according to Dr Steinbaum greatly alters the perception of a woman's position. Then there are those already-mentioned steps: improve your diet, get proper amounts of sleep, decrease your stress levels, and take regular (but notexcessive) exercise. None of these are likely to help a great deal with the visible symptoms of menopause, such as the hot flushes, brain fog or the anxieties, but they will help with your heart health, maintaining the suppleness of the cardiac blood vessels for longer.
And then there are hormones, and hormone replacement therapy (HRT).
The role of HRT in promoting heart health
As Dr Steinbaum points out, if the heart's health is protected in younger women by the presence of estrogen, then surely in menopausal women it makes sense to restore those lost hormones by starting a course of HRT as early as possible. According to her, studies have shown that being on HRT for just two years results in a 30% reduction in risk of heart disease. This is a clear illustration of the critical role of HRT in protecting the menopausal female body against decline. Not only does it greatly reduce such well-known visible symptoms as hot flushes, brain fog, fatigue, anxiety and depression, but also it protects against all the things you cannot see: a whole range of metabolic health issues, including damage to the heart muscles' blood supply. Without HRT, these metabolic issues slowly develop, but remain hidden until too late, when the damage is done and symptoms become apparent. In the case of a woman's heart muscles these come in the form of those chest pains, palpitations, shortness of breath and lack of energy described earlier, culminating eventually in a heart attack.
Dr Steinbaum's main interest during her talk in the effectiveness of HRT lay with the role of estrogen. Something she didn't mention was the role of progesterone, the hormone that has to exist in the female body in balance with the levels of estrogen.
There is still a prevailing sense in much of the medical world, largely out-dated in my view, that progesterone is important only in protecting the womb. The fact is that increasing numbers of studies have shown progesterone to have multiple, largely protective effects on organs around the body, including not only the heart but also the thyroid gland, the nervous system, and the control and effectiveness of insulin.
There is still some controversy surrounding the positive effects of progesterone on heart health provided as part of menopausal HRT, probably due to data suggesting that some synthetic progestins used in HRT can have a negative impact on heart health.
There are few such doubts, however, with the use of bio-identical progesterone, biochemically identical with the progesterone naturally found in the body. This has been shown repeatedly to be a powerful natural vasodilator (it causes blood vessels to enlarge), lowers blood pressure, inhibits coronary hyperactivity, and helps to restore and maintain a healthy structure to cardiac blood vessel walls.
When it comes to HRT, then, the conclusion is that such treatment in menopausal women is a critically important tool in maintaining heart health and so preventing the development of heart disease.
Hormone replacement therapy (HRT) at Hebe Medical
We at Hebe Medical are strong advocates of the use of HRT in menopausal women, not just for its beneficial effects on the well-known and visible symptoms, but also for its protective effects on the unseen metabolic processes so vital to a woman's health around the body, including the heart. HRT is not simply for symptomatic relief from the menopause, but a real deep-seated integral protection of a menopausal woman' entire health.
All hormones used at Hebe Medical are bio-identical, meaning that they are identical to those found naturally in the human body. We use no synthetic products, all of which are slightly different at the molecular level to the naturally occurring bio-identical hormones, often resulting in unwarranted side-effects.
We strongly believe that bio-identical hormone replacement therapy (BHRT) is critically important in the long-term protection of women's health, from the moment menopause starts all the way through for the rest of their life. Protecting the heart's blood supply is just one part of it.
Additional notes:
1. Harley Street At Home is an online system developed by doctors to provide help and guidance to menopausal women in protecting their health and minimising their menopause symptoms. www.harleystathome.com.
2. Dr Suzanne Steinbaum is head of Women's Heart Health at the Lennox Hill Hospital, New York, and is national spokesperson for the Go Red for Women initiative for the American Heart Association. www.drsuzannesteinbaum.com.
You can see Dr Steinbaum's talk by going to: https://www.youtube.com/watch?v=Wm_nNM3MeC4.