What just happened
On October 26, 2026, 4 major medical groups published 3 joint papers in the journal Circulation.
- American Heart Association
- American Academy of Pediatrics
- American College of Obstetricians and Gynecologists
- Society for Maternal-Fetal Medicine
It’s the first time all 4 have released shared guidance.
The papers follow a woman’s heart through the stages of her life, from her first period to the decades after menopause. They advise clinicians to note a woman’s life stage at every visit.
These are expert consensus papers, meaning experts agree on what the evidence shows. They are not rules your doctor has to follow.
Why it matters: heart disease and stroke kill more than 400,000 US women a year, more than anything else.
Sources: AHA/AAP/ACOG/SMFM Presidential Advisory, Scientific Statement and Science Advisory, Circulation 2026 · AHA newsroom, 2026-10-26.
The 4 stages, plus pregnancy
The papers split a woman’s life into 4 stages. The stages follow your menstrual cycle, not your age.
Around your first period (about 8 to 15)
- What changes: periods start. ACOG calls the menstrual cycle a vital sign.
- What to check: your life stage, noted at every visit.
The cycling years (about 15 to 44)
- What changes: PCOS (polycystic ovary syndrome, a hormone condition that often causes irregular periods) is being renamed PMOS, short for polyendocrine metabolic ovarian syndrome. It’s the same condition, renamed to show it’s about metabolism, how your body uses energy, too.
- What to check: 30-year heart risk alongside 10-year risk (your chance of a heart attack or stroke in the next 10 years). A low 10-year number can hide risk that builds over a longer time. The 30-year score is for ages 30 to 59 only.
Pregnancy
- What changes: pregnancy works like a stress test. It can uncover heart risk that was already there.
- What to check: your pregnancy history belongs in every heart check. More on that in the next section.
Perimenopause (about 45 to 51)
What changes: for most women, perimenopause falls somewhere around 45 to 51. It can start years before your last period.
Early sign: your cycle length changes by 7 days or more, again and again.
LDL (“bad”) cholesterol rises faster than usual around the last period, about 3 times its normal yearly pace. In 1 big US study, average LDL went up about 7 points from before to just after the last period. Yours may differ.
Lp(a) is a cholesterol particle set mostly by your genes. It mostly stays the same, but it can shift around menopause.
Blood pressure doesn’t jump at menopause for most women. It creeps up with age.
Heart disease before 50 is uncommon in women. But the numbers behind it start moving in your late 40s. They change fastest around your last period, so roughly 45 to 51 is a good time to check them. If you’re past that, checking now still counts.
- What to check: menopause symptoms as part of heart care, starting as early as 40.
After menopause (about 51 on)
- What changes: most women have their last period around 51, and many live 30 years or more after it. When women do have a first heart attack, stroke or heart failure (when the heart can’t pump as well as it should), most happen after menopause. That’s why the numbers in the “What to track” section matter.
- What to check: blood pressure at least once a year, and cholesterol on a regular schedule.
Sources: AHA/AAP/ACOG/SMFM Presidential Advisory and Scientific Statement, Circulation 2026 · Teede et al., Lancet 2026 (PMOS consensus) · Matthews et al., JACC 2009 (SWAN) · Derby et al., Am J Epidemiol 2009 (SWAN) · 2026 ACC/AHA cholesterol guideline.
Your female heart history
Some things only women go through count in your heart picture. The papers call them risk enhancers. A risk enhancer is a reason to look more closely at your numbers. It isn’t a cause, and it isn’t a diagnosis.
The female risk enhancers
- Pregnancy complications: preeclampsia, high blood pressure in pregnancy, pregnancy diabetes and preterm birth
- Menopause before 45
- Frequent hot flashes that keep going (listed as possible)
- Poor sleep (listed as possible)
The 2026 cholesterol guideline expands the pregnancy list.
Pregnancy complications
- What it means: preeclampsia (high blood pressure in pregnancy with signs of strain on organs like the kidneys) is linked to about 2 times the risk of heart disease later. “2 times” compares groups of women. It doesn’t tell you your own chance. Pregnancy diabetes and preterm birth are also linked to higher heart risk later.
- What it doesn’t mean: some pregnancy problems are early warning signs for higher heart risk later. Higher risk doesn’t mean you’ll get heart disease.
Menopause before 45
- What it means: a last period before 45 is flagged as a heart risk enhancer.
- What it doesn’t mean: it’s a reason to check your numbers. Higher risk doesn’t mean you’ll get heart disease.
Hot flashes
- What it means: frequent hot flashes that keep going are linked to higher heart risk in studies, and the papers list them as possible risk enhancers.
In a big US study:
- About 1 in 4 women had frequent hot flashes that kept coming back.
- Over up to 22 years, those women had a higher rate of later heart attacks, strokes and heart failure. Most of them never had one.
- Occasional hot flashes weren’t linked.
In that study, the link was still there after counting blood pressure, cholesterol, weight and smoking. Not every study agrees. In some other studies, part of the link was explained by those numbers. Women with frequent hot flashes tend to run slightly higher blood pressure and cholesterol, which is why those are worth checking.
What it doesn’t mean: hot flashes aren’t known to damage your heart.
They’re not part of the heart risk score yet.
If you had bad hot flashes in the past, mention them too.
If you’re past 60, I’d put more weight on your numbers today than on hot flashes from years ago.
Important. New palpitations, sudden chest pain or pressure, or trouble breathing may warrant an immediate and emergent medical evaluation. Do not delay care based on anything contained in this document.
Sources: AHA/AAP/ACOG/SMFM Scientific Statement and Presidential Advisory, Circulation 2026 · 2026 ACC/AHA cholesterol guideline · Wu et al., Circ Cardiovasc Qual Outcomes 2017 · Kramer et al., Diabetologia 2019 · Wu et al., 2018 (preterm birth) · Thurston et al., JAHA 2021 (SWAN) · Muka et al., 2016 · Jackson et al., 2016 (SWAN) · Armeni et al., 2023 · AHA, Heart Attack Symptoms in Women (2024).
Hormone therapy and your heart
Hormone therapy means estrogen, sometimes with a progestin, which is a lab-made form of progesterone.
- It isn’t recommended to prevent heart disease. It’s still a treatment for symptoms, decided with your doctor.
- This guidance isn’t saying take hormones for your heart. It’s saying your heart risk should shape which option you choose.
- We don’t know yet whether treating hot flashes lowers heart risk.
What the timing data show
- In the big US trial of hormone pills, the Women’s Health Initiative, women who started in their 50s didn’t show a clear rise in heart attacks. But that group was small, and the result was uncertain. That’s not the same as protection.
- Researchers think timing may matter. It’s still a hypothesis, an idea still being tested, and it’s not a reason to take hormones for your heart.
- If you’re still having periods, there’s much less data.
- A big 2026 Danish study of women 50 to 69 found that estrogen pills were linked to a small rise in heart attacks and strokes. The rise showed up mainly with higher-dose pills taken for over a year.
Patch vs pill
- Pill: estrogen by mouth raises the chance of a blood clot in the legs or lungs. In that same Danish study, that came to about 1 extra clot for every 1,000 women, each year they took it. That extra clot risk goes away after you stop.
- Patch or gel: in studies that followed women, that extra clot risk didn’t show up.
- Clots in the legs or lungs are not heart attacks. No trial has put the patch against the pill to see which means fewer heart attacks or strokes.
For most women the extra risks are small, but they’re real: clots, stroke, and with estrogen plus progestin, breast cancer.
The FDA label change
A boxed warning is the strongest warning the FDA puts on a label.
- November 2025: the FDA moved to take most of the boxed warning off hormone therapy labels.
- February 2026: it approved the first new labels, with heart disease, breast cancer and dementia out of the box.
- Still in the box: the warning about cancer of the uterine lining, on estrogen-only products that work through the whole body.
That’s a label change, not a statement that hormones are risk-free. For hormone therapy that works through the whole body, the heart and breast cancer risks are still in the label.
Where your heart risk comes in
- PREVENT score of 10% or higher: the new guidance uses a heart-risk calculator called PREVENT. If your 10-year risk of heart attack or stroke comes out at 10% or higher, it prefers non-hormone options for hot flashes. That’s a preference, not a ban. It also weighs your age and how long since your last period. It’s a new cut-off, and it hasn’t been tested yet in women taking hormones.
- Non-hormone options: there are 3 FDA-approved prescriptions for hot flashes that aren’t hormones.
- Menopause before 45: the guidance advises hormone therapy until about 51, usually at higher doses than for hot flashes, unless there’s a reason not to. Whether that fits you is a question for your doctor.
- Low-dose vaginal estrogen (the cream, tablet or low-dose ring) barely reaches the bloodstream. In big studies that followed women, it hasn’t been linked to more heart disease or stroke. If you’ve had breast cancer, this is a choice to make with your cancer team.
Sources: AHA/AAP/ACOG/SMFM Scientific Statement, Circulation 2026 · USPSTF, JAMA 2022 · Manson et al., JAMA 2013 (WHI) · Berggreen et al., BMJ 2026 · Canonico et al., Circulation 2007 (ESTHER) · Vinogradova et al., BMJ 2019 · Crandall et al., Menopause 2018 · Bhupathiraju et al., Menopause 2019 · FDA, menopausal hormone therapy labeling changes, 2025-11-10 and 2026-02-12.
Heart attack symptoms in women
If you have heart attack warning signs, call 911. Chest discomfort is the most common sign: pressure, squeezing or fullness, not just pain. Other signs can come with it, or sometimes without it:
- Shortness of breath
- Nausea
- Pain or discomfort in the back, neck, jaw, or 1 or both arms
- Most women having a heart attack still feel chest discomfort.
- In a review of 27 studies, about 3 in 4 women with a heart attack had chest pain, close to men (about 4 in 5).
- Women are more likely to also have nausea or shortness of breath.
Chest pain during a heart attack
Women and men, review of 27 studies
Doctors’ own guideline now says not to call chest pain “atypical,” because people hear it as “not a heart attack.”
When it gets called anxiety
- The new guidance says women having a heart attack are more likely to have it put down to anxiety.
- In 1 study, doctors watched the same heart symptoms acted out by a 55-year-old woman and a 55-year-old man. About 1 in 3 women got a mental-health answer as the most likely diagnosis, versus about 1 in 6 men. Those were actors, not real patients, and the gap wasn’t seen at age 75.
- In a large US heart attack study of adults 18 to 55, women were nearly 2 times as likely as men to think their own symptoms were stress or anxiety. Many women think it’s stress at first. That’s common, and it’s why getting checked matters.
- The American Heart Association lists anxiety itself as one of the symptoms women can have during a heart attack.
Feeling anxious doesn’t rule out your heart. Only a medical check can tell them apart.
Sources: AHA, Warning Signs of a Heart Attack (2024) · AHA, Heart Attack Symptoms in Women (2024) · van Oosterhout et al., JAHA 2020 · Gulati et al., Circulation 2021 (AHA/ACC chest pain guideline) · AHA/AAP/ACOG/SMFM Scientific Statement, Circulation 2026 · Maserejian et al., J Womens Health 2009 · Lichtman et al., Circulation 2018 (VIRGO).
What to track
The papers list:
- Cholesterol every 4 to 6 years, more often if it’s not normal
- Blood pressure and weight at least yearly
- A check for menopause symptoms from 40
These are general adult intervals.
Cholesterol. On average, LDL climbs faster in the years around the last period. If your last cholesterol panel is from before your periods changed, I’d want a newer one.
Lp(a). The 2026 cholesterol guideline says to check Lp(a) at least once in all adults. It mostly stays the same, but it can shift around menopause.
Blood pressure. For most women, it creeps up with age, so it’s checked every year. About half of women 40 to 59 have high blood pressure by today’s cutoff (130 over 80 or higher, or on blood pressure medicine). Checking it is how you find out.
About half
Women 40 to 59 with high blood pressure (130 over 80 or higher, or on medicine)
Your heart risk score. You can ask for your 10-year heart risk score, and your 30-year score if you’re under 60.
Symptoms. Perimenopause is diagnosed from your symptoms and cycle changes. Routine hormone blood tests aren’t recommended for that, because levels swing. There are exceptions, like menopause that seems to come very early. For tracking symptoms week by week, my free perimenopause guide has an 8-week log.
Sources: AHA/AAP/ACOG/SMFM Scientific Statement, Circulation 2026 · 2026 ACC/AHA cholesterol guideline · USPSTF 2021 (blood pressure screening) · NCHS Data Brief 511 (2024) · Matthews et al., JACC 2009 (SWAN).
What these papers are and aren’t
- They are expert consensus papers. They pull together what’s known about women’s hearts at each life stage.
- They aren’t rules your doctor has to follow. They advise clinicians to note your life stage; they don’t require it.
- Hot flashes aren’t part of the heart risk score yet.
I checked the numbers in this guide against the original studies, and I kept only the ones that held up.
Sources: AHA/AAP/ACOG/SMFM Presidential Advisory, Scientific Statement and Science Advisory, Circulation 2026 · AHA newsroom editor’s notes, 2026-10-26.
My heart history
Fill this in and bring it to your next visit. Write “don’t know” where you’re not sure.
Pregnancy history
Write yes, no or not sure, and the year.
| In any pregnancy | Yes, no or not sure | Year |
|---|---|---|
| Preeclampsia | ||
| High blood pressure | ||
| Pregnancy diabetes | ||
| Preterm birth | ||
| Other problems |
My last period
Write your answer.
| Question | Answer |
|---|---|
| Age at my last period | |
| Still having periods |
Hot flashes
Write your answer.
| Question | Answer |
|---|---|
| Days in the past 2 weeks | |
| Years I’ve had them | |
| Worst stretch (ages) | |
| Still having them |
My numbers
Write the date and each number you have.
| Date | LDL | Lp(a) | Blood pressure |
|---|---|---|---|
Questions to bring to my next visit.
- Does my pregnancy history or my age at my last period change how you read my numbers?
- Have I had my Lp(a) checked?
- What’s my 10-year heart risk, and my 30-year risk if I’m under 60?
- Do my hot flashes matter for my heart picture?
- If I’m weighing hormone therapy, how does my heart risk shape which option fits me?