Latest / The Dr Louise Newson Podcast / 48 – Why heart disease in women is still being missed

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48 – Why heart disease in women is still being missed · The Dr Louise Newson Podcast

• 0:00
  Doctor Jane Morgan is a cardiologist from the US who's
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  on my podcast today. We talk about cardiovascular
• 0:06
  disease and hormones. It's a really important topic
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  because globally, the commonest cause of death in women is
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  cardiovascular disease. And we know the incidence
• 0:17
  increases when we're menopausal. So it's a wonderful conversation
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  where I hope you will just think differently about your heart,
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  your blood pressure, maybe your brain as well.
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  So enjoy. So Jane, it's great to have you
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  on my podcast. We're going to be talking about
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  heart disease or cardiovascular disease actually.
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  And cardiovascular disease is #1 killer of women globally.
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  Yeah, if you Google heart attack, it will be a man
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  clutching his heart. And it's not really thought
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  about for women. And I'm got a medical
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  background. I did quite a lot of cardiology
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  as a junior doctor. And I never really thought about
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  heart disease and women, which I feel very embarrassed about.
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  I didn't think about hormones because I wasn't taught about
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  hormones. But when you understand how our
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  basic hormones, estrogen, progesterone, testosterone work
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  on our cardiovascular system, we can't keep ignoring it.
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  But let's just start really basically like what is
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  cardiovascular disease and why are you interested in it?
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  Well, to your viewers, I'm a cardiologist, so I'm definitely
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  interested in cardiovascular disease.
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  And it really developed more of an interest in women just from
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  noticing symptoms really during my internal medicine residency
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  and cardiology fellowship. I mean, we're talking two or
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  three decades ago now and I wouldn't notice that we have a
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  nomenclature which is actually the way that physicians talk to
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  each other called atypical. We would call it atypical chest
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  pain or atypical symptoms. And basically that would mean a
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  person who's coming in, they kind of maybe have risk factors
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  for heart disease. They've got vague symptoms that
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  we can't really pin down. It's probably not heart disease,
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  but we might give it a nod. And we call it atypical.
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  And I began to notice that when I'm dictating and writing my
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  charts, and I would be giving that term more often to women
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  and not to the men. And I would think, oh, the women
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  come in with these atypical symptoms.
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  What does that mean? And I would ask my attendings
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  and you know, it's the power structure and they are all
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  knowing and they would say yes, because these are the symptoms
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  that they come in. Usually for women, it's going to
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  be anxiety and panic disorders and these types of things.
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  They rarely come in with real heart attacks.
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  And I sort of would accept that because.
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  That's how you're told, yeah. You know, they tell it to you
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  very emphatically knowledgeable. But then you know, months would
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  go by, you would see more and more patients and that thought
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  would kind of come back into your head like I'm seeing these
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  female patients. But I also would notice is that
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  we would prescribe antidepressants and and anti
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  anxiety medications. I also would notice that
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  oftentimes, more often than men, when I would do an initial
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  evaluation on a woman, I could see on an EKG that they had had
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  a prior heart attack and when I talked with them about it, they
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  were unaware. That almost never happened with
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  men I do. Their EKG's were normal, or if
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  they had had a prior heart attack, their EKG.
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  When I talked with them about it, they had some awareness of
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  it. Again, I would talk with my
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  attendings and I was just sort of getting nowhere with it, you
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  know? And you can you can imagine, you
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  know, in a system, a big system, healthcare system, the United
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  States of America, which is where I am.
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  I'm sure all your listeners can hear my American accent.
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  The system kind of just continues to churn.
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  And you are part of the system and you question it.
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  But at every question, you sort of get pushed back from people
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  who are smarter than you are, who know more than you are, who
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  are more senior than you are, who are more, who are more power
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  structures. But the fact of the matter is
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  now I sit here on your podcast, I was on to something two and
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  three decades ago. Something is not right.
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  And that's something for women to think about really for your
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  lifetime in whatever you're doing.
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  We know our bodies, you, we also know each other.
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  When you have a sense of something that's not right, when
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  you're seeing patterns, feel empowered to speak up, even
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  though, you know, in that situation, I was powerless.
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  I was not in a powerful position.
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  I was the most junior person on the team.
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  But try to find allies, which is what we try to do here, to speak
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  up for women, because there's an innumerable number of women who
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  have been harmed by the system while we've been relegating
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  people to panic disorders. In fact, it would be called
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  atypical chest pain. Rule out panic disorder.
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  Very common diagnosis. We almost never gave that
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  diagnosis to men. It's quite something, isn't it?
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  Because certainly in the acute medicine medicine departments,
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  in in casualty departments, if someone comes in with the chest
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  pain, there's a sort of criteria, there's a set standard
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  of blood tests that you do. Obviously you do an EKG or we
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  say ECG, you do their blood pressure.
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  And then depending on what their results show depends on what
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  treatment they have. But those guidelines have always
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  been set up based on men with their essential crushing chest
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  pain. So when women have feel light
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  headed or dizzy or they might feel they might have some nausea
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  and vomiting. These are all symptoms that
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  could indicate a heart attack. But if you go to the nausea and
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  vomiting pathway, it won't say do the blood test for a heart
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  attack because people don't join the dots.
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  And this is where this atypical as in not classic chest pain.
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  Well, it is typical for women, which is what you're really
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  saying, isn't it? It's not typical for men to
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  present with dizziness or nausea and having a heart attack, but
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  actually we can't exclude it. Why?
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  Is it atypical for women? You know, it's because the
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  structure, the health system has been created by men.
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  So we are receiving this, this, you know, connotation of
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  atypical. But the fact of the matter is
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  we're the majority of the population, so we're not the
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  ones with the atypical symptoms. It's maybe the men who are
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  having the atypical symptoms. Now, I want to be clear, women
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  can also get chest pain and shortness of breath.
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  But we get into this, this other spectrum of symptoms, women run
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  the spectrum much more often than men.
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  And once we get out of the main area and off into the spectrum
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  of symptoms, that's where we start to be triaged to lower
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  levels of care and concern. That's why the first heart
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  attack of a woman is more often fatal than a man's.
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  It's because of delay in care, delay in recognition,
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  inappropriate discharges from the emergency room.
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  That's why the first heart attack of a woman is more often
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  fatal than that of a man. If a man and a woman come into
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  the emergency room at the same time and the man has has the
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  quote UN quote classic symptoms and a woman has the quote UN
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  quote atypical symptoms. The man will be in the Cath lab
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  within 20 minutes having his artery open and a stent plates.
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  And the woman will still sit in the emergency room having
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  enzymes drawn every six hours while we try to figure it out.
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  And eventually, maybe if the enzymes rise, she may the next
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  day end up in the Cath lab. And and when we talk about the
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  next day, 37 minutes of a delay is significant enough to have a
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  difference between life and death.
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  And women don't receive that consideration because oftentimes
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  our symptoms are out on the spectrum and the spectrum is
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  denoted as a typical, which is kind of a wink, wink to the
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  doctors, to each other going. Another case of the panic
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  disorder, another woman with hysteria, another person who
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  needs an antidepressant, We'll babysit her in the emergency
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  room, draw a few enzymes and and off she'll go.
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  So that needs to change. Absolutely.
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  But when we talk about cardiovascular disease, it's not
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  just heart attacks, is it? So just explain other conditions
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  that are associated with cardiovascular disease.
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  So cardiovascular disease is a is, you know, in
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  all-encompassing and, and it includes the peripheral
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  arteries, meaning arteries in your legs and in your arms.
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  And we have something called claudication.
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  That's actually a term that sort of means that you get cramping
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  and pain in your legs when you're walking.
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  That means that you have poor circulation in the arteries of
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  your legs, blockages, calcium atherosclerosis, the same as in
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  your heart. So your legs actually are an
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  indicator oftentimes of things that are going on in your heart,
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  and your heart is oftentimes an indicator of the health of your
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  brain, of circulation and oxygen and blood supply to the brain.
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  It's why more often people who have heart attacks have a higher
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  risk of developing dementia and Alzheimer's later, because
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  oftentimes what's happening in those coronary arteries, meaning
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  the arteries of your heart are also happening in the carotid
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  artery. So the arteries in your neck
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  that are feeding the brain and the other arteries in your
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  brain, there is that connection. The heart pumps and that blood
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  goes out to the brain to infuse it and give it oxygen.
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  And then the brain sends neurologic signals back to the
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  heart to squeeze again. And round and round we go.
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  It is the brain and heart are very interconnected and what you
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  see happen in the heart you need to think may also be occurring
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  in the brain. We need to protect the brain as
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  well. So cardiologist and neurologist
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  and neurosurgeons go back and forth on who's got the most
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  important organ. Is it the heart or the brain?
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  So I'm sure you can imagine which one that I say, but the
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  fact of the matter is you can't live with either.
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  So we we may be both right and both wrong.
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  Absolutely. And it's so important.
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  And because when we look at the blood vessels, they're lined by
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  something called our endothelium, the lining of our
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  blood vessels. And we know with age they can
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  become narrower. We, we, a lot of people will
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  have heard of atheroma, this sort of so-called fairing of the
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  arteries. And I'm very interested in how
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  we can reduce inflammation throughout our bodies.
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  We can reduce inflammation in our endothelium.
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  It will reduce atheroma deposition, reduce the fairing
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  of the arteries. And if we keep our arteries
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  open, they're less likely to get blocked.
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  They're less likely to lead to heart attacks, strokes, and and
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  so forth. And we know there's a really
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  important role of hormones to do this.
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  There's lots of other reasons that can reduce inflammation and
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  lifestyle and so forth. But we know that when people
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  have low hormones and obviously become menopausal, the risk of
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  cardiovascular disease really increases, doesn't it?
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  So not only do you does your risk cardiovascular disease
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  increase again, your risk of brain dysfunction also increases
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  a lot. To make certain that we sort of
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  keep that in mind when a woman enters perimenopause, at the
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  beginning of perimenopause, her risk of heart disease is really
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  only half that of a man. By the time you hit menopause,
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  when you've had your last menstrual cycle, it's been 12
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  months since your last menstrual cycle.
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  Your risk of heart disease double S during that time.
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  It actually equals that of a man.
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  By the time you reach menopause, prior to menopause, it's only
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  half that of a man. And what has happened is we are
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  losing the protection of estrogen on our hearts.
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  Estrogen, their receptors are a heart for estrogen actually
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  receptors all over our body. That's one of the things that
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  really drives me to have these conversations because since the
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  beginning of time, since the beginning of healthcare, Women's
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  Health has always been reduced to just reproduction, just
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  breast vaginas, mammograms and pap smears, as if we had no
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  other organs at all. And oftentimes, if I were to see
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  a woman in an emergency room, a man and a woman, let's go back
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  to that example where two people, a man and a woman, come
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  into the emergency room at the same time.
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  The man will have an EKG on his record because he's had them
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  before as part of his normal physical exam.
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  The woman will not have an EKG. Why is that important?
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  It's important because we can compare any changes that may
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  have occurred and we also also can see the interval in which
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  that time change has occurred. We can't.
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  It gives us a lot of information.
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  For a woman, we don't have that information.
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  We don't have an EKG. There should also be an EKG on
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  that record. So back to your point, yes, as
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  estrogen decreases, we lose that protection on our heart, those
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  estrogen receptors. So estrogen is not binding to
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  those receptors, but estrogen also does what Estrogen is a
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  natural anti-inflammatory agent for women.
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  We've got this estrogen, so we have decreased inflammation.
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  You may ask, I don't really know what that means.
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  Why should I care about that? It's because inflammation now
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  has been recognized as a driver of atherosclerosis, meaning
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  again, those blockages in those arteries of your heart, which
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  increases your risk of heart attack.
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  Chronic inflammation also is a contributor for the development
• 14:12
  of cancer. But you know, that'll be another
• 14:14
  conversation. We're going to stick today to
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  heart disease. But when we talk about
• 14:19
  inflammation, that is what is important, that estrogen serves
• 14:23
  as a natural anti-inflammatory agent for that woman, and
• 14:27
  inflammation drives heart disease.
• 14:32
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• 14:35
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• 14:41
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• 15:17
  Thanks so much. Now back to the episode.
• 15:22
  And the other thing that can drive heart disease is raise
• 15:25
  blood pressure. And we know that our hormones,
• 15:29
  estradiol as well will act on our renin angiotensin system,
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  which controls our blood pressure as well in our kidneys.
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  And people somehow forget that kidneys are really important
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  when it comes to cardiovascular disease risk, too.
• 15:43
  We also have baroreceptors, so receptors that can help regulate
• 15:47
  our blood pressure, and those are regulated as well by our
• 15:50
  hormones. So blood pressure is something
• 15:53
  that we all have blood pressure, we need it, of course.
• 15:56
  But when it becomes raised and sustained, you know, it it, it,
• 16:01
  it stays raised for a period of time.
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  That puts more strain on our cardiovascular system and
• 16:06
  increases our risk of heart disease and strokes.
• 16:09
  So it's really important to think about that as well because
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  a lot of people have no symptoms, do they?
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  But they have raised blood pressure.
• 16:16
  You know, Louise, I did an article for Healthline News
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  looking at an interesting study that looked at sleep as well as
• 16:26
  blood pressure. And you know, but my comments on
• 16:30
  that are right in line with what you were saying.
• 16:35
  Is that estrogen is the driver of vasomotor tone of our
• 16:41
  arteries, meaning it supports compliance, meaning elasticity
• 16:46
  of your arteries, how well they expand and contract.
• 16:50
  It supports that Ross system, just as you said, the Rengen
• 16:53
  angiotensin aldosterone system, which also can either Rev up and
• 16:58
  increase your blood pressure or Rev down.
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  You know, it's important as well when we talk about women in mid
• 17:05
  life, that silent killer, the blood pressure increasing
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  without you being aware of it, asymptomatic.
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  You're unaware that your blood pressure is increasing as your
• 17:17
  estrogen levels are becoming more erratic and gradually
• 17:21
  decreasing. So that's a risk factor for
• 17:24
  heart disease. But did you know that
• 17:26
  sleeplessness, difficulty sleeping, insomnia is also a
• 17:32
  risk factor for heart disease? And as your estrogen and
• 17:35
  progesterone levels once again become erratic and gradually
• 17:38
  decline, you can start to lose sleep.
• 17:42
  Not only do we know that duration of sleep is important,
• 17:46
  and we know that quality of sleep is important, increasingly
• 17:49
  we are learning that regularity of your sleep schedule is
• 17:55
  important for our ancient circadian rhythm, the our
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  internal clock that responds to hormones and responds to light.
• 18:06
  And women are more sensitive to it as we go through
• 18:09
  perimenopause and our hormones are more erratic.
• 18:13
  That circadian rhythm that we often interrupt with technology,
• 18:17
  with alarms, with lights, with phone lights, with all kinds of
• 18:21
  things. All of that increases your blood
• 18:25
  pressure because it decreases your resting hormones at night
• 18:28
  and you also then don't have the surge of cortisol and when the
• 18:32
  sun comes up, but it also impacts your blood pressure
• 18:36
  because your blood pressure also doesn't have an opportunity to
• 18:40
  drop those 5mm of mercury at night or it drops late and then
• 18:47
  picks up later as well. So you have a longer period of
• 18:50
  time of raised blood pressure. So sleeplessness and high blood
• 18:55
  pressure are both risk factors for heart disease and they occur
• 18:58
  together in women during perimenopause along with other
• 19:02
  risk factors like high cholesterol, gaining weight.
• 19:06
  So these are when people talk about, well, how does menopause
• 19:11
  impact heart disease? Why does, how can you say that
• 19:14
  menopause impacts heart disease like if there are no studies?
• 19:18
  So people like to say there's not a lot of randomized clinical
• 19:21
  trials. So first of all, there are
• 19:22
  randomized clinical trials and you're correct that they are not
• 19:25
  a lot of them. And that's another podcast that
• 19:28
  is due to women not being included in clinical trials and
• 19:32
  we're not studying women in clinical trials and with only
• 19:36
  thing that we study women for is reproduction.
• 19:39
  And so all of that has to change.
• 19:42
  So my response to that is we know that estrogen impacts the
• 19:47
  risk factors that are well established by the American
• 19:50
  Heart Association, the European Society of Cardiology, the
• 19:54
  Association of the American College of Cardiology and the
• 19:57
  Association of Black Cardiologists will establish
• 20:00
  risk factors that drive heart disease.
• 20:03
  Estrogen impacts those risk factors, so it impacts.
• 20:08
  Hypertension and blood pressure. It impacts sleep, it impacts
• 20:12
  cholesterol, it impacts weight. These are all risk factors for
• 20:18
  heart disease. So that is the response while we
• 20:21
  continue to await with regard to whether or not we're going to
• 20:25
  have randomized clinical trials, whether or not we will be
• 20:28
  enrolled, whether or not research will expand to really
• 20:31
  seriously include women as a whole body and not just
• 20:38
  reproduction. It'd be nice, wouldn't it?
• 20:40
  But what was interesting is that we've talked about how Easter
• 20:45
  Island, which is the the most anti-inflammatory form of
• 20:48
  estrogen, has all these one wonderful effects throughout our
• 20:50
  bodies. We've known for decades, like
• 20:53
  you say, that when women are menopausal, the longer they are
• 20:57
  menopausal as well. So the longer they are without
• 21:00
  estradiol, the greater the risk of cardiovascular disease.
• 21:04
  Yet the menopause guidelines say there isn't enough evidence to
• 21:08
  support the use of HRT to, to reduce risk of cardiovascular
• 21:12
  disease. And I have a real problem with
• 21:14
  this because it depends on what you're talking about.
• 21:17
  If you're talking about synthetic hormones, they can
• 21:20
  increase risk of cardiovascular disease.
• 21:22
  But if you're talking about estradiol replacing the same
• 21:26
  molecule as the same molecular structure of estradiol with one
• 21:30
  that we prescribed through the skin as a patch or gel, then why
• 21:34
  wouldn't it reduce risk of cardiovascular disease?
• 21:37
  It makes like no sense. Right.
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  And so logically we would say that I think with the menopause
• 21:44
  society is being very specific and stating that there are not
• 21:52
  large phase three randomized clinical trials and I think they
• 22:00
  are sticking to that as their scientific rigor.
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  In the meantime, while we wait on randomized clinical trials,
• 22:08
  that could be 10 years, 15 years.
• 22:11
  And so another generation of women go by with it's not just
• 22:15
  heart disease, it's it's bone loss, it's high cholesterol,
• 22:19
  it's, you know, anything you can think estrogen is really the
• 22:23
  driver of so many functions of the women's body.
• 22:26
  In fact, you can think of it almost like a car.
• 22:28
  And as the car starts to run out of gas, it begins to sputter.
• 22:32
  So we've got to. So that's the argument.
• 22:36
  Yeah. On the other side, you've got to
• 22:38
  stick with the rigor of randomized clinical trials.
• 22:41
  So. But here's the conundrum.
• 22:43
  You haven't included us in clinical trials, so you use that
• 22:46
  as a reason for not treating us. You don't treat us because we're
• 22:49
  not in trials. We're not in trials.
• 22:50
  So you don't have therapies. You don't have therapy, so you
• 22:53
  can't treat us. You can't treat us because we're
• 22:54
  not in clinical trials. And on and on and on we go.
• 22:58
  So you use the problem that has been created by the system to
• 23:03
  justify continuing to inadequately treat women.
• 23:08
  So that's the position, and I understand it as a scientist, I
• 23:12
  understand it like these. This is our gold standard,
• 23:15
  randomized clinical trials, and women cannot be excluded from
• 23:19
  our gold standard. But the fact of the matter is
• 23:22
  the system has created this problem.
• 23:25
  And the fact of the matter is, we know that estrogen impacts
• 23:28
  all the risk factors that drive heart disease.
• 23:31
  So there's the conundrum. It's really interesting.
• 23:35
  And you know what, there are no randomized control studies going
• 23:39
  on now. So in my lifetime, maybe your
• 23:41
  lifetime, we never have answers. But when you have a patient
• 23:45
  sitting in front of you, you know, we have to do what's best
• 23:50
  for them and we have to individualize care and we have
• 23:53
  to use the knowledge, the scientific academic knowledge
• 23:56
  and the clinical knowledge that we have.
• 23:59
  And actually, we do have some studies showing that
• 24:02
  cardiovascular disease will reduce.
• 24:05
  People are concerned over the age of 60 because of the WHI
• 24:09
  study, but that was synthetic hormones.
• 24:12
  I can't see how my body, when it's 60 is going to behave
• 24:16
  differently to when I'm 59. You know, the body doesn't wake
• 24:20
  up on your 60th birthday and go, hey, guys, my cells are all
• 24:23
  going to respond differently to estudiol.
• 24:26
  This doesn't work like that. I agree with that.
• 24:28
  And, you know, it is my hope that it will be Women's Health
• 24:32
  that will do away with the, the score this the, the, you know,
• 24:38
  the I, you know, I don't even know what I want to call it.
• 24:41
  I will say it is my hope that it'll be Women's Health that
• 24:44
  will drive randomized clinical trials into the background
• 24:49
  because we need something better than a system that takes 10 or
• 24:56
  15 years. Now.
• 24:57
  It has been an arduous and a rigorous system for standards,
• 25:02
  but the fact of the matter is we now have artificial
• 25:05
  intelligence. We now have the ability to
• 25:08
  model. Can we not leverage artificial
• 25:11
  intelligence to create the clinical trials that we need and
• 25:16
  get us answers within days instead of decades?
• 25:20
  And it may be Women's Health that will be the group to
• 25:25
  actually drive this because our need is the greatest to say we
• 25:28
  will not depend on randomized clinical trials any longer.
• 25:32
  We will not wait 15 years for answers.
• 25:34
  It's just so important that we change the narrative and allow
• 25:37
  women to choose actually, because I'm not here saying that
• 25:40
  we have to prescribe hormones to reduce risk of cardiovascular
• 25:43
  disease. And I'm not saying we shouldn't.
• 25:45
  I was saying that we should put our patients central to the
• 25:48
  conversation. And actually, I've never met a
• 25:52
  woman who really has no symptoms anyway.
• 25:55
  So usually we prescribe hormones for the symptoms, but find that
• 25:59
  their cholesterol reduces, their blood pressure reduces, you
• 26:02
  know, their cardiovascular risk reduces.
• 26:04
  So we're looking in entirety. We don't just look at one part
• 26:07
  of the body. So your work is so important,
• 26:10
  your advocacy work, your knowledge, your research is just
• 26:13
  brilliant. So just before we end, just
• 26:17
  three reasons really why people should be connecting hormones
• 26:23
  and cardiovascular disease. I know we've spoken about them,
• 26:26
  but it's just useful to summarize really 33 important
• 26:29
  things that we maybe have forgotten over the last few
• 26:32
  decades, OK? Three reasons to connect
• 26:35
  hormones to your overall well-being.
• 26:38
  Heart health, incredibly important.
• 26:41
  Brain health, incredibly important, and something we
• 26:46
  didn't talk about today. Genital urinary health, The
• 26:50
  increase of urinary tract infections as we lose our
• 26:54
  estrogen and the skin thins and our muscles began to atrophy.
• 27:00
  The increased risk of urinary tract infections, which is the
• 27:02
  number one reason that women end up getting admitted to nursing
• 27:06
  homes. So those are three reasons to
• 27:09
  think about how estrogen revitalizes your body and
• 27:13
  continues to keep you on whole and feeling good.
• 27:18
  Women live longer than men by 6 years.
• 27:21
  People often tell me that why would we talk about hormones?
• 27:24
  The fact of the matter is women do live longer, but we spend 25%
• 27:29
  more of our time in poor health. So we have quantity without
• 27:37
  quality, and we need to regain the quality of our lives.
• 27:44
  I love that. Thank you so much for your time,
• 27:46
  Jane. It's been really wonderful
• 27:48
  talking to you. Thank you.
• 27:50
  Thank you, Louise. I've got something really
• 27:54
  exciting to share with you. Every Thursday I'm going to be
• 27:57
  releasing an extra episode for those of you that sign up.
• 28:01
  It's an opportunity that I can have more guests share more
• 28:04
  information, dig deeper into the research that I can share with
• 28:08
  you. And when you subscribe, this
• 28:10
  money is going to be used to help with research, much needed
• 28:14
  research that's away from pharmaceutical companies.
• 28:17
  So information is down in their show notes.
• 28:20
  So have a look and subscribe and enjoy.