Women’s Heart Health and Estradiol Deficiency
When it comes to women’s health and hormones, it’s typical to think of sex hormone levels, periods, night sweats, bone loss, mood swings, and even cancer. Check, check, and check. But did you know awareness of heart health is just as — if not more so — important? In honor of American Heart Month, this issue of My 28 Days focuses on better understanding the importance of estradiol deficiency in adolescent young girls and women younger than 45 years.
Just last month, the American Heart Association (AHA) released its latest findings and, once again, heart disease is responsible for more deaths in women than all types of cancer combined, including breast, ovarian, uterine, and lung cancer. In fact, cardiovascular disease is the leading cause of mortality for women in the United States for the 14th straight year, accounting for 314,186 — or about one in five — female deaths in 2020.
It was in 2009 that The Heart Truth Campaign reported heart disease as the leading cause of death for women — up from 34 percent in 2000 to 69 percent in 2009. Yet, despite campaigns to educate women, which have spanned several decades (heart disease has been recognized as the leading cause of death in men since the 1950s), only 56 percent of women reportedly recognize it as their number one killer. Many women — especially younger and minority women — are unaware of the risk factors.
Women’s Hormone Health as Heart Health
For the most part, women’s risk factors for heart disease are similar to those for men — including age, high blood pressure, and high cholesterol, lack of physical activity, obesity, diabetes, smoking, and family history — but there’s one underreported risk factor that’s worth noting: estradiol deficiency.
In fact, research shows that once a woman’s estradiol levels decrease, her risk of developing cardiovascular disease increases — and it’s especially notable in younger women. In fact, heart disease investigators studying growing rates of cardiovascular disease in young women have found that an alarmingly high number of this population — more than two-thirds — have abnormally low estradiol levels.
The National Institute of Health’s (NIH) WISE (Women’s Ischemia Syndrome Evaluation) Study, initiated in 1996, provided many insights into these factors over several years. Included in its findings were that 69 percent of young women with coronary artery disease had low levels of estradiol compared with just 29 percent of their heart-healthy counterparts — and that low estradiol was associated with worse coronary artery disease.
“These findings make clear that estradiol in young women is an important component in keeping the heart healthy,” says Dr. Lawrence M. “Doc” Nelson. He is a former NIH physician and scientist and lead principal investigator on the NIH Intramural Research Program on Primary Ovarian Insufficiency (POI). “This makes it vital for women with POI to seek preventative primary care and to talk to their clinicians about necessary lifestyle changes and the option for physiologic hormone replacement therapy (P-HRT).”
Be on the Lookout
A woman’s heart attack is more likely to have symptoms of subtle and confusing discomfort rather than agonizing chest pain. Because women’s symptoms of heart disease often present differently than men’s, it’s important to recognize their subtleties. When having a heart attack, for instance, women might experience sudden and unusual shortness of breath or profound fatigue and heartburn rather than extreme chest pain.
Other symptoms women with heart disease might experience include:
- Nausea and dizziness
- Pain in the shoulder and upper back
- Atypical pain in the stomach or abdomen
- Cold, sweaty skin and paleness
- Swelling of the ankles or lower legs
- Irregular heartbeat
The Menstrual Cycle: A Vital Sign of a Woman’s Hormone Health
The lack of symptomatic knowledge makes it easy for women at increased risk for heart disease to miss detection by clinicians and even cardiologists. “Unless these women are specifically asked about their menstrual cycles as part of their preventive care, women with POI with estradiol deficiency can fly under the radar of detection and delay proper management,” Nelson said. “Additionally, most younger women don’t recognize missing periods as a legitimate cause for concern or a signal of a hormonal health problem. This is exactly why we must treat the normal menstrual cycle as a vital sign, similar to heart rate or respiration rate,” he added.
Nelson went on to say that clinicians need to not only ask about menstrual cycle history but also whether or not there have been any prolonged periods of missed cycles. “Many women are likely to be surprised by the menstrual cycle/heart health connection,” he said.
First and foremost, there are many traditional lifestyle choices women can make to help reduce their risks of cardiovascular disease, including following a healthy diet with reduced saturated fats, getting regular exercise, limiting alcohol intake and reviewing their family history of heart disease. It’s also important that women see their clinician regularly to monitor vitals like blood pressure, cholesterol levels and blood sugar. And if clinicians don’t ask about menstrual cycle regularity, women should bring it up.
“Early detection is essential to prevention,” Nelson said. “And lifestyle choices should be reviewed as a primary way to reduce risks.”
Women with the lowest risk of heart disease are those who:
- Avoid or quit smoking
- Lose weight and/or maintain their ideal body weight
- Participate in aerobic exercise for 30-40 minutes, three to five times per week
- Follow a diet low in saturated fat (< 7% daily amount); low in trans-fat (partially hydrogenated fats such as margarine or shortening); and high in fiber, whole grains, legumes (such as beans and peas), fruits, vegetables, fish, and folate-rich foods
- Treat and manage medical conditions such as diabetes, high cholesterol, and high blood pressure that are known risk factors for heart disease
Estradiol and Women’s Heart Health
Scientists continue to gather data on the actions of estradiol in the body. Studies have shown that estradiol influences almost every tissue or organ system, including the heart and blood vessels. The good news is that estradiol relaxes, smooths, and dilates blood vessels, and increases blood flow. Estradiol also soaks up free radicals (or naturally occurring particles in the blood that can damage the arteries and other tissues). For decades women have been misinformed about the risks and benefits of estradiol replacement, which makes the subject a difficult discussion in a 20-minute office visit. The major message is for women to take this subject seriously, educate themselves about the evidence, and advocate for themselves with their primary care team.