The female sex hormone, estrogen, plays a significant role in a girl’s development into a woman capable of bearing children. Estrogen is also important for cardiovascular health. “Estrogen helps the arteries stay flexible. It helps blood flow to be optimal. It keeps our cholesterol levels in check, and holds back inflammation,” says Maria Delgado-Lelievre, M.D., a cardiologist and founder and director of the Comprehensive Hypertension Center at the University of Miami Health System. All these effects support circulation and the heart.

“During perimenopause and menopause, the estrogen goes down. That cloud of protection fades to nothing,” she says. Women whose blood pressure or cholesterol levels had been normal before menopause often see those numbers rise after “the change.”

The past 50 years have seen remarkable strides in ways to prevent and treat heart disease, yet it remains the leading cause of death for women in the U.S. Only about half of women in the U.S. realize that, according to the Centers for Disease Control and Prevention.

Your estrogen level is only one factor among many that affect your cardiovascular risk.

There are many others, some of which you can influence.

All genders produce estrogen, but after puberty, women’s bodies make much more, and those higher levels confer strong protection.

Higher estrogen levels are one reason that women, at least early in life, are different from men in terms of cardiovascular risk. “Generally, men have a rapid rise in markers that lead to heart disease at younger ages, compared to women,” Dr. Delgado says.

“When estrogen levels decrease with age, that gives opportunities to other things to affect a woman’s cardiovascular health. Many women find that their blood pressure, which had always been low, goes up around menopause. Where they had been able to eat whatever they wanted without becoming prediabetic, they find their A1C is now high,” she says. A1C levels are an indicator of diabetes.

Estrogen does not protect all young women equally, though.  “Some very young women have high cardiovascular risk levels and experience events like heart attacks,” Dr. Delgado says.

And in recent years, although heart attack rates have been dropping among older adults, they have been rising in 35-to 54-year-olds, especially women, according to a significant recent study. The Atherosclerosis Risk in Communities Study analyzed more than 28,000 U.S. hospitalizations for heart attacks.

The researchers did not explore reasons for the increase in younger people. But they stated that it may reflect more young people today, especially women, having more risk factors for heart disease than they used to — high blood pressure, high cholesterol, and smoking.

Estrogen replacement is no longer used to prevent heart disease.

In the 1990s, doctors tried giving postmenopausal women estrogen to protect them from heart disease, figuring it had protected them before menopause.

“That was catastrophic. Women were taking estrogen while men were counseled to lose weight and control their prediabetes, blood pressure, and cholesterol. Women and men need to do the same things for cardiovascular prevention,” she says.

Today, doctors prescribe estrogen to reduce menopause symptoms such as hot flashes,  not to prevent heart disease.

“If a woman’s gynecologist prescribes hormone replacement for symptom relief, we still must monitor her blood pressure and cholesterol,” she says.

Estrogen is also sometimes used to treat osteoporosis.

Various factors influence estrogen’s decline.

Being overweight can speed up the body’s biological aging, leading to an earlier and more rapid decline in estrogen levels.

“You get older faster,” she says.

Besides estrogen, cardiovascular risk factors include your:

• diet
• exercise
• stress management habits

People often call these factors “lifestyle choices,” which suggests that individuals have full control over them. But if you are poor or belong to an ethnic minority, these factors are often not completely or even largely within your control. Today, researchers discuss these nonmedical “social determinants of health” as having a major impact.

You don’t choose your social determinants.

The health of every woman is shaped not only by biology but also by the world around her. The term social determinants of health describes the everyday conditions in which we are born, raised, work, and age.

These include:

• income stability
• education
• access to care
• neighborhood safety
• the strength of our social connections

For many women, these influences quietly set the stage for cardiovascular health long before any diagnosis appears. When healthy foods are hard to find, when there are no nearby parks or safe spaces to exercise, or when stress and sleeplessness become constant companions, the heart carries much of the burden. Add limited healthcare access or lack of insurance, and prevention often falls into the background.

Protecting women’s hearts means looking beyond medications. It requires access to prevention, healthier environments, and the support needed to balance the demands of work, family, and wellbeing. By improving the conditions that surround women’s daily lives, we also strengthen the foundation for lifelong cardiovascular health.

Throughout the 20th century, the medical establishment viewed heart disease as a man’s problem.

Preventive efforts for women focused on mammograms and Pap smears.

Dr. Delgado describes what she sees as a typical scenario. Two people, one man and one woman, see their primary doctor. Both have high cholesterol, slightly high blood pressure, and concerning family histories. The man goes through diagnostic testing and receives proper counseling about diet and exercise. He is prescribed medications to lower both blood pressure and cholesterol.

“Meanwhile, the woman is told. ‘You need to relax. Don’t worry. You’re skinny, and you exercise. This may be normal.’ This bias is worldwide. It also happens with women physicians,” Dr. Delgado says. It’s a serious barrier to women getting evidence-based care, and it is worse for women of color, she says.

If your own health care provider dismisses your symptoms or concerns, find one who listens and takes the needed steps, in terms of both diagnosis and treatment.

Various exposures affect estrogen’s decline.

Factors besides aging affect our hormone balance.

“Exposures we have over the years to chemicals in food, toiletries and makeup affect it too. Anything you apply to your skin regularly can affect your hormone balance immensely.” Dr. Delgado says.

Women often use beauty products made with potentially harmful ingredients. “Most additives in products sold in the US are forbidden in Europe, Asia, and South America,” she says. These ingredients can hasten the decline in the users’ estrogen levels, thus raising their cardiovascular risk. 

Dr. Delgado recommends the Yuka app, which screens foods and cosmetics for harmful additives. The Environmental Working Group offers screening apps called SkinDeep and the Healthy Living App.

Avoid ultraprocessed foods.

Steer clear of chemical-laden ultraprocessed foods such as frozen dinners, sweetened drinks, lunch meats, hot dogs, packaged desserts, and most salty snacks. Many links have emerged between increased risk of cardiovascular disease and death and high intake of ultra-processed foods. Mostly, eat simple, whole foods your great-grandmother might have eaten.

“The center of every woman’s health is good, robust heart health. It keeps us alive, keeps every organ working. Find a doctor who listens to your concerns about high blood pressure or cardiovascular risk. Empower yourself,” says Dr. Delgado.

Written by Milly Dawson. Medically reviewed by Maria Delgado-Lelievre, M.D.

Tags: Dr. Maria Delgado