Article – Heart & hormones: this is what every woman wants to know about cardiovascular disease during & after menopause

Alma (57) has had a feeling of pressure in her chest for weeks. She’s tired too. Dog tired. But she is a freelancer, and she doesn’t dare cancel her clients, so she just toils on.

Last year she also had to miss a lot because her husband had suffered a cardiac arrest and was in a coma in the hospital for weeks. A super stressful time, from which she has barely recovered. Fortunately, he recovered, even though he had to recuperate for months. Now that peace has finally returned, she suddenly suffers from all kinds of ailments. Only after two months does she dare to tell her husband about the pain and fatigue. He immediately drags her to the doctor, who refers Alma to the hospital the same day. Alma is catheterized; She turns out to have a seriously narrowed blood vessel and is immediately put under angioplasty. Now she is back home, with a lot of medicine and the fear: it would have been too late for the same money.

For obscure reasons, it is still far too little known, but the number one cause of death in women is cardiovascular disease. To be clear: the term cardiovascular disease covers all arterial and arterial diseases that can occur in the body, from strokes in the head to heart attacks and claudication.

One in four women in the Netherlands dies from such a condition: 19,000 women per year, 53 per day. For comparison: 3,121 women died from breast cancer last year, 8 to 9 per day. Women between the ages of 50 and 75 are examined every two years for breast cancer with a mammography, but there is no screening for cardiovascular disease. While an examination of your cholesterol with a blood test is a piece of cake and only costs 5 euros. A lot cheaper than a mammography that costs almost 110 euros per patient.

You would say that with such alarming figures, all alarm bells should go off for both women and doctors when there are heart complaints. Yet many women do not think of a heart problem when they experience chest pain and do not quickly call 911. On average, women call 21 minutes later than men, even though those first minutes are so important.


What is also very strange, according to gynecologist Dorenda van Dijken and cardiologist Janneke Wittekoek, is that medical research and also in the doctor’s office often do not look at the impact of hormones on the female body. They therefore wrote a book together: Heart & Hormones, fit into menopause.

What about those hormones again? Hormones are signaling substances made by hormone-producing (endocrine) glands. These substances reach cells or organs where they do their work via the blood and other body fluids. Most hormones are a kind of regulatory cousins: they can initiate, accelerate or slow down processes. They also influence each other. In addition to a lot of other hormones, the sex hormone estrogen is essential for women. Estrogen is secreted by your ovaries and fat cells can also produce this hormone. It ensures that you become sexually mature, can become pregnant and can give birth. In addition, estrogen is the largest collagen builder: collagen is a protein that ensures that the skin, mucous membranes, ligaments, tendons, muscles, bones, cartilage and also blood vessels remain supple and elastic.

When we enter menopause, the amount of estrogen decreases dramatically; by 80 percent in five to ten years. This decrease causes the typical menopausal symptoms such as mood swings, ‘brain fog’ and loss of concentration, night sweats, hot flashes, etc. The risk of cardiovascular disease also increases. It works like this: the inner lining of the blood vessels contains receptors for estrogen, through which the hormone can be absorbed. Estrogen ensures that the vessels remain flexible and elastic, it has a vasodilatory effect, keeps cholesterol levels and blood pressure low and protects against arteriosclerosis. When this hormone largely disappears during menopause, the vessels become stiffer and stiffer. Arteriosclerosis (clogging of the blood vessels) and contractions: spasms of the blood vessels can occur. This can cause pain or a tight feeling in the chest.

The sooner you enter menopause, the greater the risk of cardiovascular disease. Women who enter menopause (too) early are therefore always urgently advised to use hormone supplementation, i.e. a pill or a patch that supplements the estrogen deficiency.


In her HeartLife clinic, which Wittekoek founded ten years ago, she stands for a holistic approach, by which she means that the entire patient is looked at, not just cardiovascular problems.

“While talking, I and the woman find out where the pain points are. I always include lifestyle and risk factors, while also being alert to stress. For some of my patients – the majority of them women, often who have been struggling in the medical circuit for a long time, often also looking for a second opinion – you can let go of the usual protocol, home-garden-and-kitchen cardiology: they have a rhythm disorder, a valve problem, a clogged blood vessel. A large number of my patients go off the rails due to hormonal disruption. This starts around the age of fifty. Then you can gain weight in a short time – on average two to four kilos in the first four years of menopause. Especially if you were already overweight, extra belly fat can cause inflammation in your body, which in turn has a bad effect on your blood vessels. Being overweight also means that your heart has to pump harder, causing high blood pressure to develop. Being too thin is also not good, as estrogen levels that are far too low can cause cardiovascular disease and osteoporosis. So it is better to have a size 38/40 than a size 34.”


Wittekoek: “Fifty-plus women often sleep less well due to night sweats or stress. And if you don’t sleep well, the incinerator does not work properly and the hormones that regulate your feeling of hunger – ghrelin and leptin – can become disrupted. You also see this among people who work night shifts. And because you are tired during the day, you exercise less and perhaps eat more comfort food. If high blood pressure and increased cholesterol are added, you may develop vascular problems. Especially if you belong to the risk groups (see box), you can have a closed vessel within two years.”

Because losing weight is so terribly difficult, Dorenda and Janneke say: make sure you are fit and without excess weight for that transition in time. So start eating healthy, drinking very moderately, not smoking, and exercising a lot around the age of forty. Janneke: “Prevention is the magic word.”


What Janneke sees remarkably often in her patients: that they suffer from excessive stress. “It is often a little bit of everything: a little high blood pressure, a little too high cholesterol, a little too heavy, a little too little exercise. If you add a lot of stress, you can have a stress attack. Stress releases large amounts of the hormones adrenaline and norepinephrine. These cause cramping of the small vessels around the heart. Then there is a lack of oxygen in the heart muscle without clogged blood vessels. Much more research needs to be done, but we already know that hormone balance plays an important role in this type of heart attack. That is why it is so important for doctors that we do not focus on our own small field of expertise, but look at the woman with all her facets, including her head and her hormones. We really need to move towards integrated women’s care.”

Wittekoek is convinced that the current times, with all their stimuli, cause much more stress than, say, thirty years ago. “Because of the 24-hour society, our screens that constantly distract us, because of a lot of light and sound stimuli, we are constantly on. This has an effect on our brains: we can hardly read a book anymore, we have an attention span of nothing. Women seem to be less able to cope with this than men and suffer more from stress than ever. I don’t think it’s surprising that this is causing new heart diseases. Chest pain due to stress is what I call neuro-vascular angina pectoris. I really think that is a new disease. This is also confirmed by the scientific literature that already exists on this theme. Sleep also plays a major role in this. A person can be quite stressed, as long as you recover sufficiently. Eight hours of sleep is not an unnecessary luxury. That is why I often refer people to a sleep clinic to have their sleep quality examined.”

What can you do for patients suffering from excessive stress?

“Sometimes the stress is caused by great sadness or trauma, which of course I cannot treat. At most I can refer these women to a psychiatrist. I also refer women in whom I suspect ADHD – and many more women than was previously assumed – have them. Women with ADHD often suffer from hormonal mood swings or depression and cardiac complaints. With the rest of these patients I talk about the importance of sleep, relaxation, yoga, mindfulness, walking and looking at art, saying no more often, and regaining control of your own time. I listen carefully and ask: what do you really like in life? You should not underestimate what attention and care can do for a person. Once they have been here for a few hours, they have had all kinds of tests and I can assure them that there is nothing wrong, but that the palpitations do indicate that they are in overdrive and they should take it easy, then they are often so relieved and reassured. At HeartLife I really had to learn to do nothing sometimes. Reassuring, explaining that the heart is good, but of course reacts if you are an overworked woman with a job and children and informal care responsibilities and only sleeps four hours because of the stress. If I succeed, I will arrive at what, for me, is the core of being a doctor. That makes me so happy.”


“About eight years ago my periods became irregular. I also got migraines again. I slept poorly and was exhausted. My doctor said: ‘You are in menopause, half of humanity experiences this.’ That was the end of the matter for him. But not for me. Over the years my complaints became worse: I suffered from hot flashes and mood swings. I wanted hormone supplementation, but my doctor thought that was nonsense. I lost my son at that time, which caused me a lot of sadness and he blamed all my complaints on the grieving process.

I became increasingly tired, emotional and worried. My father was also terribly tired in his early 70s and suddenly he dropped dead from a stroke. Maybe I also had something on my mind? Only after much insistence did my GP refer me to a gynecologist and through her I ended up with a cardiologist for a CT scan. He asked: ‘What are you actually doing? I can see that there is nothing wrong with you, because you are slim and sporty.’ Was I sure I wanted that research? Six weeks later he called me. He cheerfully informed me that I had moderately to severely narrowed coronary arteries and that my cholesterol needed to be lowered. It was as if I had been sent home with my death sentence and now all I had to do was wait out my stroke.

I started taking a cholesterol-lowering drug and hired a dietician to improve my lifestyle even more, but I remained worried. I switched doctors, a woman this time. She took me seriously and referred me to Janneke Wittekoek. Janneke was the first to really take the time to listen to me. I told them that I had fifty hot flashes a day, that I slept poorly, that I worried a lot and was therefore stressed. She had me do the cycling test and made an ultrasound of my heart. She reassured me: she saw some narrowing in one spot, but the carotid arteries looked fine, and that was an indication for the rest of my body. She also said: ‘You eat healthy, you exercise enough, I will discuss with Dorenda whether you can start using the hormone patches after all.’

When I walked out the door I was so happy, but also stunned: couldn’t I have been told this before? I had lived in sky-high stress and anxiety for a year and a half. I had so many complaints, questions and concerns, and now there was finally someone who calmly looked at everything and explained it, who thought along with me and came up with solutions.

Because it’s that simple: you want someone who listens to you, who gives you recognition, but who also tells you what can be done about it. Who gives you tips to give you something to hold on to. Who doesn’t make you feel like a whiner. I’m so done with all those indifferent doctors. And not just me: in my massage practice I meet many women between 40 and 60 with all kinds of complaints, all of whom are sent from pillar to post. I say to them: ‘John, look further, don’t let yourself be put off, keep asking questions.’

Two weeks ago I thought: I am a heart patient, now I think: my life can become a lot of fun.”


We need integrated women’s care: that is the opinion of cardiologist Janneke Wittekoek, gynecologist Dorenda van Dijken and professor of psychiatry Sandra Kooij. That is why they have founded a new platform that will launch on March 8 – H3: head, heart and hormones. This network aims to collect and disseminate knowledge among all healthcare professionals who treat women with hormonal, cardiac and psychiatric problems. These types of problems reinforce each other and must be treated in conjunction with each other. Now these women often see three different specialists, each of whom tackles a part of her list of complaints. This should be possible better and faster, these three specialists believe.


Every woman over 50 should know what her blood pressure and cholesterol levels are. Cholesterol: that is the fatty substance in your blood. The good HDL cholesterol clears away bad fat particles in your blood vessels, the bad LDL sticks to the walls of the blood vessels, causing them to clog up. Therefore, have your cholesterol measured regularly.

Rule of thumb for your blood pressure: below 140/90.

Rule of thumb for your cholesterol: 5-3-1. (Total cholesterol below 5, bad cholesterol below 3, good cholesterol above 1).


* Did you have any problems during pregnancy (high blood pressure, growth retardation, miscarriages)?

* Does cardiovascular disease run in the family?

* Have you had migraines?

* Are you overweight?

* Do you suffer from stress, anxiety, depression, sleep disorders?

* Do you exercise too little?

* Do you smoke?

* Do you have high blood pressure?

* Do you have high cholesterol?


For pain in the chest, back, left jaw, armpit, shoulders or upper abdomen

Palpitations that last longer than 5-10 minutes

Shortness of breath or shortness of breath after quietly climbing stairs or cycling

Persistent flu-like symptoms, fatigue or poor sleep

Nausea and vomiting

Sweat attacks

Feelings of anxiety or feeling rushed


Heart & hormones, fit into the menopause , Dorenda van Dijken and Janneke Wittekoek, Lucht publishers,

The heart/head connection , Janneke Wittekoek publisher Lucht

The Women’s Heart , Janneke Wittekoek, Lucht Publishers

The transition, the no-nonsense handbook , José Rozenbroek and Jos Teunis, Atlas Contact publishers