Heart Health Facts That Could Save Your Life

Heart disease is the leading cause of death in women—yet many women don't realize they're at risk. We all know we should take care of our hearts, but what does that actually mean? In this episode, we break down essential heart-health facts every woman should know, from how cholesterol really works and why family history matters to the role menopause plays in cardiovascular risk. You'll learn why heart disease often develops later in women, how heart attack symptoms can look different, when statins or aspirin may be helpful, and which risk factors deserve the most attention. We also cover practical steps for screening, prevention, and the everyday habits that can help protect your heart for years to come. Are you at higher risk? What should you know about blood pressure? When is it time to see a cardiologist? We answer these questions and more, giving you the information you need to take charge of your heart health before problems develop.

We take a moment to remind you that while this is a medical discussion, it is not providing a diagnosis or treatment or any medical advice. The only way to get a diagnosis, treatment or medical advice for your particular condition is through a discussion with your doctor.

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This episode was produced and edited by Erin Stein. Music: “All We Live For (instrumental)” by Wolfclub licensed through Audiio.com. Intro and outro edited, and video created, by Ian Mayer. The Savvy Patient logo by Amanda Spielman.

TRANSCRIPT

00:00 Intro

00:33 Defining Cardiovascular Disease

09:14 Why Does Heart Disease Kill So Many Women?

13:21 Assessing Family History and Other Risk Factors

24:03 All About Cholesterol

30:58 Revisiting Statins

34:57 The Role of Estrogen in Cardiovascular Health

43:57 What Should You Be Doing?

47:41 Pregnancy and Heart Health

49:17 What About Aspirin?

51:43 Recognizing Heart Attack Symptoms in Women

59:07 OUTRO 

Erin Stein: Hello, everyone. Welcome to this episode of the Savvy Patient. Last time, we talked about when you turn 40, what should you do, what should you be checking, and one of those things you should check is your heart, because it's important.

Gillian Goddard: This is true. Just a little bit.

Erin Stein: Just a little bit, right? It's sort of, I mean, we need a brain, but we need a heart to make that brain work, I think. Yes?

Gillian Goddard: Well, our brains need blood and to circulate that blood you need a working heart and a working cardiovascular system in general.

Erin Stein: Indeed, the brain heart connection is not just an esoteric concept.

Gillian Goddard: True enough. 

Erin Stein: True enough. But the big reason we want to talk about it, is it's the number one cause of death amongst adults. Is that right?

Gillian Goddard: Right, it's the number one cause for adults, men and women, but it's also the number one cause of death in women and one in three women dies from cardiovascular disease.

Erin Stein: That's terrifying.

Gillian Goddard: It's a lot of people. It's actually more than all types of cancer combined.

Erin Stein: It's a lot of people. Think about how much we talk about cancer and how worried and scared we are of cancer or even a plane crash or a car crash. And we never really talk about cardiovascular disease. So, we're going to change that today.

Gillian Goddard: Yes, we are. You know, I think people have this idea that when you have a heart attack you like, clutch your chest, keel over and that's it. 

Erin Stein: Yes, that's what happens in the cartoons. 

Gillian Goddard: Right. But that's not how it happens in real life. A lot of times people survive their cardiac events, and they just live with diminished quality of life afterwards. That's no fun. A key point to repeat: you may have a cardiac event and then continue to live with diminished capacity, with disease, with frailty, and all kinds of things. 

Erin Stein: So, it's not just preventing yourself from keeling over, which some of us I think, would be like, well, as long as I keel over quickly and it's over, maybe that's fine. Because you “won't know,” but that's not usually what happens.

Gillian Goddard: Right. Right. Exactly. And I think the reason we're talking about it now is not because women in their 40s and 50s are keeling over from heart attacks. In fact, we'll get into this in a minute but we're at relatively low risk at this point in our lives. But this is when we set ourselves up for health in the future. There are things we can do now to lay the groundwork to reduce our risk for cardiovascular disease in the future.

Erin Stein: Yes, right now, when our executive planning is at our lowest is when we should be planning for the future.

Gillian Goddard: Well, and this is one of the challenges, right? Because the executive function that we do have, we often have focused in lots of other directions and often not on ourselves.

Erin Stein: So that's the point of this podcast. It's about you and yourself. All right, well, let's start at the beginning as we like to do. What is cardiovascular disease?

Gillian Goddard: That's right. This is another thing that I think people have a lot of confusion about. Cardiovascular disease is this big broad category that includes things that happen within the heart muscle itself, things that happen within the vasculature in the blood vessels, and things that happen in the blood vessels in the brain. So, things like strokes.

Erin Stein: I think most people think of heart attack and stroke as the [main] two.

Gillian Goddard: But a heart attack is actually a vascular event. It's actually a blockage in a blood vessel in your heart. It's within the heart itself. It's the blood vessels that circulate blood to the heart so that the heart can pump.

Erin Stein: Right, so go ahead and define a stroke. What's the difference between a heart attack and a stroke? Because many of us think they're basically the same thing and don't really think through the difference.

Gillian Goddard: Yet they're analogous events. A heart attack is a blockage in a blood vessel going to the heart, so bringing oxygen to the heart. A stroke is a blockage in a blood vessel going to the brain, bringing oxygen to the brain. And oxygen is important to both the heart muscle and the brain cells. And when they don't get oxygen, those cells die.

Erin Stein: I've never heard it explained that way that succinctly and that's very helpful actually. Good job, Gillian.

Gillian Goddard: My specialty.

Erin Stein: Those are the two main things we think about and talk about and know people that have suffered from it. But what are the other kinds of things?

Gillian Goddard: Yeah, so people can also, as a result often of poor blood flow to the heart, and other things, they can develop arrhythmias, which is irregular heartbeats. Over time, the valves in the heart can develop problems. They can get old and leaky, which can then put strain on different chambers of the heart, on the heart muscle itself. And then our blood vessels are all connected. And so, people can also form blockages in blood vessels in other parts of the body. And that is called peripheral vascular disease. So peripheral meaning in the periphery out at the edges, not in the middle. Vascular being in the blood vessels. Interestingly, sort of the process of forming plaque is one that takes place over years where there's inflammation in the wall of the blood vessel and that actually allows plaque, which is like cholesterol chunks, to deposit in that area that's inflamed. Then you recruit all these white blood cells that are like, “there's something stuck in here that's inflamed, we've got this inflammation.” And so this process goes on over years where this plaque becomes sort of solidified and then something can happen where the plaque ruptures I always think of it as being kind of like popping a zit. [laughs]

Erin Stein: Okay, first of all… I've never heard plaque described as chunks of cholesterol. And I actually think we should always talk about it like that. That makes it so much easier to visualize the problem with cholesterol, right? 

Gillian Goddard: Well, it's chunks of cholesterol and other stuff, but yes.

Erin Stein: Sure, but that's the problem. You're creating a solid substance that's causing blockages.

Gillian Goddard: Yep, kind of glommed on to the wall of the artery.

Erin Stein: Yeah, so when the zit of cholesterol pops, as you so vividly put it, what is causing that?

Gillian Goddard: A lot of different things can cause that. Shearing can cause that. Increased blood pressure can cause that. Sometimes we don't know what causes it. Then when it ruptures, it draws all these inflammatory cells like platelets and other things that are circulating in the blood to make like a scab in the middle of the blood vessel. And that process, that rupture and then accumulation of all of those cells that are trying to clean up the rupture, that actually blocks the artery. So that's why there's an acute event on top of this process that's been going on for often decades before the pimple pop.

Erin Stein: Okay, so great. Do we know why women in particular? I mean, this affects everyone and is a high cause of death for all of us, but it seems like it overly affects women or affects women more statistically anyway. Is there any reason why women more than men?

Gillian Goddard: I think that's a great question. I think the biggest reason is that women don't realize they're at risk. And so, they don't always seek out the preventative care or they may even actively avoid some of the preventative care that can prevent the early stages of cardiovascular disease from progressing. When women do have heart attacks, they often don't have the same classic symptoms that men have. When we talk about heart attacks, we talk about feeling chest pressure, like there's an elephant standing on your chest, and the pain radiates up to your jaw and down your arm. And a lot of women don't experience that classic pain that is described in the literature. A lot of women experience symptoms like nausea that can be mistaken for something else. And so, I think women don't always get the attention that is helpful in preventing heart disease and stroke from progressing and getting worse. We get lulled into complacency a little bit because men develop cardiovascular disease before women do. And so, we see our male counterparts, starting to show signs of cardiovascular disease and we aren't showing those same signs because women on average develop cardiovascular disease about 10 years after men do. And so, we can kind of think that we’re out of the woods. That delay is actually directly related to estrogen. 

Erin Stein: Like everything!

Gillian Goddard: Like everything. So many things are related to estrogen, but this one really is. Estrogen reduces the inflammation in the blood vessel walls. And so, when we have estrogen during our reproductive years and during the perimenopausal years, it actually prevents us from developing plaques. And estrogen positively affects our blood pressure. It keeps our blood pressure low, and it positively affects our cholesterol. It keeps bad cholesterol low. And so, we are really quite protected from cardiovascular disease until menopause. And then, estrogen levels drop as we so often talk about. And when those estrogen levels drop, then our blood pressure goes up, our cholesterol goes up, we get that inflammation in the blood vessel wall, and we can start to form plaques. So, most women don't have clinical signs of cardiovascular disease until their mid 60s, because it takes about 10 years from that time when estrogen levels are really low for women to develop disease that then becomes apparent, as high blood pressure, high cholesterol, heart disease.

Erin Stein: I think that's really important to summarize that for women and men, these are the same issues, the same risks and health concerns. 

Gillian Goddard: Outcomes.

Erin Stein: Yes, outcomes is good. That's clearly a medical term. But the fact that we don't always have the same symptoms, which I want to come back to later and talk about heart attack symptoms because everyone's like your chest, your arm, you'll smell toast. So, we'll come back to that. But also, that it happens later for women. I think that's really important because like you said, we might think, well we're doing fine, and we don't have it. And I also think this is a nice segue into family history because you often hear more about male relatives having heart attacks or strokes because they're having them younger.

Gillian Goddard: Yeah.

Erin Stein: And at least in my family, they weren't always super healthy people to begin with. So, you think, well, it happened to them in their forties or fifties or whatever. And if you get past that age, you tend to think you're out of the woods, which is sort of a false equivalency, obviously.

Gillian Goddard: Yeah, no, it's true. I think the other thing that is a little tricky about family history—it is very important—but one of the things that's tricky about it is… I don't know about you, but when I think about all my grandparents and my parents, four of them smoked heavily and two of them did not. And of the four who smoked heavily, three of them have cardiovascular disease, but they're all men: both of my grandfathers and my father. And so, it gets really easy to be like, well, it was the smoking. And, certainly, smoking is the number one risk factor and if you do smoke, it should be the first thing that you do to improve your health, to stop smoking. But it also kind of skews that family history, you know?

Erin Stein: Yeah, smoking's not good for you. Yeah. Let's talk about family history. Like what are the things that are important to consider for you, especially as a woman. Does male family history matter for heart disease and also how to parse out whether they were smokers or ate a lot of fried food and all that stuff.

Gillian Goddard: So, the effects on diet and cardiovascular disease I think have been, it's not that it's not important, but I think the effect of that is overestimated significantly. Smoking, I would say no. But when you think about the men in your family, so father or grandfathers, you basically have to look at the age at which they were diagnosed and essentially add 10. So, you know, if grandpa had a stroke at 61, then I add 10 years to that and subtract the two packs of unfiltered camels he was smoking a day and kind of go, well, sure, I'm at risk, but maybe not quite to the same degree. The other thing that's super important is not necessarily just the age at which the person was diagnosed. It's really important to understand blood pressure history in your family. When people were diagnosed with high blood pressure and high cholesterol, because much more than diet, the biggest factor in whether or not you'll develop high cholesterol is your genes. And so sure, if you're eating fried food, breakfast, lunch, and dinner that is high in saturated fat, you will have higher cholesterol. But if you are eating a relatively healthy diet, then the bigger contributing factor to your high cholesterol is likely to be your genes. And I've got bad news for everyone because at this point your genes are the one thing we cannot change.

Erin Stein: Yeah, I will say someone I was just talking to has inherited really high cholesterol and it's always been that way since a very young age and her father had heart issues and I think it was heart attacks at a younger age but she just has really high cholesterol, always has, and is the healthiest eater I've ever met in my life and exercises constantly. And her cholesterol is still high because that's just her genetics.

Gillian Goddard: Exactly, exactly. So, I think this is a good point at which to talk about risk factors, the ones that we can change and the ones that we can't because there are some of both. So, risk factors that we cannot change: Age, so our risk for cardiovascular disease increases as we get older. There's nothing we can do about that. Family history, this is that genetics piece of things. We can't change our genes. And the other thing that we really can't change is the age at which we go through menopause. Women who have primary ovarian insufficiency, so menopause before age 40, and women who have early menopause, which is menopause before age 45, are at increased risk of heart disease, and that makes sense because they have fewer years before that estrogen level drops. And so, they will often not just have an increased risk of heart disease, but an increased risk of heart disease at an earlier age. 

Erin Stein: Okay, so let me interrupt because these risk factors we can't change… How to assess the level of risk because, as you said, all of us are at risk as we get older. There's a baseline level, we're all at risk. We all should look after our heart. But then some of these things are definitely increasing our risk more than others.

Gillian Goddard: Yeah, I mean, I would say family history is probably the number one thing. If you look back at your family history and it's littered with people having heart attacks and strokes, you should pay attention.

Erin Stein: Yeah, but if the early menopause is a factor for you, and you tell me if this is correct, maybe that's not increasing your risk a million percent, but if you also have family history and high blood pressure and high cholesterol, then that's another factor that should really make you look after things.

Gillian Goddard: All the things we're talking about, in studies have been shown to independently raise your risk, but they are additive to some degree. And so, the more factors you have, the more you want to watch out. And there's some others that are big factors and we'll talk about those. Other factors, we already talked about smoking. If you're still smoking, just stop. 

Erin Stein: Just stop.

Gillian Goddard: I know it's an addiction. I know it's not easy to stop, but there are a lot of tools now and it is still by far the best thing you can do for your health. We talked about high blood pressure and high cholesterol. Having a history of preeclampsia during pregnancy or shortly after pregnancy, or gestational diabetes actually increases your cardiovascular risk. This is why telling your doctor about your pregnancy history can be really important. A lot of doctors don't ask for your pregnancy history once you're a woman in midlife, but it's important to offer that information if you experienced those pregnancy complications.

Erin Stein: A really good sound bite for whoever's listening to take away. If you had things going on during your pregnancies or your pregnancy, you should definitely be telling your primary care doctor and specialists.

Gillian Goddard: Absolutely. Having diabetes is a massive risk factor for cardiovascular disease. It's such a big risk factor that people who've already had a cardiac event are at extremely high risk of having another event. And people with diabetes have the same risk of having a cardiovascular event as someone who's already had a cardiovascular.

Erin Stein: Now why is that?

Gillian Goddard: Because diabetes, the high blood sugar causes increased inflammation in the blood vessel walls, so it helps plaque form.

Erin Stein: And is that any kind of diabetes or one or two more or so?

Gillian Goddard: Yeah, so that's a great question. Like are people with type 1 diabetes diagnosed in their teens at the same risk as someone with type 2 diabetes? Diabetes itself is an independent risk factor. Having overweight or obesity is also a risk factor. You are more likely—and this is not 100 % by any stretch of the imagination—but you are more likely to have diabetes and overweight or obesity if you have type 2 diabetes than if you have type 1 diabetes. So, you're more likely as someone with type 2 diabetes to have multiple risk factors. You're more likely to have high cholesterol. You're more likely to have high blood pressure. It's the combination of all of it. And then, I mean, excessive alcohol intake and unhealthy diet. Those are the things we can change most easily.

Erin Stein: I mean, I don't know that wine causes heart issues. It doesn't say that on the bottle. [laughs] Smoking, because we've heard it so much, it seems obvious. And we also know that alcohol is bad, and a lot of alcohol use is bad, but I don't know that it's necessarily obvious that it could affect your heart. 

Gillian Goddard: Fair. When we look at the data on cardiovascular disease specifically, it really seems to be that moderate intake does not significantly increase risk. Moderate intake is a drink a day for women and two drinks a day for men. And then, how sedentary or active we are; of course, an unhealthy diet. An unhealthy diet in this case is a diet high in simple carbohydrates and saturated fats. So saturated fats are fats that are solid at room temperature. So, animal fats primarily, although actually coconut oil also has some saturated fat. But most saturated fat and cholesterol specifically comes from animal products.

Erin Stein: So, let's talk about cholesterol. Because, again, we know that having high cholesterol is bad. We know that having high levels of bad cholesterol is bad. I happen to be someone who has had high levels of good cholesterol.

Gillian Goddard: Sure.

Erin Stein: So, the doctor, even if my number inches up, they're not that worried because there's this whole thing that you've learned how to look at these numbers without totally understanding what is happening, right? 

Gillian Goddard: So, let's talk about this, because when you get a typical cholesterol panel has four numbers. It tells you your total cholesterol, your triglycerides, your LDL cholesterol, and your HDL cholesterol. And there's a formula for adding up triglycerides, LDL, and HDL that make total cholesterol. And in most cases, what they're doing at the lab, is measuring total cholesterol, triglycerides, and HDL, and then they're calculating the LDL cholesterol. They're not measuring it directly. They're using math. 

Erin Stein: So, you do use it for something! Well, actually, the computer uses it.

Gillian Goddard: Yes, this is true. So total cholesterol is not such a useful number depending on what the individual numbers are. A lot of people suggest that we should be looking at a number called your non-HDL cholesterol, which is your total cholesterol minus your HDL, which is what you're talking about. HDL is the good cholesterol and so basically, we're saying let's just measure all the bad cholesterol and count that. Which makes sense when you think about it in most cases. Triglycerides are actually more influenced by the simple carbohydrates in your diet than they are by the cholesterol in your diet. When someone is drinking a lot of soda or if someone has insulin resistance, their triglycerides will go up. And that's important because then the way to get triglycerides down is to reduce the simple carbohydrates and the really highly concentrated sugars in the diet and to manage blood sugar more than take a cholesterol medicine, for example.

Erin Stein: So how are the triglycerides interacting with the cholesterol? 

Gillian Goddard: I knew you were going to ask me this question.

Erin Stein: You knew I was going to.

Gillian Goddard: So basically, when we consume excess sugar or when our body isn't processing sugar well, the liver takes that sugar and turns it into fatty acids to store it. And those fatty acids get turned into these blobs of triglycerides.

Erin Stein: Okay.

Gillian Goddard: And so basically, it's a way of storing the excess sugar that our muscles and brain can't take up. So, the liver is actually churning out, cholesterol…

Erin Stein: Blobs!

Gillian Goddard: Yeah, cholesterol blobs. And then LDL, which is the quote unquote bad cholesterol, your LDL level, if you're not consuming a very high saturated fat diet is really a function of your liver's ability to metabolize it. It's not always something that people can control with changes in their diet. The only real way to lower LDL effectively for most people is with a medication that helps process that cholesterol more efficiently.

Erin Stein: In the liver. So, this is interesting that we're talking about heart health and keeping your heart healthy, but clearly the liver is very important to that function and process. As we've said before, everything's connected. Everything's a system, but that does explain the alcohol risk a little bit better because alcohol obviously affects your liver directly.

Gillian Goddard: And we've made our way to the liver. It raises your triglycerides. So, if someone's an alcoholic, they will often have very high triglycerides.

Erin Stein: Okay, so cholesterol does have a function because we have some cholesterol all the time, right?

Gillian Goddard: It has a huge function. Every single cell in our body has a wall made out of little cholesterol molecules.

Erin Stein: Okay, so that seems really important! 

Gillian Goddard: So, when women are breastfeeding or pumping, their cholesterol is high because you have to have high cholesterol in the blood so that you can get cholesterol into the breast milk. I love this fact; this is a good one. Because babies are growing at a prodigious rate. They are making new cells at a much higher rate than almost any other point in our lives, right? Like they double their body weight in a few months. Think about that. And they need all that cholesterol because they need to make all these new cells. They need all these new cell walls. So, cholesterol in and of itself is not bad. It's the amount we have and what our body is doing with it.

Erin Stein: And what is our body doing with it? I mean, we're using it to build cells, and so basically, we're saying extra cholesterol is just piling up like garbage floating around. 

Gillian Goddard: Our liver's trying to clean it up and get it out of the way, but it can't always do it fast enough.

Erin Stein: Yeah, pollution piling up in the landfill called our liver. Okay, so what do you do about cholesterol? We know that you can eat healthier, you can not smoke, you can not drink. You can do all of those things, but if you have a genetic predisposition and you have naturally high cholesterol, which I guess means a lot of extra…

Gillian Goddard: Yeah. Yeah. Yeah. Mm-hmm.

Erin Stein: Or does it mean that you inherited an inability to process it? I guess it could be either.

Gillian Goddard: Yeah, it's more that you can't clean it out of blood efficiently. 

Erin Stein: So, what do you do?

Gillian Goddard: You take a statin. So, Lipitor, Crestor, are very good at helping the body metabolize that cholesterol.

Erin Stein: A lot of people don't want to take them and I'm not sure if that's just resistance to taking medication or if they're side effects or what's the deal with the statins? I feel like they have a bad rap.

Gillian Goddard: Yes, everybody loves to hate statins. It's funny, they were sort of, you know, we think about how much we talk about GLP-1s right now and like how much they're everywhere and everyone's like, these are miracle drugs that should be in the water. That was the conversation that was going on when statins were originally developed. They were the wonder drug of their day.

Erin Stein: Ha ha!

Gillian Goddard: Statins actually are incredibly well tolerated. They're actually all generic now, including Crestor, which was the last one that was developed, the most powerful one. And so, they're cheap. They're really effective. I'll say that again. They're really effective. The reason that they've gotten a bad reputation is that there is a small percentage of people for whom they cause muscle pain. So not joint pain, muscle pain and achiness. This is most likely to happen older women.

Erin Stein: Lucky us again!

Gillian Goddard: But people also have aches and pains, and the placebo effect is really strong. And so, I think that there's a lot of muscle soreness and pain that gets attributed to statins that is not statin related. It's like people are waiting for that achy muscle when they start the statin and the minute, they've got a twinge they're like, “that's it. I can't take statins. They make me feel terrible.” Which is part of the reason why I think people are A, resistant to going on them, but B, end up not having their cardiovascular risk really effectively managed. And so, I would say a couple of things about that. Some statins are more likely to cause muscle aches and pains than others. The least likely to cause muscle aches and pains are Pravastatin, which was Pravachol, and Rosuvastatin, which is Crestor. And so, if you're on an Atorvastatin, which is Lipitor, and you have symptoms, it's definitely worth switching to a different statin or reducing the dose before just calling it quits because they really are quite powerful. There are some newer kids on the block that are even more effective at lowering cholesterol. There are PSK9 inhibitors, but these are injections. They're very expensive right now. And at the moment they're specifically for people with something called familial hypercholesterolemia, which is like very high cholesterol genetically, but not normal high, like 300 plus, or people who've already had a cardiac event. So, for most of us at the moment, those are not going to be an option.

Erin Stein: If you need it, try a statin. And if you don't feel that great on it, try a different one because there's multiple ones to choose from. And that's the case with a lot of medications, not all of them, but something like this, there are multiple options, and you may have more success on one than the other. 

Gillian Goddard: Correct!

Erin Stein: Look at me!

Gillian Goddard: Yeah.

Erin Stein: Let's move on from our fun favorite, cholesterol, and let's go back to our other favorite, estrogen.

Gillian Goddard: Sure.

Erin Stein: How does estrogen play into all of this? I know you've recapped it a little bit, but let's go a little more in depth.

Gillian Goddard: Yeah, absolutely. So, as I mentioned before, estrogen keeps the inflammation in the blood vessel walls calm. It keeps LDL low, and it lowers blood pressure. And so, in women who have primary ovarian insufficiency and early menopause, it's been observed that they have an increased risk of cardiovascular disease. So, then the question becomes, should I then take estrogen to prevent cardiovascular disease in the future? And this was actually the question that the Women's Health Initiative study was trying to answer. This was their main question. Does taking estrogen reduce your cardiovascular risk? However, this is super hard to prove. So, you and I are in our late 40s. Sorry, it's true. If we start taking estrogen now, our cardiovascular risk doesn't even start to go up for another 20, 25, know, 20-ish years. So, if we're going to do a randomized study that looks at giving women estrogen and seeing whether that prevents cardiovascular disease, that's going to be a really long study. It could be a 30- or 40-year-long study. That's hard to do. First of all, you're going to need multiple generations of researchers. You're going to have to try and keep track of thousands of women over decades. This is just not logistically feasible. So, what the Women's Health Initiative tried to do was take a shortcut by giving estrogen to women who were already closer to that time period where they were at risk. So, in the Women's Health Initiative study, you could be up to age 78, I think, 78 or 79 when you enrolled. And the age of the women in the studies was the late 60s, 68 or 69. And so they were giving all these women estrogen. Many of them had never taken estrogen before. And the reason that the original Women's Health Initiative study was stopped, people talk about breast cancer all the time. It wasn't breast cancer. was cardiovascular disease that got the study stopped early. And it was because women who were randomized to the hormone replacement therapy group were having more cardiovascular disease than the women who were randomized to the placebo group. This led to the development of a theory called the timing hypothesis. The timing hypothesis says that if you give women estrogen right around menopause before they have the beginnings of cardiovascular disease. That estrogen is beneficial, that it will reduce your risk of cardiovascular disease. But if you give women estrogen later, more than 10 years after their last menstrual period, when their risk is already starting to increase, it increases their risk. So, but, notice I said that this is a theory. This has not actually been proven.

Erin Stein: Yes.

Gillian Goddard: The jury is still out because of the complications and studying this that I already mentioned.

Erin Stein: Why would that make sense if it usually does all these good things to lower your risk? Why would it suddenly make things worse if you're taking it later?

Gillian Goddard: Because when you're older and your cardiovascular risk is higher, it is more likely to cause, especially taken orally, which is what was given in the Women's Health Initiative study, it's more likely to cause clotting. And so, then you get clots where these plaques are. And so that's really where the issue is.

Erin Stein: So, at that point you have more plaque automatically, because of age. And if you're taking estrogen, which could increase clots, then that's bad.

Gillian Goddard: Yeah, most people do, yeah. Yeah, you're more likely to have clotting around one of those plaques that gets destabilized. But this is a theory. This is not something that's been proven and people have tried really hard to find ways around the 40-year-long study to prove it. They use things called surrogate markers. So, these are things that are early indications that someone is developing a disease. So, in the case of cardiovascular disease, we can ultrasound your carotid artery and we can look at the thickness of a part of the artery wall called the intima and we can measure how thick that intima is. It's called carotid artery intimal thickness.

Erin Stein: Intima could either be a lingerie brand or another new medication name. it could go either way.

Gillian Goddard: Hahaha! Well, in this case, it's a chunk of your artery wall. So, we know that having a thicker intima, a thicker carotid artery thickness, is a sign of increased risk for cardiovascular disease. 

Erin Stein: Interesting.

Gillian Goddard: And so, one of the studies that people have tried doing, is randomizing women to take estrogen or not take estrogen and then monitoring their carotid artery thickness so that they can estimate their risk. And they've actually found there's no difference between the women who take estrogen and the women who don't. So currently, as of May 2026, we do not recommend that women who have menopause at the typical age, so between 45 and 60, we do not recommend estrogen just to lower your cardiovascular risk. We also don't think estrogen increases your cardiovascular risk if you start it within 10 years of menopause. So that's a complicated message.

Erin Stein: It is complicated. Also, the women's health study didn't prove that it caused those increased cardiac events, did it? Because wasn't that just a correlation?

Gillian Goddard: Well, it's a randomized control. No, because the Women's Health Initiative study was a randomized control trial. And so, then you can say that there's causation because you've randomized two women to two different groups, and they should be the same. And they were roughly the same. But one group is getting the estrogen and one group's not. And we're keeping everything else the same. And so.

Erin Stein: Right, but I don't know that they looked at family history or cholesterol or drinking or smoking.

Gillian Goddard: They looked at smoking, they looked at some comorbidities, and they were roughly the same.

Erin Stein: Okay. Fine.

Gillian Goddard: If you have symptoms, it is safe to take estrogen, particularly if you are within 10 years of your last menstrual period. It's not going to cause cardiovascular disease. But if you are more than 10 years out and you haven't been taking estrogen, you shouldn't start it. And you shouldn't start estrogen in your 40s and 50s just for the purpose of preventing cardiovascular disease, because it's not clear whether it does that or not.

Erin Stein: Right, but if you're having perimenopause symptoms, go for it.

Gillian Goddard: But if you're having symptoms, go for it. Women who have primary ovarian insufficiency and early menopause, it actually is recommended that they take hormone therapy at least until the average age of menopause, which is early 50s, because we think that that may reduce that added risk that they have, although we don't have great studies about that either.

Erin Stein: Shocking.

Gillian Goddard: I know it's always shocking when we don't know the answer to something.

Erin Stein: So, let's go back to the original purpose of this episode, which is what you should be doing for yourself. You should avoid smoking. You should exercise. You should eat healthy foods. We all know that, right? But what should you be doing when you go to the doctor? What should you be getting checked? What are the tests? You know, there's a lot going on here that there could potentially be something you can do.

Gillian Goddard: Yeah, so most primary care doctors will do a lipid panel every year. 

Erin Stein: That checks your cholesterol.

Gillian Goddard: That's your cholesterol, that's right. If your cholesterol is high, you should be treating it. There's a lot of inertia in doctor's offices as much as there is among patients to put people on medicines. And so a lot of times, when your cholesterol is high, the doctor will be like, cut back on steak and burgers and we'll recheck it in six months or we'll recheck it next year. I would say I would be pretty forceful if you're already someone who's eating a relatively healthy diet, particularly if you have a family history. I would be a little more forceful about starting medication in that situation, especially if you're a woman and you're later 50s, early 60s. If you have a strong family history and you have normal cholesterol, it is worth asking for a referral to a cardiologist. if you have a strong family history, it's worth asking for a referral to a cardiologist for a baseline exam period. But one of the things that cardiologists will do is do some other, more in-depth cholesterol testing. And they will often do something called a coronary artery calcium score, which is a super low-dose CT that looks for calcified plaques in the arteries of the heart. And is just another piece of information about your cardiac risk. They'll usually do that sonogram of your carotid arteries. And they'll really, get down into the details with you about statins, cardiologists love statins. And if you have overweight or obesity and you have high cholesterol, high blood sugar, you have signs of metabolic disease, it's pretty clear that adding a GLP-1 to your regimen will reduce your risk for cardiovascular disease as well.

Erin Stein: I would say when you go to the regular doctor, they check your cholesterol levels. They—

Gillian Goddard: They take your blood pressure.

Erin Stein: They take your blood pressure. Every time I go to the doctor, whether they need to or not, they take my blood pressure. Also—

Gillian Goddard: We're required to by law.

Erin Stein: Yeah, well, it's clear that you're required to, but also the EKG starts at a certain age during your annual physical. If you do have high blood pressure, don't just take a medication and forget about it. I would go to a cardiologist. There's no reason not to go to a cardiologist to check things out.

Gillian Goddard: Yeah, especially it's nice to establish care if you have any increased risk.

Erin Stein: It's not always just a heart attack or a stroke. Sometimes people have other things like arrhythmia, or some people have loose vessels, and their heart is not functioning properly because it's not sealing and there are surgeries people do that, you know, tighten all that stuff up so it functions better. I mean, there are other heart conditions to check for. If you're a woman who's planning to or a person planning to give birth, to get pregnant and give birth, are there special considerations for your heart that you should be aware of or looking out for doing?

Gillian Goddard: You know, not necessarily actually. The current recommendations around pregnancy are really focused on maintaining the things that you're currently doing. So, we used to tell women to stop exercising and stuff. Maybe you don't want to train for a marathon if you've never run a mile before while you're pregnant, but you can continue doing your usual physical activity. But you don't need to do anything special. They will measure, believe you me, they will measure your blood pressure at every single visit. And that is important in pregnancy because they're monitoring for signs of preeclampsia, which is a type of high blood pressure and other changes during pregnancy. And so, you'll be monitored for those things. If you have any risk factors for preeclampsia at all, at all, these days women in their second and third trimesters are typically started on a baby aspirin because that's been shown to reduce the risk for preeclampsia. But other than that, there's nothing really to do. it's more that pregnancy kind of reveals weaknesses in the system that may be important information about your future health.

Erin Stein: That you should tell your doctor about. That makes sense actually. And what about…you mentioned baby aspirin. I forgot that the old adage that you should take an aspirin every day for your heart. Is that true?

Gillian Goddard: The guidelines for aspirin changed a few years ago for primary prevention, meaning you've never had a cardiovascular event. If you're between the ages of 40 and 70 and you have very high risk of cardiovascular disease and there's ways to categorize that, then you might consider taking a daily baby aspirin. And so, if you know that you have an increased risk, it's worth chatting with your doctor about whether you fall into that category. Anybody who's at increased risk for bleeding and people over the age of 70, we don't actually recommend routinely taking baby aspirin for primary prevention. If you've already had a cardiovascular event, then you should take a daily baby aspirin and you will then also be the proud owner of a cardiologist who you will be following up with regularly and they will be making sure that you're following all these guidelines. Once you've had an event, the recommendations change completely around all the different medicines that you should be on and how that should be managed.

Erin Stein: And what is it about aspirin and baby aspirin that is helpful? What is it doing?

Gillian Goddard: Yeah, so baby aspirin just refers to the dose. So, baby aspirin is 81 milligrams of aspirin. Back in the day, like in the ancient times when you and I were babies, people used aspirin for babies for fevers until we found out that there was this weird interaction that could happen in kids with taking aspirin. And so, we don't use baby aspirin for that anymore. We use it for grownups, but it just refers to the dose of 81 milligrams, which is lower than a regular aspirin. And aspirin's an anti-platelet. So, it stops platelets from clumping up with one another. And so, if you take aspirin, it irreversibly binds to the platelets and keeps them from forming clots. And so, 81 milligrams is enough to reduce your cardiovascular risk, but not so much that if you really needed your blood to clot, would still get the job done.

Erin Stein: Again, this is all about clumps.

Gillian Goddard: Yeah, it is. And clumps forming where you don't want them.

Erin Stein: Clumps and blobs. Welcome to your heart health! It's all about clumps and blobs. Okay. So, I want to get back to heart attack because there have been public health campaigns to teach people the signs of a heart attack, so you don't ignore it and you go to the hospital, and you get it checked out. But I think a lot of those signs and symptoms are really talking about men's symptoms. As you mentioned earlier, women might experience different symptoms. So how does a woman know if she's having a cardiac event or not?

Gillian Goddard: Some women will have chest pain and they will have the classic symptoms.

Erin Stein: The classic symptoms are the chest pain, the arm, the jaw radiates up, radiates down…

Gillian Goddard: …the jaw, the pain that radiates up to the jaw, and down the left arm, sometimes through to the back as well.

Erin Stein: Do you smell burning toast? Because that's the thing that always stuck in my memory, that you might smell burning toast.

Gillian Goddard: I don't know where that comes from. I don't know where that comes from. But women are much more likely to have non-chest pain symptoms. So back, just back pain, just jaw pain, nausea, vomiting, shortness of breath, like, epigastric, so like stomach discomfort, you know, where your ribs kind of come together under your sternum. They're much more likely to have those types of symptoms that get attributed to all kinds of other things.

Erin Stein: I was just going to say, I have all those symptoms at various times, but I'm not having a heart attack every day, I don't think. 

Gillian Goddard: I assume not.

Erin Stein:  Are these symptoms all happening at the same time? Does it feel more acute, as we say? Is it more painful than the average back pain I'm having on a daily basis? Like, how do you know this is something different, or do you not? We should all become hypochondriacs?

Gillian Goddard: Yeah, so, okay, let's not encourage that. When we talk about heart events, we're talking about things that typically the pain comes and goes over minutes to hours and not over like seconds to minutes. It tends to be that you would have like a cluster of these symptoms all at once. The other thing about most cardiac pain is that it's not based on your position. So, like your back pain is most likely related to your muscles and your bones, right? And the way they're not getting along together. And so, if you move in different positions, that might make it better. That's not so true for cardiac pain. 

Erin Stein: Okay.

Gillian Goddard: And so that's super helpful. Doctors will do things like press around on your chest because if we can make you feel the pain pressing on your chest, that's not a heart attack. And so, there's some things like that. Twinges that happen like super-fast, that's not a heart attack. So, you can get something called costochondritis, which is an inflammation of the joints between the ribs and the sternum and like the breastbone. And when I was a young med student, it was always taught that costochondritis, people would come in thinking they were having a heart attack, but what they really had was costochondritis. And the way you could tell is you could press on that joint and they would jump, and it would be painful. And that the pain of costochondritis is super-fast. 

Erin Stein: “Let me just cause you pain and jab you right there.”

Gillian Goddard: It's not that bad. And I remember being like, how could this joint inflammation make people think they were having a heart attack? And then I got costochondritis, and it is indeed really painful, but it's based on what position you're in and you can press on the joint and make the pain and recreate the pain. So, there are ways to kind of suss this stuff out.

Erin Stein: I think those are two very good ways to assess if you have a new pain or twinge. Does changing your position alter it and or can you replicate it with pressure or not? And that might be a sign that something else, something new and fun is happening. But yeah, I think that's really hard. It's not an easy PSA to say, “Hey, if you're having weird pains that seem new and you can't just change your position, then maybe you should get it checked out.” 

Gillian Goddard: I know. I mean, you can always call your doctor before you head to the ER if you're not short of breath and sweating and things aren't getting, you have this whole constellation of symptoms. 

Erin Stein: Well, it's better safe than sorry.

Gillian Goddard: Although we often then tell you to go to the hospital. It's hard to tell someone with chest pain not to go to the hospital.

Erin Stein: So, you might have these various pains. Do they need to be happening in conjunction with other things like shortness of breath or is it you could just have these pains?

Gillian Goddard: I mean, technically pain is enough, but it tends to be pretty severe pain. And it tends to last for more than a few seconds. It tends to last for minutes to hours.

Erin Stein: Okay, and so the other symptoms that might accompany the pain are—?

Gillian Goddard: That's the nausea, the fatigue, sweating. Some people report, feeling like a sense of doom. Yeah.

Erin Stein: That's something to study. That's actually fascinating to me what your brain is doing to tell you to go to the doctor. “Something's happening, doom!” 

Gillian Goddard: Yeah, your brain is like, “hello, there's a problem here.” Yeah.

Erin Stein:  That's fascinating. Now I need to read some stuff about that. Okay. So basically, your heart's important. You should be monitoring it. You should be talking to your doctor about family history and risk factors. They might not all be obvious. It is related to your liver function. Your risk will happen later than your husband's or your brother's or your dad's. Eat better.

Gillian Goddard: If your cholesterol is high, take the cholesterol medicine. It works.

Erin Stein: Yes, your cholesterol is a factor, but also your blood pressure, also your genetics, also whether you smoke or not or drink or not or eat well or not an exercise or not. That's a lot of things. And get some sleep.

Gillian Goddard: Sleep is helpful.

Erin Stein: I feel like every episode we're going to say the same things, like, eat well, exercise, get some sleep. 

Gillian Goddard: There's a reason why those are the things we recommend.

Erin Stein: It's already annoying me. So, I know it will be annoying, but it is true. And it's really hard. So not sexy. But we need to prioritize that for ourselves. We have to keep reminding ourselves to do that.

Gillian Goddard: It is true. They're not sexy.

Erin Stein: That's your heart. Love it.

Gillian Goddard: Thanks for listening.