For decades, women’s heart disease was understood through a narrow lens — one shaped largely by men’s bodies, symptoms, and risk profiles. The result? Missed diagnoses, misunderstood symptoms, and care pathways that didn’t fully reflect how heart disease actually shows up in women.
In a recent conversation, Colleen Norris, Professor and Associate Dean of Research at the University of Alberta and Cavarzan Chair in Women’s Health Research at the Alberta Women’s Health Foundation, spoke with Jackie Ratz — founder of the Facebook community Canadian Women with Medical Heart Issues, creator of the Life In Hearts website, Women’s Lead for the HeartLife Foundation, and a woman with lived and living experience of heart disease. Together, they unpacked what researchers and patients are learning about how women’s heart disease is not simply a variation on a male pattern. It is different — biologically, clinically, and experientially. And one of the most important reasons why lies in hormones.
What “different” actually means: Ischemia with no obstructive disease (INOCA), microvascular disease and vasospasm
When we say women’s heart disease is “different,” we’re not talking about subtle variations. We’re talking about a different disease process.
Many women do not develop heart disease that blocks the main coronary arteries. Instead, the problem often lies in the small blood vessels that supply the heart, or in how those vessels function moment to moment. This includes conditions such as microvascular dysfunction and coronary vasospasm, where blood vessels constrict unpredictably or fail to dilate properly.
As Dr. Norris explains, “Women’s heart disease is different. It’s more a dysfunction of the cardiovascular system .” In these cases, the coronary arteries themselves may appear structurally normal, and standard imaging can look reassuring, even while blood flow is impaired and symptoms persist.
This helps explain a familiar pattern: women experiencing shortness of breath, chest discomfort, palpitations, dizziness, or extreme fatigue, only to be told that tests are “normal.” The disease is real, but it doesn’t always register on tools designed to detect obstructive disease in larger arteries.
Over time, repeated episodes of impaired blood flow and vascular dysfunction can contribute to heart failure, including forms where the heart’s pumping ability appears preserved, but the system supplying it has been damaged.
Why hormones matter in this picture
A major contributor to these patterns in women likely lies in hormonal biology, especially changes in estrogen.
Estrogen plays a central role in maintaining vascular health. It supports the inner lining of blood vessels, promotes healthy blood flow, helps regulate inflammation, and influences how vessels respond to physical and emotional stress. When estrogen levels are stable, these systems are better protected. When levels drop or fluctuate, vulnerability increases.
This is why events across a woman’s life — puberty, menstrual regularity, pregnancy, the menopausal transition, cancer treatment, chronic stress — are not separate from heart health. They are part of the same physiological story.
Why amenorrhea is a warning sign — even when pregnancy isn’t a concern
Amenorrhea — going months without a period — is often treated as a reproductive issue only, and is sometimes dismissed. But from a cardiovascular perspective, that’s a missed opportunity.
As Dr. Norris notes, amenorrhea reflects prolonged low or disrupted estrogen exposure, which can have downstream effects on blood vessels, metabolism, bone health, brain/mental health and inflammatory processes. Research now links amenorrhea to vascular complications of pregnancy (high BP, gestational diabetes which in turn is linked to premature cardiovascular disease, including microvascular disease — the very patterns that are more common in women.
Dr. Norris describes how women are sometimes told not to worry about missed periods unless they are trying to conceive — but the absence of a period is not benign; it is a signal.
This is especially relevant for young women and athletes, where missed periods may be normalized, and for women navigating high stress during midlife, a time when cardiovascular risk is already rising.
Heart failure as a whole-body condition
For people living with heart failure, the impact extends far beyond the heart itself.
Jackie Ratz, who has lived with heart failure for nearly a decade, describes it not as a single event, but as a chronic condition that reshapes daily life. “Our capacity changes, our energy changes,” she says. “With heart failure, most often we end up carrying the symptoms and the burdens of that illness for as long as we are alive.”
Fatigue, breathlessness, cognitive changes, and reduced stamina are common — and they don’t always match how someone appears on the outside. For women in particular, these effects can accumulate gradually, making them easier to overlook or dismiss.
Catching up — and acting on what we know
Much of this knowledge isn’t brand new. But it hasn’t always been integrated into practice, policy, or public understanding.
For years, gaps in research, flawed interpretations of early studies, and a lack of sex-specific data slowed progress. As a result, generations of women were told that symptoms were stress-related, hormonal “noise,” or simply part of aging, rather than early warning signs.
That’s beginning to change.
Researchers across Canada are now connecting the dots between hormones, pregnancy history, vascular health, and heart failure. Patient advocates are ensuring that lived experience informs both research priorities and care models. And conversations like this one are helping translate emerging science into practical awareness.
As Ratz reflects, “If you don’t know, you can’t do better. We now know — and we can do better for women.”
Women’s heart disease is different. Science is catching up. The responsibility now is to use that knowledge — in research, in care, and in how we listen to women’s experiences — to improve outcomes across the lifespan.
