Hormonal changes a key detail when assessing cardiovascular risk in a female patient
Women tend to face a disproportionately higher risk of cardiovascular complications than men. With this trend in mind, cardiac imagers need to consider hormonal status when assessing female patients, according to Ady Orbach, MD, MSc, a cardiologist and multimodality cardiac imager at the Edith Wolfson Medical Center in Holon, Israel.
She spoke on this topic at SCCT2026 and shared her key take aways with Cardiovascular Business in a video interview. Orbach said cardiovascular imaging needs to account for how a woman’s cardiovascular risk changes throughout her life depending on their hormone levels, including during pregnancy, menopause and periods of hormonal therapy.
"It is a big sex difference between men and women," Orbach explained. "We know that having atherosclerosis plaque in women actually increases the risk for cardiovascular outcomes twice as much compared to men. We know that women have lower plaque burden in their coronary arteries, but they have a higher risk for mortality and morbidity."
Although women generally have less coronary plaque, they are more likely to develop softer, noncalcified plaque. Men tend to have a greater burden of calcified, more stable plaque. Hormonal differences, including the effects of estrogen and associated lipid profiles, may contribute to those differences.
The clinical presentation of cardiovascular disease also makes it more challenging to make a diagnosis when evaluating women. They are less likely to present with the classic chest-pain symptoms commonly associated with coronary disease in men, potentially delaying recognition and treatment.
Orbach highlighted patients who present with chest pain and elevated cardiac enzymes, but have no obvious coronary obstruction. Conditions such as coronary vasospasm and spontaneous coronary artery dissection (SCAD) can play a role. SCAD is particularly important in younger women, she said.
Orbach also looked at why hormonal history should become part of the standard template for cardiac assessments of women. She said clinicians should ask about menopause, early menopause, oral contraceptive use, hormone replacement therapy and gender-affirming hormone therapy when making their assessments.
For cardiac imagers, that history can influence the choice of test. In women receiving hormone replacement therapy, for example, Orbach said clinicians should consider coronary CT angiography (CCTA) rather than relying solely on a coronary artery calcium score, because there is a greater potential for soft plaque.
Estrogen may help explain why cardiovascular disease frequently emerges later in women than in men. Before menopause, estrogen has several potentially protective cardiovascular effects, including promoting vasodilation and contributing to a more favorable lipid profile.
Menopause brings an abrupt reduction in estrogen exposure, potentially unmasking or accelerating other cardiovascular risk factors, including hypertension, diabetes and arterial stiffness. Those changes can become apparent on cardiac CT as the atherosclerotic process develops.
Pregnancy and the peripartum period represent another important window for cardiovascular risk. Orbach said clinicians should have a particularly high level of suspicion for SCAD when women develop chest pain during this period. She also emphasized that necessary cardiac imaging should not automatically be avoided because of pregnancy-related or postpartum concerns. When clinically indicated, coronary imaging can be performed, and Orbach said lactating patients can undergo contrast-enhanced imaging without a need to avoid breastfeeding because of the contrast.
The broader message for cardiac imagers is that a woman's hormonal history is not simply background information, she explained. It can affect cardiovascular risk, disease presentation and the type of imaging that provides the most useful information.
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: [email protected]