Not-so-fun fact: While many people think of heart disease as primarily impacting men, it’s actually the number one killer of American women as well. Women typically develop heart disease later than men, and risk increases after menopause.

Declining estrogen is associated with increased risk of heart disease. However, there are many mechanisms at play, making both risk and treatment complex. Scientists are continuing to learn more about how estrogen impacts the cardiovascular system, but it’s clear that hormonal status matters. The reality of cardiovascular disease among women should be taken seriously, but it’s also important to remember your heart health is, in fact, in your hands.

Women who experience early or premature menopause are at higher risk for cardiovascular disease (CVD), possibly due to a longer time without the protective effects of estrogen. Women who experienced pregnancy complications such as preeclampsia, gestational diabetes, or pregnancy-induced hypertension should also pay extra attention to their heart health during perimenopause and postmenopause.

There are some more general well-established risk factors for heart disease in postmenopause. Knowing your risk is key to making informed decisions to promote your health, and you may want to discuss the following with your healthcare team.

• Family history. Your risk is higher if you have a close male relative who had a heart attack before age 55 or a close female relative who had a heart attack before age 65.
• Your blood pressure. High blood pressure increases the risk of heart problems and stroke. Knowing your blood pressure and working with your healthcare team to control it can substantially lower your risk.
• Cholesterol. Basic lipid panels (LDL, HDL, total cholesterol, and triglycerides) are commonly part of routine bloodwork. Some women, especially those at higher risk, may also benefit from advanced testing such as Apo-B, particle size, and Lp(a). These tests can help clarify what approach to risk reduction will be most beneficial.
• CAC and other imaging. Some healthcare providers may recommend a test such as a coronary artery calcium scan (CAC) to help understand risk. This test is useful when basic testing doesn’t answer all the questions or when it’s not clear whether you need a medication such as a cholesterol-lowering statin.

The good news: Plenty of scientific evidence demonstrates that healthy lifestyle practices can substantially reduce your risk of heart disease. The impact of these simple strategies can be massive.

Nutrition

Adopting an overall healthy eating pattern like the Mediterranean diet can reduce heart disease and overall mortality. Even better, this powerful approach is not only good for your good for your heart and brain, it also helps you manage your metabolic health and menopause symptoms. Heart-healthy diets include vegetables, fruits, whole grains, lean proteins, nuts and seeds, and unrefined plant fats like olive oil. Though diets strictly limiting fats or carbohydrates have been popular over the years, these diets are not beneficial to long-term heart health for most people.

One key aspect of heart-healthy eating is type of fat consumed. Many “low-fat” or “diet” products aren’t healthier after all, especially if they replace fats with processed carbohydrates. Including some fat in your diet is healthy, and replacing saturated fats (often from animal products and coconut or palm oils) with unsaturated fats (like those from olive oil and nuts) protects heart health. And though blood cholesterol level is associated with heart disease risk, dietary cholesterol is not.

Exercise

Aerobic exercise reduces risk of heart disease in previously sedentary postmenopausal women. Benefits begin with even very low levels of activity, so any movement is better than none. Some evidence suggests that at least moderate intensity exercise and a combination of strength and aerobic training are especially helpful. Experts recommend 2.5 hours of moderate activity or 75 minutes of vigorous activity weekly to promote heart health. Exercise is broadly beneficial to health as well, including bone health, mood, sleep, and body composition.

Sleep

Most people need 7-9 hours of sleep each night, and sleeping much more or much less than this is associated with greater risk to your heart. Prioritizing quality sleep is key, especially as the menopausal transition can make sleep tricky (more on sleep in week 5).

Tobacco and Alcohol

Tobacco use is the single most powerful risk factor for heart disease in women, so if you smoke, you should consider stopping. There are medical treatments available to help, so speak to your healthcare provider. Although there has been conflicting messaging about the role of alcohol in heart health, experts recommend that, if you don’t already drink alcohol, you don’t start (as the risks generally outweigh any potential benefit) and, if you do drink alcohol, limit your consumption to no more than one drink per day.

Though lifestyle changes are the first-line option to reduce risk of heart disease, some people require medications, too. If you have high blood pressure, it’s common to need one or even more than one medication to get it under control. For some women, medications are sometimes necessary for lowering high cholesterol. These medications can include “statin” drugs, which reliably reduce cardiac events, and others. You should discuss the options with your healthcare provider.

Based on available evidence, menopausal hormone therapy is not currently recommended as a treatment to lower risk of heart disease. As time since your last period increases, the benefits of estrogen therapy on heart health are less clear, so the risk may not be worth it for some women. We also don’t know for sure how different formulations might work differently — more research is needed. Hormone therapy may still be safely used for other reasons, though, depending on your individual needs and risk factors.

Unfortunately, the healthcare system doesn’t always treat men and women equitably. When women do have heart attacks, they’re less likely to receive timely diagnosis and treatment and more likely to die. One way to combat this unfair bias is to know your own risks and advocate for yourself when you interact with the medical system.

Often, a woman isn’t diagnosed with heart disease until she has a heart attack. Symptoms of a heart attack in women may differ from those in men, and older women in particular are less likely to experience the “classic” presentation. Besides chest pain and pressure, other symptoms to be aware of include nausea, back or shoulder pain, sweating, and unusual fatigue**. If you feel like something isn’t right, it’s important to seek care quickly. Ask questions and if you can, have a support person with you to help you navigate.**

Of course, another way to advocate for yourself is simply showing up for yourself every day, keeping up with screenings and monitoring, and managing your risk. Remember, you’re already in great hands: your own!