Experts outline four phases of women’s heart health

Cardiologist says the aim is to help clinicians see that women’s health is interconnected

Women’s hearts are not the same as men’s, and decades of research have repeatedly shown that difference, from variations in chromosomes in heart muscle cells to differences in heart attack symptoms and causes. Even so, major gaps remain in heart care for girls and women across medical specialties.

To address that fragmentation, four medical societies — the American Heart Association, American Academy of Pediatrics, Society for Maternal-Fetal Medicine, and the American College of Obstetricians and Gynecologists — have released a framework designed to bring clinicians and patients together across a woman’s lifetime of care, with the goal of pushing cardiovascular disease out of its place as the leading cause of death in women. Alongside the framework, three articles were published in Circulation offering guidance across the life course.

The central message is that female-specific biology affects girls’ and women’s hearts throughout life, and that care should be connected and holistic from adolescence onward to account for transitions that do not appear in male-centered models of care: periods, pregnancy, perimenopause, and menopause.

“What happens in adolescence and young adulthood impacts your life for years and decades to come, so having action at that point can really change the course of someone’s cardiovascular health story,” said Sadiya Khan, chair of the writing group and professor of cardiovascular epidemiology at Northwestern University Feinberg School of Medicine. “So that these are all connected and not siloed, even though that’s typically how we have approached care, will require an integrative approach.”

Perimenopause is especially important as a cardiovascular turning point, the guidance says. It refers to the transition marked by changing cycle length, skipped periods and hormone fluctuations, typically occurring from about age 45 to 51. During this time, shifts in cholesterol and metabolic health can be early warning signs of cardiovascular risk. “Identifying risk early and acting on it may reduce risk of cardiovascular disease,” Khan said.

Khan spoke with STAT about the new guidance, how it was developed and where its authors hope it will lead. This interview has been edited for clarity and brevity.

What problem were you trying to solve?

Women often see many different clinicians, but there was no shared playbook. Each specialty was focused on its own area, and that can miss the links between them.

What’s an example?

Pregnancy is one of the clearest examples. A great deal of work has shown the connection between blood pressure and diabetes during pregnancy. That matters not only during pregnancy itself, but throughout the rest of a woman’s life.

How does that play out?

There has been growing attention on moving from postpartum care to primary care and then to lifelong preventive care. A similar shift is now emerging around perimenopause, including not only menopause symptoms but also the cardiovascular risk that changes during that stage.

These issues do not happen in isolation. They shape a woman’s current health and influence what comes next.

How does adolescence fit into this framework?

It is critical to recognize that hormone-related transitions are biologically unique to women. The first few years around the first period, or perimenarche, represent a shift away from sex-agnostic medicine that should continue from that point forward. It is not limited to reproductive or hormonal health. It is also tied to cardiovascular health and psychosocial health, and those factors should be assessed together.

What is the psychosocial piece?

Hormone biology affects the heart as well as the mind and brain. When thinking about mental health and well-being, depression and anxiety in teen girls are known to rise and to continue across the life course. In key stages such as pregnancy and the postpartum period, those issues can become even more pronounced, tied to hormonal changes. It is all connected.

How can this play out?

Eating disorders and disordered eating add another layer, including the influence of social and structural differences tied to gender norms. Women are more likely to live in poverty, less likely to be paid fairly, and more likely to be single parents. Those societal pressures are also part of cardiovascular health.

What else is important to watch for in adolescence?

Changes in menstrual cycles, including cycle length and bleeding volume, matter for two reasons. Heavy menstrual bleeding can cause iron deficiency, which can limit a girl’s ability to be active or exercise and can also affect cardiovascular health. It can also signal polyendocrine metabolic ovarian syndrome, now called [formerly PCOS, or polycystic ovary syndrome]. It is important to keep that on the radar because diagnosis is often delayed for years in teens and young adults.

Is there a through-line you recommend to coordinate care?

For adolescents and adults, clinicians should discuss what to expect with periods, what is normal, and what is not. The same applies to perimenopause and menopause, when many people say, “I didn’t know what to expect. What is normal? What should I be looking out for?”

Clinicians and patients need a shared language so everyone understands where a person is in her health journey and what to expect next. In adolescence, that means providing a roadmap for the future. It is similar to what pediatrics already does.

Such as?

The Ages and Stages Questionnaire is a basic part of the first two years of life. I still remember it from my kids — when are they going to crawl, when are they going to walk? Everything is framed around positive development and healthy change.

We are extending that approach across the life course for female-specific biology, covering transitions men do not experience around periods, pregnancy and perimenopause, while also recognizing that postmenopause has major cardiovascular implications that should be monitored.

What about midlife and later?

One of the most important parts of this framework is identifying perimenopause as its own stage. There is confusion about what counts as menopause, postmenopause and perimenopause. Those distinctions matter for evaluating cardiovascular health and making sure symptoms are assessed and treated when needed.

Looking ahead, what do you see?

Although the focus is on women’s health, the lessons apply more broadly. They also help us understand the differences for men and how to approach care for every patient. Ultimately, the goal is to advance personalized medicine. Sex is one part of that, and the real question is how to care for the patient sitting in front of us.