Top Things to Know: A Female-Specific Life Course Approach to the Prevention and Management of Cardiovascular Disease: A Presidential Advisory
Updated: October 26, 2026
Prepared by Radhika Rajgopal Singh, PhD, FAHA; Sr Vice President, Science and Medicine
- Cardiovascular disease is the leading cause of death among women, yet cardiovascular risk remains incompletely recognized, prevented, and managed. Cardiovascular disease accounts for 1 in every 3 deaths among women worldwide. In the US, fewer than half of women recognize cardiovascular disease as their leading health threat.
- As part of the Compendium on Women’s Health, this Presidential Advisory brings together four leading societies (AHA, AAP, ACOG, and SMFM) to introduce the Female Life Stage construct that is organized in four life stages: S1 perimenarche, S2 ovarian cycling, S3 perimenopause, and S4 postmenopause. The framework recognizes that cardiovascular health is shaped by hormonal and psychosocial health and is influenced by social and structural factors across all stages. Stage-specific assessment is intended to complement traditional cardiovascular risk assessment and support more personalized cardiovascular care in girls and women.
- Hormonal and psychosocial health are central to cardiovascular health, are interconnected, and should be assessed together. Stage-specific evaluation and management of these interconnected health domains are needed in addition to recognition of female-specific risk enhancers. Menstrual cycle history and patterns can serve as a cardiovascular vital sign (e.g., when dysregulation of hormonal health is recognized such as polyendocrine metabolic ovarian syndrome, formerly known as polycystic ovary syndrome). Psychosocial conditions (e.g., depression, anxiety, eating disorders) are disproportionately common in girls and women, beginning in adolescence and can adversely affect cardiovascular health.
- Menarche begins during S1 (perimenarche) and marks an important transition for female-specific health considerations when the earliest signals of disruption in hormonal, psychosocial, and cardiovascular health may emerge. Fewer than 1 in 4 adolescent females have high cardiovascular health. Menstrual cycle irregularity, hyperandrogenism, eating disorders, and concerns related to body image can uniquely influence cardiovascular health behaviors in girls. Recognition of these signals creates an opportunity to intervene before adverse trajectories become established.
- During S2 or the ovarian cycling stage, common hormonal and psychosocial conditions can influence cardiovascular health. Irregular menstrual cycles may signal underlying cardiovascular risk due to conditions such as polyendocrine metabolic ovarian syndrome or contribute to iron deficiency from heavy menstrual bleeding. Cyclical hormonal changes may also be associated with clinically important mood symptoms, including premenstrual dysphoria disorder. Exogenous hormone therapy is frequently used during this stage for a variety of indications, such as abnormal or heavy uterine bleeding, ovarian suppression, contraception, fertility treatment, and polyendocrine metabolic ovarian syndrome. Decisions about hormone therapy should consider indication, cardiovascular and thrombotic risk, and individual preferences.
- The menopause transition during S3 (perimenopause) and the years after during S4 (postmenopause) are important stages when cardiovascular risk may accelerate and clinical cardiovascular disease may emerge. During S3, or perimenopause, adverse cardiometabolic changes frequently occur beyond those attributable to chronologic aging alone. During S4, or postmenopause, clinical cardiovascular disease becomes increasingly common. Both hormonal and nonhormonal therapies are available and can address menopause-related symptoms while considering individual cardiovascular risk, contraindications, and preferences. Premature or early menopause is associated with greater cardiovascular disease risk and should be recognized as a female-specific risk enhancer.
- Pregnancy is a cardiovascular stress test that can reveal new or previously unrecognized susceptibility. Adverse pregnancy outcomes, including hypertensive disorders, gestational diabetes, preterm birth, and small-for-gestational-age infants, affect approximately 1 in 5 pregnancies and are associated with elevated future cardiovascular disease risk. These pregnancy outcomes should be routinely recognized, documented and incorporated into long-term prevention as risk enhancers. Additionally, the full peri-pregnancy period, spanning 12 months before pregnancy through 12 months after delivery, offers a critical yet frequently missed opportunity to improve maternal and cardiovascular health through a coordinated, life-course approach.
- Sex differences in cardiovascular physiology, clinical presentation, and phenotypes should be recognized and integrated into a comprehensive screening, diagnostic, and management plan. Women may be uniquely, disproportionately, or differentially affected by several cardiovascular conditions, including a greater burden of non-obstructive coronary artery diseases (e.g., myocardial infarction with non-obstructive coronary arteries, ischemia with non-obstructive coronary arteries), spontaneous coronary artery dissection, Takotsubo cardiomyopathy and stroke. Greater recognition of these differences is necessary to reduce diagnostic delays, avoid misclassification, and ensure evidence-based treatment.
- Scientific progress requires the full inclusion of girls and women throughout the research process. The current evidence base remains limited by underrepresentation of women and the inadequate analysis and reporting of sex-specific findings. Improvement in representation is needed across clinical trials, implementation studies, and community-engaged research. Results should be stratified by sex, age, and the Female Life Stage, when scientifically appropriate. Research should also be conducted “for women, with women” by engaging patients and communities in identifying priorities, co-designing studies, interpreting findings, and planning dissemination.
- A coordinated clinical, research, and public health agenda is needed to translate the Female Life Stage framework into better cardiovascular outcomes. The central objective is earlier identification of adverse cardiovascular health trajectories before the onset of symptoms, thereby improving quality of life, preventing disease, and extending healthy years of life. The Female Life Stages moves beyond episodic care toward longitudinal, life course-based risk assessment, prevention, and management.
Citation
Khan SS, Grobman WA, Perak AM, Angell S, Brubaker L, Cameron NA, de Ferranti S, El Khoudary SR, Ferranti E, Hameed AB, Hannon TS, Johnson HM, Kennedy S, Kim ESH, Maradik ME, Martin KA, Miller EC, Reed SD, Tabak RG, Tandon SD, Thurston RC, Verma N, Weedn AE, Singh RR, Rosen SE; on behalf of the American Heart Association; American Academy of Pediatrics; American College of Obstetricians and Gynecologists; and Society for Maternal-Fetal Medicine. A female-specific life course approach to the prevention and management of cardiovascular disease: a presidential advisory from the American Heart Association, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, and Society for Maternal-Fetal Medicine. Circulation. Published online October 26, 2026. doi: 10.1161/CIR.0000000000001483