Why Women’s Heart Disease Is Overlooked — and How to Change That | Blue Shield of California

by Beth Trimarco

Heart disease is the leading cause of death for women in the U.S., yet it remains widely misunderstood and underdiagnosed because it often presents differently than it does in men. Understanding these differences is key to prevention and early detection.

According to Dr. Bethany Gray, senior medical director at Blue Shield of California Promise Health Plan, women are four to six times more likely to die of heart disease than breast cancer. “Women need to monitor heart disease as much as we monitor breast cancer,” she said. “There’s no simple screening like a mammogram, and symptoms can be subtle. We need to better educate women so they can advocate for their heart health.”

Women’s heart disease risk factors

Traditional risks like high cholesterol, smoking and high blood pressure affect everyone, but women also face additional, often overlooked risks. Hormonal changes during perimenopause and menopause, as well as pregnancy complications such as preeclampsia and gestational diabetes, can significantly increase the likelihood of heart disease.

Layered on top of biological factors is chronic stress. Caregiving, marital strain and domestic violence disproportionately affect women, and have been linked to cardiovascular risk. Chronic stress contributes to inflammation, high blood pressure and sleep issues — all of which strain the heart.

“Women’s cardiovascular risk is shaped not only by biology, but by social roles,” said Dr. Gray. “Women often carry more of the mental and emotional load for families, creating a constant baseline of stress where rest and self-care are deprioritized.”

Heart disease symptoms that don’t match the stereotype

The most recognized heart attack symptom — sudden, severe chest pain — is more common in men. Women are more likely to experience subtle symptoms, including shortness of breath, nausea, jaw or back pain, unexplained fatigue or dizziness. Because these signs are less dramatic, women may second-guess their instincts or delay seeking care.

“Women often downplay their symptoms because there might not be ‘an elephant sitting on their chest,’” said Dr. Gray. “And when they do seek care, symptoms are too often dismissed as stress, anxiety or gastrointestinal issues. That bias has dangerous consequences.”

Research by the National Institutes of Health shows that women are less likely than men to be referred for diagnostic testing, receive timely treatment or be taken seriously. As a result, heart disease in women is often detected later, when it is more advanced and harder to treat.

A broader definition of prevention

Improving heart health outcomes for women requires proactive, gender-aware care that recognizes prevention looks different across women’s lifespan.

Clinicians increasingly encourage women to track cardiovascular changes during perimenopause and menopause and to discuss pregnancy history as part of routine heart health assessments. Symptoms like persistent fatigue or breathlessness should be evaluated, not dismissed. Stress, sleep quality and social support must be treated as health factors — not afterthoughts.

“Unlike blood pressure and cholesterol, there isn’t a quantifiable test for stress,” said Dr. Gray. “Women need to be their own lab test and develop stress management strategies that work for them.” Women can also play a key role in their own care by asking questions, understanding their risks and seeking second opinions when something feels off.

Working closely with a doctor to understand key health markers is essential. Optimal heart health targets for women include: blood pressure below 120/80, cholesterol under 200, a BMI of 18.5 to 24.0 and a waist circumference of under 35 inches. Regular exercise, seven to 10 hours of sleep each night and a heart‑healthy diet further support long‑term cardiovascular wellness. Medications may also be recommended to help keep risk factors in check.

“As a woman, a patient and a physician, I know the importance of being seen and heard,” said Dr. Gray. “When women trust their instincts, and clinicians recognize women’s unique risks, outcomes improve. With informed care, heart disease can be detected early and managed to extend women’s lives.”

Blue Shield resources

• Wellvolution, a digital lifestyle-medicine platform available at no additional cost to most Blue Shield members, offers programs to support mental well-being and lower blood pressure.
• Live Healthy: Lifestyle medicine and wellness resources