The Female Heart: Unveiling the Unique Risks Women Face from Puberty to Menopause

Welcome back to Infinite Health! On today’s episode, host and cardiologist Dr. Arasi Maran dives into a topic that is both surprising and urgent: heart disease is the number one killer of women outpacing cancer, including breast cancer. Yet for most women, the risks and warning signs remain shrouded in mystery, and the medical system too often relies on research based predominantly on men.

Dr. Maran to unravels how a woman’s risk of heart disease changes dramatically across her lifespan from her very first period, through pregnancy, to perimenopause and beyond. Together, they explore why hormonal transitions are not just reproductive milestones, but critical windows that can reveal early signals of cardiovascular risk.

Whether you’re in your teens, planning a family, navigating menopause, or simply want to advocate better for the women in your life, this conversation will empower you with cutting-edge science, practical insights, and actionable steps for every stage. Heart health isn’t just a man’s issue, it’s every woman’s story. Let’s uncover what every woman needs to know, and why it’s time we all start listening to the signals our bodies are giving us.

00:00 Early childhood events and heart risks

08:47 PCOS and cardiovascular risk factors

13:38 Heart changes during pregnancy

17:35 Recognizing peripartum cardiomyopathy signs

22:01 Pregnancy-related heart attack risks

28:13 Gestational diabetes and heart risks

32:50 Effect of declining estrogen levels

38:07 Atrial fibrillation concerns for women

44:48 Understanding heart health in women

52:45 Discussing pregnancy health concerns

57:19 Advocating for women's health issues

01:00:45 Discussing women's cardiovascular health

Transcript

SPEAKER_01 0:00

Almost everything we know about heart disease comes from research done predominantly on men. So when a woman walks into an emergency room with a heart attack, she is two more likely than a man to be sent home with a diagnosis of anxiety. But here's what the last 20 years of research is finally teaching us. A woman's heart disease story does not begin at menopause. It begins much earlier. It begins at her very first period, and every hormone transition she moves through, puberty, contraception, pregnancy, any menopause, is a window into her future cardiovascular risk. It's truly one of the most underdiscussed issues in a woman's life.

SPEAKER_00 1:17

But heart disease is the number one killer in women. Not cancer, not breast cancer, but heart disease. And yet most women I talk to, most women I know even, have never really sat with that fact. And here's the part that genuinely really stopped me in my tracks. A woman's heart disease risk is not constant throughout her life. It actually changes dramatically with heart hormones. So with her menstrual cycle, with pregnancy, with every hot flush of perimenopause, her biology is really giving her signals across her entire lifespan. And as a woman, I think this is shocking and super concerning. So by 2050, the American Heart Association projects that more than 60% of women in this country will have cardiovascular disease. 60%. That's drastic. And that's not even a statistic about old age or anything like that. It actually includes women in their 20s and 30s as well. So today, Dr. Moran is going to walk us through a woman's life from her first period to postmenopause and at each stage tell us what is happening with her heart, what the risks are and what she needs to know. So I cannot wait to dive into this. So let's get into it. Are you excited about this episode, Dr. Moran? Absolutely, Leila.

SPEAKER_01 2:27

This is one of my favorite topics because no one else talks about it. And I want to start with one sentence that frames everything we are going to discuss today. Women's hearts are not smaller versions of men's hearts. They are biologically distinct. And for most of medical history, we ignored that. And almost everything we know about heart disease comes from research done predominantly on men. The symptoms we taught doctors to look for, drug doses we calibrated, the risk scores we built, they were all based on male physiology. Women were excluded or not included in these trials for decades. So when a woman walks into an emergency room with a heart attack, she is still more likely than a man to be sent home with a diagnosis of anxiety. But here's what the last 20 years of research is finally teaching us. A woman's heart disease story does not begin at menopause. It begins much earlier. It begins at her very first period. And every hormonal transition she moves through, puberty, contraception, pregnancy, perimenopause, is a window into her future cardiovascular risk. If we start reading those windows correctly, we can intervene earlier, prevent more, save far more lives. That's what today's conversation is about.

SPEAKER_00 3:58

Absolutely. So I'm definitely really interested in this, especially as a woman for all the women listeners, I'm sure this is kind of shocking information. So let's start in the beginning, right? Let's start where a woman's hormonal life really begins: puberty, right? So most people would never really connect a girl's first period to her future heart health. And I know, I mean, I wouldn't, but should they? Is that something that you think is the right time to start thinking about that? Absolutely.

SPEAKER_01 4:24

And it's truly one of the most under-discussed issues or time in a woman's life, okay? Age at which the girl has her first period. It is now recognized as a cardiovascular marker. Early monarchy is defined if a child gets their first period before the age level. That is associated with twice the likelihood of developing obesity-related high blood pressure in midlife. That is a doubling of risk from an event that happened so early in childhood, we never even talk about it. Now, we don't even remember it, you know, seriously. And as it goes further, if a child has irregular menstrual cycles in adolescence and young adulthood, they are associated with higher risk of coronary artery disease later in life. We fully do not understand the mechanism. It likely involves hormonal dysregulation affecting vascular inflammation and metabolic pathways. But the association is real and it is consistent across multiple studies. The American Heart Association now explicitly states that the menstrual history should be included in routine pediatric evaluation. A girl's period is not just a reproductive event, it is a biomarker of her cardiovascular future. Okay? So let me end with a stat. Girls experiencing early monarchy, that is, a getting their first period before the age 11 or younger, have twice the likelihood of developing obesity-related hypertension in their midlife.

SPEAKER_00 6:06

And I feel like when we talk about puberty, we never really talk about puberty in terms of heart health. It's always reproductive development, emotional changes, normal things that we go through growing up as women. But it actually sounds like there's such a cardiovascular story that starts there. So, what should parents and doctors actually be doing differently?

SPEAKER_01 6:25

Okay, fair question. It's very simple, very specific. The conversation needs to happen. Let's start there. So when a girl has a first period, whether it's early, late, irregular, painful, very heavy, not so heavy, that information should be recorded in her medical history and it should be revisited at every well-being check. So you have your 11-year-old checkup, 12-year-old checkup, 13, 14, 15, 16, 17. In every time the patient needs or the mother needs to talk about it, or the child needs to talk about it, the doctor or the provider needs to specifically ask questions about it. Not because anything is wrong, but we are building on a cardiovascular biography that will matter enormously in 20 years. Heavy, painful periods can be a sign of conditions like endometriosis, which itself is now linked to higher cardiovascular risk. Irregular cycles can be related to or can signal polycystic ovarian syndrome, TCOS, which carries metabolic risk factors, including insulin resistance and dyslipidemia. These are cardiovascular conversations and not gynecological ones. So my takeaway here, a girl's menstrual history from first period onwards is a cardiovascular document, and every healthcare provider, pediatrician, nurse practitioner, physician assistant should be recording it, revisiting it, and connecting it to long-term health.

SPEAKER_00 7:59

Absolutely. And beyond that, moving into a woman's 20s and 30s, the most reproductive years, women might go in, go on the pill, for example, contraceptive pills, like you said, might be dealing with PCOS or endomesiosis. So in that phase, what's happening to a woman's heart during that chapter of her life? And I also think that even touching on that, I think that so many women in this age group feel that heart disease is just really not their problem yet. It's not something to really worry about. And it feels like that's something that happens to older people, but I don't think that that's correct. It doesn't sound right based on what I'm hearing.

SPEAKER_01 8:35

You are absolutely correct. That statement is not correct. Heart disease happens to middle-aged women. The data is starting back and it's backing it up in ways we did not expect. So the American Heart Association's in 2025 projection found that nearly one-third of women between the ages of 22 to 44 are expected to have some form of heart disease by 2025. By now, diabetes in this age group is projected to double. Part of this is lifestyle, diet, activity level, stress, but part of it is also conditions that uniquely are only female and that carry the cardiovascular loading. PCOS, very common in the reproductive age group, affecting 8 to 13% of women globally. And it's a cardiovascular risk factor in its own right. Women with PCOS have insulin resistance, elevated androgen levels, abnormal lipid profiles, higher rates of high blood pressure, and these are all atherosclerosis activators, accelerators. Endometriosis, which roughly affects 10% of women in the reproductive age group, and we are learning it's a systemic inflammation marker. So that itself is a cardiovascular risk. We talked about LDL levels and whole body inflammation. Endometriosis causes whole body inflammation. Research published in the European Heart Journal links endometriosis to a higher risk of blockages in the blood vessels of your heart, particularly in the younger women. So, you know, we are in 2026. By 2025, we know one in three women aged 22 to 44 is projected to have some form of cardiovasculase. Diabetes is projected to double. This is from American Heart Association. It's not some random TikTok statistic or something like that. Right, absolutely.

SPEAKER_00 10:41

And what about the contraceptive pill? Every woman I know has either tried it or been on it or is on it at some point in their life. So is that something that women should worry about?

SPEAKER_01 10:51

It's a very complex issue. So I'm going to give you a nuanced answer. It depends. It depends on the individual. The combined oral contraceptive pill, those that contrain both estrogen and progesterone, do carry a small but real risk of blood clots, including deep vein thrombosis, which ultimately leads to clots in the lung. In absolute terms, for a healthy young woman who does not smoke, who does not have migraines with aura, who does not have clotting disorder, the risk is very small. But the risk compounds dramatically with smoking. The combination of a combined OCP, the oral contraceptive pill, plus smoking in women over 35 years increases stroke risk by a clinically significant margin. This is not a theoretical concern. It's a well-documented interaction that every woman on the pill should understand. Now, let's talk about the progesterone-only pill or the mini-pill. It has a different, generally more favorable cardiovascular profile. For women with cardiovascular risk factors, migraine with aura, or family history of clotting disorder, the prot-only route is typically preferred. This is an important conversation that should be happening with your provider at every appointment. And unfortunately, it is not. The combined oral contraceptives pill with smoking in women over 35 years significantly increases your stroke risk. Every woman who's on the combined pill who also smokes, or let me flip it around, for every woman who is smoking but wants to be on a contraceptive pill needs to have a very honest, candid conversation with their provider about their smoking history and other family history to decide whether they should be on the combination contraceptive pill or the progesterone only contraceptive pill or other local intrauterine devices or something like that.

SPEAKER_00 12:56

Absolutely. And speaking about the pill, let's talk about pregnancy a little bit. So I know you describe it as the most comprehensive cardiac stress test that a woman will ever undergo. And that phrase like stopped me in my tracks because it's a huge thing to really take in. And beyond that, I know that those words kind of stayed and lingered with me, but what happens to a woman's heart during pregnancy? Okay.

SPEAKER_01 13:22

So pregnancy is an extraordinary physiological, emotional, social point. Okay. But from a from the cardiovascular standpoint, it even takes the next step. Okay. It truly is amazing how much a woman's body goes through and everything about it and every sense about it. It's beautiful, it's fascinating, but we need to break it down. The first trimester, the first three months, the woman's blood volume increases by 40 to 50 percent. The heart rate rises by 10 to 20 beats per minute. The cardiac output, the volume of blood, the heart pumps per minute, increases by up to 50% mid-pregnancy. The heart literally grows larger, like figuratively and emotionally as well. The left ventricular mass, the left ventricle is the most important chamber of the heart. It increases by 50% in the third trimester. This is a profound physiological demand on a muscle that in most women has never been tested this hard. So for a woman with a healthy heart and no underlying cardiac condition, the body manages it beautifully and reverses most of the changes within six to eight months after delivery of the baby. But in a woman with undiagnosed condition or genetic predisposition or pre-existing risk factors or who are smoking, pregnancy is where those vulnerabilities are unmasked. So this is why I call it the ultimate cardiac stress test. The heart cannot hide during pregnancy. So again, remember blood volume increases by 40 to 50%, cardiac output increases by 50%, heart rate rises by 10 to 20 beats per minute. The left ventricular mass goes by 50% by the third trimester. These are normal. This is a normal expectation. This is what happens. But if you are predisposed, they expose the pre-existing vulnerabilities.

SPEAKER_00 15:32

Wow, and there's so many different factors that go into pregnancy. It's wild to think about. But what are the conditions that can really emerge or be even unmasked during pregnancy?

SPEAKER_01 15:42

Okay. The two most important ones in this conversation are pre-eclampsia and peripartum cardiomyopathy. Let me take them one at a time because they are different conditions with different implications. Okay? So let's start with pre-eclampsia. Pre-eclampsia is a pregnancy complication involving high blood pressure, 140 over 90 millimeters of mercury or above, or signs of organ damage, such as protein in the urine, points to pre-eclampsia. Okay? That's why every pregnant, every time a pregnant woman goes to an OBGYN's office, they are asked to pee in a cup because they want to check the amount of protein in the urine. This affects about 5 to 8% of pregnancies globally. It sounds like a pregnancy alone problem, it is, but it does not extend to delivery. It's not like that. Women who have pre-eclimpsia have two to four times higher risk of high blood pressure, heart disease, and strokes later in life. The pregnancy was a warning. The cardiovascular events may come decades later, but unfortunately, this connection is never made. We doctors don't ask about was your pregnancy complicated? Did you have pre-eclimpsia? We never even talk about it. And that requires re-education. Moving on to peripartum cardiomyopathy, it's rarer, but more immediately dangerous. It's a form of heart failure that develops in the last month of pregnancy, but extends to five months after delivery also. The heart muscle, the left ventricle we were talking about earlier, just weakens. The left ventricle dilates, it becomes just thins out and becomes dilated. The ejection fraction or the squeeze capacity of the heart drops below 45%. The normal ejection fraction is 53% and above percentage, but when it comes to below 45%, the body begins to show signs of it. The symptoms can be breathlessness, swollen ankles, exhaustion. Unfortunately, these are all normal symptoms of pregnancy. A pregnant woman is breathless. She does have swollen ankles, she is exhausted all of the time. So it gets very confusing. And because of this, diagnosis gets delayed, treatment gets denied, and that dismissal costs life. So if a pregnant woman has breathlessness, which does not improve in the first two few weeks of postpartum, or there's persistent swelling of the ankles and legs, and you are waking up several times in the night because you can't breathe, and you have fatigue, which is unbearable, it can be a sign of peripartum cardiomyopathy, and you have to seek urgent assessment.

SPEAKER_00 18:40

That's so good to know because I think once you have a baby and you're going through all these changes, it's probably hard to really figure out what's normal and what's not normal. So, how common is peripartum cardiomyopathy? And who would you say is at risk?

SPEAKER_01 18:56

It occurs roughly in one in thousand to one in four thousand pregnancies, though rates vary significantly by geography and population. For in the US, African American women are disproportionately affected, and the reasons are not fully understood. It could be a combination of genetics, baseline cardiovascular risk, or the disparities in the systemic health care. The risk factors for pre-eclampsia, which is present one-third to half of all postpartum cardiomyopathy cases, that's even more obvious. If you have a twin pregnancy, if you have a maternal age over the over 30, which is very, very common right now as women are focusing more on their careers, or you have multiple previous pregnancies, then you are most likely to, more likely to have pre-eclampsia, which ultimately leads to postpartum cardiomyopathy. And there's also a very important genetic dimension. Around 15 to 20% of peripardum cardiomyopathy is now linked to mutation in the titan gene, the same gene associated with cardiomyopathy in the general population. So if a woman has postpartum or peripartum cardiomyopathy, her first degree female relatives may be at elevated risk in their own pregnancies. So this is a critical fact both women and clinicians need to know. And recovery of cardiac function, you know, occurs in about 50% of women within six months with adequate medical treatment. But for women who don't recover function, subsequent pregnancy carries a much higher risk of heart failure and death as high as 20%. So future pregnancies should not only be discussed with your obstetrician, it should also be discussed with a cardiologist and a maternal fetal medicine specialist. So that's the important takeaway here.

SPEAKER_00 21:05

And another thing to talk about is SCAD, spontaneous coronary artery dissection. It sounds alarming. So what is it and why are pregnant women especially vulnerable? It sounds pretty alarming. Okay.

SPEAKER_01 21:18

Let's break it down. Spontaneous coronary artery dissection literally means what it describes: a spontaneous tear within the wall of the blood vessel going to a heart. Okay? Each blood vessel has three layers. So you have a tear between the innermost layer and the middle layer, which creates a false channel. And the false channel compresses the lumen of the heart and obstructs blood flow. This results in a heart attack. Unlike the traditional heart attack where you have a plaque buildup which obstructs blood flow, here blood within the layers of the blood vessel that Is blood in a place where it should not be pushes the blood vessel wall against the opposite end of the wall and causes a blockage and leads to heart attack. And this is the most common cause of heart attack in a pregnant woman. It's terrifying precisely because it has nothing to do with atherosclerosis, which is blood buildup. A woman can have pristine blood vessel, perfect cholesterol, no risk factors, but can still have spontaneous coronary artery dissection. It occurs sometime in the peripartum period, the weeks around delivery, when the hormonal and hemodynamic stresses on the arterial wall are at its peak. It is also predisposed in women who have this condition called fibromuscular dysplasia. This is a non-inflammatory condition of the arterial wall that disproportionately affects women, particularly of childbearing age. Or women with fibromuscular dysplasia has structurally weaker arterial walls, which makes them more vulnerable to dissection under the cardiovascular demands of labor and delivery. Once again, SCAD or SEAD is the most common cause of heart attacks in pregnant and postpartum women. It can occur in women with no traditional risk factors or no prior heart history. And the peripartum period is the highest risk. We have to keep this in mind. And every clinician and healthcare provider needs to keep this in mind so that they don't dismiss this complaint of chest pain in pregnant women or women after delivery in the peripartum period.

SPEAKER_00 23:45

So how does it present? So would a woman even know if she is having a heart attack? How would that work? How does that work?

SPEAKER_01 23:51

The nuances again, this is why it gets missed. The symptoms of SCAD can be identical to a heart attack. Chest pain, chest discomfort, left arm pain, breathlessness, jaw pain. In a pregnant woman, you know, you can have such bad reflux disease that present itself as discomfort. They are already breathless and they, you know, they can attribute everything to reflux disease also. That's why it gets missed. You can, and it's attributed to other causes, musculoskeletal anxiety, the stress of being a new mother, the physical strain of labor, etc. But SCAD is not caused by blocked arteries. The standard imaging used in the typical assessment of heart attacks can miss it. So you need to have a high index of suspicion and direct the patient to the right imaging technique. Management is also completely different, okay? So in a patient who's having a heart attack because of a plaf buildup, you want to give blood thinners. But in SCAT, you don't want to give blood thinners because it can propagate the tear. And sometimes doing nothing is the best thing. You can take them to the Cadillac to take pictures of the heart, which itself is stressful in a pregnant woman because you're exposing the baby to radiation, but you don't want to be putting wires, you don't want to be putting stents, because all those interventions can worsen the tear and worsen the outcome. So just treating them with medications like penal blockers can do more. The worst-case scenario patients can may need mechanical support to offload the heart of the stress it is going through and support it externally till the safe time it is for the baby to be delivered, and then you can treat the mother in different ways.

SPEAKER_00 25:46

Wow. So pregnancy is essentially a stress test that reveals cardiovascular vulnerability, pretty much. But and the idea of pregnancy, the idea that pregnancy outcomes could be a window into future health really fascinates me. I think pregnancy still is super fascinating to me overall and terrifying if I'm being honest. But is this an established medical concept now? And what would you say happens during pregnancy that really tells us anything meaningful about a woman's heart health in decades or years to follow?

SPEAKER_01 26:18

So the most important point of this podcast is to give you information, but not to scare you and uh fear monger you into something crazy. Okay. This is information, okay? You just need to put it in the back pocket of your brain and just be aware. Oh, when you, if there's a pregnant woman listening to this, she wants to, I think it's for that person to say, oh, this is within the normal limits, it's not that bad, versus, oh, this sounds a little scary for me. So please do not use this as a tool to become over cautious or ask for unnecessary tests or get too fearful. Use it with the umbrella of common sense. Now, coming back to your question, the American Heart Association recommends a cardiovascular risk assessment at any stage of a woman's life. It should look at a detailed obstetrict history, gestacial diabetes, pre-eclimpsia, preterm, babies which are born small for gestational age, they're all listed as risk-enhancing factors for future heart disease. We didn't talk about gestacial diabetes, but that is a profound signal. It indicates the women's metabolic system struggled under the demands of pregnancy, specifically that her insulin response was insufficient. Women who have had gestacial diabetes are have a 7 to 10 higher risk of developing type 2 diabetes, which significantly elevates the cardiovascular risk. So if she is discharged after delivery with nothing to do but with the advice of watch your diet, that's a missed opportunity for intervention. Pre-ecclampsia, we talked about it, but it truly rears importance that we should repeat it. It is recognized as an independent cardiovascular risk factor for life. Women who have had pre-eclampsia, two to four times risk of high blood pressure, heart attack, stroke in the later life. The biological mechanisms appear to involve persistent endothelial dysfunction, vascular inflammation, and adverse effects on the kidney function that does not fully resolve after delivery. So my takeaway here would be women's pregnancy history is a cardiovascular photo album. Pre-eclampsia, gestational diabetes, preterm delivery, small for gestational age babies, they're all signals that should trigger lifelong cardiovascular monitoring, not a discharge note, come back in six weeks. I hope I'm being very clear about this.

SPEAKER_00 28:59

Yeah, absolutely. And I think, like you said, it is such good information just to know and use your common sense of and be aware of that these are the things that could be happening. And what about women who have had completely healthy pregnancies? Does that tell them anything? Does that indicate anything at all?

SPEAKER_01 29:15

So a completely healthy pregnancy is genuinely reassuring. The absence of complication, no pre-eclapsia, no gestacial diabetes, good blood pressure control, good glycemic control, appropriate bait gain suggests that the cardiovascular and metabolic systems handled the stress pretty well. But it does not mean a woman can ignore her heart health from that point onwards. It means she now enters the next chapter, perimenopause, with a relatively clean cardiovascular state, but she needs to work hard, fight for it, to preserve it in that clean cardiovascular state. Interestingly, breastfeeding is associated with reduced cardiovascular risks for the mother. Women who have breastfed have lower rates of obesity later in life compared to those who did not. We are not sure of the exact mechanism. It may be metabolic, hormonal, or both, but the association is consistent and it is worth mentioning. But again, you know, it's not a one size fits all. Each woman should look at the risks and benefits of breastfeeding with her whole life before she makes a decision. Breast milk is the best milk, but if the woman is going to lose sleep over it and is going to put her life in danger and is going to get stressed out about it, she needs to look at the risks and benefits and make a holistic decision, which is good for both herself first, baby next, the family in general as third.

SPEAKER_00 30:51

And let's talk about perimenopause a little bit. I think it's one of the most neglected chapters in a woman's cardiovascular life. I think people don't talk about it enough or even really know what it is. And not menopause itself. People talk about menopause frequently. We've all heard about it. But let's talk about the transition leading up to it. And I know a lot of women think of it as hot flashes and mood swings and the beginning and the end of their periods. But what are they not thinking about with their hearts? And what are maybe people missing? What's actually happening to the heart during these years of perimenopause?

SPEAKER_01 31:24

Perimenopause does not get the dis attention it deserves. It's almost like the whole world is uncomfortable to talk about menstrual history, the age at which you got your periods or the age at which your periods might be going away. Let's come to perimenopause. Perimenopause is a menopausal transition. Okay, it begins five to ten years before the final menstrual period. For most women, that's somewhere in their mid to late 40s. During this phase, estrogen levels become erratic. They begin to decline. And estrogen, especially 17 beta, which is one of the most potent cardiovascular protective hormones in the female body, is kind of going haywire. This hormone keeps the LDL low, keeps the HDL high, blood vessels flexible, systemic inflammation much lower. It does all of this simultaneously. When the oestrogen level starts fluctuating, okay, every one of those protective mechanisms starts to erode. LDL rises, triglycerides rise, blood pressure rises, body fat distribution changes. It moves away from the hips and thighs towards the abdomen, which is where the visceral and metabolically active fat is. That drives insulin resistance, inflammation, and direct cardiovascular risk. This redistribution happens to women who have not changed their diet, who have not changed their activity level. They have done nothing wrong. It's completely hormonal, and it is happening to almost every woman that goes through this transition. The important statistic you need to remember is LDL levels increase average of 10 to 15% during menopausal transition. Triglycerides go up, blood pressure rises, visceral abdominal fat accumulates. These changes are not lifestyle failures. This is not your personal failing. And these begin years, or sometimes even a decade before your final menstrual period.

SPEAKER_00 33:33

Absolutely. And it's something that I've recently just learned about perimenopause. And I have some friends that are going through it, and it's something that no one I I like that now. I think it's getting more talked about. So it's so good to have these conversations because so many women don't even know about it at all. I think people think about menopause and then hot flushes. But let's talk about hot flushes for a second because I've always just thought of them as something that's uncomfortable that women go through. But are they actually a sign of cardiovascular signals? Are there any cardiovascular signals that go along with that?

SPEAKER_01 34:07

Okay. This is one of the most important things to come out of recent research, and most women and doctors do not know about it. Vasomotor symptoms, hot flashes, night sweats, they are not just symptoms of hormonal change. They are now independently associated with increased cardiovascular risk and higher rates of stroke. The current thinking is that the vascular dysregulation that causes heart flashes, that is the sudden dilation of the peripheral blood vessel, is driven by erratic central temperature regulation. This may affect impaired vascular function more broadly, and a woman with frequent severe heart flashes may have greater endothelial dysfunction than a woman with mild or no vasomotor symptoms. Her vessels are struggling with a vasomotor transition, and this is more pronounced. And then there is sleep, heart flashes and night sweats. Sleep disruption is independently associated with elevated blood pressure, increased inflammation, and higher cardiovascular risk. It's a cascade. Hormonal changes cause vasomotor symptoms, which causes sleep disruption, which causes cardiovascular risk. Each link in that change is real and documented.

SPEAKER_00 35:25

And what about palpitations during perimenopause? I know so many women talk about their heart racing or fluttering, and they're usually told it's just hormones. So is it more than just hormones, I'm assuming?

SPEAKER_01 35:37

Everything is hormonal, but just because it's hormonal does not mean it's real and it does not mean it requires attention. So, palpitation. This is a legitimate and an important clinical concern. Palpitations are one of the most common symptoms of the menopausal transition. And the default response is, as you said, it's hormonal, it will pass. It is correct, but can be dangerously inadequate. Estrogen has a stabilizing effect on the cardiac electrical conduction. Okay, as oestrogen levels fluctuate during perimenopause, some women develop new arrhythmias. The most clinically important is atrial fibrillation, which is common, the most common arrhythmia and carries an elevated stroke risk. Atrial fibrillation, the top chamber of the heart, starts bleeding independently faster rates compared to the lower chamber of the heart. And because of that, blood sloshes within the chamber, the atrium, instead of flowing. And when blood is stagnant, it forms clots, and those clots can go to any parts of your body, especially your brain, and can cause a stroke. And that's why women with atrial fibrillation have a higher stroke risk than women, and they are less likely to receive the appropriate treatment. So any new palpitations in perimenopause, which feels like a rapid fluttering and not just an extra beat, but more of a racing heart rate, which is lasting for several minutes, deserves an electrocardiogram, not just reassurance, and may even require a monitor, a four-day or a 15-day monitor. It's not hormones, an ECG is required. And as I said, you may need up to a seven-day or a 14-day monitor to capture it because it's intermittent and one resting EKG or ECG can miss it. So please, if you have new palpitations in perimetopause, get an ECG, ask for it. And if the symptoms persist, ask for a cardiac monitor. Atrial fibrillation in women is underdiagnosed, under-treated. Don't accept it's just hormones for a racing or irregular heart rate.

SPEAKER_00 37:56

And speaking about hormones, hormone therapy, I think, is one of the most politically loaded topics in women's health for the last 25 years or so. So is it good for the heart, bad for the heart? And did the women's health initiative get it right or wrong, do you think? I know that there was the women's health initiative study that came out in 2002, and the message women really took from it was hormone therapy causes heart attacks and breast cancer. Do not take it. And millions of women stopped overnight. But do you think that was the right conclusion from that?

SPEAKER_01 38:26

Oh God, Leila, sometimes you ask me questions which are quite complicated. It does not have a simple yes or no answer. It was a reasonable conclusion from an incomplete reading of a complicated study. And the consequences of women's health over the past 20 years has been significantly affected because of the study. So let me be precise about what the Women's Health Initiative actually found and what we understand it to mean right now. Women's Health Initiative enrolled women with an average age of 63 years, 10 years or more past menopause. These women who had already lost their estrogen production. These women who had already lost their estrogen protection, they have already experienced the lipid and vascular changes of menopausal transition, and many of whom already had their subclinical atherosclerosis starting in them. Giving those women hormone therapy, particularly the formulations which were used, which was oral conjugated equine estrogen and synthetic progesterogen, was not the same as giving it to healthy 50-year-old women in their early menopause. The cardiovascular findings, post-menopausal women, were genuinely concerning for that population. But the blanket message, hormone therapy is bad for your heart, was applied to all women at all ages in all formulations. And that was not what the data supported. Multiple subsequent studies support what is now called the critical window or timing hypothesis hormone therapy, and that is associated with cardiovascular benefit. Starting it more than 10 years after menopause and women who are in their early 60s or late 60s, the cardiovascular milieu of atherosclerosis, which is it's already started in them, the picture gets more complex. Formulation and the roots of administration also matters.

SPEAKER_00 40:32

So it sounds like the timing really matters enormously.

SPEAKER_01 40:36

Yeah, absolutely. The timing is everything. The formulation is next. The individual women's risk profile matters. So as I said when earlier, you know, this is not a yes or no question. And that's the problem. For the past 20 years, it has been treated as a yes or no question. So transdermal estradiol, a patch or a gel which is applied to the skin, does not carry the same venous thromboembolic or clot risk or stroke risk as the oral estrogen because it bypasses the liver completely. This is clinically significant for women with elevated clottic risk. The micronist progesterone has a more favorable cardiovascular profile than the synthetic progestrogens, which were used in the study. Timing matters, the formulation also matters. So let's talk about the elite trial, early versus late intervention trial with estradiol, which randomized women to estradiol or placebo within six years of menopause versus 10 years later. Women who started within six years showed slower progression of subclinical atherosclerosis compared to those who started 10 years or later where there was no benefit at all. So the window is completely real. Let me conclude what the current evidence supports and what the leading menopause society now recommends is that for women who are under 60, who are within 10 years of menopause, with moderate to severe symptoms and no other contraindication, hormone therapy is appropriate and the cardiovascular risk-benefit balance is favorable. For a woman with premature menopause before the age of 40, the evidence is way more stronger. Hormone therapy, at least until the natural age of menopause, is recommended specifically for cardiovascular protection. I mean, this is one of the clearest cardiovascular indications for hormone therapy that exists.

SPEAKER_00 42:42

And what about after menopause? What does a woman's cardiovascular risk profile actually look like? I know I've read that within 10 years of menopause, a woman's cardiovascular risk essentially catches up with a man's of the same age. But is that accurate? And why do so many women not realize how significantly it has changed over time?

SPEAKER_01 43:01

Cardiovascular disease is a disease of age. Okay. So that's why the heart health is at the center of all the longevity programs and things like that. Okay. Cardiovascular disease is the leading cause of death in postmenopause of women. And after menopause, the rate of new cardiovascular events increase very sharply. The protective effect of estrogen is gone, the lipid metabolism is changing, the blood pressure changes, the vascular structure changes itself. So the woman is in a completely different wrist trajectory compared to her premenopausal self. So critically, her heart disease does not always look like a man. Women are more likely to develop a different type of heart failure called heart failure with preserved ejection fraction, hef pef, we call it, in which the heart muscle becomes stiff, rather weak. Heart cannot relax properly between beats and fills inefficiently. This leads to breathlessness and fluid backup. The drugs we have for heart failure with preserved injection fraction are fewer and less effective. We have a big batch of drugs for heart failure with reduced ejection fraction, which is more predominant in men, compared to the drugs for heart failure with preserved ejection fraction, which is unfortunately more common in women. So women are bearing a disproportionate burden of a condition that the pharmaceutical industry is unfortunately underinvested in. So let me again bring it together. Women account for the majority of the heart failure with preserved ejection fraction type. Okay? The stiff heart disease is very distinct from the weak heart disease, which is very common in men. And most major drug developments have targeted the male pattern and not the female pattern.

SPEAKER_00 45:03

And what about the way a heart attack presents in women? Because I've heard that it's different than men.

SPEAKER_01 45:08

It is not just different, it's profoundly different. And the difference costs women, lives, quality of life, quantity of lives, everything. The textbook heart attack, the way heart attack occurs in men, crushing central chest pain, which radiates to the left shoulder, down the left arm, sweating, they get pale. That's how heart attack happens in men. And somehow men have termed it typical presentation. But the way it happens in women is very different. Okay? And because it happens in women, it's been termed atypical. And nothing can be more sexist than this. But nevertheless, the way women experience symptoms, extreme fatigue. I mean fatigue so profound they can't get out of a chair, severe nausea, indigestion, like discomfort, jaw pain, upper back pain, breathlessness, all of this without actual chest pain. Or chest pain, it's more discomfort than pain, because this chest pain in women feels like pressure or tightness rather than the classic crushing sensation that men seem to have. The consequence of this difference is well documented, and women with heart attacks are more likely to be sent home from emergency departments compared to men. They wait longer to get their first ECG, they wait longer for their first troponin to be measured, they wait longer for CT scans or cardiac cats, and they don't get the same amount of stents, they don't get the same amount of defibrillation devices and stuff like that. The difference is very dramatic and it is very, very sad. So for women, if you have extreme unexplained fatigue that comes on suddenly, nausea, vomiting without an obvious cause, discomfort in the jaw, neck, back, between your shoulder blades, breathlessness at rest or with minimal exertion, pressure or aching in the chest, you know, if these need urgent evaluation, don't brush it away, don't wait, and don't accept anxiety as your final answer. Anxiety should be a diagnosis after all other life-threatening conditions have been excluded and not the first one.

SPEAKER_00 47:34

And this is a question I want answered for every woman listening and myself included, but what should women actually do? What are the actions, the conversations, the tests at each stage of life? So let's say if I were a woman in my 20s or my 30s or my 40s, can you walk us through the life stages practically of what should we be talked about and done? Okay, fantastic.

SPEAKER_01 47:56

So let me go stage by stage. If you are in your teens and early 20s, keep be mindful about your menstrual history, the age at which your period started, did you do you have regular cycles, how heavy they are, and share this with your primary care provider. If you have been diagnosed with PCOS or endometriosis or were suspected, then specifically talk about the heart disease risk. Okay. Ask for lipids to be checked, check your blood pressure. So if you're in your 20s and 30s and if you are on the combination oral contraceptive, please do not smoke. Even if you're not on the OCP, do not smoke, do not wave, don't do this. The combination estrogen-containing pill and smoking elevates the stroke risk significantly. There are other conditions also. If you have migraines with aura, I have repeated this multiple times. Migraines with aura is kind of a vascular disease apart from just getting headaches. Okay. In if you have migraines with aura, you should not be on the combination pill. In this time, you should be mindful about your blood pressure. Blood pressure is not a single number, but it's a trend. So just be have an overarching, don't micromanage, but at least know, oh yeah, my blood pressure always has been in the 120s or always in the 130s. Just be aware of it, okay? And again, review your contraception history with your physician every time. Now, let's say you are, you want to become pregnant, then talk to your doctor about your family's cardiovascular history, your mother, your grandmother, have a conversation with your grandmother. Hey, grandma, did you have, or my mima, or whatever you call them, did you have high blood pressure during your pregnancy? What was your birth story? Did you have stroke? Were you on bed rest? How big was my mother? These are this could be just stories shared between women, but there is such more important medical meaning to them. And that can determine how your pregnancy history could be. When you are pregnant, again, blood pressure, blood sugars, and manage your heart, blood sugar levels, and your weights itself. But if you have breathlessness, which is out of proportion, this is why they say it takes a village, because when you're in a village, you share stories and you talk to other women who are pregnant, and they're like, my symptom seems ridiculously exaggerated compared to what your best friend had or something like that. Discuss it and just have a conversation with your obstetrician. Okay. Now, if you've had pre-exampsia, gestacial diabetes, or a premature birth, you need to talk to your primary care physician. Now, your primary care physician comes into your life and you need to talk about them. Now, let's move on to a complicated pregnancy. You need a cardiologist, and within six months after your delivery, you need to be evaluated by a cardiologist. Now, moving on to your 40s, perimenopause is approaching. Get your baseline cardiometabolic panel, your lipid profile, which includes your total cholesterol, LDL, HRL, triglycerides, your fasting blood glucose, hemoglobin A1C, blood pressure, the most important metric, your waist circumference. Because your waist circumference, about 30 inches, tells you you have visceral fat which predisposes you to heart disease. And now in this time, you have palpitations, get an ACG. Once again, I'm going to say don't get overwhelmed by all what I'm saying. Don't start micromanaging your life. Again, common sense, overarchingly, blood pressure. What's your lipid panel? You know, you need to know about it. Are you mindful about what you're eating? How much is your physical activity? And you don't need to keep track of it, but make sure your primary care physician or provider is tracking it for you.

SPEAKER_00 52:10

That's their job. And final question, because I want to end this with the bigger picture, because everything we've discussed today really suggests that the problem isn't just that women don't know enough. It's that the system isn't really set up to serve women properly. So, what do you think needs to change in medicine and research and how we talk to women and for women's cardiovascular outcomes to genuinely improve?

SPEAKER_01 52:33

Okay. The three things, if that would be changed, would save tens of thousands of lives per year. First, women need to be enrolled in more research studies. For decades, women were excluded or not just enrolled. No effort was made to enroll them specifically. The justification was that hormonal variability in a woman's life would complicate the data. The result was that we built an entire evidence base for cardiovascular medicine on male physiology and then applied it to women as if there's no physiological difference. We are still catching up from that. Expanding a woman's cardiovascular research by 2040 has been projected to generate 1.6 million additional years of healthy lives and 28 billion US dollars in economic value. That is the cost of doing things right. Second, reproductive history needs to be part of cardiovascular history, always in every clinical encounter. A cardiologist seeing a post-menopausal woman with hypertension should talk about pre-eclampsia. A primary care provider reviewing a woman's annual blood work should ask about her menstrual history and whether she had gestacial diabetes or pre-eclampsia or preterm delivery. These are not gynecological questions, these are cardiovascular questions, and they need to move from obstetric notes to heart disease risk assessment. Third and probably the most important is women need to advocate for themselves. We just don't do that very well, and we need to constantly get better with that. The system is not yet consistently doing it for us, and therefore we need to do it for us. Okay? So when a woman presents with symptoms which our provider does not recognize as typical symptoms, and it's labeled under atypical symptoms, and it's just told this is anxiety, we need to ask for an ECG. So this is extremely important that we advocate for ourselves. We are not just anxiety and drama and hormones. We are all that plus more. So when we self-advocacy is not a satisfying systemic solution, but until the system catches up, it's an essential survival skill and we need to embrace it and own it for ourselves.

SPEAKER_00 55:03

Absolutely. And like what you said, having these conversations and knowing these things that we need to ask and think about really will help us advocate for ourselves as women. And is there anything that genuinely gives you hope? A lot of things.

SPEAKER_01 55:18

The science is moving. The science is genuinely improving. Menopause medicine is being rehabilitated from the post-women health initiative overreaction. Wearable technology is beginning to give us continuous cardiovascular data tied to women's hormonal health in ways we could not study before, which means we will understand the relationship between cycle, hormone, cardiac function at a level of precision that was impossible 10 years ago. And there is a cultural shift happening. Women are asking better questions. Podcasts like this one exists and the conversation is changing. That matters because women who know their risk are women who can act on it, and women who act on it early enough can dramatically change their outcomes. The biology is not destiny, it's just information. The question is whether are we teaching women to ask the right questions and do they have access to the correct information?

SPEAKER_00 56:22

Absolutely. But what I want to leave every woman listening with is this the fact that heart disease is the number one killer of women is not new information. But what is new or newer is really the understanding that your cardiovascular story starts with your first period, that your pregnancy history is a cardiac document, like you said, and that your hot flashes are a vascular sign, that the hospital might send you home when you're having a heart attack because your symptoms don't look like a man's. It's super important to realize that and recognize that. And you know more about your heart health now than most people walking out of a doctor's appointment. So make sure you use it. If this resonated with you at all, any women this should resonate with. So share this episode. And before I close, I definitely want to make sure I give you the opportunity to say anything else or add anything on, Dr. Moran.

SPEAKER_01 57:11

Thank you, Leila. One final thought. Women have been told for centuries that their bodies are too complicated, too hormonal to study, too variable to include in research, too emotional to be objective about their own pain. And here is the extraordinary irony of that dismissal. Those hormonal variations, the ones that made women too complicated to study, are the very mechanisms that protect their hearts in the 20s and 30s. The same estrogen that gives her more complex biology gives her 15 years of cardiovascular advantage over men. That's not a complication. That's a superpower we barely bother to understand. When that protection fades, when her estrogen drops and when her risk rises, she walks into a healthcare system that was built around a male template with male symptoms on diagnostic posters, male dosages on treatment protocols, and a culture that has historically been more likely to attribute her chest pain to anxiety than to her blood vessels of her heart. Women who will live longer, healthier lives are the ones who stop waiting for the system to catch up and start demanding the knowledge and the conversations their heart has always deserved. Your body has been talking to you about your health since your very first period. It's time you started listening.

SPEAKER_00 58:45

Absolutely. That's such powerful information. And thank you so much. This was such a very important and informative conversation. I know I learned a lot. And for everyone listening, again, even if you're not a woman, you know women in your life, make sure you share this episode. It resonates with everyone. This is another great episode of Infinite Health. Make sure you subscribe, follow, share. And as always, it's amazing speaking with you, Dr. Moran. And I cannot wait for our next conversation. Thank you.