A Woman’s Guide To Heart Health: Symptoms, Labs, & Lifestyle

Feeling strong isn't just about how much you can lift; it's about how well your body functions and supports you over time. And at the center of that system? Your heart.

For too long, the default image of someone having a heart attack has been male: crushing chest pain, collapsing to the ground. But women's experiences with heart disease are often very different, and far more subtle. Especially around midlife, as hormone levels shift and protective estrogen wanes, cardiovascular risk spikes. And many women are unaware of how to read the signs.

"There are signs and symptoms that can go unattended and disregarded if not connected to potential heart issues," explains Jessica Shepherd, M.D., board-certified GYN, menopause expert, and author of Generation M. 

"Women often report fatigue, shortness of breath with exertion, indigestion, or sleep disturbances—symptoms that can be dismissed as stress, aging, or even menopause itself. But these can also be subtle signs of underlying heart disease.”

The numbers tell a sobering story:

Historically, cardiovascular research centered on men. As a result, clinical guidelines, diagnostic tools, and even symptom checklists were not designed for women. This leads to misdiagnosis and under-treatment. 

Perimenopause represents a critical turning point in a woman's cardiovascular health trajectory. Estrogen has a protective effect on blood vessels, helping to keep them flexible and reducing the buildup of plaque. Once levels decline during perimenopause and menopause, women face a sharp rise in risk, even if they don't fit the "classic" profile for heart disease.

"Women in midlife are often balancing multiple roles—caring for aging parents, supporting children, managing careers, and carrying the invisible 'mental load,'" notes Shepherd. 

Chronic stress wreaks havoc on your cardiovascular system by:

Forget everything you think you know about heart attacks. Women are more likely to have heart attacks without chest pain. Instead, watch for these often-dismissed symptoms:

Immediate warning signs include:

Women tend to experience coronary microvascular dysfunction, which affects the heart's smaller vessels. These don't show up on standard angiograms and often present as vague, diffuse symptoms that are easy to brush off. 

Women of all ages, especially younger women, are more likely than men to develop this type of heart disease.

In microvascular disease, the heart doesn't receive as much blood as it needs to do its job well. Patients may sense this as discomfort or pain in the chest, or in another area of the upper body, or as shortness of breath or fatigue. 

What makes diagnosis particularly challenging is how these symptoms overlap with everyday life and aging: fatigue, anxiety, insomnia—these can be chalked up to aging, stress, or hormonal changes. But sometimes, they're red flags for underlying heart issues.

"For example, what feels like acid reflux could actually be angina. Listening closely to your body and noticing when symptoms persist or worsen is key," explains Shepherd. 

Women are also more likely to carry invisible burdens, whether it’s the mental load, caregiving responsibilities, or chronic stress, that quietly chip away at cardiovascular health. Add in the fact that poor sleep and metabolic changes become more common during perimenopause, and the risk only compounds.

Women's bodies aren't just smaller versions of men's; they're physiologically different. Acknowledging this is essential to equitable care. These differences extend to how heart disease manifests, how symptoms present, and how risk should be assessed.

"Even doctors sometimes are unable to recognize menopause symptoms, which can lead to major effects on well-being," Shepherd points out. 

Being proactive is essential. Start tracking your cardiovascular risk factors before problems arise.

Essential metrics to monitor:

Beyond standard tests, specialized screenings like Coronary Artery Calcium (CAC) scans or lipoprotein(a) tests can provide invaluable information about your personal risk profile. 

A CAC scan is a simple, noninvasive imaging test that uses a CT scanner to assess the level of calcification in your coronary arteries. Calcium buildup in these arteries can be an early warning sign of heart disease. The test provides a clear number (your "calcium score") that can help guide lifestyle changes and treatments.

Lipoprotein(a), on the other hand, is a genetically determined type of cholesterol particle that doesn’t respond much to diet or lifestyle changes. Elevated levels can increase cardiovascular risk, even when other cholesterol numbers look normal, making it an especially important marker for women with a family history of early heart disease.

Taking control of your heart health requires a multifaceted approach. Here's a comprehensive action plan to guide you.

What to track:

Start by monitoring key health metrics regularly. Target values provide concrete goals to work toward:

• Blood pressure (target: ~115/75 mmHg)
• Resting heart rate (typically 60-80 beats per minute is considered healthy)
• Blood sugar & A1C (fasting glucose below 100 mg/dL and A1C below 5.7%)
• Lipid panel & inflammation markers (particularly tracking LDL, HDL, triglycerides, and hs-CRP)
• Fitness metrics (VO2 max, grip strength, HRV)

What to change:

Based on these metrics, implement targeted lifestyle modifications:

1. Prioritize sleep: Aim for 7–8 hours and address insomnia. Sleep problems in midlife significantly raise the risk of heart disease later on. Women with persistent insomnia symptoms were 70-75% more likely to develop heart disease compared to those with low or no insomnia symptoms.

"Anywhere from 35% to 60% of women in postmenopause experience sleep disturbances and conditions like insomnia and sleep apnea. This is partially attributed to those low sex hormone levels triggering night sweats,” Shepherd notes.

2. Eat for metabolic health: Focus on fiber-rich, anti-inflammatory, protein-forward meals. The Mediterranean diet is widely regarded as one of the best for heart health. 

Incorporate extra-virgin olive oil, nuts, and seeds for healthy fats; fatty fish like salmon and sardines for omega-3s; leafy greens and berries for antioxidants; and fiber-rich beans and whole grains to support blood sugar and cholesterol levels.

3. Move with intention: Incorporate daily walks, strength training, and zone 2 cardio into your routine. "I encourage strength training because preserving muscle helps with metabolism, blood sugar, and overall heart health," advises Shepherd.

4. Manage stress: Practice meditation, breathwork, therapy, or spend time in nature. "Chronic stress activates the body's fight-or-flight system, leading to higher blood pressure, inflammation, and disrupted sleep," explains Shepherd.

Effective advocacy is crucial for women's heart health. Shepherd advises, "Women should be encouraged to keep a detailed record of their symptoms, including when they occur and what triggers them. Bringing this information to an appointment makes it harder to dismiss.”

Prepare for your appointment by having these questions ready:

Heart disease in women often whispers before it shouts. By understanding the subtle, silent signs, women can take action before a crisis occurs. Particularly during perimenopause and beyond, when estrogen's protective effects wane, vigilance becomes even more critical.