When Vikie Shanks collapsed during a day out in London with her daughter, she assumed her chest pain was indigestion.
‘I walked out of Covent Garden tube station and collapsed in agony with what felt like severe heartburn,’ recalls Vikie, 66, an autism campaigner and author.
‘I sat on the pavement for half an hour before it eased off enough for me to move.’
At the time, aged 59, she admits she ‘wasn’t overly alarmed’ as she’d had similar pains on and off for weeks which she’d ‘written off as indigestion’ — but it turned out to be something much more serious: a heart attack. Otherwise fit and healthy with normal blood pressure and cholesterol, it never crossed Vikie’s mind that her symptoms might relate to her heart — or that she was at risk because of the menopause.
‘I suppose I thought of heart attacks as a male issue,’ she says. ‘I had been fully menopausal for two years — but had no idea that menopause increases women’s risk of a heart attack.’
When Vikie Shanks collapsed during a day out in London with her daughter, she assumed her chest pain was indigestion
Vikie is not alone — three in five women have no idea the menopause can affect heart health, according to a 2022 study for the charity Heart Research UK.
And heart disease kills more than 23,000 women in the UK every year — this is double the death toll from breast cancer.
While younger women are less at risk of heart attacks than men, ‘after menopause, women’s risk of heart attacks and heart disease rises five-fold’, explains Vijay Kunadian, a professor of cardiology at Newcastle University and a spokesperson for The British Heart Foundation.
A study presented at an American College of Cardiology conference in April dramatically illustrated how fast women’s risk can increase post-menopause.
Researchers tracked 579 post-menopausal women taking statins to help control their cholesterol levels. Scans showed that over a year, despite the medication the women accumulated potentially deadly plaques in their arteries twice as quickly as men of the same age.
Plaques — made of fat, cholesterol and calcium — cling to blood vessel walls and harden over time, narrowing the arteries and restricting blood flow. They can also break off, forming a clot that can lead to heart attacks.
Worse, the risk factors for heart disease — such as high blood pressure and abdominal fat — seem to have a bigger impact on women post-menopause than on men at this age.
So what is the link between menopause and heart disease? The answer is oestrogen.
The hormone has ‘many powerful protective effects on cardiovascular health,’ says Professor Kunadian.
Not only is oestrogen a vasodilator, helping blood vessels to relax and allowing blood to flow more freely, it also helps remove inflamed cells that could grow into fatty plaques, he explains.
But ‘at menopause these protective effects disappear’.
When Vikie and her daughter Kacie, 23, returned to their home in Kenilworth, Warwickshire, Kacie demanded her mother see her GP.
On hearing Vikie’s symptoms — chest pain that went into her back, shoulder and arm — the GP gave her an aspirin, and referred her straight to hospital where she was admitted.
Vikie woke the next morning ‘in terrible pain’ and was diagnosed with a massive heart attack: one of the main arteries to her heart was blocked.
‘The “indigestion” pains I’d been experiencing were angina caused by my artery starting to close up,’ she says.
‘I had emergency surgery and was fitted with two stents to keep the artery open.’
Vikie’s heart attack ‘completely changed’ her life. Seven years on, she’s easily tired and takes statins, aspirin and calcium blockers to cut her risk of another attack.
‘It’s imperative women realise heart attacks aren’t just something that happens to men,’ she says.
Chris Gale, a professor of cardiovascular medicine at the University of Leeds, adds: ‘When we think of a person with a heart attack, we typically envisage a middle-aged man who is overweight, has diabetes and smokes. This is not always the case: heart attacks affect the wider population — including women.’
Risk factors more dangerous in women
Most of us know risk factors for heart disease include high cholesterol, high blood pressure, diabetes, smoking, stress and obesity — but less well-known is that these can be more dangerous for women than men.
Women under stress are at a significantly higher risk of heart disease than men in a similar situation, according to the American Heart Association.
It could be that stress causes women’s small peripheral arteries to tighten more than men’s, potentially starving the heart of oxygen, according to a study last year by Emory University in the U.S., involving women with an average age of 51.
There is also a connection with mood, says Amie Leckie, an adviser and specialist in menopause and heart health at Heart Research UK.
‘Around 20 per cent of women experience depression at menopause — and depression is linked to a greater risk of heart attacks in women than men for reasons that aren’t fully understood.’
Vikie is convinced her heart attack was linked to stress.
‘It happened on the tenth anniversary of the day my husband took his own life leaving me with seven children, six of whom had special needs,’ she says. ‘I was under relentless stress for years.’
Post-menopausal women under stress are also more likely to develop an irregular heartbeat, or atrial fibrillation (AF), increasing their risk of heart attacks and stroke, according to research in the Journal of the American Heart Association last year.
Symptoms include breathlessness and palpitations, but some have no signs at all.
Meanwhile, even if men and women have the same amount of plaque in their arteries, women are at higher risk of heart attacks because their arteries are narrower — so the same amount of plaque has a larger impact on blood flow, according to research by Leiden University Medical Centre in the Netherlands in 2023.
This helps to explain why high blood pressure increases a woman’s heart disease risk 80 per cent more than it does for men, according to the British Heart Foundation.
These narrower, less flexible arteries are also a reason why blood pressure increases in women after menopause.
Diabetes harms the heart because high blood sugar levels can damage blood vessels
Type 2 diabetes is also more common in women after menopause, partly because hormonal changes can lead to weight gain round the middle and higher blood pressure — both risk factors for type 2.
Diabetes harms the heart because high blood sugar levels can damage blood vessels. Type 2 diabetes increases women’s risk of heart disease 50 per cent more than in men, according to the British Heart Foundation.
Even raised blood sugar levels in the pre-diabetes range can make a woman more likely to develop heart disease than a man, suggests a 2023 study by the London School of Hygiene & Tropical Medicine and University College London.
Smoking is another risk. According to the British Heart Foundation, it increases plaque formation — a greater risk in women’s narrower arteries: women who smoke have a 25 per cent higher risk compared with male smokers.
Period problems harm heart later on
Gynaecological problems are also associated with an increased heart risk later in life — including polycystic ovary syndrome, which affects women’s hormones, and endometriosis (where tissue similar to the womb lining grows in other places, such as the ovaries).
‘Even having irregular periods can affect cholesterol metabolism and increase the risk of heart disease,’ says Professor Kunadian.
Pregnancy complications (including miscarriage and pre-eclampsia — high blood pressure) can be early warnings of future heart problems, too.
The demands of the foetus means more blood needs to be pumped around the mother’s body — effectively providing a ‘stress test for the cardiovascular system’ decades before heart attacks occur, says cardiologist Professor Angela Maas, author of A Woman’s Heart: Why Female Heart Health Really Matters.
Research also suggests that the 70-80 per cent of women who have menopausal hot flushes more commonly develop heart problems than women who don’t.
The worse they are — and the longer they go on — the greater the risk. This may be because hot flushes can be a sign a woman’s arteries are already stiff.
The SWAN study, a U.S. research programme that has monitored more than 3,000 women since 1994, found those who began the study with frequent hot flushes (six days a week) in peri-menopause had double the risk of heart attacks, stroke and heart failure later in life, even if they didn’t have risk factors such as high cholesterol.
Both early menopause (before the age of 45) and premature menopause (before 40) can also increase heart risks (because of less protection from oestrogen).
Professor Kunadian says: ‘We need to be proactive in monitoring women and offer them treatments for conditions such as high blood pressure, rather than waiting for them to have a heart attack, when it can be too late. Most heart disease is preventable.’
How to care for your heart after menopause
CHECK YOUR CHOLESTEROL
The body needs cholesterol to build healthy cells, but high levels can contribute to the build-up of plaque.
Healthy levels should be below 5mmol/L — Professor Kunadian says a woman’s levels can easily double from 3 to 6 post-menopause, without a change in diet or exercise habits due to dwindling levels of oestrogen, which regulates cholesterol production in the liver.
On average, menopause results in 10 to 15 per cent higher levels of ‘bad’ LDL cholesterol — and slightly lower levels of ‘good’ HDL cholesterol.
A Mediterranean diet (high in fruit and veg, fibre, unsaturated fats and oily fish) can cut women’s risk of heart disease by almost 25 per cent, says Marcela Fiuza, a dietitian in London.
‘Although it’s not known exactly why, the diet helps reduce inflammation, a crucial factor in preventing heart disease, and can help lower cholesterol levels and blood pressure.’
Professor Kunadian says post-menopausal women with high cholesterol may also need a higher dose of statins than men.
KNOW YOUR BLOOD PRESSURE
Untreated high blood pressure is the leading cause of heart disease in women.
Moreover, symptoms of high blood pressure — which can include hot flushes, night sweats, tiredness, poor sleep and palpitations — are often mistakenly attributed to menopause or stress, says Professor Maas.
The ideal blood pressure reading is between 90/60mmHg and 120/80mmHg: around a third of adults have high blood pressure and although men are slightly more likely to be affected overall, by the age of 65 more women have high blood pressure than men, due to lack of oestrogen and weight gain.
Professor Maas recommends testing your blood pressure at least annually from the age of 50 and discussing medication options with your GP if readings are consistently high.
Blood pressure testing is available in GP surgeries and local pharmacies — and at-home monitors are available to buy from about £20.
The proportion of women with salt sensitivity also doubles (from 22 per cent to 52 per cent) post-menopause. This causes blood pressure to rise quickly. The general advice is to cut salt to under 6g a day.
Gynaecological problems are also associated with an increased heart risk later in life
TACKLE MIDDLE-AGE SPREAD
Belly fat is ‘more harmful for women than men’, says Professor Kunadian.
Researchers who tracked 500,000 middle-aged Britons for seven years found that the women with more weight around their middles were 20 per cent more likely to have a heart attack than those who were heavier overall. But the same amount of belly fat only increased the risk in men by 6 per cent, reported the 2021 study in the Journal of the American Heart Association.
Meanwhile, a 2019 study found that just one extra kilogram of belly fat can increase a woman’s risk of type 2 diabetes more than seven times.
‘Loss of oestrogen causes fat to accumulate around women’s middles, regardless of how much they eat,’ says Professor Kunadian.
This is because our hormones determine where fat is stored, with oestrogen driving fat to the thighs and bottoms, where it is stored under the skin. However, the type that collects around the abdomen wraps itself around internal organs and pumps out inflammatory chemicals.
Your waist should measure less than half your height. If you’re 5ft 9in (175cm), for example, then your waist measurement should be less than 34in (87.5cm).
Weight loss and resistence exercise especially can cut abdominal fat. A 2023 study found post-menopausal women who did three weight workouts a week for 15 weeks lost abdominal fat.
MOVE MORE
The good news is that women may need less exercise to gain the same heart benefits as men.
New research in the Journal of the American College of Cardiology found that women who exercised for at least 150 minutes a week were 36 per cent less likely to have a heart attack or stroke, compared with a 14 per cent reduced risk for men who exercised the same amount.
Exercise helps by reducing blood pressure, improving insulin resistance (which affects blood sugar control) and improving cholesterol markers, says Amie Leckie.
Just 30 minutes of moderate-intensity walking, three times a week for three months, reduced ‘bad’ LDL cholesterol by 27 per cent and increased ‘good’ HDL cholesterol by 30 per cent, according to a 2015 study of postmenopausal women in the Journal of Exercise Rehabilitation.
