The 4 stages of women’s heart health: New framework for doctors and patients

Women’s hearts are different from men’s. Research from clinical trials that have required female participants only since 1993 have repeatedly drummed home that message, from varying chromosomes in heart muscle cells to different heart attack symptoms and causes. Yet wide gaps remain in heart health care for girls and women across specialties. 

Recognizing that clinical fragmentation and the resulting harm to women’s health, 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 issued a framework intended to unite clinicians and patients over a lifetime of care, all aimed at dethroning cardiovascular disease as the leading cause of death in women. In that spirit, three articles offering guidance across the course of a woman’s life were published Monday in Circulation.

Their message: Because female-specific biology affects girls’ and women’s hearts throughout their lives, it requires connected, holistic care starting in adolescence to reflect transitions not found in the male models that have dominated health 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,” Sadiya Khan, chair of the writing group and professor of cardiovascular epidemiology at Northwestern University Feinberg School of Medicine, said. “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 in particular is a cardiovascular inflection point, the guidance says. It’s defined as the transition to variable period cycle length, skipped cycles, and hormone changes, occurring from about age 45 to 51. That’s when changes in cholesterol and metabolic health can be early signs of cardiovascular risk. “Identifying risk early and acting on it may reduce risk of cardiovascular disease,” she said. 

Khan talked with STAT about the new guidance, where it came from and where its framers hope it will go. This interview has been edited for clarity and brevity.

What problem were you trying to solve?

Women uniquely see many different clinicians, yet there wasn’t a shared playbook. We were all working on our specific problem area or focus, but that misses the connections between them. 

What’s an example?
We’ve really seen that with pregnancy. There’s been so much great work that has helped to highlight the connection between blood pressure and diabetes in pregnancy. That matters not just during that pregnancy, but across the life course. 

How does that play out?

The importance of transitioning from postpartum care to primary care to preventive care for the life course has gained a lot of attention. And we’re seeing a similar bubbling to the surface around perimenopause now, and how we’re addressing symptoms of menopause, but also the cardiovascular risk that’s changing during that time.

These things aren’t happening in isolation. They inform where their health is now, and what they do now matters for their health in the future.

Tell me how adolescence fits into this framework.

It is really critical that we recognize that hormonally mediated transitions are biologically unique to women. Those first few years, or perimenarche, at the time around the first period, is the departure from sex-agnostic medicine that should then continue. It doesn’t end with reproductive or hormonal health. It’s connected to cardiovascular health, and so is its impact on psychosocial health. Those things are really connected and need to be assessed together.

What is the psychosocial piece?

We know that hormone biology influences the heart as well as the mind and brain. So when we think about mental health and well-being, we know that depression and anxiety in teen girls starts to increase, and that continues for the rest of life. And particularly in key periods like in pregnancy and postpartum, those things can really increase, and that’s related to the hormonal changes that are happening. It’s all connected. 

How can this play out?

Eating disorders and disordered eating bring in this additional layer of societal and structural differences in gender and the gendered norms that can also influence health. Women are more likely to live in poverty, are less likely to be compensated fairly, are more likely to be single parents. So when you start to incorporate some of those structural issues related to societal gender norms, they’re also a part of cardiovascular health.

What else is important to watch for in adolescence?

Changes in periods related to cycle duration and the amount of bleeding are important for two reasons. Heavy menstrual bleeding can lead to iron deficiency, and that can actually impair a girl’s ability to participate in activity or exercise, and also can impair cardiovascular health. It can serve as a flag for polyendocrine metabolic ovarian syndrome, as it’s now called [formerly PCOS, or polycystic ovary syndrome]. It’s really important to have that on our radar because it takes years, usually, before it gets diagnosed for most teens and young adults.

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

For adults or adolescents, we’ll talk about what they should expect with their periods, what’s normal, and what is not. Similarly, around perimenopause and menopause, we’re clearly hearing, “I didn’t know what to expect. What is normal? What should I be looking out for?” 

We should have a shared language for clinicians and patients so that we understand where someone is in their health journey and what to expect or anticipate for what comes next, so we can prepare people. And I think in adolescence, that’s the forward-looking part of it, so that they have this roadmap. It reminds me a lot of what we do in pediatrics already.

Such as?

The Ages and Stages Questionnaire is a fundamental part of the first two years of life. I still remember from my kids, right? When are they going to crawl, when are they going to walk? Everything is framed from positive developments and positive health changes.

We are now extending that across the life course for female-specific biology that is unique and accounts for transitions that men don’t experience around periods, pregnancy, perimenopause, and importantly, also recognizing that postmenopause has a lot of cardiovascular implications that we want to make sure that we’re monitoring. 

What about midlife and later?

I think one of the key things in this framework is calling out perimenopause as its own stage. I think there’s confusion on what is menopause, what is postmenopause, what is perimenopause. And what should that tell you about evaluating your cardiovascular health and making sure that symptoms are getting assessed and treated if needed.

Looking ahead, what do you see?

We’re focusing on women’s health, but everything we learn here means that we also need to understand what the differences are for men and how we can approach this for every single patient. How do we use all of this to really advance personalized medicine at the end of the day? Sex is a part of that, and it’s really about saying, how are we taking care of the patient in front of us.

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