Five under-reported causes of heart disease in women, according to doctors

A new study from the University of Pennsylvania, published last week, has found that women with Polyendocrine Metabolic Ovarian Syndrome (PMOS) are four times more likely to develop cardiovascular disease. PMOS (recently renamed from Polycystic Ovary Syndrome or PCOS) affects an estimated one in eight women around the UK. Per the research, the elevated risk of heart disease persisted even after accounting for other cardiovascular risk factors such as high blood pressure and diabetes. Cardiovascular disease is the leading cause of death among women globally. But despite that, leading experts say that women in the UK are dying “unnecessarily” from heart disease. This is, in part, because heart disease is still seen as a “man’s disease”, with women largely underrepresented in clinical trials. As a result, the treatments that emerged are primarily tested for and catering to men’s bodies. This confirmed connection between PMOS and cardiovascular risk is part of the push-back against the underdiagnosis and undertreatment of women for cardiovascular disease. Here, cardiologists Dr Francesco Lo Monaco and Dr Ali Khavandi explain why five conditions and experiences (pregnancy, menopause, autoimmune diseases, PMOS and type 2 diabetes) can elevate a woman’s risk of heart disease and how to counter it. Shorts Hormones and heart health PMOS is a lifelong condition characterised by irregular periods, high testosterone levels, and ovaries with multiple small follicles. It is linked with several health risks, including a raised cardiovascular risk, because of the metabolic effects of these shifting hormones, explains Dr Francesco Lo Monaco , a preventative cardiologist in London. “PMOS is closely linked to insulin resistance, high blood pressure and unhealthy cholesterol patterns, all of which place extra strain on the heart.” This is because levels of androgens like testosterone can promote abdominal fat storage, increase appetite and reduce insulin resistance. Dr Ali Khavandi, consultant interventional cardiologist in Bath, explains that metabolic problems like these can then become a self-perpetutating machine for cardiovascular risk. “When you start developing fat around your organs, that in itself becomes an endocrine organ that disrupts your hormones and causes all sorts of problems: insulin resistance or poor sugar control, high blood pressure, high fats in the blood and so on. These are all linked cardiovascular risk factors that create inflammation and proatherosclerosis – an increased risk of furring in the arteries, which is what cardiovascular disease is.” Our arteries and certain organs are particularly vulnerable to this process: the heart, the brain, the kidneys can all show disease processes. This is just one of the ways that women’s endocrine systems can increase their risk of cardiovascular disease. Another is the mid-life transformation of menopause. “Postmenopausal women’s risk of heart disease almost doubles, especially from the mid-fifties onwards,” explains Lo Monaco. “This is due to the drop in oestrogen, a heart-protective hormone. It also helps keep arteries flexible and supports a healthy balance of HDL and LDL cholesterol. As oestrogen falls during perimenopause and menopause its protective effects on blood vessels, inflammation and cholesterol gradually fade.” Then there are other genetic differences that are not just connected to hormones. Pregnancy can play a significant role in determining a woman’s cardiovascular risk later in life. “The first pregnancy is often considered one of the first major ‘stress tests’ on the heart,” Lo Monaco says. “During pregnancy, the heart is put under more pressure to pump blood around the body, with blood volume potentially increasing by up to 50 percent to support the baby.” This is exacerbated for women who experience pre-eclampsia, gestational diabetes or high blood pressure during pregnancy. “In cases of pre-eclampsia or gestational diabetes, this added strain is compounded by inflammation and damage to the lining of the blood vessels. That doesn’t necessarily resolve after birth, it can leave lasting changes that raise the risk of hypertension and heart disease years, or even decades, later.” Women are also at greater risk of autoimmune diseases thanks to genetics, which can also increase cardiovascular risk. “Autoimmune diseases such as lupus and rheumatoid arthritis are far more common in women,” explains Lo Monaco, “and research shows they’re significantly more likely to die of cardiovascular disease than men with the same diagnosis.” This is thanks to the chronic inflammation caused by the autoimmune condition which over time damages blood vessels and speeds up plaque build-up in the arteries. How to reduce your risk While the genetic and hormonal aspects of increased cardiovascular risk are out of our hands in many ways, there are happily small lifestyle changes that can significantly reduce your risk, Lo Monaco adds. “Regular strength training, ideally at least two sessions per week, can improve blood pressure, cholesterol, blood sugar control and overall cardiovascular health. Combined with aerobic exercise, it forms an important part of reducing long-term heart disease risk.” He also points to the significance of stress management and good quality sleep, particularly for women. “Women often carry a lot of invisible stress around work, family and relationships, and if it isn’t handled effectively, it can put serious strain on the heart. Sleep is also key, as getting fewer than seven hours of quality sleep a night raises blood pressure, insulin resistance and heart risk, even more so for postmenopausal women.” Making dietary, fitness and other lifestyle choices can make the management of risk far easier. But equally important is being able to identify signs of problems as soon as they arise. “It’s important to note that women may present with different or less typical symptoms of heart disease than men, such as breathlessness, nausea, fatigue or pain in the back, jaw or upper abdomen. Greater awareness of these differences is essential to avoid delayed diagnosis.” He adds that you shouldn’t overlook medical monitoring and intervention, especially if you are diagnosed with an autoimmune condition of PMOS. “Regular monitoring is just as important as lifestyle changes. Blood pressure, cholesterol and blood sugar should be checked more closely than for the general population, so changes are caught early.”