Tackling the #1 Killer of Women

This week, I appeared on The View to talk about two topics that directly affect us all: heart disease and hormones. I am the daughter of a cardiologist, and thus, an interest in and awareness of cardiovascular disease is literally in my blood. Here’s a fact I need you to know: one in three women will die of heart disease.

I want you to really sit with that for a second, because most women I talk to have absolutely no idea that is the reality. Heart disease is our biggest risk. Not breast cancer. Not a stroke. Heart disease is the number one killer of women in this country, accounting for roughly one death every 80 seconds. And yet it remains one of the most underfunded, underdiagnosed, and undertreated conditions in women's health.

As an OBGYN, I’ve always believed that some of the most important windows into a woman’s long-term health happen in those exam rooms. Pregnancy complications, menopause symptoms, and blood pressure changes are not isolated events. They are clues to disease states and opportunities to improve health. But too often there’s a big gap: cardiologists don’t understand OBGYN conditions, and OBGYNs often don’t know how best to screen for heart disease.

That gap has always bothered me, which is why I am so proud to share that my husband, Tom, and I have joined a new initiative specifically aimed at closing it through continued education and better access to cardiovascular care for women by including their OBGYNs. This work feels deeply personal to me, and I want to bring you along for it.

So let's talk about what is actually going on, because the conversation around women and heart disease is far more nuanced than most people realize.

Why Women Are Different (and Why That Matters)

For decades, cardiovascular research was almost exclusively conducted on men. The symptoms we learned to recognize, the treatments that were developed, the risk thresholds that were established, all of it was built around the male body. Women often present differently. We are far more likely to experience atypical symptoms like jaw pain, nausea, back pain, or profound fatigue rather than the dramatic chest-clutching image we have all seen on television. Because of that, women get missed. We get sent home from emergency rooms. We get told it is anxiety. We are underscreened, under tested, undertreated, and understudied. The consequences of that are fatal.

What changes after menopause is significant, too. Before menopause, women actually have a lower risk of cardiovascular disease than age-matched men. Estrogen appears to play a genuinely cardioprotective role, supporting healthy cholesterol levels, insulin sensitivity, and arterial function. Once estrogen drops, that protective advantage disappears, and CVD risk climbs sharply. This is not a coincidence.

The HRT Conversation We Need to Have

I want to talk about hormone replacement therapy (HRT) here, because the research is nuanced, the history is complicated, and too many women are making decisions based on fear rather than facts.

Most of the confusion traces back to 2002 and the Women's Health Initiative study, which for years led both doctors and patients to believe that HRT was dangerous for the heart. What we now understand is that the timing of when HRT is initiated matters enormously. The Women’s Health Initiative enrolled women with an average age of 63, many of whom already had subclinical cardiovascular disease. When researchers went back and looked specifically at women who started HRT closer to menopause, the picture looked very different. In other words, the risks involved for a woman of 46 or 50 are much different than the risks involved for a woman of 63 or 70.

A large meta-analysis showed that women who initiated HRT before age 60, or within 10 years of menopause onset, had a statistically significant 32% reduction in coronary heart disease events and meaningful reductions in all-cause mortality compared to placebo. This is what researchers now call the "window of opportunity," and another landmark analysis confirms that the earlier you act within that window, the more pronounced the benefit. The data is consistent across both randomized controlled trials and observational studies.

Then there is the question of how HRT is delivered, and this is where things get really important for the decisions you are making with your doctor. A major 2024 Swedish study published in the BMJ, drawing on data from over 900,000 women, found that transdermal forms of estrogen (meaning patches, gels, and creams) did not carry the same cardiovascular risks as certain oral combined hormone therapies, which were associated with a modestly increased risk of ischemic heart disease. Transdermal estrogen showed no clear increase in any cardiovascular outcomes, and in fact suggested a borderline reduction in both heart attack and composite CVD risk. That is a meaningful distinction and one that is not making its way into enough conversations between women and their doctors. (The lowered heart risk is likely a result of the fact that when a hormone is delivered through the skin, metabolism by the liver is bypassed, which LOWERS the risk of clotting that is seen with all hormonal formulations- including birth control pills.)  

None of this is a blanket endorsement of HRT for everyone. Route of administration, type of progestogen, dosage, timing, and your individual health history all factor in. This is not a one-size-fits-all conversation, which is exactly why you need to be having it directly with your physician rather than relying on what you heard from a friend or read online from a menopause influencer.  But I do want you to walk into that appointment informed, because the science is moving in a direction that is far more favorable than the fear-based messaging of the early 2000s suggested.

What You Can Do Right Now

Whether or not HRT is right for you, there are foundational habits that move the needle on cardiovascular health significantly, and they are things you have control over starting today. Remember: 80% of heart disease can be prevented with behavioral modification. The key is knowing what to modify!  

1. Know your numbers. Blood pressure, fasting blood sugar, and a full cholesterol panel, including LDL, HDL, and ideally lipoprotein(a), which is sometimes called the heart's quiet killer and is significantly underscreened in women. Knowing cholesterol particle size is also important and is really just beginning to be considered in risk assessment. These are not just numbers on a lab report. They are your early warning system.
2. Move your body consistently. Resistance training in particular is one of the most underutilized tools for cardiovascular health in women (and it is something we work on directly inside The Wellness Experiment.) Aerobic exercise is needed too; it’s not either / or.
3. Prioritize sleep and manage chronic stress. Inflammation is a very real cardiovascular risk factor that does not get nearly enough attention in women's health conversations. Sleep helps reduce inflammation, as do prescription medications like statins and GLP-1’s. More on this in next week’s newsletter!
4. Eat in a way that supports metabolic health. Blood sugar stability, adequate protein, fiber-rich meals, all of it feeds back into your heart health in ways that compound over time.

And please, advocate for yourself at every single appointment. Ask about your cardiovascular risk. Push for a full workup. Ask if you can get a CAC CT scan to check for calcium deposits in your coronary arteries. Do not accept "you're fine" without the data to back it up.

This is the work. And this is exactly why Tom and I said yes to supporting this initiative. I believe deeply in continued education, not just for myself but for our entire field. Medicine evolves, science evolves, and if we are not actively learning, we are falling behind for the women we are here to serve.  

This initiative is rooted in that commitment to staying current, connecting specialties, and ensuring that OBGYNs and Cardiologists are equipped with the most up-to-date cardiovascular and menopause knowledge so we can identify risk earlier, intervene sooner, and ultimately save lives and truly change the trajectory we’re on.

In short, if we reach women sooner and connect these dots sooner, we can prevent heart disease, and improve, and save lives.  

This is the work that keeps me thinking at night and gets me up in the morning. And I’m so grateful to have you here for it! More to come, but I hope this is a starting point for a conversation you carry into your next doctor's visit.

From my heart to yours, thank you.
Xx

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