The hidden heart: Why women’s cardiovascular health needs a new approach

By Dr. Ashley Riskin, MD The good news? Heart disease is treatable. The bad? It often remains underdiagnosed and undertreated in women, making it a leading cause of mortality among females. While cardiovascular disease has long been framed as a “man’s disease,” 20 to 25% of female deaths are attributed to heart disease. Women’s heart disease has often gone unrecognized by both patients and healthcare providers, leading to delayed diagnosis, worse outcomes, and preventable deaths. Through both functional medicine and longevity science, we have an opportunity to shift this harmful paradigm. Rather than waiting for disease to manifest, we can identify cardiovascular risk factors early, understand the unique biological factors that influence women’s heart health, and implement targeted, prevention-focused strategies that optimize long-term vitality. How heart disease presents differently in women The classic heart attack, including crushing chest pain radiating down the left arm describes the typical male presentation. Women, however, experience subtly different symptoms that are often dismissed or misattributed to anxiety, stress, or gastrointestinal issues. Common presentations include subtle chest discomfort (rather than acute pain), shortness of breath without chest pain, fatigue and weakness, nausea, jaw or neck pain, and palpitations. Women are significantly more likely than men to experience coronary microvascular dysfunction (CMD), where the small blood vessels of the heart don’t function properly. Critically, traditional coronary angiography may appear completely normal in CMD, yet the patient experiences real ischemia and symptoms, a disconnect that has historically led women to be labeled as having “non-cardiac” chest pain when they actually have genuine cardiac pathology. Women’s cardiovascular health is uniquely influenced by hormonal fluctuations across the lifespan. Estrogen provides cardiovascular protection through multiple mechanisms: improving endothelial function, reducing inflammation, and promoting vasodilation. The dramatic decline in estrogen during menopause coincides with a sharp increase in cardiovascular risk. Additionally, pregnancy complications like gestational diabetes and preeclampsia signal underlying metabolic and endothelial dysfunction, predicting future cardiovascular disease risk. Why women’s heart disease is under-recognized Most cardiovascular research has historically focused on men, leaving significant gaps in understanding how disease presents in women. Risk prediction tools, diagnostic criteria, and treatment guidelines have been male-centric, potentially missing important female-specific risk factors. Coupled with provider bias, where women’s cardiovascular symptoms may be attributed to psychiatric causes and the fact that women’s risk profiles often differ from men’s (driven more by metabolic syndrome, autoimmune conditions, depression, and inflammatory markers rather than LDL cholesterol alone), the result is systematic under-recognition. Functional medicine and longevity approach to prevention Rather than waiting for disease to develop, functional medicine takes a proactive, systems-based approach to cardiovascular health. Comprehensive metabolic assessment: Beyond standard lipid panels, we assess advanced lipid profiles (particle size, apoB, Lp(a)), inflammatory markers (hs-CRP), metabolic markers (fasting insulin, glucose tolerance, HbA1c), endothelial function markers (homocysteine), and hormonal status. This deeper insight reveals root causes of cardiovascular risk. Endothelial function optimization: The endothelium, which is the inner lining of blood vessels, is fundamental to cardiovascular health. When compromised, inflammation increases, blood vessels stiffen, and clotting risk rises. Functional approaches include optimizing nitric oxide production, managing oxidative stress through targeted antioxidants and support for natural antioxidant production (SOD, catalase, glutathione), optimizing blood flow through exercise, and addressing chronic inflammation through diet. Precision nutrition and metabolic optimization: Rather than one-size-fits-all recommendations, functional medicine uses metabolic assessment to guide personalized nutrition. This may include anti-inflammatory dietary patterns, omega-3 optimization, blood sugar stabilization, micronutrient sufficiency (magnesium, potassium, B-vitamins, vitamin D), and personalized carbohydrate tolerance assessment. Movement and stress resilience: Exercise is one of the most powerful cardiovascular interventions, yet should be individualized, combining aerobic conditioning, resistance training, and flexibility practices, aligned with hormonal cycles and stress levels. Chronic stress is a significant cardiovascular risk factor in women, particularly given their greater reactivity to psychosocial stressors. Evidence-based stress management includes mindfulness practices, sleep optimization, social connection, and trauma-informed approaches. Hormonal balance across life stages: Women’s cardiovascular risk evolves throughout their lifespan. Functional medicine addresses risk in reproductive years (optimizing estrogen metabolism), perimenopause and menopause (supporting healthy estrogen decline, individualized HRT assessment), and postmenopausal years (metabolic and inflammatory optimization). For women, hormonal health is cardiovascular health. Targeted supplementation: Based on individual assessment, targeted supplementation can support cardiovascular health, such as CoQ10 for mitochondrial function, magnesium for vascular tone, omega-3 fatty acids for inflammation, plant polyphenols for antioxidant support, and L-arginine/L-citrulline for nitric oxide production. No longer hidden Women’s cardiovascular health deserves to be understood on its own terms, not as a hidden subset of men’s heart disease, but as a distinct biological reality requiring nuanced assessment and personalized prevention tactics. By shifting patients and healthcare providers from a disease-management model to a prevention-focused, longevity-based approach, we can better identify risk early, address root causes, and help women thrive throughout their lives. Dr. Ashley Riskin, MD, is clinical co-director and co-founder of Connect Health Centre for Integrative and Functional Medicine. connecthealthcare.ca