Younger women are often focused on their careers, their families, and their lives. They’re not usually thinking about heart disease. Dr. Chrisandra Shufelt, associate director of the Barbra Streisand Women's Heart Center, calls them the "walking well." Why should heart disease be on their radar? Heart disease deaths among women in their mid-thirties to mid-forties are increasing.

In this Q&A to wrap up American Heart Month, Dr. Shufelt explains what tests women should ask for, why they should worry about missed periods, what pregnancy can tell you about heart health, and why awareness is key.

There are five traditional risk factors linked to heart disease:

• high cholesterol
• high blood pressure
• diabetes
• family history
• smoking

Every year a woman should have her blood pressure checked and an exam that includes someone listening to her heart. Also, women should make sure to have a fasting cholesterol and blood sugar test to check for pre-diabetes or diabetes. Around 35-44 years old is a good time to have an evaluation by an internist. If you do have a family history of heart disease and stroke, this may put you in a different bracket because your genetics can increase your heart health risk. You should discuss preventative measures with your doctor.

If you look at younger women between the ages of 35 and 44, they are generally leading a healthy lifestyle by being active, fit, and eating a balanced diet; they don't think heart disease could impact them. I call them the "walking well." They are at the early prime of their lives; we think of mid-life as 50 and older. These younger women have possibly started a family, focused on a career, and think of themselves as healthy. They are more concentrated on their lives than heart health, yet the rate of heart disease deaths are starting to trend upward in these younger women and we really need to look at why.

The issue may go undetected especially if at routine visits the gynecologist only asks “When was your last period?” I hope our research will change the way this question is asked so “Do you have a regular menstrual cycle?” is included. This is an important distinction.

Most commonly, when women miss multiple periods (and are not pregnant) the hormone that has shut down is estrogen. This condition is referred to as hypothalamic amenorrhea and is caused by stress, excessive exercise, under eating, or a combination of all. Women with this type of amenorrhea have estrogen levels similar to women that are post-menopausal. We know that in these young women, as in post-menopausal women, bone health is impacted, but no one had looked at their heart health until now.

In a small sample of women who missed menstrual cycles due to low estrogen, we have shown that their small blood vessel function is low, which is an early sign of heart disease. While this information is in the preliminary stages, we have a potential window to intervene and possibly reverse this effect. Now, in a study funded by the National Institutes of Health, we will be giving women with amenorrhea an estrogen patch or placebo patch to determine the impact on blood vessels and immune function. If these young women’s estrogen levels are low like those of post-menopausal women, could increasing estrogen reverse it? It's an exciting five-year study.

Another area we are studying is adverse pregnancy outcomes. 80% of women in the US have had at least one child. We used to think: What happens during pregnancy, stays during pregnancy—meaning high blood pressure, gestational diabetes, or conditions such as preeclampsia all resolve after the baby is born. Now we are learning more. When a woman is pregnant it is an opportunity to see how her body responds to higher heart rates and blood flow—it is a physiological stress test. If these conditions occur during pregnancy, it's a sign that the physiologic stress test was abnormal.

Preeclampsia, along with other risk factors including gestational hypertension, contributes to the development of heart disease as early as 5 years after a woman has given birth. The Women’s Heart Center has a Postpartum Heart Health Program specially designed to see women six months after the baby is born to do a risk assessment.