Women's cardiovascular health
Cardiac assessment for women through and after menopause, coordinated with the clinic’s menopause care.
Dr Farrah Othman (FRACP), cardiologist, provides women’s heart health assessment in Balmain within The Endocrine & Wellbeing Clinic, working with Dr Isobelle Smith (FRACP), who manages menopause and metabolic health in the same rooms.
What we commonly see in patients
We commonly see women in their late 40s and 50s whose cholesterol, blood pressure or weight has risen through menopause, who are being assessed for or already taking menopausal hormone therapy (MHT), and whose GP or endocrinologist wants a cardiologist’s view before continuing.
We see women with chest discomfort or breathlessness whose stress test was normal, or whose angiogram showed no obstruction, and who have been told the symptoms are not cardiac. In many of these women they are.
We see women who had pre-eclampsia or gestational diabetes a decade or two ago and have never been told that those pregnancies changed their cardiovascular risk.
We see women whose menopause came early, before 45, who are at higher cardiac risk than their age alone would suggest.
The common thread is that cardiovascular disease is the second most common cause of death in Australian women, after dementia, and that the risk accelerates at menopause. The diagnoses are hypertension, dyslipidaemia, angina with and without obstructive coronary disease, spontaneous coronary artery dissection, and cardiovascular risk after early menopause or a complicated pregnancy.
How we treat the condition
Ischaemic heart disease killed 6,122 Australian women in 2024, nearly twice the number who died of breast cancer. Women develop coronary disease on average later than men, and the decade after menopause is when the gap closes: in the year around the final menstrual period LDL cholesterol rises sharply, blood pressure and central weight gain follow, and the protection of earlier decades is lost. Assessment at this point, rather than after a first event, is the purpose of this clinic.
1. Risk assessment with the factors that apply to women. The 2023 Australian cardiovascular risk guideline assesses five-year risk from age 45, and specifically directs that a pregnancy history be taken: hypertensive disorders of pregnancy and gestational diabetes may triple a woman’s risk in the following decade. In meta-analyses, pre-eclampsia carries a 2.5-fold risk of coronary disease and gestational diabetes roughly doubles cardiovascular risk, even in women who never develop type 2 diabetes. Menopause before 40 carries a 55% higher cardiovascular risk and menopause at 40 to 44 a 30% higher risk than menopause at 50. Lipoprotein(a) is measured once if it never has been. Where the calculated risk is borderline, a coronary artery calcium score reclassifies it.
2. MHT, assessed rather than avoided. MHT is not prescribed to prevent heart disease, and Australian and international guidance is explicit on that. It is also not the cardiac hazard it was taken to be after the first Women’s Health Initiative reports. In women who start MHT within ten years of menopause or before 60, coronary risk is not increased (WHI secondary analysis), and in the ELITE trial oestradiol started within six years of menopause slowed the progression of carotid artery thickening, whereas started after ten years it did not. Eighteen-year follow-up of the WHI found no difference in cardiovascular or all-cause mortality. Oral MHT roughly doubles the risk of venous thromboembolism, so transdermal preparations are preferred where cardiovascular risk is raised. Dr Smith prescribes; Dr Othman’s assessment establishes whether the cardiac risk profile supports it.
3. Chest pain without a blocked artery. In a registry of more than 11,000 angiograms for stable angina, 65% of women had no obstructive coronary disease, compared with 32% of men, and those women still had a higher rate of cardiac events than people without symptoms. Ischaemia with non-obstructive coronary arteries (INOCA) is caused by small-vessel disease or coronary spasm, and is diagnosed and treated differently from a blocked artery. Spontaneous coronary artery dissection (SCAD), a tear in the artery wall that causes a heart attack, occurs almost entirely in women (89% in the largest cohort), typically around 50, often with no conventional risk factors. Dr Othman’s interventional training is the reason these diagnoses are made rather than missed.
4. Menopause and the heart managed together. Dr Isobelle Smith manages menopause, MHT and the metabolic changes that accompany it; Dr Othman performs the cardiac assessment, the echocardiogram and stress testing, and the coronary imaging where it is needed. A woman referred from the clinic’s menopause service is seen by both in the same visit series, with one plan for blood pressure, lipids and MHT rather than two.
What happens at your first appointment
- Consultation and examination. Dr Othman takes your history, including menopause, pregnancy and family history, and reviews your blood tests. Around 20 minutes.
- Investigations in-rooms. An ECG and, where indicated, an echocardiogram or stress echocardiogram, taking a further 20 to 30 minutes. Wear comfortable clothing in case you need to walk on a treadmill.
- Your plan. Your cardiovascular risk, whether MHT is appropriate from a cardiac standpoint, and the blood pressure and lipid targets that apply to you, coordinated with Dr Smith.
- Letter to your GP. A letter is sent to your GP or referrer within the week.
A note about MHT and heart disease
The 2002 Women’s Health Initiative findings led a generation of women to stop or avoid MHT on cardiac grounds. The later analyses, by timing and by age, tell a different story: started close to menopause, MHT does not increase coronary risk, and the earlier harm signal came largely from women who began it in their 60s and 70s, a decade or more after menopause. That is not a reason to take MHT for the heart, and no guideline recommends it for that purpose. It is a reason to make the decision on menopausal symptoms and bone health, with the cardiac risk assessed properly rather than assumed.
Frequently asked questions
Menopause does not cause it, but it removes a protection. LDL cholesterol rises in the year around the final period, blood pressure and abdominal weight follow, and cardiovascular risk accelerates over the following decade. Early menopause, before 45, increases the risk further.
Started within ten years of menopause or before 60, MHT does not increase coronary risk, and transdermal oestrogen avoids most of the clotting risk of oral preparations. It is not prescribed to prevent heart disease. The decision is made on your symptoms, your bone health and your assessed cardiac risk.
Yes. Pre-eclampsia and gestational diabetes roughly double or more the later risk of heart disease, and the Australian guideline asks that a pregnancy history be part of every cardiovascular risk assessment. Tell Dr Othman.
It can be. Most women with stable angina have no obstructive coronary disease on angiography, yet many have small-vessel disease or coronary spasm that causes real symptoms and carries real risk. These are treatable, but they require a different assessment from a blocked artery.
A referral from your GP or another specialist is required for a Medicare rebate on a specialist cardiology consultation. If you are a patient of the clinic’s menopause service, Dr Smith can refer you directly.
Book an appointment
The Endocrine & Wellbeing Clinic
Phone: (02) 9870 3256
Locations: Balmain (inner west Sydney) and Telehealth Australia-wide
Affiliated with: Cardiac Society of Australia and New Zealand, Australian Atherosclerosis Society, European Society of Cardiology
This page is not a substitute for individual medical advice. Book a consult for assessment specific to your situation.