When you think of cardiovascular disease, you might envision plaque — a sticky, waxy substance that builds up in the arteries leading to the heart, where it can cause a heart attack. But arteries run throughout the body, and plaque can accumulate anywhere along this network. When this happens in the legs, it can cause peripheral artery disease (PAD), a condition in which blood flow is restricted to the limbs.
It’s about equally common in men and women, affecting at least 7 million to 12 million people in the United States (based on the most conservative estimates). However, it tends to be underdiagnosed and inadequately treated more often in women, which can have serious consequences: As PAD progresses, it raises the risk not only of worse leg issues — slow-healing wounds, gangrene (or tissue loss) and rarely, limb amputation — but also major cardiovascular events.
In general, “people still assume women are less affected by cardiovascular disease,” said Heather Gornik, medical director of the Women’s Cardiovascular Center at University Hospitals Harrington Heart & Vascular Institute. While sex differences in heart disease have become better understood and publicized in recent years — for instance, it’s now widely recognized that women can have distinct kinds of heart attacks and unique symptoms — there’s still an awareness gap when it comes to issues that impact the circulatory system, or the network of arteries and veins that make up the rest of the cardiovascular system.
Research suggests women with PAD are less likely than men to have the textbook symptom of claudication, or pain in the calf with walking that subsides within 10 minutes of rest, Gornik said. Their day-to-day function also tends to take a bigger hit, with PAD more significantly limiting their mobility, walking speed and endurance. And women, especially Black women, are also less likely than men to receive the guideline-recommended treatment for PAD.
Without proper and prompt care, serious complications are more likely. PAD is tied to a sixfold spike in risk of heart attack and a two- to threefold increase in risk of stroke. “PAD is a systemic problem,” said Palma Shaw, professor of surgery at SUNY Upstate Medical University and chief of vascular surgery at Community General Hospital in Syracuse, New York. If you have plaque-riddled arteries in your leg, chances are you have disease elsewhere, too, she explained.
Below, experts explain what PAD looks like in women and how to stay ahead of the condition.
Symptoms of PAD in women
PAD symptoms such as calf pain while walking are caused by inadequate blood flow to the legs. They classically appear with movement because “oxygen demand rises when you are physically active,” said Mabel Chan, a vascular surgeon at the nonprofit health system Inova in Virginia. So, clogged arteries especially struggle to get enough blood to the legs during exercise.
But in the women’s health and aging study, which included nearly 1,000 women aged 65 and older with a disability, 63 percent of participants with PAD did not report the classic leg pain with activity and were considered “asymptomatic.”
Research also shows that women are twice as likely as men to have “atypical” symptoms of PAD. “For women, it might be that they feel more fatigued in their legs or experience a kind of numbness, burning, throbbing or shooting pain and weakness,” Chan said, either in addition to or instead of cramping with walking.
Gornik sees many women with PAD whose chief complaints are that they’re slowing down or just can’t walk very far anymore. Research suggests women with “asymptomatic” PAD walk more slowly, have poorer balance and are more likely to struggle with climbing stairs than women without PAD. (It’s thought that many women with PAD may not report leg pain with exertion simply because they’ve limited their physical activity to avoid it — whether they realize it or not.) These shifts can all be written off as general fatigue, Chan said.
Women may also be less likely than men to report physical symptoms to a doctor and more likely to power through or ignore them. “A lot of times, women are the caretakers of the family,” Shaw said. “They put their kids or their husband first, and they put themselves second.”
PAD tends to develop later in women, striking them more commonly in their 60s and 70s, versus about a decade earlier in men. Women’s risk peaks during postmenopause due to the loss of estrogen’s protective effects on the arteries, Chan said. By this point in life, vague symptoms of PAD such as heavy-feeling legs, fatigue and even leg discomfort can be easy to blame on the physical decline of aging or menopause, she said. Other conditions with similar symptoms such as arthritis and osteoporosis also become more common during this phase of life and can wind up overlapping with or masking PAD in women, she added.
How to lower your risk of PAD — or catch it early
Risk factors for PAD mirror those of cardiovascular disease more broadly and are similar across women and men. “There are a few that are most dominant in PAD, which are smoking, diabetes and older age,” Gornik said. “But other risk factors like high blood pressure and high cholesterol also contribute.”
Quitting tobacco, exercising regularly and eating a nutritious plant-forward diet can mitigate your risk of PAD, as can developing a plan with your doctor to manage underlying cardiometabolic conditions such as diabetes.
If you’re dealing with any kind of leg pain or heaviness, or just feel like you’re not able to get around as easily as you once were, start a conversation with your primary care provider. They can get a quick estimate of blood supply in your limbs by simply checking for a pulse in your ankle, Gornik said.
Even if you don’t have symptoms of PAD, it may be worth asking your doctor to check the blood supply to your feet if you have any of the above risk factors for PAD or a history of cardiovascular disease.
If you’re missing a pulse at the ankle, your doctor can refer you to a vascular specialist for a simple test called an ankle-brachial index (ABI). It involves comparing the blood pressure in your ankles to the pressure in your arms, Gornik said. If the former is lower than the latter, that signifies a lack of healthy blood flow to the legs and is generally a sign of PAD. (In patients with diabetes, stiffened arteries can make it tough to accurately assess blood pressure at the ankle, so doctors often use a toe-brachial index to diagnose PAD instead, Shaw said.)
A multitude of treatments are available, and many cases can — and should — be addressed without procedures, Shaw said. Surgical interventions to widen, stent or bypass narrowed arteries may be necessary in severe cases, but are not a permanent fix and come with risks of bleeding or worsened leg circulation over time so should be used conservatively, she noted.
The key first step in all cases, Shaw said, is minimizing your cardiovascular risk factors. That might mean starting a medication such as an ACE-inhibitor for high blood pressure or a statin for high cholesterol. A supervised exercise program — typically, periods of walking on a treadmill under the guidance of a health care provider — can help your body safely create new vessels to circumvent blockages, Chan said. There’s also a prescription drug called cilostazol that may widen the arteries and boost blood flow for some, Shaw added.
Detecting PAD sooner rather than later will make it easier to treat and help you avoid a serious complication such as a heart attack or stroke. “Women may especially need to be advocates for themselves,” Gornik said. “Don’t be afraid to speak up if you feel like you’re slowing down and your legs are limiting you because it could be a very treatable diagnosis.”
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