Women’s Heart Health: Unique Cardiometabolic Risks

Women’s Heart Health: Unique Cardiometabolic Risks (PODCAST TRANSCRIPT)

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Welcome to Healthier World with Quest Diagnostics. Our goal is to prompt action from insight as we keep you up to date on current clinical and diagnostic topics in cardiovascular, metabolic, endocrine, and wellness medicine.

Maeson: cardiovascular disease is the leading cause of death in both men and women. Yet nearly half of women aren't aware of that a staggering 71 percent of women never discuss heart health with their physician. This episode will explore this gender disparity and elucidate why women carry unique risk factors for cardiovascular and metabolic disease. I'm Dr. Mason Latsko, a researcher by training with a passion for learning. And today I'm joined by my fellow clinical educator, Dr.

Tricia Winchester, who's the director of clinical education within the cardiometabolic, endocrine, and wellness segment at Quest Diagnostics. Welcome, Tricia. Thank you so much for joining me today.- [00:01:00]

Trisha: Thanks, Mason. It's a pleasure to be here.

Maeson: So Trisha, we know there's a huge gender gap in cardiovascular disease. Why is cardiovascular disease often seen as a man's disease? And how does this perception affect both awareness and prevention in women?

Trisha: You are absolutely right that there is a gender gap in terms of the knowledge base about cardiovascular disease. It's been long thought of as a man's disease because typically women tend to have their first cardiovascular event later in life compared to men. There was also a lack of research to understand if there were any differences in men and women, And so because of that, women and men were identified with cardiovascular disease the same, managed the same. It wasn't until 2001 that there was a real push to fund sex specific clinical trials.

and while men and women share the top three most common risk factors for cardiovascular disease, including hypertension, high lipid values, like an elevated LEL cholesterol and smoking. Researchers shown that women tend to be undertreated when they did present with the same symptoms or risk [00:02:00] factors. Unfortunately, though, the first symptom of cardiovascular disease is most commonly in a heart attack or a cardiovascular event.

And at that stage, you know, that's the very last stage where you want to identify that someone has cardiovascular disease. There's a lot of conditions that occur in different life stages for women that can be seen as risk factors. and many times these risk factors are overlooked. So it really is a matter of education, making sure that we're evaluating risk factors in women, and also using lab testing to identify those clinically silent conditions in order to prevent the clinical manifestation of a cardiovascular event later on in life.

Maeson: Absolutely. I agree that it's a matter of education and it's a matter of awareness.

 You know, the idea that one in three female deaths are from cardiovascular disease compared to say one in 31 deaths from breast cancer. Right? I'm sure most women listening in today have had a breast exam before,

yet, how many of them have been routinely asked [00:03:00] about their reproductive history or

any syndromes that they experienced during pregnancy, Or even hormone perturbations that can alter our lipid particle numbers, right? So let's make sure that we bring awareness to these disease states because they do really matter.

And that's not to minimize breast cancer at all, But we have clearly made the push to educate women on breast cancer. The question becomes, why haven't we done the same thingFor cardiovascular and metabolic conditions.

Trisha: Exactly. you mentioned this earlier, but 71 percent of women never discuss heart health with their physician.

They come in saying, Oh, I know I need to have my annual reviews for, the bikini area, right? the breasts. the ovaries, all of sex organs, however, the heart is never given its due diligence.

Maeson: So as we talk aboutthe signs and symptoms of cardiovascular disease in women, it's also important to  identify the difference in risk factors. You hinted at the idea that men and women share common risk factors like smoking, high cholesterol and high [00:04:00] blood pressure. But what are some of the unique risk factors that women carry? Can you expand a little bit on this, Tricia, and help us understand what that means for women?

Trisha: Yeah, so like you mentioned, risk factors for men still apply to women and most of the time, and really as historically thought menopause is the time in which women need to look at their cardiovascular health. And while that's true, it's a huge metabolic shift that we will speak to later on in the podcast.

Um, but by time women are reaching menopause, there's already been decades of risk factors that have been working silently in the background that sets the stage for cardiovascular health later on in life.

 So let's go back earlier in a woman's life and talk about other unique risk factors that should be taken into account. So, for example, in the adolescent ears. earlier, late Menarchy weight gain and irregularity of menstrual cycles in the primary reproductive years in fertility, polycystic ovary syndrome, endometriosis, adverse pregnancy outcomes like gestational [00:05:00] diabetes, preterm labor, preeclampsia.

Maeson: And in the perimenopausal years, which is the four to five year transition into menopause, things like left breast cancer, radiation, heart palpitations, immune disorders, and thyroid disorders, all of these conditions can increase risk for cardiovascular disease. So really, if a woman has had any one of these in any stage of life, she should be put into a higher risk bucket for cardiovascular disease risk stratification. That's a great point. So menopause is a huge hormonal shift that occurs for women and some of these unique risk factors that arise before that can just heighten that risk later on in life. , so PCOS, during adolescent and the reproductive years, infertility and adverse pregnancy outcomes also during those reproductive years and then of course the events that you mentioned during perimenopause can all leave a woman at greater risk.

 So let's dive into bringing awareness to some of those conditions that can increase a person's risk. And one condition that I wanna. Start with that has a growing focus [00:06:00] in this area is PCOS or polycystic ovary syndrome.

We know PCOS impacts many aspects of women's health, but how does it specifically contribute to cardiovascular disease? And what should listeners with PCOS know about the potential long-term effects on heart health?

Trisha: Yeah, and let me first say that PCOS is an extremely underdiagnosed condition, likely because of varying clinical presentation and diagnostic criteria. But just to be clear , the Rotterdam criteria is recommended along with the diagnosis of exclusion, and in many cases, lab testing can be used to diagnose individuals.

Quest Diagnostics has A-P-C-O-S algorithm to help providers with this, and it is highlighted in another healthier world podcast. While PCOS is commonly identified in the reproductive ages, it has a strong influence on risk factors later on down the line. And one characteristic that's found in many women with PCOS is insulin resistance, which is really the foundation to a whole slew of conditions.

You might have immediately gone to type two [00:07:00] diabetes, which is true. And in fact, 50% of women with PCOS develop type two diabetes by the age of 40. That's a staggering statistic. Because of this metabolic derangement driven by PCOS, there's likely also an influence on lipid packaging. and because of hyperinsulinemia increases the risk of developing fatty liver disease.

So when we think about these women, they are prime candidates for cardiometabolic evaluation, so that way they can be treated early enough or even have the opportunity to really commit to a diet and lifestyle. Knowing that they have these risks to prevent them from having to go on a medication,

 But really first is just being informed of the condition and being aware of it. Because being aware is the first step in order to be in charge of your health

Maeson: Yeah, and that's a great point. These are adolescents and young adults, right? So we typically don't identify PCOS until a woman is. Consider to be infertile and and struggling to become pregnant, but this is so early on in a women's journey that we could [00:08:00] really make a difference by just being aware of this condition.

Now, you mentioned the Rotterdam criteria, which is pivotal in understanding whether or not a patient has PCOS. And that, of course has laboratory testing involved, such as testing

 for LCMS, testosterone, 17 hydroxy progesterone and thyroid conditions,

And you also mentioned the link between PCOS and cardiometabolic conditions.

So assessing a patient's cardiovascular risk and assessing a patient's metabolic risk, early on in their trajectory could really help inform them later on in life. now what about those women who overcome PCOS or overcome infertility or never face those issues with infertility and become pregnant?

Uh, this is obviously a very pivotal and unique stage in a woman's journey, but pregnancy also pushes our bodies to the limit, right?

it adds a ridiculous amount of stress to the body and essentially pushes you to that brink. And so you can see how patients with underlying [00:09:00] conditions that may be lay dormant can rear their ugly heads during pregnancy.

So let's talk about some of those adverse pregnancy outcomes or APOsand discuss how these conditions can have long lasting impacts on their cardiovascular and metabolic health. And before you dive in, I just want to emphasize here that this is a topic that really hits home for me as many women that I know and love have faced these conditions. So,

I hope this serves as a way to bring awareness to those women and acts as a way to say, hey, take your health in your own hands and be your own advocate to really protect yourself against those cardiometabolic conditions down the line

Trisha: Yeah, out of all the women that you can think of,  a safe bet that a woman that you know has experienced some form of an adverse pregnancy outcome. If you don't, I can share personally that I have. So now you do, and I'll share more about my experience, in a bit. But first, I wanted to discuss the hypothesis around APOs and that many cardiometabolic conditions [00:10:00] are silent, obviously, until they are not.

And when they're not silent, that's when someone experiences a clinical symptom like dizziness or seeing stars or being out of breath, and so when they experience those symptoms, that's when they've passed a clinical threshold. Many women who experience APOs may have had risk factors prior to pregnancy that puts them closer to this threshold, and that when they have the stress of the body due to pregnancy, is when women are pushed over that threshold and experience the clinical symptoms of these adverse pregnancy outcomes.

It's not always the case,But equally important to know where a woman's risk is and try to optimize that prior to pregnancy, which as a woman always baffled me that this was not a discussion that I was having with my OB, GYN. So once the woman delivers the baby, the stressor goes away.

And when the woman comes back down below that threshold, many times it's forgotten about. However, because that woman experienced the adverse pregnancy outcome, they are now closer to that threshold than [00:11:00] she was prior to pregnancy. And because of that, these women experienced a higher likelihood of developing chronic cardiometabolic conditions earlier than women who did not.

And I don't mean that to scare anyone, I really mean this from a place of being informed. And so, if we take my own example, I was a former division one athlete, played softball at Hofstra University, go Pride. Um, you know, I live a fairly active lifestyle and I love to be outside. However, I do have a family history of diabetes.

So being aware of that, going into my first pregnancy, um, I was very conscious of my glucose control and, and eating well. However, turns out I did develop preeclampsia, uh, and needed to induce labor. Luckily, it was after 37 weeks, I know prior to 37 weeks. There's also additional risks to cardiovascular disease later on.

Um, but later on I also found out that I have a family history of hypertension as well. So being aware of that that having preeclampsia put me at a future risk. Of developing [00:12:00] hypertension as well as cardiovascular disease. I am now more motivated to go and one have a PCP 'cause many women use their

OBGYNs as their PCP. Um, but to have a PCP to manage my, my overall health and to assess my risk factors and implement changes to my diet and lifestyle, and as a part of that regimen is also inclusive of a number of lab tests to make sure that I'm tracking to where I want to be.

Maeson: That's really powerful. Thank you for sharing your experience. You know, I, I am guilty of using my OB GYN as A PCP until very recently as well. So I think that it's, you know, an eye-opening, story to bring awareness to. Adverse pregnancy outcomes. and we also know that the American Heart Association considers APOs as a risk enhancing factor, meaning that basically having an A PO bumps up that individual into a higher risk category,

and that woman should be considered to be treated more aggressively For cardiovascular disease and knowing that, let's talk about a [00:13:00] few major adverse pregnancy outcomes. You alluded to both. Let's start with gestational diabetes.

This condition is not only one of the most common pregnancy related complications, but also plays a crucial role in shaping long-term cardiovascular health for both mothers and child. And unfortunately, right now, a lot of women are taught that gestational diabetes doesn't really count as diabetes.

Trisha: Right? That it's something that our bodies experience during pregnancy. Our bodies have a tough time controlling that blood sugar during their pregnancy, but not to worry because their blood sugar will come back down postpartum and everything will kind of dissipate and disappear. And while that can sometimes happen, isn't always the case, is it?No, it's not. And in fact, Women who experienced gestational diabetes have significant cardiometabolic risk, including a 2. 4 fold increased risk for metabolic syndrome, a 10 fold increased risk of developing type 2 diabetes, as well as a 2 fold increased risk for future cardiovascular disease events. The American [00:14:00] Diabetes Association guidelines recommend individuals with gestational diabetes to get an oral glucose tolerance test or an OGTT.

Between four to 12 weeks postpartum and every one to three years after thatdue to the lifelong risks of diabetes. However, this is rarely done. Women might be returning to work, juggling a newborn, a care schedule, maybe a pumping schedule with little time or desire to go in and drink a sugary drink and wait for an hour.

Luckily, quest Diagnostics has other lab diagnostic tests that can help to alleviate this, issue with a simple blood draw using the insulin resistance panel with score tests

Maeson: Yeah, and we talk about the insulin resistance panel with score in a number of other healthier world podcasts, but absolutely an option for these women who struggle with glycemic control during pregnancy to have, you know, kind of an easier solution for assessing and addressing their glycemic control postpartum.

and I think if women knew how much of an increased risk they were at for cardiovascular and metabolic [00:15:00] conditions, they wouldn't just be considering gestational diabetes, just a blip in the road. Now, another adverse pregnancy outcome that you alluded to is one that you, shared your experience with, and that is preeclampsia.

Now preeclampsia has the greatest morbidity and mortality risk to mothers and fetuses during pregnancy. Let's go ahead and expand a little bit on this condition and the cardiovascular risk associated with preeclampsia.

Trisha: Yeah, preeclampsia is defined by high blood pressure with protein in the urine, and like you mentioned, can confer risks for mothers during pregnancy, but also postpartum. So many people are tend to be caught off guard with preeclampsia, and sometimes that can result in an emergent situation for the mother and child, but really focusing in regards to post-pregnancy, it increases the risk for developing chronic hypertension by threefold.

It also increases your risk for developing heart failure by four times and increases the risk for developing cardiovascular disease by [00:16:00] twofold. So overall we know that there's future cardiometabolic risks associated with individuals with preeclampsia because of that high blood pressure. Um, for me personally, again, you know, high blood pressure is a, a family history and so going forward, I want to be aware and making sure that I'm monitoring my blood pressure and getting those consistent checks with my PCP.

who's aware of my a PO because that does increase my risk of developing chronic hypertension in the future. if I do develop hypertension, I'm going to want to manage it earlier, otherwise I'm risking the damage that hypertension can have on my body without it being managed.

Maeson: Yeah, so taking your experience with preeclampsia, making sure that you tackle any hypertensive issues that you have later on because you are your own advocate now. Right.

So now we've talked a little bit about the different adverse pregnancy outcomes that can increase a person's cardiometabolic risk. What testing is available to [00:17:00] assess that patient's increased risk ?

Trisha: Yeah. So step one is really to make sure that either the patient is conferring the information to their provider,whether that be an OB GYN or a PCP about their adverse pregnancy outcome. it's important for the patient to bring it up to PCPs who aren't asking the question, but also important for the primary care to be asking the question about pregnancy history, um, and streamlining this information into their risk evaluation for this patient.

Because all too many times, you APO is one in five. So, if a primary care provider isn't asking the question, they might be missing a significantly increased risk individual in one out of five women.

Second would be to utilize lab testing that can provide a comprehensive view of where someone sits within the cardiometabolic spectrum. So that might include using a lipid panel and APO lipoprotein B, which is a measure of lipoprotein particles in the bloodstream, which indicates cardiovascular [00:18:00] risk specifically and especially in individuals with any type of metabolic dysfunction or insulin resistance, from a metabolic standpoint, an HBA one C is, giving a three month average of your blood glucose levels.

However, the insulin resistance panel with score is telling us, in which direction are you moving? Are you moving to better glycemic control and being insulin sensitive, or is this patient insulin resistant which increases the risk of developing type two diabetes .. Fatty liver disease and a slew of other conditions that we discussed earlier, Last but not least, A TSH with a reflexive free T four, which is a Clinically relevant way to evaluate thyroid conditions.

Maeson: we recognize that adverse pregnancy outcomes are obviously a very daunting and a heavy topic . This is already a time of immense physical and emotional change. So to layer on the added burden of, Hey, A patient with an adverse pregnancy outcome also has greater risk for cardiovascular disease down the line. I know that can feel heavy. So I hope [00:19:00] identifying the teststhat can assess a patient's risk will help again bring awareness and empower those women to prevent cardiovascular and metabolic disease from forming to begin with.

Now, for all women, they'll then go through menopause later in life. This is another major life stage that plays a pivotal role in cardiovascular and metabolic health. If we think about that disease risk threshold that we were talking about previously, menopause is one of these other situations that pushes a patient to that disease risk threshold and potentially over that barrier, given the changes in hormones that affect a woman's cardiovascular and metabolic disease risk.

Tricia, can you speak a little bit about these hormone shifts and how that leaves an individual at greater risk after menopause?

Trisha: Yeah , agreed Mason, and really, you know, first, let's define menopause as a hormonal change that indicates the loss of estrogen. This typically occurs between the ages of 45 and 50 years [00:20:00] old, and it's defined by the absence of periods for 12 months. So really with the loss of this important cardioprotective hormone, estrogen, it really implements changes to the vasculature.

So changes to the vasculature can lead to the development of hypertension. it's also impacting the ability for the liver to metabolize cholesterol, which leads to an increase in cholesterol levels.

So increases the potential for atherosclerosis to ensue, leading to plaque buildup. on top of that, it's also a metabolic shift. the loss of estrogen can increase insulin resistance.

And with that. Increases the likelihood of developing a worsening glycemic control. And since estrogen plays a role in the sleep wake cycle, it can lead to worsening sleep, which also can contribute to that metabolic shift. So sleep is connected with insulin resistance and with estrogen playing a role in both of those.

It really is this huge metabolic shift that women are experiencing. And all of those risk [00:21:00] factors are all rooted in cardiometabolic conditions.

Maeson: Yeah. So losing that protective role of estrogen during these menopausal years really does play pivotal role in increasing our risk for cardiovascular and metabolic conditions.

Now I just wanna acknowledge that there has been a lot of controversy around hormone replacement therapy over the years, primarily due to studies suggesting that it may actually increase risk for conditions like breast cancer, blood clots, and even stroke.

So these concerns have led to a decrease in utility of hormone replacement therapy. But there has been some research highlighting a potential benefit for hormone replacement therapy on heart health, especially when implemented earlier in menopause. So it's important to consider these perceptions and how they have evolved over time because that may influence how a woman or a healthcare provider approaches menopause and cardiovascular disease risk management today. Now because this is such an important step in a woman's healthcare journey, We do need to study hormone replacement therapy more efficiently and directly in [00:22:00] a research setting.

Trisha: (Maeson maybe an oppporuntity here for you to talk about the reserach component) yeah, we've definitely made strides in better understanding that women are not little men. Um, and they shouldn't be treated the same. However, the risk factors that play a role in the cardiometabolic disease progression is really similar between genders. So while the timing may be different, particularly for women going through menopause, uh, for developing atherosclerosis, if previous risk factors weren't prevalent, the evaluation from a lab perspective for cardiometabolic conditions still applies.

Maeson: right, so not only throughout a woman's lifetime, but especially during these windows, when we know we can be approaching and exceed that threshold for cardiometabolic risk and disease, that's really when women should be getting these advanced testings, the ApoB, the insulin resistance panel with score a TSH. You know, all these tests that you had previously mentioned. So thank you so much for walking us through these major life changes in women and what we can do about it being our own advocate as women. and , alerting us to what testing options are available to determine [00:23:00] our risk for cardiovascular disease moving forward. Any final thoughts before we round out today?

Trisha: Yeah, so I think the idea here is that These individual, conditions that happen in these different phases of life, whether that be in adolescence, primary reproductive years, where we're experiencing PCOS, adverse pregnancy outcomes, perimenopause, menopause, um, All of these things can add up to what our cardiometabolic risk is going to be in the future.

And so by knowing what these are can help us to better prepare and to better avoid the complications of these. Again, the first symptom of cardiovascular disease is commonly a cardiovascular event. So by identifying who has these red flags, let's evaluate cardiovascular risk in these individuals and determine who could be a good candidate for therapies to be either initiated or modified.

Maeson: Great. Thank you so much for joining me, Trish.

Thank you [00:24:00] Mason.

That's a wrap on this episode of Healthier World with Quest Diagnostics. Please follow us on your favorite podcast app and be sure to check out Quest Diagnostics Clinical Education Center for more resources, including educational webinars and research publications. Thank you for joining us today as we work to create a healthier world, one life at a time.