Women tend to think that breast cancer is their biggest health threat. While it is important, heart disease remains the No. 1 killer of women, even young women.

The risk of heart disease in women increases with age. Heart disease is the leading cause of death in women over 40 years old, especially after menopause. Every year, more than 500,000 U.S. women die of heart disease. This translates to approximately one death every minute.

A great deal of women get heart attacks and many of them die as a result. Despite this, many women just don’t seem to realize how great a threat heart disease really is. Even in the emergency room, doctors often attribute a woman’s symptoms to something other than heart disease. There is simply not enough awareness on either side of the stethoscope.

Why does a woman’s risk of heart disease rise with age?

Menopause is a normal stage in a woman’s life; it comprises any of the changes a woman experiences either before or after she stops menstruating. As menopause nears, the ovaries gradually produce less estrogen (a female hormone), causing changes in the menstrual cycle and other physical changes.

The most common symptoms of menopause are hot flashes, night sweats, emotional swings, and changes in the vagina, such as dryness.

Menopause usually occurs naturally in women between the ages of 45 and 55. However, loss of estrogen can occur earlier, particularly if the ovaries are removed during surgery, such as during a total hysterectomy.

The loss of natural estrogen as women age may contribute to the higher risks of heart disease seen after menopause. Other factors that may play a role in postmenopausal risks of heart disease include:

•Changes in the walls of the blood vessels, making it more likely for plaque and blood clots to form.

•Changes in the level of fats in the blood.

•Increases in levels of fibrinogen, a substance in the blood that helps the blood to clot. Increased levels of blood fibrinogen are related to heart disease and stroke since it makes it more likely for blood clots to form, narrowing the arteries and reducing blood flow to the heart.

How can menopausal women reduce the risks of heart disease?

First and foremost, “traditional” risk factors for heart disease should be addressed after menopause. Women with the lowest risk of heart disease are those who:

•Avoid or quit smoking.

•Lose weight and/or maintain their ideal body weight.

•Exercise for 30-40 minutes three to five times per week.

•Follow a diet low in saturated fat and trans-fat, and high in fiber, whole grains, legumes such as beans and peas, fruits, vegetables, fish, and folate-rich foods.

•Treat and control medical conditions such as diabetes, high cholesterol, and high blood pressure, which are known risk factors for heart disease.

Can hormone replacement therapy reduce the risk of heart disease?

For many years, research was thought to show that hormone replacement therapy could reduce the risk of heart disease in women by replacing the estrogen lost during menopause. More recent studies of women with heart disease have not shown benefits after four years of HRT. In fact, data show that some forms of HRT may be harmful in these women. Experts no longer recommend HRT to protect postmenopausal women against heart disease.

Women’s heart health true or false quiz

1. As long as my cholesterol and blood pressure are normal, I don’t have to worry about having a heart attack.

Answer: False. While both cholesterol and blood pressure are contributing factors to heart disease, there’s clearly not enough emphasis on the other factors that can also play a role. There are other important risk factors such as family history, diabetes mellitus and obesity.

2. Estrogen and other hormones protect women from heart disease, so young women don’t have to worry.

Answer: False. One of the biggest misconceptions out there right now is that young women don’t get heart disease or heart attacks, or that they don’t have to worry about the risk factors linked to heart disease. But nothing could be farther from the truth.

According to the AHA (American Heart Association), women under age 55 account for up to 16,000 heart-related deaths and 40,000 cardiac-related hospitalizations in the United States each year.

3. A stomachache, nausea, vomiting, or unexplained sweating and fatigue can all be signs of a heart attack in women.

Answer: True. While the “classic” signs of a heart attack ― like squeezing and crushing chest pain and pain down the left arm ― can still occur in women having a heart attack, women are more likely to present with “atypical” symptoms ― including gastrointestinal upset, pain in the jaw, shoulder, or upper back, or sometimes just extreme fatigue. In terms of symptoms of heart disease, you should look for signs such as unusual shortness of breath or sudden changes in your level of activity. If you’re a regular exerciser and run 5 kilometers a day and suddenly you can only run 1 kilometer a day, that’s something to pay attention to. If you find yourself getting nausea and having an upset stomach and vomiting every time you exert yourself, that’s something you need to talk to your doctor about.

4. Rapid heartbeat can sometimes be a sign of heart disease ― but not always.

Answer: True. While any heartbeat-related problems could be an indication of heart disease, this is not a hard-and-fast rule. Sometimes they can also be clues to other ailments or problems not related to heart health. The problem could be linked to an overactive thyroid, to hormonal changes in menopause, to signs that you are experiencing increased stress, or that you’re overcaffeinated. It may not be heart disease, but looking into the health of your heart may help you find and solve other problems that are causing your heart symptoms.

5. A hot flash is always a sign of menopause and never the sign of a heart problem.

Answer: False. While hot flashes are most often associated with ― and caused by ― the hormone changes of perimenopause and menopause, they can also be a symptom of certain cardiac conditions. It depends on how and when they occur. If you get hot flashes when you’re just sitting around watching television or talking on the phone, then it’s probably hormonal. If you only get them when you exert yourself, then it could be a symptom of angina. When should you see a doctor? Anytime a symptom is really bothering you. But more important is how your symptom fits within the picture of your overall health screenings and risk factors for heart disease, including high blood pressure, high cholesterol, and a family history of heart disease.

6. Smoking increases your risk of a heart attack.

Answer: True. According to the AHA, on average, women who smoke have heart attacks 19 years earlier than nonsmokers. Smoking is a major cause of heart disease and stopping, at any age, will help reduce those risks. 

By Park Sung-Ji, M.D., Ph.D.

The author is a doctor at the Cadeology Department of Samsung Medical Center. ― Ed.