Heart Disease in Women – Risk Factors and Why Misdiagnosis is Common

by Leigh on June 19, 2018

symptoms of heart disease in womenFor years, heart disease has been seen as ‘a man’s disease’. While it’s true that heart disease remains the biggest killer of men worldwide, this commonly held view has serious consequences for women’s health. Many medical doctors miss symptoms of heart attack and heart disease in women, and women are less likely to be educated on heart healthy behaviour. The result? More women than men now die each year from heart disease.

Why is heart disease in women being misdiagnosed?

There are many reasons why heart disease in women may be missed or misdiagnosed. For one thing, the ‘classic’ symptoms of a heart attack were defined based on studies only involving men. As such, doctors look out for those symptoms most commonly seen in men, including chest pain, pain in the left arm, etc.

In contrast to the usually acute symptoms of a heart attack seen in men, many women have symptoms that last for weeks or days before they seek medical attention. Then, if a woman does make it to hospital, it is alarmingly common for women’s symptoms of a heart attack to be dismissed as something less concerning. For instance, differential diagnoses for a heart attack in women can include indigestion, anxiety, or stress. Symptoms may be downplayed by women themselves as well as by medical staff and family, and are often attributed to psychosocial problems (DeVon & Noureddine, 2014).

And there are other issues that can delay diagnosis and treatment. For example, the tests that work to detect a heart attack in men might not work for women. Even if a physician is diligent and takes a woman’s symptoms seriously, the female heart is smaller on average than the male heart. This means that blockages can occur more easily in the smaller blood vessels, but these may be missed on a normal angiogram that only detect bigger blockages.

Risk Factors for Heart Disease in Women

As well as the usual risk factors such as smoking, poor diet, lack of exercise, and sedentary behaviour, women have several additional risk factors for heart disease compared to men. These include endometriosis and polycystic ovary disease, and gestational diabetes and high blood pressure that develop during pregnancy. In some women under the age of 40, endometriosis raises the risk of developing coronary artery disease by a staggering 470% (Mu et al., 2016). And, again, many women have their symptoms of endometriosis (severe period pain, bloating, cramping, etc.) dismissed as simply part and parcel of being a woman.

While symptoms of endometriosis resolve after menopause, for the most part, menopause itself poses an increased risk of heart disease for women. Estrogen has a protective effect against cardiovascular disease by supporting the health of the inner layer of the arteries, helping to keep arteries flexible (American Heart Association, 2017). This is one of the reasons why the rate of heart disease skyrockets in women after menopause. And, in recent years, research has suggested that while estrogen has a protective effect against heart disease, testosterone is toxic to the heart. In one study, a greater ratio of testosterone to estradiol (a form of estrogen) was significantly associated with an increased risk of cardiovascular disease in women (Zhao et al., 2018).

Diabetes also confers greater risk for heart disease in women than men, with the protective effect of estrogen lost for women with diabetes. So much so that the death rate from cardiovascular disease is three times higher in women with diabetes compared to men (DeVon & Noureddine, 2014).

What’s more, women who have gone through menopause are less likely to have young children at home and more likely to have paid help in the home, which may reduce the amount of physically demanding activity they perform daily.

Sedentary Behaviour and Hearth Disease Risk for Women

While the negative impact of sedentary behavior has been seen in women, the effects of too much sitting have been far more widely documented for men (Sisson et al., 2009). Let’s talk a bit more, then, about sedentary behaviour as a risk factor for heart disease in women.

Interestingly, raising small children and associated and independent domestic labor (the ‘second shift’) often goes unreported, with many women considering themselves physically sedentary because they don’t necessarily engage in intense and discreet exercise such as running or playing squash. This potential disparity in physical labour could be a factor in the heterogeneity (variability) of the results of studies looking at the relationship between sedentary behavior and cardiovascular disease in wome. The data is more homogenous (consistent) in studies looking only at men (Hamer & Chida, 2014). Using wearable tracking devices in studies, instead of relying on self-reporting, would help to clarify whether this disparity exists and contributes to a lower perceived effect of sedentary behavior in women.

Sedentary women have been found to have a greater mean waist circumference and a higher prevalence of obesity (both risk factors for heart disease), as well as more severe menopausal symptoms, including insomnia and depressive mood compared to more active women (Blümel et al., 2016). It’s also important to note that menopausal symptoms and pelvic floor dysfunction can create barriers to moderate-to-vigorous physical activity for women, meaning that recommendations by health authorities go unheeded (Laakkonen et al., 2017).

What can we do to reduce the risk of heart disease in women?

While this all sounds rather depressing, it does, however, identify an opportunity to tailor health advice to pre- and postmenopausal women to highlight the benefits of avoiding sitting for too long. This removes the focus from trying to cajole women into doing physically uncomfortable vigorous exercise when they are already pressed for time, money, and energy. This is, of course, in addition to:

  • Not being a smoker
  • Eating a predominantly plant-based diet low in processed foods and high in fibre, healthy fats, and lean protein
  • Using healthy stress management techniques such as meditation, yoga, and time in nature
  • Avoiding the use of harmful drugs (including cannabis, which has been linked to death from hypertension)
  • Minimising alcohol intake
  • Getting enough sleep.

Heart disease is now the biggest killer of people of every gender. Indeed, more women than men die each year from heart disease in both developed and developing countries. How we mitigate that risk, as individuals and in the medical profession as a whole, relies first on acknowledging the problem. Only then can we take steps to help everyone adopt heart healthy habits for life.

Signs of a Heart Attack in Women

  • Uncomfortable pressure, squeezing, fullness or pain in the centre of your chest – lasting more than a few minutes, or coming and going
  • Pain or discomfort in one or both arms, the back, neck, jaw or stomach
  • Shortness of breath with or without chest discomfort
  • Breaking out in a cold sweat
  • Nausea
  • Lightheadedness or dizziness.

If you have any of these signs, call 9-1-1 and get to a hospital right away. Women who experience a heart attack may also feel like they have the flu, indigestion, or fatigue. Don’t ignore these symptoms, especially if you have risk factors for a heart attack.


DeVon HA, & Noureddine S. (2014). 20 things you didn’t know about women and heart disease. J Cardiovasc Nurs, Sep-Oct;29(5):384-5.

Mu F, Rich-Edwards J, Rimm EB, et al. (2016). Endometriosis and Risk of Coronary Heart Disease. Circulation. Cardiovascular Quality and Outcomes, 9(3), 257–264.

American Heart Association. Menopause and Heart Disease. 2017.

Hamer M, & Chida Y. (2008). Walking and primary prevention: a meta-analysis of prospective cohort studies. Br J Sports Med, Apr;42(4):238-43.

Blümel JE, Fica J, Chedraui P, et al. (2016). Sedentary lifestyle in middle-aged women is associated with severe menopausal symptoms and obesity. Menopause, May;23(5):488-93.

Laakkonen EK, Kulmala J, Aukee P, et al. (2017). Female reproductive factors are associated with objectively measured physical activity in middle-aged women. PLoS One, Feb 22;12(2):e0172054.

Zhao D, Guallar E, Ouyang P, et al. (2018). Endogenous Sex Hormones and Incident Cardiovascular Disease in Post-Menopausal Women. Journal of the American College of Cardiology Jun 2018, 71 (22) 2555-2566.

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