Menopause Doubles Your Heart Attack Risk - Here's What to Do

Before menopause, our risk of heart disease is half of what a man's is, but within a few years of our last period, it is equal, and by our 70s, it's actually higher. So why is nobody screening us for this? So here's what nobody has really told us. Menopause is not just a hormonal shift, it's a cardiovascular event. The drop in estrogen we go through in our 40s and 50s triggers a cascade nobody screens for. Our arteries stiffen, our cholesterol jumps about 20%, visceral fat moves around our organs, blood pressure creeps up, and the symptoms Fatigue, jaw pain, nausea, dizziness, palpitations. We've been told for decades these are not atypical, they are women's symptoms. The healthcare system was built around the male body and we are paying the price. I've already had 3 cardiologists on this show and every single one of them changed how I think about my heart. But today's guest is different. She is a research cardiologist who is calling out menopause itself as the most missed opportunity in preventative cardiology. She's the creator of Sterile Chronicles. She is a VP of Medical Affairs at Halo Heart. She has spent 25 years in cardiology research and she's advised the the FDA on heart devices, and now she's on a mission to translate the science for women and us so we can advocate for ourselves. Dr. Jane Morgan, welcome to Midlife Conversations. So you've built your career on a message most cardiologists are still not saying out loud. Um, you call it menopause as a cardiovascular event. Can you help us understand why? What do you mean by that?

You know, for all of eternity, all of the time that healthcare has existed, women's health has always just been reduced to reproduction. And we've accepted that. But is that really true? Because the fact of the matter is it's heart disease that's actually killing us. It's what's sitting behind the breast. And what we focused on are our breasts, our pelvis, our vaginas. And a lot of that is primarily because the healthcare system is driven by men and You know, that's been their focus. That's what they find is important. And so it's the sexual function and reproduction function. And the fact of the matter is we've kind of just gone along with it. And so most of us, without really thinking much about it, most of us spend the majority of our adult lives being taken care of by OB-GYNs. And that is probably insanity because it's heart disease. That's the number one killer. Yeah. But we've been conditioned to think about, you know, breast cancer and, and sexual function and reproductive function. All of those things are important. I'm certainly not negating it. And I want to be clear to say I'm not saying that one needs to step aside such that the other can come up. They are both important. We should not remove our focus on breast health just so we can focus on heart health. We can actually do both. But the fact of the matter is breast cancer is the number 7 cause of death for women. Number 7.

It's so wild because it's so loud. We hear so much about that and we just don't hear enough about heart disease. When we hear about it, it's typically for men.

That's right. That's right. Because heart disease is viewed as a man's disease. And even for myself as a cardiologist and cardiology training, it was very, very, very much viewed as a man's disease. When women were admitted, that's why, you know, I began talking about this word atypical years ago. I began talking about it. I despise that word because it mostly was applied to females and it drives action. More importantly, it drives inaction. It slows down, it delays your care by labeling you as atypical. And what I noticed even in my cardiology fellowship, I rarely admitted men and gave them a diagnosis of atypical chest pain or atypical symptoms. By the way, that is a formal diagnosis. This is not just chatter between doctors. Like, this is a formal diagnosis that's in the CPT codes that you get reimbursed for. Atypical chest pain. And the fact of the matter is it's applied mostly to women. And I noticed that years ago in my cardiology training and could never get a great answer for that. You know, over the years, going through research, doing a long stint in research and managing clinical trials and directing clinical trials, I started to kind of just connect the dots and intersect all of these circles and say, oh my goodness, this is a huge problem that's starting way back with clinical trials. It's starting way back with, you know, who's running the healthcare system. And it's heart disease that's the number one killer of women, and it's by and large invisible in our system.

Now, I know you're working in Georgia to pass legislation requiring medical schools to teach menopause and heart health, and that seems to be this, this huge gap. How did we get here?

Yeah, how did we get here? When we talk about women and healthcare, we generally don't talk about any of the other organs in the body that we also share with men. So it's never about our brains and our hearts and our livers and our pancreas and our kidneys. You know, intestines, surprise, we've got all of those. It really isn't about that. It's really just kind of been about our sexual function. And by and large, that is what has been the thought of what is important, what is the driver of our health, and what is the driver of our illness. And heart disease has been forgotten. Now, in some ways, the healthcare system has stumbled into the correct answer because the fact of the matter is Estrogen, which is produced by and large from the ovaries, is a big driver of a woman's health. But that estrogen is not just confined to our reproductive organs, and, you know, it's everywhere. And one of the things that I talk about is how estrogen really impacts the milieu in which the female heart operates within the body differently from the male heart, including how disease progresses. And so in some ways it is reproduction, but in some ways it's cloaked as reproduction. So it's— we get confused because it's coming from the ovaries. It must be a reproductive hormone. Actually, no, it's a biologic and physiologic hormone for the entire body. And we've gotten confused because it's simply coming from the ovaries.

So when estrogen starts to decline and start— things start going up, does HRT— women that choose HRT, does this help? Prevent that? Or is it still going to be a problem because we don't have the doses that we used to have, the levels that we used to have?

Yeah. So, you know, when we talk about HRT, which is hormone replacement therapy, or MHT, you know, menopausal hormone therapy, the levels when you replace them, the levels are not at the levels of, of where you were premenopausally. And they certainly don't approach the levels of any woman who's taking birth control pills. The aim currently is to control symptoms and to make the woman more comfortable. Now, why is that the aim? The aim is comfort and care because we don't have data on clinical trials regarding dosing. We do have data regarding the route of dosing, meaning oral versus transdermal, which are usually patches or gels or creams. But we really don't have phase 2 dose finding data on what is the optimal dose for prevention of whatever you want to name. I'm a cardiologist, so we'll say heart disease, but maybe prevention of dementia or prevention of whatever you want to name.

Sure.

Gum decay, teeth decay, whatever. Vertigo, neurologic. I mean, estrogen is really impacting everything. And so currently what we try to do is manage symptoms and restore a woman's health and vitality. And in doing so, decrease the rate of bone resorption, decrease the risk of falls and fractures, and decrease the rate of muscle atrophy. All of these things contribute to later poor health. If you're not able to maintain your muscle mass, if your bones become brittle, no matter how well you're eating, you simply aren't going to be able to, to function physically. And so, all of these things, you know, sort of go hand in hand.

So, my dad actually died when he was 49 of a heart attack. So, male, but he had a lot of the traditional things that we would think that would be a trigger. For example, he had a lot of visceral fat. It was obvious. He had that, the big hard stomach. He had very high blood pressure, very high. He had very high triglycerides. And he was very stressed all the time. And when he had a heart attack, he had the traditional, like, it was like shortness of breath. And then, he— it was an instant. They call it the Widowmaker. That's how my dad died. And I think a lot of women think that's what would have to happen to them. But I know the symptoms in women are very different. Can you talk about that?

Yeah. And women can have those symptoms. I want to be clear, they can. But we also can have these other symptoms that men don't commonly have. And, and that's what they call atypical. And that's the challenge when we get into this atypical spectrum, which many women will experience and display. Not only do we not recognize them, the healthcare system doesn't recognize them as well. And so you certainly can have the chest pain, the chest pressure, the shortness of breath, the sweatiness. You can lose consciousness. Very dramatic. And the reason that happens is because you can get a sudden blockage of one of those main arteries to the heart. But the fact of the matter is a woman's heart generally is smaller and we also have smaller arteries and the blockages in our hearts will— may not necessarily be one large blockage that gives you that sudden— those sudden symptoms because there's a sudden decrease in oxygen supply. So you get an immediate reaction. It may just be a stuttering of plaques along the arteries. So blood flow can still go through, but it's kind of meandering, right? Because you've got kind of like little small blockages, none of which are enough to completely cut off that vessel. But what happens over time, you're getting less and less oxygen. You're still functioning, but you've got these mini blockages that are studding your arteries. No one, no single one is cutting off all the blood supply. So you may just feel tired, right? You just don't— not getting enough oxygen. You don't have enough reserve. You're just— you're fatigued. One woman in midlife with children, aging parents, a full career, a spouse, pets, all kinds of things, doesn't have a reason to feel tired. Feeling tired generally does not trigger you to say, oh my God, I'm having a heart attack. Got a million things going on, 12 different lists running in your head. You're not sleeping well. You're constantly trying to go through, cross off things on your list. Everyone's depending on you. You put yourself last because our culture says that we should put ourselves last. And just like the word atypical, we bought into that. So we are pouring into others, not into ourselves. So if we become tired, we kind of have a lot of reasons to be tired. We're not saying, "Hey, let me call Dr. Morgan. Think I'm having a heart attack." So, but fatigue should— that doesn't excuse the healthcare system for not recognizing that fatigue is a primary symptom of heart disease in women. You could also have nausea, you could have back pain, you could have jaw pain, which is actually referred pain from the heart. And I, you know, I'm starting to give talks at dental conferences to make sure dentists are aware. When you see these midlife women in your office and they're being examined because their jaw is hurting and you're doing an oral exam and you literally cannot find a reason, or you do find a reason and you complete that root canal and they're still complaining of jaw pain, you need to send that person to the emergency room or to a physician.

Wow.

This is not something that you send home to say, oh, I don't know why you're having jaw pain, but your teeth are fine, your gums are fine. I don't see any reason, you know, go home. That's not a go-home moment. And so we're trying to bring dentists in to make certain that they understand their role as well in screening these women and making certain that they are getting them into the medical system for appropriate care.

You know, you mentioned these things like tired. I mean, that's every midlife woman has these things.

Of course.

Tired, right? And then the nausea too, and then back pain. So, how do we like— what do we do when you're— is this always an ER thing, or is this— is there specific screening tests that we go get if we're feeling this? What do we do? Because these are very common symptoms.

If you are feeling this, I would say an ER thing, but at the very least, go and see your doctor immediately.

Okay.

I am having these symptoms. I need an EKG. I need a workup. Maybe I need a referral to a cardiologist. Make certain someone is taking these symptoms seriously and that heart disease is number one in the differential. Yeah. And I say that because there are many reasons for fatigue. There are many reasons for nausea. There are many reasons for back pain. And the problem is we've always brought those many reasons to the top of the list and heart disease is at the bottom. And I'm saying heart disease needs to be at the top because it's the thing that's going to kill you. And then let's work our way down through some of these other things.

Yeah, you're right, because we're talking so much about mammograms or like breast screening and even Pap smears, even though you don't necessarily need one every year. And then, but we're leaving this part out. Most of my friends in their 50s, they don't go to a cardiologist yet. But why not? Why are we seeing a cardi— you know, an OB-GYN but not a cardiologist? It's a good question.

Right, right. Or at least having basic cardiology screenings done with your primary care physician. There should be conversations about menopause with your primary care physician, even with your OB-GYN, and then a decision about whether or not you need to see a cardiologist. Baseline studies need to be done. Let's look at your EKG or or ECG. Let's draw some baseline labs. Maybe let's get a calcium score. Let's talk about your symptoms. Let's discuss your family history. All of this. See what medications you're on. Let's see if your blood pressure is increasing. Let's look and see if your cholesterol is increasing. How's your sleep? I mean, like, we're talking about a whole menopause doctor's visit, which doesn't exist, by the way, to give you an idea of whether this woman needs to see her cardiologist or not. We need a menopause visit.

Yeah. You know, this is— okay, so I have some more questions about that, but I want to— I got this stat from you that women wait 37 minutes longer than men to get cardiac care in ER. That is astonishing. And when I first read that, I thought, that doesn't sound right. But I have a client in my groups who recently had a heart attack, and she said literally this. She said, I had all these random symptoms, and I thought maybe, but I just went and laid down. Like, it was like she had this fight with herself before she finally went to the ER and learned she had a heart attack.

Right. And that's one of the things we go, "Oh, we're going to lay down. I need to rest." You know, listen, if you rest and you're waking up in the morning after sleeping and you're tired and you're still in the bed, you wake up tired.

Yeah.

That's a big red flag. Having any difficulty completing tasks that you used to have. I mean, physically, not mentally, just physically. And I mean, when I say minor tasks, I mean things that sometimes don't require a lot of physical exertion. So, just standing and cooking just is tiring for you. You know, to cook a meal, it's like, oh my gosh, I need to just pull up a chair and sit. It's, you know, this is long to stand here at the stove. Those kinds of things where we need to begin to adjust. But 37 minutes is long and it's not 37 minutes that the woman waits. It's a combination of 37 minutes that the healthcare system also delays. So it's a combination of What is the delay in the woman to actually getting heart care? And it's a combination, combination of her delaying, but also once she reached the healthcare system, healthcare system, what happened there? They also delay and give you that diagnosis of atypical and start to watch you. And that's another way of basically triaging you to lower levels of care and concern.

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And especially when we're talking about midlife women. So here's what happens. As your estrogen levels decrease, you have less estrogen binding to receptors of your heart. And estrogen is a direct cardioprotective agent of the heart. Estrogen also provides anti-inflammatory protection for the entire body. It's a woman's natural anti-inflammatory agent. Chronic inflammation is the driver of heart disease. It's also the driver of cancer. So we start to lose that protection. And what sets up is more chronic inflammation. So the other thing that occurs is, you know, when I talk about estrogen receptors being everywhere, they're also on the arteries. And so as estrogen decreases, it's the estrogen that keeps our arteries compliant. That's a medical term. It means flexible. It means that they can expand and contract when needed, right? So that's how we control our blood pressure naturally. The vessels have the ability to relax and then become— and stiffen. But as we lose estrogen, they remain more in that stiffer position, more rigid, and therefore our blood pressure is up.

Yeah.

Blood pressure is the primary driver of heart disease. And then what happens to cholesterol. Estrogen and cholesterol share common metabolic pathways in the liver. We see cholesterol begin to rise as our estrogen levels drop as well. That can impact— it definitely impacts LDL. We see LDL increasing, what they call the bad cholesterol, but we can also see HDL, the good cholesterol, dropping and triglycerides also rising in midlife women. So That's yet another risk factor for heart disease. High cholesterol is a known risk factor for heart disease. And in fact, blood pressure and cholesterol are both known as silent killers because you feel fine whether your blood pressure and cholesterol are high or low, you feel exactly the same. And so oftentimes it's hard to think, why should I take medications? I feel fine. The other thing is I think mentally people associate taking medication with being sick. Or with being old. And so if you're not having any symptoms and you feel fine and you can say, "Hey, I don't take any medications." And what I say to people when they come up to me and they're in their 50s and they say, "Dr. Morgan, I just want you to know I take no medications and I'm 50 years old." You know, my response—

Like a badge of honor. Yeah.

Yeah, it's a badge of honor. Like, "Look at me." It's like my response often is that doesn't mean that you shouldn't be. And here's something to think about when we talk about longevity. There is no longevity without heart health. When we talk about longevity, we literally are talking about taking care of your heart. Your heart pumps oxygen, blood, and nutrients to every single organ in your body. There is no longevity in aging without heart health. So it is better to take medication and bring your numbers down under control than to not take them and have your numbers high, but have bragging rights. Because ultimately it's your numbers that are going to drive your risk of heart disease. And I just wanna make this point, 10 millimeters of mercury that are elevated of your blood pressure will increase your risk of heart disease by 20%.

Wow.

As your cholesterol increases you will also have an increased risk of heart disease and heart failure and stroke. And so that's why I often talk with women about taking medications because women tend to be underprescribed statins. Even when we are prescribed them, we tend to decline them because we've heard bad press. And so we tend to take them less than men. But heart disease is not a man's disease. It's heart disease.

No, it makes sense. Everything you're saying makes sense. I think the question, and this is me too, so I'm, you know, putting myself out there around this, is my struggle around it is my question is always what is causing the high cholesterol? Like, what is— and then you hear things like, well, it's brain protective or your body produces it to help you. And so, in my— and you can totally tell me if I'm completely wrong in my thinking here, I'm open to that. In my thought process, I'm like, well, if my calcium artery scan is fine and blood pressure is fine and all these other things are fine. Why do I need to address LDL if everything else is fine?

So, I don't know what your LDL level is, but I will say, and congratulations on your zero calcium score and your good metrics, but the fact of the matter is the elevated LDL will eventually catch up with you. And you will feel fine until the moment that you don't. The other thing that I will say, not trying to provide any scare to anybody. The other thing that I will say is oftentimes women— now we're talking about our, our physiology that's different in our hearts. Oftentimes women, we can have plaques that may not show up on the calcium score, but they're because they're not hardened.

Makes sense.

They're soft plaques. And so they go undetected. We call that part of that microvascular disease that's been very hard to identify and diagnose in women. So these are all things to consider. My perspective, and the data shows that women are underprescribed statins.

Makes sense.

And take them less often, but we have the ability to benefit from them. And I like to see them being used, especially in midlife women, to control our numbers because I know how impactful elevated LDL, elevated triglycerides, elevated blood pressure, sleeplessness, visceral fat, how all of these things come together and don't work to your advantage. They don't work to your advantage by themselves. And then in midlife, oftentimes they're all occurring at the same time. Yeah. So we need to take it very seriously. Medication adherence Compliance is important, meaning that if you're prescribed medications, you should take them. There is no medication that works that someone doesn't actually take.

Makes sense.

And we want to make certain that you bring your numbers down into the normal range. So not only do you have bragging rights that, oh, I don't take any medications, and so you feel psychologically healthy, we actually want you to have bragging rights that you actually are healthy, and you've decreased your risk of heart disease. Yeah.

And I have no shame in anyone that is— I always tell my, like, everyone has to do what's best for them. I do have a question about PCSK9 inhibitors. They seem to be a newer thing. Repatha. How is that different than a statin? And are you a fan of that? Like, tell us, help us understand.

Yeah, you know, PCSK9 inhibitors, I think as well, you should definitely be considered along with statins. Look, these are classes of medications that have been shown to cause regression of atherosclerosis, meaning the plaques actually get smaller. So why should men be the only ones benefiting from that when heart disease is the number one killer of women? Yeah. Estrogen also has been shown to have some regression of plaques. So we need to begin to wrap our heads around heart disease being the number one killer of women. And what do we need to do to dial that clock back such that we can have longevity, meaning heart health as well? You know, even currently, women still outlive men generally by about 4 to 6 years. But the fact of the matter is we spend about 25% of our lives in poor health, suffering, suffering silently, coping, managing. Gradually declining as we kind of, you know, push through, suffer through, grin and bear it. And no one says anything. But the fact of the matter is, you know, our quality of life declines gradually over time and we just continue to make these little adjustments, little adjustments, little adjustments.

Yeah. I have maybe an odd question, but I'm just curious your opinion. Why do you think so many cardiologists or so many— not, I wouldn't say cardiologists, so many people are so anti-statins specifically? Like, I don't hear that about metformin or about blood pressure medicine, but why specifically statins? Why does that make sense?

And you don't hear it in men either. They're not really anti-statins for men. It's kind of anti-statins for women. So statins have some of the side effects of muscle soreness, which in trials have been shown to occur a little bit more frequently in women. And for what we call that myositis. And for whatever reason, That has been the major driver of, "Oh, women shouldn't take it because they get muscle soreness." Listen, this happens very rarely. Mm-hmm. And if it does happen, there can be dose adjustments, but it should not be a reason to not take these medications and bring your numbers down into the normal range if you need it. Now, are there other ways to address it? Absolutely. You know, we never say take medicines instead of nutrition. Take medicines instead of exercise. Take medicine. You know, this is not a magic pill. We're saying everything. We will also address nutrition, you know, address, you know, what types of foods are more anti-inflammatory, which types of foods are higher in cholesterol. And cholesterol is not all bad. There is a reason that we do have cholesterol and fat in our bodies. Cholesterol is not all bad. What we're talking about is when we have excess levels. And just like anything, when you have excess, it has to go somewhere. And where it ends up is in our arteries building up plaques when you have excess. So how can we bring it down into levels where we're still utilizing it physiologically, but we're not overdoing it where now the body's trying to figure out where to store it.

Now, what is your take on what your opinion is? Working with so many clients and seeing so many patients and your own experience, what's your nutrition thing? I know that so many— there's so many different opinions. Some cardiologists follow Pritikin diet, some are more carnivore, like some are— there's— some are vegan. Do you have a preference on where— what you see being successful with patients on reversing heart disease or preventing?

So my recommendation almost always is the Mediterranean diet for a number of really high in colorful fresh fruits and vegetables, meaning it's carrying a lot of antioxidants and a lot of anti-inflammatory factors, but it's also high in protein. It has chicken, it has poultry, it has fish. So I don't necessarily ascribe to this vegan diet or vegetarianism for midlife women because we need the protein to maintain our muscle mass. It's the muscle mass that increases, keeps your metabolism going. And that's the metabolism that will slow the deposition of visceral fat. It all starts with your muscle mass. So the less muscle mass you have, the lower your metabolism will be. And so you're contributing to this. We want you to be strong, not skinny. And the Mediterranean diet, I think for midlife women, pushes you towards being strong. Now, please—

Yeah, and I love the olive oil with Mediterranean diet. So you get the polyphenols from that.

That's right. And olive oil though is high in calories. So what I wanna make sure that you hear is something I'm not saying. I'm not talking about calories. Yeah. I don't really care about calories. I don't, I'm not concerned about you counting calories. I want you to get the nutrition and support that your body needs. In fact, I'm not saying diet either or take anything away. I'm saying add.

Yeah.

Lots of fruits and vegetables. Make that a bigger part of what you're eating every day. I love that. Make sure you're incorporating protein. Now, you know, if people are vegan, there are, you know, other ways you can get proteins in beans and things like that. But, you know, when you're really looking for protein, I'm not, you know, endorsing one way or another of getting protein. But I am saying why I support the Mediterranean diet, especially for midlife women. It's not about dieting. It's not about counting calories. It's about being strong, giving your body what it needs, having your muscles atrophy less, increasing your metabolism, decreasing visceral fat because you're eating food that's supporting your muscles. It's all coming together. And here's something else, the heart is a muscle. It's your only organ in the body that is striated muscle, the same as your arms and legs. All the other organs are smooth muscle. Your heart is a muscle. So, think about that when you're talking about feeding your muscles. We're talking about that heart too.

Why do so many cardiologists go back to the Pritikin diet?

Where did—

what was the history on that? Where did that from? It's so strict with the no fat.

Yeah. You know, again, no fat, low fat. We're trying to keep you from having, you know, high cholesterol and atherosclerosis and heart attacks. I have just backed away from that years ago. I don't think it's practical for midlife women. And I don't think the diet specifically, as in most things in medicine, considers women's biology and physiology. I say the same thing about the DASH diet, which is actually the diet the American Heart Association recommends, which is a low Salt Diet. I think it's great because it focuses on hypertension. I don't think it focuses on the unique biology of women. So, I deviate from the American Heart Association as well to say, so maybe I'm out here on a limb all by myself, but I'm specifically focused on midlife women, which the Pritikin Diet is not, which the DASH Diet from the American Heart Association is not, but Dr. Jane Morgan is, and those diets are not actually serving midlife women well in all of our needs and what it is that we need. And of those that I know of, the Mediterranean diet is the best diet to follow. And it's not necessarily low in calories. It's high in omega-3 fatty acids. Olive oil is high in calories and fat, good fats, unsaturated fats. Avocados are high in fat. So listen, I'm not saying don't eat fat. I'm saying we eat the better fats, the ones that are fueling our cells, our cells in our bodies, and not depositing in our arteries because we've got all this extra excess that our body didn't use. I'm not saying diet. I'm not saying only eat 1,400 calories. I'm saying add some protein.

Yeah, I love that. I love that.

Build your body up.

No, it's great. And it's also interesting you brought up the dash and the salt because the salt really is more about processed food. Like, yes, extremely processed food, but we need some sodium if you're getting it from natural Himalayan rock salt. Like, we need minerals. We need that. So, dehydration is a bigger problem. So, it's so funny how along the way these messages get taken out of context and they become like a big marketing thing. I really do think a lot of it is—

Medicine has been driven, and I talk a lot about this, by a one-size-fits-all. And so these are all examples of one-size-fits-all, and I'm rejecting that, saying, "I love that." "Doesn't really fit what my needs are. So I'm going to be over here talking about something that kind of fits this group that fits some people, but it doesn't fit these people.

I need to talk to these people." I have one more question about cholesterol before I drop it, and then I'm going to get into kind of like the practical next steps for people. So you mentioned that, you know, one of the reasons with cholesterol medicine is the muscle soreness. When— and you said you can change doses. There's a whole idea around this microdosing of statins. Have you heard that, where people will take like a— they do it every other day, or they do a super small level? Do you find that can be an effective method if someone works with their doctor on that?

So I don't have any data on microdosing of statins. I'm going to recommend that you take a stable dose daily. Now, if you can take a stable dose every other day and that be your dose and you literally do it every other day and you can do it regularly, then I'm okay with that. But it can't be something that's jumping around. You've got to have a regular pattern such that when you're coming in for labs, we really understand what those labs mean. It doesn't mean that it's hard to read it because you haven't taken your statin for 5 days. Or you, or today, you know, you took it for the last 3 days, but you didn't take it for 2 weeks. You know, we can't help you. We can't work with you. So if you're going to do the microdosing, make it very regular such that we understand when you're having your labs drawn how to actually interpret them. And guide you further. Great.

Okay. So I want to get really practical. I know you have to wrap up soon. So if a woman's listening right now and they're going to call their doctor because they're like, okay, I've been confused, but I need to take cardiovascular seriously. What do you want them to specifically ask for from their doctor? Like, what tests should they be asking for?

Yeah, I think if you're a midlife woman and you're going in, let's say you have, you know, no cardiac symptoms, but let's say you've got some perimenopausal symptoms, which are, you know, Oftentimes I hear women say, "I don't have any symptoms." But, you know, because everybody only thinks about hot flashes and night sweats, right? They don't— they're like, "60 symptoms, a million symptoms." And you're thinking, "Oh, I didn't know that was one of the symptoms." You have a little vertigo, you got a little dry mouth, you've got some itchy ears, you know, you've got a little abdominal bloating, you've got some painful sex, you've got— all of these are symptoms of perimenopause, some incontinence. So the conversation that you want to have, you want to talk about your symptoms and you want to talk about them transparently. Parentally, because that's an opportunity to talk about not only HRT, but it is an opportunity to talk about HRT, but it's also an opportunity to talk about other vasomotor drugs that may be available to control your symptoms. It's a time to talk about nutrition that might be helpful for your symptoms. It's a time to talk about sleep hygiene that might be helpful for your symptoms. So labs that you may want to think about I always, always— I'm a cardiologist. I want you to get that ECG. I want an ECG, even if you're not feeling well, that's fine. We want your baseline on the record. We want to know what you looked like when your heart was fine. That's called a baseline record. It's just like your mammogram. We can compare. Every year when you go in, we compare them to your normal. Your ECG should be the same. So don't think you only need to get an ECG like, oh, when you're sick. No. Get it in your will, 'cause we want it on your record so we have something to compare to. And the other thing is vitamin D, huge, huge. Vitamin D really impacts your heart health. Vitamin D. The other thing to think about as well is your iron and ferritin stores, which we often can see are low in women that can increase your risk of heart disease. And then of course your cholesterol profile, adding you know, Lp to the profile as well. Sometimes, you know, you think about thyroid, especially if women are symptomatic with palpitations, with heart symptoms, want to take a look at thyroid, which can be a big mimicker of menopausal palpitations and heart disease. We want to take a look at that. So I think those are probably, you know, good places to start and to start sort of the conversations of, you know, kind of what's going on with me. And what do I need to do? That's good. It's time to maybe consider a home blood pressure monitor so you can monitor your blood pressure and know when it's going up and you're not sort of between when your visits and the next time you see your doctor, your blood pressure's high and she says, "Well, how long has it been high?" And nobody knows, right? Blood pressure drives heart disease. 10 millimeters, that's all it takes. Yeah. Of heart disease is up by 20%. So, ask for home blood pressure monitor. Get a prescription for it. Pick it up at the store. All of these things you can start to do for yourself.

So, some of the stuff I pulled off of your site just that I want to add to this was make sure you have a lipid panel. So, she likes you to go deeper on that. So, ApoB and Lp if available. You said CRP. So, inflammation markers you want to look at.

Yeah, yeah. You know, CRP is probably lower down my list, but I think we can look at CRP, especially if the woman is going to now work on her diet and work on other things and look and see if CRP is actually improving.

Great. And then I know you mentioned A1C and then a coronary artery scan.

So when we talk about the glycosylated hemoglobin, which is the A1C, so we're looking at insulin resistance, which we, which we haven't talked about today, which is another topic, but this is also something that we can see worsening during midlife. Meaning you have an increasing risk of developing not only diabetes, but your body has a decreased ability to handle sugar. So now we're back to kind of this visceral fat.

Yeah.

When we talk about calcium scores, this is an indicator. It is not a diagnostic workup. A calcium score is a risk assessment tool tool that we use to calculate your 10-year risk of heart disease. It does not drive a workup. So if you already have symptoms of heart disease, you're having symptoms, you should go forward for a workup, maybe a stress test or an echo. A calcium score is for people who have no symptoms and we're having conversations with the cardiologist about what your 10-year risk is and what you need to do. It's generally for the asymptomatic person.

Well, thank you, Dr. Jane Morgan. I know that you are on a time crunch today and I rapid-fired some questions for you, but this is super informative. Where can people learn more? Where can they find you?

Sure. Yeah. Follow me on Instagram @drjanemorgan, D-R-J-A-Y-N-E. There's a Y in my first name. Dr. Jane Morgan, M-O-R-G-A-N. But I'm also on LinkedIn, on Threads, on TikTok. So, you know, feel free to reach out. And I talk a lot about heart health and specifically women's hard hill.

I love that. Thank you so much.

Thanks so much.