Women and heart disease — what every woman should know

Women can have the classic central chest pressure of a heart attack, but they are significantly more likely than men to present with atypical symptoms — severe unexplained fatigue, breathlessness, jaw or upper-back pain, nausea, indigestion, light-headedness, or simply a profound sense that something is deeply wrong.

These atypical symptoms can build over hours, days or even weeks before a heart attack, and are frequently dismissed as stress, perimenopause or a viral illness — by the patient herself as well as by clinicians. Any new, severe or unfamiliar symptom, particularly in a woman over 40 with risk factors, deserves urgent assessment. The working assumption should always be "let's rule out the heart", not "it's probably nothing".

There are three intertwined reasons. First, the classic teaching about heart disease was developed largely in men, so the textbook picture of a heart attack — crushing central chest pain in a middle-aged man — is masculine. Second, women themselves often delay seeking help, attributing symptoms to stress or hormones. Third, even when women do seek help, diagnostic and treatment gaps persist — women are less likely to receive timely angiography, less likely to be offered cardiac rehabilitation, and less likely to be prescribed guideline-directed medications at appropriate doses.

The British Heart Foundation's "Bias and Biology" campaign has highlighted the consequences: thousands of UK women die needlessly from heart attacks that would have been survivable with earlier treatment. The fix is awareness — in patients, in primary care and in cardiology.

Yes. Before menopause, oestrogen has a protective effect on the cardiovascular system — improving the cholesterol profile, maintaining vessel flexibility and modulating inflammation. After menopause, that protection is lost, and women's risk of heart attack and stroke rises significantly, eventually reaching and overtaking that of men.

Early menopause (before age 45) increases risk further and is now recognised in guidelines as a cardiovascular risk factor in its own right. The years around menopause — perimenopause — are a strategic window for cardiovascular risk assessment, lifestyle change and, where appropriate, starting preventive treatment. This is the right time to know your numbers.

For most women under 60 starting transdermal HRT within 10 years of menopause for menopausal symptoms, the cardiovascular safety profile is reassuring and may even confer modest protective benefits. The earlier concerns from the Women's Health Initiative studies have been largely revised — those participants were on average older and started HRT many years after menopause.

The decision should always be individualised. Risk factors for venous thromboembolism, breast cancer history and time since menopause all influence the balance. HRT is not started purely for cardiovascular protection — but it is no longer treated as a cardiovascular barrier in suitable candidates. A conversation between you, your GP or menopause specialist and a cardiologist is often the most useful approach.

Microvascular angina (sometimes called cardiac syndrome X) is chest pain caused by dysfunction in the heart's smallest blood vessels rather than in the large coronary arteries. It is significantly more common in women than men and is one of the main reasons that women with chest pain are too often told "your arteries are clear, you're fine" — when they are not.

Microvascular dysfunction can cause genuine, exertional angina with completely normal-looking large arteries on a CT or invasive angiogram. Diagnosis requires specific tests — coronary reactivity testing or stress cardiac MRI. Treatment with beta-blockers, calcium channel blockers, statins and ACE inhibitors, alongside aggressive risk-factor management, usually controls symptoms effectively.

Heart disease kills more UK women than all cancers combined, yet breast cancer awareness is significantly higher than heart awareness — a gap that translates directly into delayed presentations and worse outcomes. The Office for National Statistics consistently records ischaemic heart disease and stroke as leading causes of death in women, particularly after menopause.

The causes are partly biological (oestrogen withdrawal, sex differences in arterial disease) and partly social (later presentation, fewer investigations, under-treatment). The picture is improving — but the most effective intervention is for women to know their own cardiovascular risk and take it as seriously as they take breast cancer screening.

Yes — and arguably more useful in women than in men, because QRISK3 and similar risk calculators underestimate cardiovascular risk in women more often than they overestimate it. A coronary calcium score gives an objective, individual measurement that can refine the decision about starting a statin or other preventive therapy.

For peri- and postmenopausal women in the decision-uncertain zone — particularly those with an intermediate QRISK score, a family history, or an elevated Lp(a) — a calcium score frequently changes management. A score of zero is genuinely reassuring; a score above 100 is a clear call to act decisively on risk factors.

Yes — pregnancy is increasingly recognised as a "cardiovascular stress test", and several complications double or triple later cardiovascular risk. Pre-eclampsia, gestational hypertension, gestational diabetes, preterm birth and a small-for-gestational-age baby are all flagged in current UK and European guidelines as risk factors deserving long-term cardiovascular follow-up.

If you have had any of these, a baseline cardiovascular risk assessment in your 30s or 40s — blood pressure, full lipid profile, glucose, BMI, often a coronary calcium score — is well worth doing proactively. The aim is to identify and modify risk factors decades before they would otherwise declare themselves as a heart attack or stroke.