Cardiovascular disease remains the leading cause of death for men and women. Yet, some female-specific risk factors often go unnoticed, creating a gap in prevention and early intervention.
Nebraska Medicine cardiologist Christina Dunbar Matos, DO, outlines key considerations for primary care providers to better identify, counsel and coordinate care for female patients.
Commonly overlooked risk factors
Two important, but often overlooked, red flags include:
- History of pregnancy-related cardiovascular complications – Conditions such as gestational hypertension, gestational diabetes or other cardiac events that resolve postpartum can still indicate long-term cardiovascular risk.
- Menopausal status – Women who experience menopause before the average age, whether naturally or due to hysterectomy/oophorectomy, face increased lifetime cardiovascular risk and may require earlier screening.
“These risk factors don’t always surface in a standard history, but they should,” Dr. Dunbar says.
How hormone changes shape heart disease risk
Hormone shifts across a woman’s lifespan can significantly influence cardiovascular risk. For example, research suggests that hormonal changes during pregnancy and postpartum may contribute to spontaneous coronary artery dissection (SCAD), which occurs most often in women. Conversely, cardiovascular risk rises sharply in the decade after menopause — likely related in part to the loss of estrogen and progesterone’s protective effects.
“Women who’ve been postmenopausal for 10 years or more are at the highest risk of developing certain cardiovascular conditions,” Dr. Dunbar explains. “When estrogen replacement begins earlier — ideally during perimenopause — we often don’t see the same cardiac impact.”
Considerations for pregnancy
Women with the following conditions need preconception counseling and coordinated care with cardiology:
- Congenital heart disease.
- Known coronary artery disease.
- Pulmonary hypertension or disease.
- Severe valve disease.
“It’s important for these patients to work closely with a multidisciplinary care team to weigh risks for both mother and baby,” Dr. Dunbar says.
Additionally, certain cardiovascular medications, including some antihypertensives, can cause fetal harm, particularly early in pregnancy. PCPs should review and adjust medications in advance for women who are pregnant or planning pregnancy.
Screening and collaboration
When assessing cardiovascular risk in women, remember that standard tools, such as the Atherosclerotic Cardiovascular Disease (ASCVD) risk calculator, do not factor in pregnancy-related complications, which can lead to underestimating. Including reproductive history, menopausal status and stage of hormonal transition in your evaluation gives a more complete risk picture.
Putting it into practice
By addressing patient-specific risk factors, adjusting treatment during different life stages and collaborating with cardiology, PCPs can significantly improve cardiovascular outcomes for women.
“Managing these patients well requires a multidisciplinary approach,” Dr. Dunbar says. “If primary care providers recognize these risk factors in their patients, it’s important to have a clear threshold for referral.”
Key takeaways for PCPs
- Include reproductive and menopausal history in cardiovascular risk assessments.
- Screen women with prior pregnancy-related complications for long-term risk.
- Recognize early menopause or oophorectomy as a marker for increased cardiovascular risk.
- Review medication safety for women who are pregnant or planning pregnancy.
- Refer high-risk patients for collaborative care with cardiology before conception.
- Remember that standard risk calculators may underestimate risk in women — consider specialist input when in doubt.