Top Things to Know: Consensus Guidance for the Female-Specific Prevention and Management of CVD

Updated: October 26, 2026

Prepared by Anne Leonard MPH, BSN, RN, Senior Science and Medicine Advisor - Lead

  1. As part of the Compendium on Women’s Health, this Scientific Statement brings together four leading societies (AHA, AAP, ACOG, and SMFM) and provides consensus guidance according to the Female Life Stage construct that is organized in four life stages: S1 perimenarche, S2 ovarian cycling, S3 perimenopause, and S4 postmenopause introduced in the Presidential Advisory. The framework recognizes that cardiovascular health is shaped by hormonal and psychosocial health and impacted by social and structural factors across these stages. Clinicians should assess cardiovascular health beginning with the Life’s Essential 8 lens along with hormonal and psychosocial health. Movement across the Female Life Stages is not defined by chronologic age alone and care should be personalized to achieve optimal health in all three interconnected domains across the life course.
  2. For hormonal health, clinicians are encouraged to ask, assess, and document menstrual cycle history and patterns and recognize its relevance as a cardiovascular vital sign. Dysregulation of hormonal health may provide an early signal of adverse cardiovascular health trajectory and should prompt evaluation for underlying conditions and more intensive surveillance of cardiovascular risk factors, when appropriate. Assessment should consider polyendocrine metabolic ovarian syndrome, abnormal or heavy menstrual bleeding, and iron deficiency, including without anemia. These conditions may affect cardiovascular health behaviors (e.g., sleep, physical activity).
  3. For psychosocial health, clinicians are encouraged to ask, assess, and refer for management of psychosocial symptoms and recognize its relevance to cardiovascular health. Symptoms of depression, anxiety and eating disorders are disproportionately more common in females compared with males, emerge during adolescence, and persist across the life course. In addition, concerns related to body image should be addressed through respectful, nonjudgemental, and developmentally appropriate conversations that support cardiovascular health without reinforcing stigmas.
  4. During S0, or premenarche, cardiovascular health behaviors and attitudes are developed that set the foundation for long-term trajectories. Cardiovascular health should be assessed beginning in childhood with the Life’s Essential 8 score as well as social drivers of health. In addition, age- and sex-specific percentiles exist and should be used to assess and monitor body mass index and blood pressure. This stage provides an opportunity to begin to monitor longitudinal trajectories of health.
  5. During S1, or perimenarche, clinicians are encouraged to recognize the emergence of female-specific cardiovascular risk across the interconnected hormonal, psychosocial, and cardiovascular health domains. Assessment should include menstrual cycle history, psychosocial symptoms, and the Life’s Essential 8 score. This stage provides an early opportunity to identify and modify adverse cardiovascular health trajectories.
  6. During S2-S4, decisions about exogenous hormone therapy should incorporate indication, evaluation of cardiovascular and thrombotic risk, and patient preferences in a patient-centered discussion. Hormonal therapies may be used for hormonal regulation due to heavy or abnormal uterine bleeding, ovarian suppression, contraception, polyendocrine metabolic ovarian syndrome, fertility treatment, or menopause-related symptoms. Selection of the formulation, dose, route, and duration should reflect the clinical indication, individual risk, and patient preferences.
  7. Screening for onset of S3, or perimenopause, and menopause-related symptoms should begin by age 40 years with evidence-based management for menopause-related symptoms. The median age of menopause in the US is 50 years, but the timing, duration, and burden of symptoms vary substantially. Clinicians should provide anticipatory guidance for menopause-related symptoms, including vasomotor symptoms, sleep disturbance, mood changes, as well as changes in cardiovascular risk factors. The onset of perimenopause or the menopause transition should prompt comprehensive cardiovascular risk assessment and management. Hormonal and nonhormonal therapies for menopause-related symptoms should be individualized according to symptom burden, cardiovascular and thrombotic risk, contraindications, and patient preferences with ongoing monitoring for improvement in symptoms.
  8. Anticoagulant or dual anti-platelet therapies during S2-S3 require anticipatory counseling to assess and address risk of abnormal uterine bleeding. During menstruating life stages, anticoagulation or dual anti-platelet therapies may cause or worsen heavy or abnormal uterine bleeding. Proactive management of bleeding and prevention of iron deficiency may improve quality of life and reduce unintended discontinuation of evidence-based cardiovascular medications.
  9. During S4, or postmenopause, prevention and management of cardiovascular disease risk should be prioritized. Myocardial infarction, heart failure, stroke, atrial fibrillation, and peripheral artery disease, are most common during this stage, although the majority of cardiovascular diseases are largely preventable. Clinicians should optimize guideline-directed medical therapy for the prevention and management of cardiovascular disease and avoid undertreatment due to age or sex. New or persistent cardiovascular symptoms warrant timely evaluation, with attention to conditions that may be underrecognized in women, such as ischemia with nonobstructive coronary arteries.
  10. During S2 and S3, pregnancy intent followed by pregnancy planning or prevention should be discussed at every encounter to support cardiovascular health and medication safety. A standardized prompt, such as the One Key Question approach, can support a patient-centered discussion for pregnancy planning or prevention. For patients planning pregnancy, optimize cardiovascular health, review medication safety, and transition from cardiovascular therapies with fetal toxicity, when clinically appropriate.
  11. For all adult females, clinicians are encouraged to ask, assess, and document pregnancy history and recognize adverse pregnancy outcomes as common cardiovascular risk enhancers. Clinicians should ask about and document adverse pregnancy outcomes (hypertensive disorders of pregnancy, gestational diabetes, preterm birth, small-for-gestational-age infant). For women who experience an adverse pregnancy outcome, a defined transition from obstetric care to longitudinal primary care should include postpartum cardiovascular-kidney-metabolic assessment.
  12. Across Stages S1-S4, female-specific care pathways are needed to inform risk assessment, diagnosis, prevention, and management of cardiovascular disease with coordinated implementation. Health systems should implement standardized histories, structured electronic health record documentation, clinical decision support, clear referral criteria, and accountable transitions among clinical specialties across the life course. Clinicians should partner with patients to ensure that care is personalized, timely, evidence-based, and coordinated across specialties and throughout the life course.
View the summary for the Compendium on Women's Health
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Citation

Cameron NA, Khan SS, Bairey Merz CN, Brewer LC, Davis MM, Ferranti EP, Grobman WA, Hameed AB, Hannon TS, Harrington RA, Johnson HM, Maradik ME, Perak AM, Reynolds HR, Rosen SE, Sanghavi M, Schulte J, Rajgopal Singh R, Sterling MR, Tabak RG, Verma N, Weedn AE, Wood MJ, Kim ESH; on behalf of the American Heart Association, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, and Society for Maternal-Fetal Medicine. Comprehensive centers of excellence for women’s cardiovascular care: a science 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.0000000000001481

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