What women need to know about heart health at every age — from childhood through menopause

Cardiovascular disease is the leading cause of death in women, yet less than half recognize it as their greatest health threat, said Dr. Sadiya S. Khan, the lead author on a new set of guidelines for assessing women's cardiovascular health risk.

Research increasingly shows that the risk of stroke, heart disease and other cardiovascular issues is associated with the hormonal shifts that happen over the course of women's lives, from their first period to their last.

"There's clearly a pattern there," said Khan, Magerstadt Professor of Cardiovascular Epidemiology at Northwestern University Feinberg School of Medicine.

The new guidelines, published October 26 in the journal Circulation by experts from the American Heart Association, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, and the Society for Maternal-Fetal Medicine, aim to make that pattern clearer, so women and their doctors know what to look for at every stage.

"Organizing care around these stages creates natural checkpoints to catch risks early, rather than leaving decades of a woman's lifespan unmonitored," said Dr. Nisha Parikh, system director of the Women's Heart Program at Northwell Health, who was not involved in the report.

The guidelines should be "empowering rather than frightening," Khan said. Understanding risk can help women now and help them to prepare for what comes next.

Preventing cardiovascular disease starts in childhood

It's never too early to think about heart health, said study coauthor Dr. Tamara Hannon, a professor of pediatrics at Indiana University School of Medicine. Parents can help their children build habits that will benefit their heart health for the rest of their lives. Encouraging healthy eating — including lots of fruits, vegetables and whole grains, and limiting ultraprocessed foods, fat from animal sources and juice and other sugary drinks — isn't just good for developing bodies but makes it the norm as kids grow up.

A healthy diet reduces the risk of obesity and type 2 diabetes, which are both associated with cardiovascular disease down the line.

Hannon also stressed treating daily physical activity as a life skill (rather than a weight-loss technique) and promoting good sleep, as both are essential for cardiovascular health.

Make sure your child's pediatrician tracks her growth, she said, as poor or excessive growth may indicate hormonal imbalances that could affect her cardiovascular health. And if there is a family history of high cholesterol, heart disease or heart attack before the age of 50, be sure to have her cholesterol checked. Plaque can accumulate in the blood vessels early on and "wear and tear on the blood vessels in the heart can start to add up," Hannon said. High cholesterol in children can be treated with diet, exercise and medication (statins) if needed.

Heart disease risk can build during the teenage years

Doctors might not pay attention to a healthy 18-year-old's cholesterol level, "but that cholesterol is going to affect her 20 years or 30 years from now," said coauthor Dr. Afshan B. Hameed, a clinical professor of obstetrics, gynecology and cardiology at University of California, Irvine. A recent European study found "silent atherosclerosis," or early buildup of cholesterol plaques in blood vessels, in 1 out of 13 people ages 18 to 29.

Adolescence is also a good time to check for markers of diabetes risk, such as blood pressure, blood sugar and A1c. Nearly one-third of adolescents and teens have prediabetes (which can develop into diabetes), research has found. People with diabetes are twice as likely as those without it to get heart disease — and the longer you have diabetes, the greater the risk, according to the US Centers for Disease Control and Prevention.

When a girl gets her first period may predict future heart health

Beginning menstruation before age 10 is associated with greater cardiovascular disease risk in adulthood, the report said. Doctors aren't entirely sure what the connection is, but weight may play a role, since higher body mass index, or BMI, and earlier periods often go hand in hand. Girls who get their periods earlier are also at greater risk of developing eating disorders, which can damage the heart.

An earlier period may indicate polyendocrine metabolic ovarian syndrome, or PMOS (previously called PCOS), a hormonal condition that can increase cardiovascular risk in adulthood. Irregular or heavy periods are symptoms, too, so it is important girls talk to their doctors about what they are experiencing.

"It's normal for the first six years after you've gotten your period to have somewhat irregular periods. It's not normal to have excessive bleeding to the point where you're missing school or having periods more often than every 28 days," Hannon said. "This pattern can be a sign of increased risk for cardiovascular disease."

If painful periods or depressive mood cause difficulty sleeping or keep girls from engaging in sports or other physical activity, that, too, can influence their heart health.

Irregular or heavy periods could be warning signs

Whether you have only had your period for a few years, or you are well-acquainted with Aunt Flow, it is crucial to pay attention to irregular cycles, changes in your cycle or heavy bleeding. Keep in mind that what feels normal to you may be "heavy" by clinical standards; a typical sign of heavy menstrual bleeding is going through a pad or tampon every hour for multiple hours.

Khan acknowledged that while there are "gaps in research" that need to be filled, doctors know that there is an association between irregular periods and higher cardiovascular risk. "It may be because of PMOS or other factors," she said, but either way, it warrants attention.

An estimated 10% to 13% of women have PMOS, which can result in increased visceral fat and insulin resistance, which increase cardiovascular disease risk, the report said. The condition is often misdiagnosed — or missed entirely. Women with PMOS are at fourfold higher risk of heart attack and strokes, Hameed said.

Your mood matters

The new guidelines emphasize the impacts of social and emotional well-being on physical health. And because of "the gendered aspects of being a girl or a woman in the world," Khan said, women need to take those impacts seriously. Body image stigma can lead to unhealthy or disordered eating, for example, which puts women at increased risk of heart damage.

Mood issues may disturb sleep, which is crucial for the cardiovascular system, and keep girls and women from engaging in other heart-healthy behaviors, such as eating well and exercising regularly. These issues also may reflect major hormonal fluctuations that, themselves, can significantly affect cardiovascular disease risk.

Mood disruptions can be "vital windows into future heart disease," Parikh said.

Pregnancy stresses the heart

Hameed likened pregnancy to being on a treadmill for nine months. That stress can cause an otherwise healthy woman to develop cardiomyopathy (weakening of the heart muscles), or bring out previously undiagnosed cardiovascular disease. Cardiovascular disease is the leading cause of death during pregnancy and for the first year after giving birth, she said.

If you are pregnant or have given birth in the last year and have shortness of breath, chest pain, extreme fatigue, swelling in the legs or don't feel up to your usual energy level, it could be due to the stress of pregnancy or having a new baby — or it could be a sign of cardiovascular disease. "Don't dismiss your symptoms," Hameed said. Talk to your doctor.

What happens during pregnancy can predict future cardiovascular health as well. Women who have complications during pregnancy — such as high blood pressure, gestational diabetes, a growth-restricted baby or preterm delivery — are at higher risk of developing cardiovascular diseases later.

Perimenopause is an inflection point

Estrogen protects the heart and blood vessels, and during perimenopause — the roughly four to seven years before a woman stops menstruating — estrogen begins to decline. These hormonal shifts can have an enormous impact on health and well-being — and specifically on cardiovascular health. For example, "bad" LDL cholesterol may rise, arteries stiffen and fat can accumulate around organs.

Perimenopausal women also may experience mood issues and night sweats. "It's super important that we are recognizing the burden that they place on quality of life," Khan said. "If you're not sleeping well, we know that's linked to cardiovascular disease risk." Fortunately, she added, there are treatments that help perimenopause symptoms, including hormone replacement and behavioral therapy.

Women should bring up their concerns with their doctors — and doctors should be on the lookout as well. With vigilance, perimenopause presents an opportunity to prevent a heart attack, stroke or coronary artery disease, Hameed said.

Women's heart disease risk increases after menopause

Women generally are at lower risk of heart disease than men. That changes with menopause, when women no longer produce cardio-protective estrogen. In the years after her last period, a woman's cardiovascular disease risk quickly catches up to and eventually exceeds a man's, Hameed said. Like men, their risk of heart disease is largely a factor of age, genetics, blood pressure, cholesterol, diabetes and the cumulative effects of lifestyle choices, such as smoking, diet and exercise.

Her hormonal and reproductive health history matters, too. Getting her first period early, irregular cycles, heavy periods pregnancy complications and going into menopause before age 45 all raise the risk of cardiovascular problems.

That's why, Khan said, it is important for girls and women to discuss these things with their doctor, in addition to standard measures of cardiovascular health, such as blood pressure and cholesterol.

"Everything that happened before can inform your risk and guide your ongoing care," she said. "There's a lot that can be done."