Cardiovascular disease (CVD) is the leading cause of death in both men and women. More women than men die from heart disease, stroke, and other types of CVD—yet women don’t realize they’re at risk. What’s more, death rates have fallen more slowly in women than in men over the past 25 years.

The relationship between heart disease and the female reproductive system often is overlooked. Uncertainty still surrounds this issue. Also, the role of estrogen in heart disease isn’t well understood. Epidemiologic studies have found fewer cardiac events occur before menopause onset—an effect most likely related to relatively higher estrogen levels. On the other hand, low estrogen levels, oral contraceptive use, and stress have been linked with CVD. Some studies show a link between irregular menstruation and later development of CVD. Others have found a link between complicated pregnancies and later CVD.

Healthcare professionals should teach women about CVD risk factors and how to lower their stress levels (especially during childbearing years). As a nurse, you should strive to develop a holistic, comprehensive care plan for patients—one based on the current evidence and practice guidelines. The American Heart Association and American College of Cardiology offer practice guidelines and a wealth of other information at http://my.americanheart.org/professional/StatementsGuidelines/ByTopic/TopicsA-C/ACCAHA-Joint-Guidelines_UCM_321694_Article.jsp.

In the past, most studies on CVD were conducted on male patients, with researchers assuming the results would apply to females. But we now know that’s not a valid assumption. Recently, more studies have focused specifically on women. Some have found that signs and symptoms of myocardial infarction (MI) and stroke are different in some women than men; nonetheless, some women have the same manifestations as men. (See the box below.)

Hormone replacement therapy and CVD

Until about 10 years ago, hormone replacement therapy (HRT) was commonly prescribed for menopausal women to relieve menopause symptoms and protect against cardiovascular problems and osteoporosis. But the Women’s Health Initiative, a large clinical study, demonstrated that HRT has no benefits in preventing CVD and may increase CVD risk. Reevaluation of this study, as well as more recent studies, suggest that starting HRT during the perimenopausal and early postmenopausal periods does have cardioprotective effects, whereas for women in late postmenopause, HRT could be detrimental at worst or ineffectual at best.

The role of HRT is still being debated, with benefits and risks under evaluation. Certain studies indicate a link between HRT and decreased coronary heart disease; some evidence shows that starting HRT early in the postmenopausal period has the greatest effect. These mixed findings underscore the need for more studies of HRT and its effects on the cardiovascular health of women of all ages. Women considering HRT should consult their healthcare provider to discuss its benefits and risks and learn about treatment options.

Pregnancy complications and CVD

Some studies suggest a link between complications during pregnancy and later CVD development. A 2012 study posits that women with a history of preeclampsia are at increased risk for ischemic heart disease, hypertension, and other types of CVD later in life. Although preeclampsia prevention may not be possible, early identification and treatment of at-risk women is vital.

Irregular menstrual cycles and CVD

While we know a woman’s CVD risk rises after menopause, some studies have found that pathologic changes, such as atherosclerosis, begin during premenopausal years, especially in women with ovarian dysfunction. Furthermore, normal ovarian function is cardioprotective, whereas autopsies of women as young as age 34 found that even mild changes in ovarian function increase CVD risk. Effects of these pathologic changes and CVD incidence commonly don’t arise until after menopause.

In a large study that followed 28,000 women in Denmark for a decade, subjects with irregular menstrual cycles were 28% more likely to develop CVD than those with regular menstrual cycles. In a 2007 study, menstrual and reproductive factors (along with smoking) increased a woman’s risk of nonfatal MI. Although women may not be able to change their menstrual cycles, they can work to lower other CVD risk factors, such as smoking, obesity, and hypertension.

Oral contraceptives and CVD

Although many women have taken oral contraceptives with no adverse effects, these drugs have been linked to deep vein thrombosis, stroke, and MI—especially in women older than age 35 who smoke. When oral contraceptives were introduced in the 1960s, they contained large estrogen doses; these doses later were associated with blood clots, nausea, and weight gain. Over the years, studies found that much lower estrogen doses are just as effective. Today’s oral contraceptives have lower estrogen doses; many combine estrogen with progesterone.

In the last 50 years, many oral contraceptive studies have been conducted, with mixed results. While all oral contraceptives carry some risk, some pose more risk than others. In a recent review by the Food and Drug Administration, contraceptives containing drospirenone (a synthetic progesterone form) seemed to pose a higher risk of blood clots than other progestin-containing contraceptives. Drug labeling now includes a warning that drospirenone carries a threefold risk of causing blood clots in some women.

Oral contraceptive risks may be mediated by such factors as age, overall health, smoking history, and genetic and hereditary factors. One study showed a higher incidence of ischemic stroke in women with inherited prothrombotic conditions (including factor V Leiden, prothrombin G20210A, and methylenetetrahydrofolate reductase C677T genotype) who took oral contraceptives. This study was important because women aren’t routinely tested for inherited prothrombotic conditions before using these drugs and thus don’t realize they’re at greater risk for stroke. The risk of adverse effects of oral contraceptives increases with age and certain other factors, so the decision to use these drugs should be considered carefully.

The nurse’s role in preventing CVD

As a nurse, you’re in a prime position to teach women about reproductive health and CVD. Explain that because of the mixed research findings, further studies of the link between CVD and women’s reproductive health, HRT or oral contraceptive use, and pregnancy complications are needed. Emphasize that although a link exists, many women may never experience CVD.

Teach patients about CVD prevention strategies, early identification, and treatment. But take care not to cause alarm and anxiety; the added stress of worrying about CVD could increase a woman’s risk. Explain which CVD risk factors they can modify (weight, stress, physical activity, smoking, cholesterol, hypertension) and which they can’t (age, genetics, and heredity).

Collaborate with the patient and other interprofessional healthcare team members to develop an individualized education plan that covers risk factors and appropriate interventions. Include these key topics in the plan:

• signs and symptoms of MI and stroke
• dietary modifications, such as the DASH diet (Dietary Approaches to Stop Hypertension)
• weight management (losing weight if needed and maintaining a healthy weight, body-mass index, and waist circumference)
• cholesterol and triglyceride management
• smoking cessation
• reduced alcohol consumption
• physical activity (at least 30 minutes per day)
• stress management.

Deborah Hunt is an associate professor of nursing at The College of New Rochelle in New Rochelle, NY.

American Heart Association. Women and Heart Disease. Updated April 4, 2013. http://www.heart.org/HEARTORG/Advocate/IssuesandCampaigns/QualityCare/Women-and-Heart-Disease_UCM_430484_Article.jsp. Accessed September 5, 2013.

Bertuccio P, Tavani A, Gallus S, et al. Menstrual and reproductive factors and risk of non-fatal acute myocardial infarction in Italy. Eur J Obstet Gynecol Reprod Biol. 2007;134(1):67-72.

Gast GC, Grobbee DE, Smit HA, et al. Menstrual cycle characteristics and risk of coronary heart disease and type 2 diabetes. Fertil Steril. 2010;94;(6):2379-81.

Haque N, Salma U, Haque IJ, et al. The impact of stress on cardiovascular disease in pre- and post- menopausal women. Trends Med Res. 2011;6(4):246-57. http://scialert.net/abstract/?doi=tmr.2011.246.257. Accessed August 29. 2013.

Kaplan JR, Manuck SB. Ovarian dysfunction and the premenopausal origins of coronary heart disease. Menopause. 2008;15(4 Pt 1):768-76.

Mosca L, Benjamin EJ, Berra K, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women—2011 update: a guideline from the American Heart Association. Circulation. 2011;123(11):1243–62.

Shapiro S. Oral contraceptives, hormone therapy and cardiovascular risk. Climacteric. 2008;11(5):355-63.

Slooter AJ, Rosendaal FR, Tanis BC, et al. Prothrombotic conditions, oral contraceptives, and the risk of ischemic stroke. J Thromb Haemost. 2005;3(6):1213-7.

Stevenson JC. A woman’s journey through the reproductive, transitional and postmenopausal periods of life: impact on cardiovascular and musculo-skeletal risk and the role of estrogen replacement. Maturitas. 2011;70(2):197-205.

Wang ET, Cirillo PM, Vittinghoff E, et al. Menstrual irregularity and cardiovascular mortality. J Clin Endocrinol Metab. 2011;96(1):E114-8.

Williams D. Pre-eclampsia and long-term maternal health. Obstet Med. 2012;5(3):98-104.

Wilton JM. Oral contraception: new options. Nurs Women Health. 2011;15(5):431-4.