Heart disease has long been known to look different in women than in men, sometimes having distinct triggers or not-so-typical symptoms — all of which threaten timely diagnosis and treatment. What researchers are increasingly learning is that differences between the sexes on this front can occur well before a cardiac event strikes. In fact, risk factors can take root as early as the first menstrual period and shift alongside key stages in a woman’s life, from pregnancy to menopause.
In a new trio of reports published in Circulation, four medical organizations — the American Heart Association (AHA), the American College of Obstetricians and Gynecologists (ACOG), the American Academy of Pediatrics (AAP) and the Society for Maternal-Fetal Medicine — outline how these major life phases uniquely shape women’s heart disease risk.
The distinctions first became obvious with pregnancy. Experts discovered that conditions such as preeclampsia in pregnancy or postpartum can be a marker of future heart disease risk, said Sadiya Khan, chair of the writing group for the new reports and associate professor of preventive medicine at Northwestern University Feinberg School of Medicine.
“Then we started getting evidence related to menopause [and heart disease],” she said. “And then we started hearing more about PMOS, or polyendocrine metabolic ovarian syndrome [formerly called PCOS], as a heart-health marker.” It became clear that there was “a shared thread,” Khan said, “and what we needed to do is tie it all together.”
Historically, “reproductive health has been squarely in the OB/GYN space, and cardiovascular health has been reserved for cardiologists,” said Emily Lau, a cardiologist and investigator at Massachusetts General Hospital and assistant professor of medicine at Harvard Medical School. Now everyone — doctors and patients alike — should know that “these are not separate things,” Lau said.
We asked experts to break down how each life stage, from puberty to menopause, can affect heart health and what women need to know about their unique risks.
Around first menstruation
It might be surprising that such a young life phase, spanning the few years surrounding a girl’s first period — known as perimenarche — could affect heart health, but a few factors can set the scene for trouble.
There’s the age a girl gets her period, for starters. Getting a period when one is younger than 10 is a “cardiovascular risk enhancer,” Khan said, possibly because it often tracks alongside metabolic concerns such as extra fat tissue that can persist into adulthood. Irregular or missing periods also can be early flags for reproductive conditions such as PMOS, Khan said, which can bump up cardiovascular risk in many ways: The high levels of androgens (a.k.a. male sex hormones) that characterize it can trigger inflammation and are linked to a poor cholesterol profile and insulin resistance.
Meanwhile, heavy or unpredictable periods, or the emergence of mood symptoms tied to premenstrual syndrome (PMS), can affect a girl’s ability to get exercise, sleep well and eat a nourishing diet, Khan noted, which are all key building blocks of a heart-healthy lifestyle.
Changing bodies around puberty also may be a catalyst for mental hurdles such as body-image issues, depression and disordered eating, all of which are associated with cardiovascular risk.
The reproductive years
The report refers to this stage as “ovarian cycling” to avoid implying that only reproductive concerns matter at this time, Khan noted. It starts when the menstrual cycle becomes more regular, around age 15, and lasts until perimenopause.
During these years, women are overall less likely than men to develop heart disease, deemed “the female advantage,” largely because of the “cardioprotective” benefits of estrogen and other hormones that fluctuate with the menstrual cycle, Khan said. People who have irregular or absent cycles at this time may have hormones that are out of balance and possibly a higher cardiovascular risk, she noted. Heavy menstrual bleeding and severe PMS also can happen in this stage, Lau said, with the aforementioned effects on heart health.
Birth control often becomes relevant at this stage, too, which could have implications for the cardiovascular system. Combined hormonal contraceptives (containing both estrogen and progesterone) can raise the risk of developing blood clots that can break loose and travel to the lungs, said Sonia Tolani, a cardiologist at NewYork-Presbyterian/Columbia University Irving Medical Center. The absolute increase in risk is low, but women with preexisting risk factors (such as uncontrolled high blood pressure) may be advised to steer clear; progestin-only options like intrauterine devices (IUDs) might be a better choice for them, Tolani said.
Pregnancy
Pregnancy can function as “nature’s cardiac stress test,” Lau said. The impact on the body can nudge women who may have had borderline risk or an underlying predisposition into a diagnosis, for instance, of a hypertensive disorder of pregnancy (such as preeclampsia) or gestational diabetes. Such complications are more likely in women who enter pregnancy with less-than-optimal heart health — which AHA research suggests is common — and are known to raise risk for heart disease postbirth.
One pregnancy complication, hemorrhaging postpartum, can double the risk of cardiovascular problems in the following year, and the risk can remain elevated for the next 15 years.
Coupled with postpartum recovery and the demands of new parenthood, perinatal mood and anxiety disorders (which affect up to 37 percent of women within three months of delivery) also can harm the heart in the long term by making it tougher to eat well, sleep and move your body.
Perimenopause
This stage — the years leading up to menopause, during which hormone levels zigzag before ultimately declining — is when women lose the heart-protective benefits of estrogen, and levels of heart disease in women begin to catch up to those in men.
Lau characterized perimenopause as a “time of acceleration” in risk related to a handful of metabolic changes: Cholesterol levels often go up, as can insulin resistance and the accumulation of fat around the midsection. “The trajectory [of risk] through menopause really is beyond what we would expect to see just with age alone,” Lau said. Declining estrogen is “a part of that story,” alongside other biological shifts coinciding with this phase of life, such as a rise in inflammation and changes in the autonomic nervous system.
More severe or frequent hot flashes and night sweats in perimenopause also are tied to greater cardiovascular risk, possibly because of changes in blood vessel function that underlie these symptoms. Facing the potential onslaught of perimenopause symptoms — which can additionally include insomnia, anxiety, vaginal dryness, joint aches, brain fog and straight-up rage, to name a few — also can disrupt your ability to adhere to heart-healthy habits.
Menopause hormone therapy (MHT) can be a “very effective treatment for vasomotor symptoms for the right woman,” Lau said, which research suggests is someone under age 60 or within 10 years of the onset of menopause. In these groups, no heart disease risk has been shown, though MHT also does not restore estrogen to pre-menopause levels, nor has it been shown to prevent heart disease. In women over 60 and for those at high risk of heart disease, the possible increased risk of strokes and heart attacks from MHT may outweigh the benefits, Lau said.
Postmenopause
This stage, which starts at 12 months after the final menstrual period, is where the bulk of heart disease cases in women arise. Some of the above symptoms can persist for the first part of this phase, with lingering effects on heart health.
Rather than being driven by hormonal changes, differences between the sexes in this stage emerge mostly from the cumulative effect of risk factors amassed in earlier stages. Women may also bear a greater burden of stressors late in life, with higher rates of chronic disease, social isolation and caregiving responsibilities, all of which may pile onto cardiovascular risk.
What women should know about heart disease risk
The new framework is meant to encourage clinicians to discuss heart health with women during routine care throughout their lives, Lau said. But being aware of the links between reproductive and cardiovascular health can help you advocate for yourself, too.
If you’re navigating heavy menstrual bleeding or other period trouble, if you’re planning for pregnancy or experienced a pregnancy complication, if you’re facing the tidal wave of perimenopause-related change, talk with your doctor about how these hormonal shifts may affect your heart and what you can do.
“There can be this feeling of, ‘I’m not going to talk about my period with my cardiologist,’ or ‘That pregnancy happened so long ago,’ but the point of this framework is helping bring these together in the same conversation,” Khan said.
It’s also critical to stay up-to-date on screenings for traditional cardiovascular risk factors — which historically have not been commonplace among women of reproductive age but are broadly recommended for this group, Lau said. For example, recently released 2026 dyslipidemia guidelines recommend a lipid profile at least every five years starting at age 19. If you’re unsure whether you’ve had heart-related screenings done, ask at your next yearly physical with your primary care provider or annual appointment with your OB/GYN.
Despite misconceptions, heart disease remains the No. 1 killer of women in the United States. “We need to be thinking about it, for ourselves, our mothers, our sisters, our daughters,” Lau said. It’s also “a lifelong disease process,” not something that typically develops overnight, she added, which means that “prevention needs to be lifelong, too.”
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