At first, no one thought Nina White had a heart attack.
Every detail of that day 10 years ago, when she was just 51, is sharp in her memory. She thought the tightness in her chest was overexertion from multiple trips up the ladder to the attic in her Portsmouth, Va., home. Her husband thought it was indigestion from tacos.
But her sister, who has a medical technology background, urged her to go to the emergency room and get a blood test that can detect heart attacks for a brief period. When she got there, even the doctor told her he didn’t think she’d had one.
Then, the test came back positive for troponin, a protein released when the heart is damaged.
Heart disease is the leading killer of women as well as men, but it’s often under-recognized in women, said Dr. Dena Krishnan, White’s cardiologist for the past two years. Krishnan practices at the Bon Secours-affiliated Cardiovascular Specialists clinic in Suffolk, Va.
“What you notice is women tend to have had symptoms for longer,” Krishnan said. “It’s really bad by the time they come to seek help.”
New research may help explain the complex reasons why heart risk increases sharply after menopause. Now, there’s evidence that as their estrogen drops, women’s risk rises faster than that of men the same age. Arterial plaque increased twice as fast on average in postmenopausal women than in men with similar demographics and medical status, according to research presented at an American College of Cardiology conference based on a study of 579 postmenopausal women.
Doctors have long known that estrogen seems to provide protection against heart disease. But it’s hard to pinpoint how menopause interacts with other risk factors, such as genetics and lifestyle, in part because its onset and length vary so significantly among women.
“What this more recent study was showing is that we have some preventative testing that we can do to look at otherwise low-risk women, say ages 40 to 70, and see, is there anything else they should be doing?” Krishnan said.
White thought she was low risk. Other than her grandmother, whose heart attack the family attributed to smoking, she wasn’t aware of any family history of heart disease. Neither of her two older siblings had been diagnosed with it then.
But White said she had a hysterectomy at age 42 due to severe endometriosis, a painful condition in which uterine tissue grows outside of the uterus. The effect a hysterectomy has on estrogen production depends on what exactly is removed; if the uterus and both ovaries are removed, “surgical menopause” begins immediately. But even if only the uterus is removed and both ovaries remain, research shows that menopause is likely to begin earlier.
“It is very complex, because we know that estrogen impacts so many things,” Krishnan said, mentioning vasodilation, or the widening of the arteries, and preventing insulin resistance, among other benefits. “So, they’re looking at all different reasons you may not have enough estrogen.”
Many women think the obvious solution would be to take estrogen, Krishnan said, but it’s not that simple. Depending on an individual’s medical history, taking estrogen could possibly increase inflammation or blood clots or even contribute to developing cancer.
“That’s what makes it so unique for every woman on how to manage their risk,” Krishnan said.
Women’s symptoms during a heart attack are more likely to include dizziness, fatigue and nausea, but women are also more likely to dismiss chest pain as indigestion or overexertion, Krishnan said.
Almost every woman who has a heart attack tells Krishnan they didn’t realize it was happening. Many have said they just thought their bra was too tight. But if women are feeling pressure or heaviness in their chest during average activities, such as cleaning the house, bringing in the groceries or making the bed, that could be cause for concern, she said.
That doesn’t mean exertion should be avoided. Regular exercise is one of the best ways to protect against heart disease, Krishnan said, adding that in animal models, aerobic training has been shown to mitigate the effects of estrogen loss.
“A lot of people think, ‘It’s out of my control. It’s just what it is. Every woman in my family gets diabetes and hypertension.’ And that’s not true,” she said. “Staying physically active is so essentially important.”
