Dr Louise Newson: [01:00:00] Dr Jayne Morgan is a cardiologist from the US who's on my podcast today. We talk about cardiovascular disease and hormones. It's a really important topic because globally the commonest cause of death in women is cardiovascular disease. And we know the incidence increases when we're menopausal. So it's a wonderful conversation where I hope you will just think differently about your heart, your blood pressure, maybe your brain as well. So enjoy. So Jayne, it's great to have you on my podcast. We're going to be talking about heart disease or cardiovascular disease actually. And cardiovascular disease is number one killer of women globally. Yet if you Google heart attack, it will be a man clutching his heart and it's not really thought about for women. And I'm got a medical background. I did quite a lot of cardiology as a junior doctor and I never really thought about heart disease in women, which I feel very embarrassed about. I didn't think about hormones because I wasn't taught about hormones. But when you understand how our basic hormones, estradiol, progesterone, testosterone work on our cardiovascular system, we can't keep ignoring it. But let's just start really basically like what is cardiovascular disease and why are you interested in it?

Dr Jayne Morgan: [01:01:24] Well, to your viewers, I'm a cardiologist, so I'm definitely interested in cardiovascular disease, and it really developed more of an interest in women just from noticing symptoms really during my internal medicine residency and cardiology fellowship. I mean, we're talking two or three decades ago now, and I would notice that we have a nomenclature, which is actually the way that physicians talk to each other called atypical. We would call it atypical chest pain or atypical symptoms and basically that would mean a person who's coming in, they kind of maybe have risk factors for heart disease, they've got vague symptoms that we can't really pin down it's probably not heart disease but we might give it a nod and call it atypical. And I began to notice that when I was dictating and writing my charts and I would be giving that term more often to women and not to the men. And I would think, oh, the women come in with these atypical symptoms. What does that mean? And I would ask my attendings and you know, it's the power structure and they are all knowing and they would say yes, because these are the symptoms that they come in, usually for women, it's going to be anxiety and panic disorders and these types of things. They rarely come in with real heart attacks and I sort of would accept that because.

Dr Louise Newson: [01:02:57] That's what you were taught, yeah.

Dr Jayne Morgan: [01:02:59] You know, they tell it to you very emphatically, knowledgeable. But then, you know, months would go by, you would see more and more patients. And that thought would kind of come back into your head like, I'm seeing these female patients. What I also would notice is that we would prescribe antidepressants and anti-anxiety medications. I also wouldn't notice that oftentimes more often than men, when I would do an initial evaluation on a woman. I could see on an EKG that they had had a prior heart attack. And when I talked with them about it, they were unaware. That almost never happened with men. Either their EKGs were normal, or if they had a prior heart attack on their EKG, when I talk with them about it they had some awareness of it. Again, I would talk with my attendings and I was just sort of getting nowhere with it. You know, and you can imagine, you know, in a system, a big system, healthcare system, the United States of America, which is where I am. I'm sure all your listeners can hear my American accent. The system kind of just continues to churn and you are part of the system and you question it but at every question, you sort of get pushback from people who are smarter than you are, who know more than you, who are more senior than you are, who are more power structures. But the fact of the matter is now I sit here on your podcast, I was onto something two and three decades ago. Something is not right. And that's something for women to think about really for your lifetime in whatever you're doing. We know our bodies. We also know each other. When you have a sense of something that's not right, when you're seeing patterns, feel empowered to speak up. Even though in that situation I was powerless, I was not in a powerful position. I was the most junior person on the team, but try to find allies, which is what we try to do here to speak up for women, because there's an innumerable number of women who have been harmed by the system while we've been relegating people to panic disorders. In fact, it would be called atypical chest pain, rule out panic disorder. Very common diagnosis. We almost never gave that diagnosis to men.

Dr Louise Newson: [01:05:15] It's quite something, isn't it? Because certainly in the acute medicine departments, in casualty departments, if someone comes in with a chest pain, there's a sort of criteria. There's a set standard of blood tests that you do. Obviously you do an EKG or we say ECG. You do their blood pressure. And then depending on what their results show, depends on what treatment they have. But those guidelines have always been set up based on men with their central crushing chest pain. So when women have, feel lightheaded or dizzy, or they might feel they might have some nausea and vomiting, these are all symptoms that could indicate a heart attack. But if you go to the nausea and vomiting pathway, it won't say, do the blood test for a heart attack because people don't join the dots. And this is where this atypical, as in not classic chest pain, well, it is typical for women. Which is what you're really saying, isn't it? It's not typical for men to present with dizziness or nausea and having a heart attack, but actually we can't exclude it.

Dr Jayne Morgan: [01:06:23] Why is it atypical for women? It's because the structure, the health system has been created by men. So we are receiving this connotation of atypical, but the fact of the matter is we're the majority of the population. So we're not the ones with the atypal symptoms. It's maybe the men who are having the atymical symptoms. Now, I wanna be clear, women can also get chest pain and shortness of breath. But we get into this other spectrum of symptoms, women run the spectrum much more often than men. And once we get out of the main area and off into the spectrum of symptoms that's where we start to be triaged to lower levels of care and concern. That's why the first heart attack of a woman is more often fatal than a man's. It's because of delay in care, delay in recognition, inappropriate discharges from the emergency room. That's why the first heart attack of a woman is more often fatal than that of a man. If a man and a woman come into the emergency room at the same time and the man has the quote unquote "classic" symptoms and a women has the, quote unquote, "atypical" symptoms, rhe man will be in the cath lab within 20 minutes having his artery open and a stent placed and the woman will still sit in the emergency room having enzymes drawn every six hours while we try to figure it out. And eventually maybe if the enzymes rise, she may the next day end up in the cath lab. And when we talk about the next day, 37 minutes of a delay is significant enough to have a difference between life and death. And women don't receive that consideration because oftentimes our symptoms are out on the spectrum. And the spectrum is denoted as atypical, which is kind of a wink wink to the doctors, to each other going, ah, another case of a panic disorder, another woman with hysteria, another person who needs an antidepressant. We'll babysit her in the emergency room, draw a few enzymes and off she'll go. So that needs to change.

Dr Louise Newson: [01:08:38] Absolutely, but when we talk about cardiovascular disease, it's not just heart attacks, is it? So just explain other conditions that are associated with cardiovascular disease.

Dr Jayne Morgan: [01:08:49] So cardiovascular disease is, you know, an all encompassing and it includes the peripheral arteries, meaning arteries in your legs and in your arms. And we have something called claudication. That's actually a term that sort of means that you get cramping and pain in your legs when you're walking. That means that your have poor circulation in the arteries of your legs, blockages,calcium, atherosclerosis, the same as in your heart. So your legs actually are an indicator, oftentimes of things that are going on in your heart and your heart is oftentimes an indicator of the health of your brain, of circulation and oxygen and blood supply to the brain. It's why more often people who have heart attacks have a higher risk of developing dementia and Alzheimer's later, because oftentimes what's happening in those coronary arteries, meaning the arteries of your heart, are also happening in the carotid artery. So the arteries in your neck that are feeding the brain and the other arteries in you brain. There is that connection. The heart pumps and that blood goes out to the brain to infuse it and give it oxygen. And then the brain sends neurologic signals back to the heart to squeeze again. And round and round we go. It is the brain and heart are very interconnected. And what you see happen in the heart, you need to think may also be occurring in the brain. We need to protect the brain as well. So cardiologists and neurologists and neurosurgeons go back and forth on who's got the most important organ? Is it the heart or the brain? So I'm sure you can imagine which one that I'd say, but the fact of the matter is you can't live with either. So we may be both right and both wrong.

Dr Louise Newson: [01:10:38] Absolutely and it's so important because when we look at the blood vessels, they're lined by something called our endothelium, the lining of our blood vessels and we know with age they can become narrower. A lot of people will have heard of atheroma, this sort of so-called furring of the arteries and I'm very interested in how we can reduce inflammation throughout our bodies, we can reduce inflammation in our endothelium, it will reduce atheroma deposition, reduce the furring of the arteries. And if we keep our arteries open, they're less likely to get blocked. They're less like to lead to heart attacks, strokes and so forth. And we know there's a really important role of hormones to do this. There's lots of other reasons that can reduce inflammation and lifestyle and so forth. But we know that when people have low hormones and obviously become menopausal, their risk of cardiovascular disease really increases, doesn't it?

Dr Jayne Morgan: [01:11:36] So not only does your risk of cardiovascular disease increase, again, your risk of brain dysfunction also increases. So want to make certain that we sort of keep that in mind. When a woman enters perimenopause, at the beginning of perimenopause, her risk of heart disease is really only half that of a man. By the time you hit menopause, when you've had your last menstrual cycle and it's been 12 months since your last menstrual cycle, your risk of heart disease doubles during that time. It actually equals that of a man by the time you reach menopausal. Prior to menopauase, it's only half that of the man. And what has happened is we are losing the protection of estrogen on our hearts. Estrogen, there are receptors on our heart fo estrogen, actually receptors all over our bodies. That's one of the things that really drives me to have these conversations, because since the beginning of time, since the begining of healthcare, women's health has always been reduced to just reproduction. Just breasts and vaginas, mammograms and pap smears, as if we had no other organs at all. And oftentimes, if I were to see a woman in an emergency room, a man and a woman, let's go back to that example, where two people, a men and a woman, come into the emergency room at the same time, the man will have an EKG on his record. Because he's had them before as part of his normal physical exam. The woman will not have an EKG. Why is that important? It's important because we can compare any changes that may have occurred. And we also can see the interval in which that time change has occurred. It gives us a lot of information. For a woman, we don't have that information. We don't an EKG, there should also be an EKG on that record. So back to your point, yes, as estrogen decreases, we lose that protection on our heart, those estrogen receptors, so estrogen is not binding to those receptors. But estrogen also does what? Estrogen is a natural anti-inflammatory agent for women. We've got this estrogen. So we have decreased inflammation. You may ask, I don't really know what that means. Why should I care about that? It's because inflammation now has been recognised as a driver of atherosclerosis, meaning again, those blockages in those arteries of your heart, which increases your risk of heart attack. Chronic inflammation also is a contributor for the development of cancer. But you know, that'll be another conversation. We're gonna stick today to heart disease. But when we talk about inflammation, that is what is important. That estrogen serves as a natural anti-inflammatory agent for that woman and inflammation drives heart disease.

Dr Louise Newson: [01:14:32] Thanks so much for listening to my podcasts. Did you know that if you prefer to watch rather than just listen, my podcasts are available on YouTube every week. You'll find full episodes and additional educational content on hormones, menopause and women's health, all grounded in science and real clinical experience. It's another way for me to share evidence-based information, challenge outdated thinking, and make complex topics clearer and more accessible. So if you want to stay up-to-date, Revisit episodes, or share them with others who might benefit, make sure you subscribe to my YouTube. Thanks so much for listening. It would be amazing if you could follow me or subscribe because it will really make a difference to grow numbers, enable this to reach even more people. Thanks so much. Now back to the episode. The other thing that can drive heart disease is raised blood pressure and we know that our hormones, estradiol as well, will act on our renin angiotensin system which controls our blood pressure as well in our kidneys and people somehow forget that kidneys are really important when it comes to cardiovascular disease risk too. We also have baroreceptors, so receptors that can help regulate our blood pressure, and those are regulated as well by our hormones. Blood pressure is something that, we all have blood pressure. We need it, of course, but when it becomes raised and sustained, it stays raised for a period of time, that puts more strain on our cardiovascular system and increases our risk of heart disease and strokes. So it's really important to think about that as well, because a lot of people have no symptoms, do they, but they have raised blood pressure?

Dr Jayne Morgan: [01:16:16] You know, Louise, I did an article for Healthline News, looking at an interesting study that looked at sleep as well as blood pressure. And, you know, my comments on that are right in line with what you were saying is that estrogen is the driver of vasomotor tone of our arteries, meaning it supports compliance, meaning elasticity of your arteries, how well they expand and contract. It supports that RAAS system, just as you said, the renin-angiotensin-aldosterone system, which also can either rev up and increase your blood pressure or rev down. You know, it's important as well when we talk about women in mid life that silent killer, the blood pressure increasing without you being aware of it. Asymptomatic, you're unaware that your blood pressure is increasing as your estrogen levels are becoming more erratic and gradually decreasing. So that's a risk factor for heart disease. But did you know that sleeplessness, difficulty sleeping, insomnia is also a risk for heart disease. And as your estrogen and progesterone levels once again become erratic and gradually decline, you can start to lose sleep. Not only do we know that duration of sleep is important and we know the quality of sleep is important, increasingly we are learning that regularity of your sleep schedule is important for our ancient circadian rhythm. Our internal clock that responds to hormones and responds to light and women are more sensitive to it. As we go through perimenopause and our hormones are more erratic. That circadian rhythm that we often interrupt with technology, with alarms, with lights, with phone lights, with all kinds of things, all of that increases your blood pressure because it decreases your resting hormones at night and you also then don't have the surge of cortisol and when the sun comes up, but it also impacts your blood pressure because your blood pressure also doesn't have an opportunity to drop those five millimetres of mercury at night, or it drops late and then picks up later as well. So you have a longer period of time of raised blood pressure. So sleeplessness and high blood pressure are both risk factors for heart disease, and they occur together in women during perimenopause along with other risk factors like high cholesterol, gaining weight. So these are, when people talk about, well, how does menopause impact heart disease? Why does, how can you say that menopause impacts heart disease if there are no studies? So people like to say there's not a lot of randomised clinical trials. So first of all, there are randomised clinical trials and you're correct that they're not a lot of them. And that's another podcast. That is due to women not being included in clinical trials and we're not studying women in clinical trials and with only thing that we study women for is reproduction and so all of that has to change. So my response to that is we know that estrogen impacts the risk factors that are well established by the American Heart Association, the European Society of Cardiology, the Association of the American College of Cardiology and the Association of Black Cardiologists well establish risk factors that drive heart disease, estrogen impacts those risk factors. So it impacts hypertension and blood pressure. It impacts sleep. It impacts cholesterol. It impacts weight. These are all risk factors for heart disease. So that is the response while we continue to wait with regard to whether or not we're going to have randomised clinical trials, whether or we will be enrolled, whether or research will expand to really seriously include women as a whole body and not just reproduction.

Dr Louise Newson: [01:20:39] It'd be nice, wouldn't it? But what's interesting is that we've talked about how estradiol, which is the most anti-inflammatory form of estrogen, has all these wonderful effects throughout our bodies. We've known for decades, like you say, that when women are menopausal, the longer they are menopausal as well, so the longer are without estradiola, the greater the risk of cardiovascular disease. Yet the menopause guidelines say, there isn't enough evidence to support the use of HRT to reduce risk of cardiovascular disease. And I have a real problem with this because it depends on what you're talking about. If you're taking about synthetic hormones, they can increase risk of cardiovascular disease. But if you're thinking about estradiol, replacing the same molecule as the same molecular structure of estradiol with one that we prescribe through the skin as a patch or gel. Then why wouldn't it reduce risk of cardiovascular disease? It makes like no sense.

Dr Jayne Morgan: [01:21:39] Right, and so logically we would say that. I think what the Menopause Society is being very specific and stating that there are not large phase three randomised clinical trials. And I think they are sticking to that as their scientific rigour. In the meantime, while we wait on randomised clinical trials, that could be 10 years, 15 years. And so another generation of women go by with, it's not just heart disease, it's bone loss. It's high cholesterol. It's, you know, anything you can think. Estrogen is really the driver of so many functions of the woman's body. In fact, you can of it almost like a car. And as the car starts to run out of gas, it begins to sputter. So we've got to, so that's the argument on the other side. You've got to stick with the rigour of randomised clinical trials. So, but here's the conundrum. You haven't included us in clinical trials, so you use that as a reason for not treating us. You don't treat us because we're not in trials. We're not in trials, so you don't have therapies, you don't have therapies, so you can't treat us. You can't treat us, because we are not in clinical trials. And on and on and we go. So you use the problem that has been created by the system to justify continuing to inadequately treat women. So that's the position. And I understand it as a scientist, I understand. Like this is our goal standard, randomised clinical trials and women cannot be excluded from our goal standard. But the fact of the matter is the system has created this problem. And the fact of the matter is we know that estrogen impacts all the risk factors that drive heart disease. So there's the conundrum.  [01:23:32][113.0]
Dr Louise Newson: [01:23:33] It's really interesting, and you know what? There are no randomised control studies going on now. So in my lifetime, maybe your lifetime, we'll never have answers. But when you have a patient sitting in front of you, you know, we have to do what's best for them and we have individualised care and we to use the knowledge, the scientific, academic knowledge and the clinical knowledge that we have. And actually we do have some studies showing that cardiovascular disease will reduce. People are concerned over the age of 60 because of the WHI study but that was synthetic hormones. I can't see how my body when it's 60 is going to behave differently to when I'm 59. You know, the body doesn't wake up on your 60th birthday and go, hey guys, my cells are all going to respond differently to estradiol. It just doesn't work like that.

Dr Jayne Morgan: [01:24:26] I agree with that. And, you know, it is my hope that it will be women's health that will do away with the score, the, you don't even know what I want to call it. I will say it is my hope that it'll be women's health that will drive randomised clinical trials into the background because we need something better than a system that takes 10 or 15 years. Now, it has been an arduous and a rigorous system for standards, but the fact of the matter is we now have artificial intelligence. We now have the ability to model. Can we not leverage artificial intelligence to create the clinical trials that we need and get us answers within days instead of decades? And it may be women's health that will be the group to actually drive this because our need is the greatest to say we will not depend on randomised clinical trials any longer. We will not wait 15 years for answers.

Dr Louise Newson: [01:25:34] It's just so important that we change the narrative and allow women to choose actually, because I'm not here saying that we have to prescribe hormones to reduce risk of cardiovascular disease. And I'm not saying we shouldn't. I'm just saying that we should put our patients central to the conversation. And actually, I've never met a woman who really has no symptoms anyway. So usually we prescribe hormones for the symptoms, but find that their cholesterol reduces, their blood pressure reduces, their cardiovascular risk reduces. So we're looking in entirety. We don't just look at one part of the body. So your work is so important, your advocacy work, your knowledge, your research is just brilliant. So just before we end, just three reasons really why people should be connecting hormones and cardiovascular disease. I know we've spoken about them, but it's just useful to summarise really three important things that we maybe have forgotten over the last few decades.

Dr Jayne Morgan: [01:26:33] Okay, three reasons to connect hormones to your overall wellbeing. Heart health, incredibly important. Brain health, incredibly important and something we didn't talk about today, genitourinary health. The increase of urinary tract infections as we lose our estrogen and the skin thins and our muscles begin to atrophy. The increased risk of urinary tract infections, which is the number one reason that women end up getting admitted to nursing homes. So those are three reasons to think about how estrogen revitalises your body and continues to keep you whole and feeling good. Women live longer than men by six years. People often tell me that. Why would we talk about hormones? The fact of the matter is women do live longer, but we spent 25% more of our time in poor health. So we have quantity without quality and we need to regain the quality of our lives.

Dr Louise Newson: [01:27:44] I love that. Thank you so much for your time, Jayne. It's been really wonderful talking to you. Thank you.

Dr Jayne Morgan: [01:27:49] Thank you, Louise.

Dr Louise Newson: [01:27:53] I've got something really exciting to share with you. Every Thursday, I'm going to be releasing an extra episode for those of you that sign up. It's an opportunity that I can have more guests share more information, dig deeper into the research that I could share with you. And when you subscribe, this money is going to used to help with research, much needed research that's away from pharmaceutical companies. So information is down in the show notes. So have a look and subscribe and enjoy.