Premenopausal women and cardiac symptoms

by Carolyn Thomas      @HeartSisters

Most of you throughout your adolescent and adult lives have no doubt observed that hormone fluctuations during a menstrual cycle can affect certain body parts on certain days of that cycle. These fluctuations cause symptoms ranging from bloating to cramps, vivid dreams, fatigue, acne breakouts, food cravings, or irritability. (That word ‘irritability’ is doctor-speak to describe the act of threatening spouses with strangulation if they leave that freakin’ toilet seat up one more time…)

For decades, scientists have also observed that women’s risk of heart attack increases after menopause. One theory for this age-related delay (compared to male heart patients, who generally tend to have their heart attacks a decade or so before we do) was the drop in female hormones at menopause, particularly estrogen. That timing seemed to intuitively make sense. Estrogen levels go down, heart attack rates go up. It’s why physicians believed for a long time that hormone replacement therapy in postmenopausal women could actually prevent heart attacks. (PLEASE NOTE: it doesn’t.*)

Still, there appears to be evidence that the hormones surging through our bodies during our menstrual cycles can worsen the symptoms of a number of health conditions (including, of course, the health of all those spouses who are now anxious about using the toilet properly!)

Although the precise cause of worsening symptoms isn’t clear, researchers point to complex interactions between our immune and neuro-endocrine systems. The impact of a woman’s menstrual cycle on the severity of chronic symptoms is well documented, including those of migraine(1), asthma(2) and cardiac arrhythmia.(3)  About half of women with Crohn’s disease (a chronic inflammatory disease of the intestines) report that their bowel symptoms get far worse just before and during their periods(4). And menstrual cycles have also been identified as a trigger for worsening bouts of depression(5).

In one Japanese study on women diagnosed with a coronary spasm disorder, researchers found that chest pain caused by the non-obstructive coronary disease called Prinzmetal’s Variant Angina was significantly affected by menstrual cycles.(6) The study suggested that painful angina spasms were most frequent (3.9 episodes per day) early in the menstrual phase, and least frequent (0.3 episodes per day) for the rest of the month.

There’s even some evidence that treatment decisions have been modified because of reported menstruation-linked changes in cardiac symptoms. A different team of Japanese researchers published their results in the International Heart Journal, based on an interesting case study of a 38-year old woman living with the arrhythmia condition called atrial fibrillation (7), for which she had been taking three different daily medications.  But after the researchers monitored her heart rhythms over a 22-month period, they found that her palpitations increased only during and just after her monthly period started. Her medication regimen was changed from daily to periodic administration for just one week, beginning a couple of days before her expected menstrual time each month. The study concluded that “the patient did not feel symptomatic variation in her menstrual cycle.”

Researchers from the Québec Heart Institute also wondered if hormones affected the cardiac risk of premenopausal women. This study, published in the American Journal of Medicine, looked at female heart attack survivors within 48 hours following hospital admission. All of the women studied had experienced a heart attack within the first half of their menstrual cycles, compared with no events during the second half of the menstrual cycle. More than half of the women, in fact, had their heart attack within six days after their periods started, rather than later during the menstrual cycle.(8)

Other research has suggested similar results. A U.K. study, for example, published in the cardiology journal Heart looked at premenopausal women (mean age 38.8 years) who lived with established coronary heart disease and symptomatic angina.(9)  Researchers found that the week during or immediately after a period starts (known as the early follicular phase, when levels of the sex hormones estrogen and progesterone are lowest) produced the quickest time to exercise-provoked angina pain (290 seconds) compared to any other weeks of the monthly cycle.

They called this  increased pain “menstrual angina”.

* What Science Says About Hormone Therapy to Prevent Heart Disease

As cardiologist Dr. Nieca Goldberg explains:

“Menopause isn’t a disease, nor does it cause cardiovascular disease. It’s a natural phase of a woman’s life cycle. Estrogen decline isn’t the only reason women face a higher cardiovascular disease risk after reaching menopause. Assorted changes in the body occur with menopause. Blood pressure starts to go up. Triglycerides (certain types of fats in the blood) and LDL (‘bad’) cholesterol tend to increase while HDL (‘good’) cholesterol declines. It’s important for women, as they approach menopause, to really take stock of their health.”

Many studies, notably the landmark Women’s Health Initiative(10), have since debunked the evidence behind the formerly-popular medical recommendation that hormone therapy prevents heart disease. Initiated in 1993, the WHI Hormone Therapy Trial was designed to test the effects of estrogen in women with an intact uterus on their risks of cardiovascular disease and breast cancer among 27,347 postmenopausal women in the U.S., ages 50–79 years.
In May 2017, the U.S. Preventive Services Task Force (USPSTF) issued a new recommendation warning against the use of combined estrogen and progestin therapy to prevent chronic conditions like heart disease. (This warning is considered a “D-recommendation”, meaning a “moderate or high certainty that this has no net benefit, or that the harms outweigh the benefits.”)
“This recommendation applies only to women who have gone through menopause and are considering hormone therapy to prevent chronic conditions,” said USPSTF member Dr. Ann Kurth. “It does not apply to women who are considering hormone therapy to manage temporary menopausal symptoms (like hot flashes or night sweats), or to women younger than age 50 who have experienced premature menopause or who have had their ovaries surgically removed before menopause.”
1. MacGregor EA, Chia H, Vohrah RC, et al. “Migraine and menstruation: a pilot study”; Cephalalgia, 1990.10:305-310.
2. Skobeloff EM, Spivey WH, Silverman R, et al. The effect of the menstrual cycle on asthma presentations in the emergency department”; Archives of Internal Medicine, 156:1996.18371840.
3. Rosano G, Leonardo F, Sarrel P et al. Cyclical variation in paroxysmal supraventricular tachycardia in women”. Lancet, 1996.347:786788.
4. Bernstein MT, Graff LA, Targownik LE, et al. “Gastrointestinal symptoms before and during menses in women with IBD.” Alimentary Pharmacology & Therapeutics, 2012;36:135-144.
5. Pinkerton JV, Guico-Pabia CJ, Taylor HS. “Menstrual cycle-related exacerbation of disease.” American Journal of Obstetrics and Gynecology. 2010;202(3):221-231.
6. Kawano H et al. Menstrual cyclic variation of myocardial ischemia in premenopausal women with variant angina. Annals of Internal Medicine, 2001Dec 4;135:977-81.
5. Bernstein MT, Graff LA, Targownik LE, et al. “Gastrointestinal symptoms before and during menses in women with IBD.” Alimentary Pharmacology & Therapeutics, 2012;36:135-144.
6. Pinkerton JV, Guico-Pabia CJ, Taylor HS. “Menstrual cycle-related exacerbation of disease.” American Journal of Obstetrics and Gynecology. 2010;202(3):221-231.
7. Sugishita, K et al., “Cardiac symptoms related to paroxysmal atrial fibrillation varied with menstrual cycle in a premenopausal woman.” International Heart Journal, 2013;54 (2):107-10.
8. Hamelin B et al. “Influence of the Menstrual Cycle on the Timing of Acute Coronary Events in Premenopausal Women”. American Journal of Medicine, May 2003. Volume 114, Issue 7, Pages 599–602 
9. Lloyd GW. “Does angina vary with the menstrual cycle in women with premenopausal coronary artery disease?” Heart. 2000 Aug; 84 (2):189-92.
 10. Women’s Health Initiative, 1992-2008

NOTE FROM CAROLYN:  I wrote more about women’s hormones and their effects on our cardiac risk in my book  A Woman’s Guide to Living with Heart Disease.  You can ask for it at bookstores (please support your local independent bookseller!) or order it online (paperback, hardcover or e-book) at Amazon – or order it directly from my publisher Johns Hopkins University Press (use their code HTWN to save 30% off the list price).

Q: Have you experienced a cardiac event or other serious condition that appeared to be impacted by your period?

See also:

14 thoughts on “Premenopausal women and cardiac symptoms

  1. Hi I’m 46 and have had 3 heart attacks, first one was when I was 35 but all 3 of them happened when I was on my period. I now get unstable angina due to another artery narrowing which can’t be fixed because it’s too close to two stents that I already have.

    I have for the last 3 months been having my period every two weeks very heavy causing me to be anemic, and also my angina gets bad when they are on the way but my doctor and cardiac nurse say they don’t believe that this is linked.


    1. Good grief, Joanne. You’re having periods every two weeks, with associated “bad angina”, and your doc and cardiac nurse say there’s no link? I’m not a physician, of course, but it appears that there is in fact quite a bit of published research being done on this very subject. I don’t usually suggest patients print off medical journal articles to show their physicians, but yours might be willing to read this one as a ‘show and tell!’ It’s published in a well-respected cardiology journal, HEART, by research scientists at St. Thomas Hospital Cardiothoracic Centre in London, England – and just one of many published studies that I’ve quoted in this article.

      Just curious: what does your cardiac team recommend for your unstable angina? Are you taking nitroglycerin for it? You might want to ask your doctor about prescribing a nitro patch as a short term experiment just during that painful pre-menstruation stage to see if that reduces your angina at all. Might be worth a try.

      Good luck to you…


      1. I am taking 90mg twice a day of diltiazem and 20mg twice a day of nicorandil which have helped but I feel weak all the time and every time I try to do things like house work the angina starts. Even just going for a walk, it has also woken me up in the night.

        Liked by 1 person

        1. Again, I’m not a physician, Joanne – but it does sound like you’re describing prescribed drugs that are NOT effective at addressing your angina pain. It could be that the dosages might be inadequate. Weakness is one of the side effects of both diltiazem and nicorandil. This is important because if your unstable angina (e.g. pain that wakes you up at night, not during exertion) is NOT being well-managed with these medications, it may be time to do more than what you’ve been doing so far (which is not working to ease your symptoms). Please consider getting a second opinion about your unstable angina. Here’s more info on this from Mayo Clinic.

          If you decide against a second opinion, ask your doctor for a medication review – because there may be something worth trying that you’re not doing right now.


  2. That is really interesting. Would “menstrual angina” be showing through regular heart test? By example, would the troponin level be higher? Would you be able to notice something on an (20 sec) ECG? etc.

    The reason I am asking is because I have been having issues with my menstrual cycle for the past 7months (post-partum like bleeding that last for about 10 days). Not too long ago, I have been admitted to the hospital with really bad chest pain, palpitation and shortness of breath. I had a constant pressure on the chest and once in a while I would feel a big squeeze. Then my heart rate would be high and I would feel palpitation.

    However, once at the hospital, my ECG was normal, so was my blood test and my chest X-rays. The only notable symptoms was my resting heart rate being 100+. The very next day, I started bleeding again (at least one week early). I am positive that the chest pain and my menstrual issues are related. I am not here for diagnostic or anything, I am seeing my Doctor in 2 weeks again for this matter, but I am wondering how hormonal-related chest pain can be “seen”?

    Liked by 1 person

    1. Good question. Although, as this post discusses, the “complex interactions between our immune and neuro-endocrine systems” are well known, the specific cardiac diagnostic tests you mentioned look for specific heart muscle changes that happen during a serious cardiac event.

      The blood test for troponins for example can reveal levels of a cardiac enzyme that would likely be present only if your heart muscle had been damaged during an actual heart attack. Angina is not a heart attack – many people live with chronic angina that’s well managed with nitroglycerine or other “vasodilator” medications. Your symptoms may be more typical of those noted in the U.K. study (9) but you should discuss the distressing symptoms you’ve been experiencing with your doctor and possibly request a cardiologist referral, just to be on the safe side.


  3. That is a confusing post. It appears to hint at a direct link between women being at higher heart attack risks during and right after their periods when their hormones drop but then also says there is no link to hormones dropping during menopause?


    1. Hi Jennifer – What it actually says is that prescribing hormone replacement therapy to menopausal women in order to reduce risk of heart attacks is no longer recommended. Re-read the ‘What Science Says…’ section at the end and follow links for more info.


  4. Wow, this is good information to know. My company recently wrote an article on the symptoms of CVD, including differences for men and women.


  5. I was on my menstrual cycle during my heart event. After my stents, every time of the month I had chest pain, fluttering, and angina. Plus, the heart meds did not help. The blood thinners make you bleed more. Overall, I felt terrible. I told my cardiologists (all men) about this and they ignored me saying “it didn’t have an impact”. I knew they were wrong. All along I knew that hormonal fluctuations did have an impact.

    Liked by 1 person

    1. Hello Mag – as you can see from this article, it seems that many cardiac researchers agree with the validity of your own experience, but that’s not what most patients care about. Being listened to and believed by our cardiologists is likely far more important to us…


  6. I had a heart attack at 48. I was very healthy, normal weight and never expected this! During an angiogram, my main cardiac artery was bisected, and I almost died. I was kept alive on machines, and was put into a coma. I woke 3 weeks later completely confused. I spent 180 days in the hospital, was put on the list for a transplant, and now, 9 years later, am doing well with the heart of a generous man in my chest.

    Be a donor! ❤️

    Liked by 1 person

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