Cardiovascular disease in women – choosing contraception to protect your heart health

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What is cardiovascular disease?

Cardiovascular disease (CVD) is a broad term which refers to a group of conditions that affect the heart and blood vessels. This includes heart attacks, strokes and damage to other organs such as your brain, kidneys and eyes, which is often caused by a build up of fatty deposits inside blood vessels. CVD is the leading cause of death in the world² and so healthcare professionals are constantly thinking about how to reduce your chances of developing the disease – and what this means for women’s health and contraception.

Cardiovascular disease in women

Cardiovascular disease is often thought of as a disease that affects more men than women. However, we know that in the US, half of all people living with CVD are female³. In fact, coronary artery disease kills twice as many women as breast cancer each year^4,5. 

Women are more likely than men to die after a severe heart attack⁶. Women are also more likely to have a heart attack without classic chest pain and instead have symptoms like shortness of breath, nausea, shoulder, neck or back pain^7,8. This means signs of cardiovascular disease in women can be overlooked. One research study showed women in the UK were less likely to receive treatment for a heart attack in the years 2003 to 2013⁹.

So it’s really important we remember women and CVD, and that if you are a woman or were assigned female at birth, you understand the risk factors for CVD and how to improve your heart health.

Cardiovascular disease risk factors

Risk factors for CVD are conditions or lifestyle factors that can increase your chance of having conditions like a heart attack or stroke. There are a number of risk factors for CVD that impact women in a different way to men.

Smoking and cardiovascular disease

Women who smoke have a 25% higher risk of having CVD than men who smoke¹⁰.

Diabetes and cardiovascular disease

Women with diabetes have a 3-7x increased risk of CVD compared to an increased risk of 2-3x in men with diabetes^11,12.

Obesity and cardiovascular disease

Women with obesity have a 64% increased risk of coronary artery disease, compared to 46% in men with obesity¹³.

Cardiovascular disease and hypertension

Hypertension is the medical term for high blood pressure. Over the age of 60, more women have high blood pressure than men, and it tends to be less well controlled in older women than men¹⁴. Having high blood pressure increases a woman’s risk of CVD 80% more than a man’s¹⁵.

Female risk factors and cardiovascular disease

Certain risk factors for CVD can only happen to women. We know that early menopause can increase your risk. This is thought to be because natural oestrogen can protect your blood vessels from CVD, and you stop producing oestrogen earlier if you have an early menopause¹⁶.

Polycystic ovary syndrome is another female only risk factor, with one study showing that women with PCOS are 30% more likely to have a heart attack or stroke than those without the condition¹⁷.

Cardiovascular disease and pregnancy

Pregnancy is hard on your body. During pregnancy, your blood volume, heart rate and the amount of blood your heart pumps with each beat all increase¹⁸. Cardiovascular disease can lead to problems during pregnancy and after delivery for both the mother and baby. This includes for women who have pre-existing cardiovascular disease like heart defects, angina (chest pain due to reduced blood flow to the heart) or arrhythmias (irregular or abnormal heartbeats), and for women who develop cardiovascular disease during pregnancy like high blood pressure or preeclampsia¹⁹. 

If you have cardiovascular disease and wish to get pregnant, it’s important to plan pregnancy in advance and discuss this with your healthcare professional to make sure a full team of specialists can care for both you and your baby. Using contraception is a great way to plan in advance by preventing pregnancy until you are ready.

Contraception and cardiovascular disease

At The Lowdown we’re experts in contraception, so let’s think about how CVD and contraception can be linked.

Certain contraceptives can increase your risk of CVD. Research from over 1.6 million women has shown that women using combined contraceptive pills are at a slightly higher risk of having a heart attack or stroke. The synthetic oestrogen found in combined hormonal contraceptives (the combined pill, patch and ring) seems to be the culprit. And the risk gets higher if the oestrogen dose increases²⁰.

Contraceptives can also affect other risk factors for CVD such as:

High blood pressure. Up to 2% of women using combined contraception develop high blood pressure in the two years after starting it²¹. 

High cholesterol. High levels of bad cholesterol (a type of fat in your blood also known as LDL) is another risk factor for CVD. One study found the progestogen-only injection initially increased levels of bad cholesterol and lowered good cholesterol, although the levels went back to normal after two years of use²². Oral contraceptives have also been shown to affect the way the body uses and stores fat, but this does not increase the risk of CVD.

My risk of cardiovascular disease

What does this mean in reality? The risk of a young woman in their reproductive age having a stroke or heart attack is very very low – think how many people you know of who this has happened to under the age of 40 or 50 ….it’s very rare. 

So why do we consider this with contraceptives? Because strokes and heart attacks can be so devastating that we just don’t want to increase the risk of them happening to young women who may be impacted for the rest of their lives.

For this reason, healthcare professionals learn all about your personal and family’s medical history to help you make the right contraceptive choice for you. We use a huge 176 document called the UKMEC (UK Medical Eligibility Criteria) that helps us balance any risks you have for CVD against the benefit of preventing pregnancy.

For the majority of women, contraceptives are considered safe. However, the UKMEC states that people who have the following CVD risk factors shouldn’t use combined contraceptives that contain oestrogen or the progestogen-only injection:

• Aged over 35 and smoke
• Have high blood pressure – even if it is controlled well by medication
• Have a body mass index (BMI) over 35
• Have angina (chest pain or discomfort caused by reduced blood flow to the heart)
• Have had a stroke or mini stroke (transient ischaemic attack or TIA)
• Have peripheral artery disease (where narrowed blood vessels reduce blood flow to muscles and tissues most commonly in the legs) 
• Have diabetes with complications such as retinopathy (affecting the eyes), nephropathy (affecting the kidneys) or neuropathy (affecting the nerves)

The UKMEC also states that if you have more than one risk factor for CVD, these risk factors add up together. If you have one or more of these, you cannot use combined hormonal contraceptives or the injection:

• Diabetes without complications
• High cholesterol
• BMI over 30
• Smoking

If you are one of the people described above, although you cannot safely use the combined pill, patch or ring or the injection, you do have other options.

The progestogen-only pill, implant, hormonal or copper coils and barrier contraception are all safe for you to use. Progestogen-only contraceptives like the pill, implant and hormonal coil do not have any impact on your blood pressure or CVD risk so are safe for you to use.

How to improve heart health

If you’re concerned about your CVD risk, there are actions you can take to keep your heart healthy. 

Diet. Follow a healthy diet, aiming to eat foods that are not processed and are not high in salt, sugar and saturated fat. Also keep an eye on those portion sizes!

Exercise.  It’s recommended to get 30 minutes of moderate intensity exercise at least five days a week²³ – this includes brisk walking and you can even break this up into 3 lots of 10 minutes. Make sure you feel warm, out of breath and can feel your heart beating to know it’s enough.

Weight. Try to keep your weight in a healthy range for you, which will be easier if you make changes to your diet and exercise!

Stop smoking. It’s hard – but there is lots of support available from NHS stop smoking services.

Cut down on alcohol. Drink alcohol moderately within the UK weekly guidelines of 14 units each week²⁴.