After long being sidelined by medicine, women’s health is gradually coming back into the spotlight. But Professor Claire Mounier-Véhier, a cardiologist and vascular physician at Lille University Hospital, has long been working on the topic. Co-founder of Agir pour le Cœur des Femmes with Thierry Drilhon, she has been campaigning for over 30 years for better care for women’s cardiovascular health in France.
Cardiovascular problems are the leading cause of death in women. How can this be explained ?
First, it’s important to remember that cardiovascular problems are diseases linked to environmental factors : in 8 cases out of 10, they could be avoided with an ‘optimal’ lifestyle in terms of diet, physical activity and sleep. Secondly, while certain traditional risk factors such as high blood pressure, smoking, diabetes, obesity, stress, etc. affect men just as much, there are risks that are anatomically, physiologically and hormonally specific to women. Starting with the arteries, which are much more sensitive and thinner : for the same amount of cholesterol plaque, the reducing effect on the arterial lumen will occur earlier in women than in men. Women’s cardiovascular risks also change throughout their lives, particularly during three key phases : contraception with oestrogens, pregnancy and then the menopause.
How can contraception affect cardiovascular health ?
Pure progestin-based contraception has no negative effect on cardiovascular health. However, when synthetic oestrogens such as the pill, vaginal ring or contraceptive patch are prescribed, cardiovascular health may be affected. These hormones are metabolised by the liver, increasing the risk of arterial hypertension and activating coagulation, with a risk of arterial thrombosis (stroke, infarction) and venous thrombosis (phlebitis, pulmonary embolism). This combined or oestroprogestogenic contraceptive is contraindicated in young girls with risk factors such as smoking after the age of 35, overweight, diabetes, high cholesterol or migraines. It is therefore important to discuss these contraindications at the first gynaecological consultation, and to take stock of cardiovascular heredity. I remember a 27-year-old patient who had to have both her legs amputated because of unsuitable contraception ! That’s unacceptable ! You should also know that after the age of 40, you should try to avoid synthetic oestrogens as much as possible.
What exactly are we talking about when it comes to cardiovascular risks during pregnancy ?
Let me give you the striking example of massive pulmonary embolism. From the second trimester onwards, a pregnant woman’s body physiologically goes into ‘thrombosis mode’, i.e. it is easier for the body to produce clots that block the blood vessels to prevent excessive bleeding during childbirth.
However, the synthetic oestrogens used in contraception have the same effect, which is why they are contraindicated for up to 6 weeks after childbirth. When women leave the maternity ward, only pure micro-progestogen contraceptives are prescribed. But when minor bleeding persists, women go back on the old pack of pills with the oestrogen left on the bedside table, and there’s a risk of massive embolism and sudden death. We’re not talking about anecdotal events here !
Other more common pathologies include hypertension during pregnancy, which affects one pregnancy in 10, and gestational diabetes, which needs to be screened regularly, particularly for pregnancies in women over 35.
The final high-risk phase in a woman’s life is the menopause, which occurs around the age of 50. But sometimes this occurs earlier…
Yes, but talking about ‘early menopause’ to a woman who is 30, 35 or 40 can be very stigmatising. Instead, we talk about premature ovarian failure (POI). In such cases, hormone replacement therapy (HRT) is recommended. This is often the case for women who have had assisted pregnancies and undergone follicular stimulation. They have therefore lost their oocyte capital earlier, resulting in an early hormonal deficiency. If cardiovascular risk increases during the perimenopause, it also increases in the case of POI !
We’ve talked about the combination of contraception, pregnancy and menopause. Are there other risk factors ?
Yes, they are linked to more feminine diseases, such as breast cancer. Women who have been through this have a greater risk of cardiovascular problems, particularly because of the treatments. Chemotherapy damages the heart muscle to a greater extent in women, radiotherapy accelerates the ageing of the arteries and, finally, anti-aromatases – which are very powerful anti-oestrogens – accentuate the early effects of the menopause. When it comes to preventing breast cancer, almost 40% of women don’t have a mammogram : so, get screened !
There are also other emerging risk factors, such as endometriosis and polycystic ovary syndrome, migraine (including migraine with aura), mammary artery calcifications, etc. Inflammatory diseases are also more prevalent in women : rheumatoid arthritis, Crohn’s disease, multiple sclerosis, etc. These have the effect of boosting the ageing of the artery.
Finally, we often forget to consider the impact of psychosis and depression, particularly postpartum depression, on women. Treatments for these illnesses such as antipsychotics and antidepressants also have an appalling metabolic impact, increasing the risk of myocardial infarction.
Are doctors trained in these cardiovascular risks specific to women ?
Students are receiving more and more training, and cross-disciplinary training sessions are being held at congresses. The most important thing is for everyone to work together to get a 360° view of women’s health. That’s what we’re doing in the Women’s Heart Bus screenings with our foundation Agir pour le Cœur des Femmes. We also work a lot with gynaecologists and obstetricians on cardio-gynaecological pathways, but there’s still a lot of training and communication work to be done. I recently did a training course at the Lille medical school with 3rd year students. Looking at the mannequins, I asked : “Is there anything that shocks you?” There were only male models. so I explained to them how to use their stethoscopes and do an auscultation with the breasts present : the students were really pleased !
In research, do scientific studies focus as much on women’s health as men’s ?
No, because therapeutic research is paralysed by the idea of giving risky drugs to a pregnant woman. Researchers want at all costs to avoid teratogenic risks that could cause foetal malformations. Women are therefore only included in the studies if they have a negative pregnancy test, are using effective contraception or, more simply, if they are already menopausal. Overall, the ratio of women to men in these intervention trials is 30% to 70%.In epidemiological registries, however, the ratio is closer to 50/50.
The symptoms of myocardial infarction in men are well known (chest pain, discomfort in the arm, etc.), but are they the same in women ?
No, not always, and that’s a problem. In women, the symptoms are largely ignored, hence the creation of an infographic on the Agir pour le Coeur des Femmes website. They often complain of a feeling of tightness in the chest, palpitations, cold sweats, malaise or nausea, atypical pain between the shoulder blades or in the jaw.
Almost 40% of women don’t have a mammogram : so, get screened !
Some patients also feel discomfort in the pit of their stomach and have the impression that they are having difficulty digesting. Patients often tell you afterwards : “it wasn’t like usual” and describe a feeling of unease and anxiety alongside these atypical and recurring symptoms. Unfortunately, however, all too often doctors fail to take these symptoms into account or do not link them to a heart problem.
Is there a psychosocial aspect to this too ?
Of course. Violence is the third most common risk factor for myocardial infarction in women. When I talk about violence, I include verbal, moral and physical abuse. Most violence against women is perpetrated by men. What’s more, women are also subject to a greater mental burden and stress.
A healthy lifestyle is also a key factor in the prevention of cardiovascular disease in women. In particular, we are seeing an increase in the consumption of ultra-processed foods, tobacco, cannabis, recreational drugs and alcohol by women, coupled with more sedentary occupations, where they sit behind a computer. Doing sport twice a week doesn’t solve everything. A sedentary lifestyle means sitting for at least six hours a day. Today, I’d say it kills as much as undrinkable water did in the last century.
Is there a kind of self-censorship among women, who put others before themselves ?
Yes, women do neglect their health. In an AXA Prévention survey of a mixed gender panel published in September 2021, 80% of women said that they put the health of their loved ones before their own, 75% put off their medical appointments and 80% self-medicate.
Access to healthcare is also very unequal in France, and we continue to be penalised by medical desertification. Hence the importance of initiatives such as the Bus du Cœur des Femmes and Agir pour le Cœur des Femmes ! The Women’s Heart Bus is made up of 1,300 health professionals who volunteer their time every year. The bus and its mobile medical centre stop off in a town for 3 days, and never stop. During the 17 stops, cardiovascular and gynaecological screening is offered to an average of 250 to 300 women per stop. Nearly 9 out of 10 women screened have at least two cardiovascular risk factors… and nearly half of them (46%) have a combination of gynaecological and obstetric risk factors. The women’s data is collected by the Observatoire national de la santé des femmes.
The important thing to remember is that we women need to take better care of ourselves and protect ourselves. Act rather than suffer a cardiovascular accident ! Let’s not forget again : we can avoid the disease in 8 out of 10 cases by effective prevention, identifying risk factors and adopting a healthier lifestyle.
