Health Advice Agnes Oblas

Women are different from men. Physiologically speaking, hormonal differences begin at conception; sex hormones influence physiologic development through all ages from infancy, puberty, the reproductive years, and continuing for longevity. A man and a woman can both become body builders, but the differences in each one’s musculature, skeletal physiology or neurologic physiology will remain different. The list of physiologic differences can go on, but one of the most interesting new bits of knowledge is the greater understanding that even cardiovascular (having to do with the heart and blood vessels) physiology is different between the male and the female of our species.

A greater awareness is coming about that when a woman is involved, she may not only experience the symptoms of heart disease differently than her male counterpart, but her symptoms may differ from what was once thought to be universally recognizable cardiac symptoms. Women may recover differently after cardiac surgery and women may develop different late effects of heart disease. All this is because of the different cardiac physiology. Heart disease in men typically involves the larger blood vessels of the heart, whereas for women, heart disease may only involve the smaller vessels of the heart.

The average life span of a woman exceeds the average life span of a man even with heart disease being the No. 1 killer in our society. The female sex hormone, estrogen, had been assumed for many years to serve a protective function for the woman against the development of heart disease. And because of this theory, prescribers believed that continuing the heart’s exposure to this hormone in the way of hormone replacement therapy even post-menopause (that period of a women’s life when her ovaries no longer produce this hormone) would continue to protect. This practice was based on the known fact that pre-menopausal women simply did not experience heart disease at the same rate as same age-matched males. Besides helping a post-menopausal woman to deal with hot flashes, irritability, fatigue and vaginal dryness, the prescribing of hormone replacement therapy was assumed to offer secondary gains of continued protection against the development of heart disease.

As medical science gained greater understanding of the subsets of cholesterol metabolism known as HDL (“good cholesterol”) and LDL (“bad cholesterol”), we learned that LDL levels tend to rise as women begin to lose their estrogen. In a sense, post-menopausal women are dealt a double whammy in that they no longer have estrogen to protect their hearts; they now also have higher LDL levels to contribute to the development of heart disease. It would seem to make sense to continue estrogen replacement exogenously (in pill form) for post-menopausal women indefinitely

Unfortunately, this practice has fallen out of favor recently for a variety of reasons, one of which is that we now know that it’s cardio-protective benefits beyond five years of therapy no longer exerts such an influence and, in fact, may be detrimental to the woman’s health for a variety of other reasons. The dilemma, however, is that we cannot allow the atherosclerotic (hardening of the arteries) effects of elevated LDL levels to go unchecked either.

Post-menopausal women whose LDL levels have risen over the years without being addressed are at risk for developing heart disease on a par with age-matched males. Yet, while women seem to be catching up to men in the development of heart disease, they are not being discovered or treated at the same rates as men.

Remember that the heart has its own supply of blood and oxygen by way of arteries that lie on the surface of the heart, some being larger and some very small. Researchers are not sure why, but women are more likely to develop heart disease involving the small vessels. Generally speaking, the larger heart vessels in men become narrowed because of atherosclerosis and “hard plaques” of fatty deposits building up and leading to decreased blood flow. This causes the crushing pressure-type of chest pain known as angina. In women, on the other hand, the smaller vessels become blocked before the larger ones, so their angina is more likely to be vague and felt as fatigue, nausea and/or dizziness. A women’s symptom complex of heart pain can frequently be less dramatic and therefore draw less attention and less urgency. When women seek care, their providers may be misled by the symptoms and a diagnosis of heart disease may be missed. In fact, a large proportion of women who have a first heart attack would say they never had any warning symptoms.

So, what are women to do?

Women need to realize that they, unlike previous generations of women, will have many more years ahead of them living without the protective effects of estrogen. Women need to be proactive and make sure that a cardiac workup is considered if they experience vague symptoms that don’t add up to another diagnosis or respond to other therapies. The vague symptoms of “dis-ease” may actually be your signature cluster of cardiac symptoms.

Whereas the Framingham Risk Factor analysis is an excellent tool for estimating the risk for a heart attack in men, it falls short in accuracy for women. A newer tool is the Reynolds Risk Score that includes parameters to increase accuracy for women. It is a simple questionnaire, but it substantially improves the ability to predict cardiovascular risk in women, so much so that if used consistently, 20-25 percent more women at higher risk for heart disease could be identified early and then offered preventive therapies.

The standard angiogram may not be a sufficient diagnostic tool for women who experience chest pain. Instead, the Calcium Heart Scan may provide useful information as it identifies atherosclerosis in the smaller vessels. The heart scan is a simple, non-invasive, affordable screening test for women to consider if they are deemed to be at risk for heart disease.

Treatment for “small vessel” disease includes much of the standard heart disease therapies with some additional modalities; but open-heart surgery is not one of them. The bottom line is for women to start taking care of themselves by partaking in a healthy diet, making time for aerobic exercise several times a week, learning how to deal with life’s stresses, making time to get adequate rest/sleep, and getting regular checkups.

As always, questions and comments are welcome.

• Agnes Oblas is an adult nurse practitioner with a private practice and residence in Ahwatukee Foothills. For questions, or if there is a topic you would like her to address, call (602) 405-6320 or email Her website is

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