Cardiovascular Diseases and Women's Reproductive History: What’s the Connection?

Cardiovascular diseases (CVD) are the leading cause of death for both men and women. In Europe, deaths due to CVD surpass those related to cancer and affect women more significantly than men, accounting for 45% of female deaths compared to 39% of male deaths.

In 2021, cardiovascular diseases (CVD) caused over 217,000 deaths in Italy, with approximately 122,000 women and 95,000 men affected.

This trend highlights the urgency of focusing on CVD prevention in women, as advocated by the European Society of Cardiology (ESC) and the international scientific community.

Over the past 10 years, there has been no improvement in reducing the risk of cardiovascular diseases in women, especially among younger women (under 55).

This differs from the progress observed in young men and older women and underscores a lack of attention to women's reproductive history in the management of cardiovascular diseases, in terms of diagnosis, care, and treatment.

Although men and women share many traditional cardiovascular risk factors (hypertension, smoking, hypercholesterolemia, obesity), the influence of these factors varies by sex.

In women, hormonal influences on metabolism and body composition play a significant role.

Premenopausal women with a normal menstrual history are less likely to develop insulin resistance, hyperglycemia, and obesity compared to men.

The Protective Role of Female Hormones

Estradiol, a hormone produced by the ovaries, has a protective effect against arterial hypertension and inflammation.

However, after menopause or ovary removal, the increase in fat mass and inflammatory markers, along with elevated cholesterol and fatty acids, leads to an increased cardiovascular risk.

Menopause and Cardiovascular Risk

Traditionally, menopause has been considered the critical moment when cardiovascular risk increases for women.

However, the ARIC (Atherosclerosis Risk in Communities) Surveillance study has shown that acute myocardial infarction is also on the rise among younger women (35-54 years), suggesting that other risk factors, present even before menopause, deserve attention.

Certain risk factors unique to women contribute to an increased cardiovascular risk. These include:

• Early menarche (<11 years of age)
• Early menopause (<40 years of age)
• Polycystic ovary syndrome (PCOS)
• Endometriosis
• Hypothalamic amenorrhea
• Hypertensive disorders of pregnancy
• Gestational diabetes
• Preterm birth
• Recurrent miscarriage
• Fetal birth weight (low or high)
• Oral contraceptives
• Hormone replacement therapy

To assess cardiovascular risk in women, collaboration between specialists (cardiologists, gynecologists, endocrinologists, neurologists, nutritionists) is essential for accurate and personalized risk stratification throughout all stages of a woman’s life.

Women with pregnancy disorders, such as late pregnancy complications, or other risk factors should be evaluated early for an accurate risk assessment and receive guidance on healthy lifestyle choices, regular examinations, and, if necessary, targeted therapies.

“We need to investigate thoroughly through a comprehensive medical history, including reproductive life, and utilize specific imaging markers, such as carotid intima-media thickness and quantification of epicardial fat. Women should:

• Receive appropriate lifestyle guidance (dietary habits, increased physical activity, smoking cessation, stress management);
• Be educated to take care of themselves through regular blood pressure monitoring, weight and waist circumference checks, and targeted blood tests;
• Receive proper therapeutic recommendations, if necessary.

All this should be done with a focus on personalized prevention, while we await updates to current risk charts to include lesser-known but likely crucial risk factors for women’s cardiovascular health,” says Dr. Castelvecchio.