What If It’s Not Just Stress? Women’s Heart Health with Dr. Sindhu Koshy

Episode 101: What If It’s Not Just Stress? Women’s Heart
Health with Dr. Sindhu Koshy

Topics Covered

• Why Women Often Miss the Early Signs of Heart Disease
• Why Dr. Koshy Became Passionate About Women’s Heart Health
• The Overlooked Risk Factors for Heart Disease in Women
• Why Many Women Don’t Learn Their Heart Risk Until It’s Too Late
• Heart Attack Symptoms in Women Can Look Completely Different
• Why Women Delay Getting Help Even When Something Feels Wrong
• Know Your Numbers: The Most Important Step You Can Take for Your Heart
• Why Dr. Koshy Is Hopeful About the Future of Women’s Heart Health

What if some things women brush off as stress, getting older, or just being busy are really signs that something more serious is going on with their heart?

Heart disease is the leading cause of death for women, but the conversation around women’s heart health is often incomplete. A lot of women are never told that things like hormone changes, pregnancy complications, and menopause can all influence their heart health, which means they may miss the opportunity to be proactive.

In this episode, I’m talking with board-certified cardiologist and certified Menopause Practitioner Dr. Sindhu Koshy. We begin with the stories of women whose symptoms were explained away and explore why women often don’t recognize their own risk until much later. Dr. Koshy shares what every woman should know about the subtle ways heart disease can present and why trusting yourself may be more important than you realize.

Why Women Often Miss the Early Signs of Heart Disease

Dr. Cindy: Hello, everyone, and thank you for coming back to the Inspired Mom MD’s podcast. Something’s been on my mind about heart disease lately, and it does remain the leading cause of death for women, yet so many women don’t think about their heart health until there’s a problem.

And sometimes the very things that women dismiss as normal or just part of busy life or getting older is something that maybe is worth paying attention to. Today’s guest is Dr. Sindhu Koshy, a board-certified cardiologist with more than 20 years of experience and a special focus on women’s cardiovascular health.

She is a Menopause Society certified practitioner, bringing expertise in how hormonal changes during midlife can influence heart health and long-term cardiovascular risk. In addition to caring for patients, Dr. Koshy is a passionate advocate for women’s heart health and is frequently featured in national media, helping women better understand the risks, symptoms, and opportunities for prevention that are often overlooked.

Welcome, Dr. Koshy, to the podcast.

Dr. Koshy: Thank you so much.

Dr. Cindy: I am so excited to have you here. So I’m an anesthesiologist, as most listeners know, and I just have a special place in my heart for cardiologists. Sometimes I wish I had one right next to me in the operating room. When I see something that’s a little different, which doesn’t happen often, but man, you guys are amazing.

Dr. Koshy: Thank you.

Why Dr. Koshy Became Passionate About Women’s Heart Health

Dr. Cindy: I would love to start with your story. So if you’d like to jump in. Why medicine? Why become a doctor? And then how did that lead you to cardiology and women’s heart health?

Dr. Koshy: So why medicine? I actually don’t even have an answer for that. My mom says starting at four years old I said I was going to be a doctor, so clearly my pediatrician was, like, amazing — because I don’t have medical people in my family. And my mom actually gave me a book recently that I had written in kindergarten, and in it I had written about the author,

“I’m gonna be a doctor one day.”

So, I mean it was set in stone. Yeah. So, I don’t know why. I mean, there was no other reason, and I can’t say anything. Cardiology, however, I was going to be a pediatrician. That’s what I thought I was going to do. And then in my first year of med school my father ended up needing bypass surgery, which then since I was the only medical person in the family, everybody was coming to me to ask questions, and at that time I was in my first year of medical school, so I knew nothing.

But as I did more and more research trying to figure out my father’s own health, that became my interest, and I ended up loving cardiology.

Dr. Cindy: And then you went a step further and got certified in menopause and have a special affinity for women’s heart health too. So how did you get down that lane?

Dr. Koshy: So I think just women and heart health, as soon as I started my cardiology career, I became more passionate about it. Cardiology is a world where there’s a lot of men in the specialty. I mean, only 12% of cardiologists in this country are women, and of that, only 3% interventional.

So it’s a really small number of us that are actually women. So I would always hear the mid-life woman coming in with symptoms and kind of being blown off even by male mentors,

“It’s just anxiety. It’s just this.”

Or if they ended up having cardiac disease, like a heart attack or a stroke or something like that, then we were saying things like,

“It was just bad luck,”

but nobody was looking at the risk factors and the fact that she was young.

And then as I went through my career we’d always learned that cardiovascular disease occurs late in women, and we kind of expected it, like in an 80-year-old woman. That’s when you were seeing… Grandma was going to come in with her heart attack. But that’s not what I was seeing. In the last 15 years, most of the women I see that have their first heart attack are between 40 and 65.

Which eventually, as I also started getting a little older, it kind of clicked. I’m like,

“Wait, there’s only one thing that happens at this time.”

And so as I started focusing more on that, you know, cardiologists in general are taught no hormone therapy. Like, that is, like, against our laws. We don’t do that.

And so I felt like it was really a disservice as more and more women were coming, complaining of their cardiac symptoms. And really, the first cardiac symptoms, or the first symptoms of menopause and perimenopause are actually cardiac. Your resting heart rate rises and you have palpitations. That’s even before your hot flashes.

And so I was like,

“This is all cardiac.”

And so that kind of drove my interest and, you know, when I began researching menopause myself, I was like,

“Gosh, I should just become certified ’cause I now have my own expertise in this in a completely different aspect, which is the cardiology realm.”

The Overlooked Risk Factors for Heart Disease in Women

Dr. Cindy: Yeah, and I hear women say,

“Oh, my heart’s racing,”

or, oh, they feel these things, and they brush it off because it’s just their age or perimenopause or menopause. But you’re actually picked up on that with your background and said

“No, there’s something here. We need to look into this a little deeper.”

One of the things I find fascinating is that women don’t really think about their own heart health, or maybe even other parts of their health, until there is a problem. And I’d love to talk about some of the risk factors that women may not realize actually matter. And what should we as women be paying attention to long before the obvious symptoms appear?

What are some of those overlooked risk factors that you’re seeing?

Dr. Koshy: The traditional risk factors are, of course, if you’re a diabetic, which in our world we really include those pre-diabetics and borderline diabetics. I mean, it’s pretty black or white. You either have it or you don’t, and I know we look for that magic number of your hemoglobin A1c, but things are already happening in your heart once you’re pre-diabetic.

You know, high blood pressure, high cholesterol, but the things that women, that are very specific to women, are things in pregnancy. So, if you had pre-eclampsia in your pregnancy, your risk of having your first heart attack is typically 10 years after that pregnancy. There’s like a 20 to 40% chance of having a heart attack 10 years later, which means if you were 31 and had a child and had pre-eclampsia, at 41 you could be having your first heart attack. Your child is only 10 years old at that point. And so that’s definitely one.

Gestational hypertension or gestational diabetes, we know those are risks for diabetes and hypertension later. But any of those, definitely are things that I recommend if you have those, that you should be seeing a cardiologist every year at least once just to go through the risk assessment once you were diagnosed with those things in pregnancy.

You know, you still consider pregnancy as the biggest stress test. Like, there’s nothing bigger than that. So if you didn’t make it through a pregnancy without some kind of a complication, you just failed a stress test as far as we’re concerned, right? So those are kind of the ones that are women-specific.

But once we hit that age of perimenopause, which is 10 years before menopause, so we’ll say late 30s we should be looking at things like your cholesterol and your blood pressure because they do start to rise.

And a lot of times women and their providers will kind of brush things off as,

“Yeah, your number’s getting a little higher, but we’ll just kind of keep an eye on it. Let’s wait six months. Let’s wait a year.”

And a lot of women don’t want to start doing risk reduction with medications right away. Whereas I feel that if it was their husband and they’re in that office and I say,

“Your husband’s cholesterol is high, and I wanna start this medicine,”

the spouse is definitely the one to be like,

“Yep, I will not only help him start the medicine, I will put it in his pill box, and I will likely feed it to him.”

But for women, there’s such a boundary where we’re like,

“Well, maybe not just yet, and I’m not sure. I have these 10 other things planned, so I don’t know if I want to work on this.”

But we take care of everybody else first, and I feel like that in itself is its own risk factor. If we do that, that is a risk factor.

Dr. Cindy: That’s true. That’s a good point.

Dr. Koshy: And then lastly, it’s the menopause. If you went into menopause early, and so let’s say you had surgical menopause. You had to have your ovaries removed for some reason, let’s say cancer or something else, when you were young, in your 30s and 40s, that puts you at the highest risk for a cardiac event.

So that or menopause before the age of 40 naturally puts you at a higher risk for cardiac disease.

Why Many Women Don’t Learn Their Heart Risk Until It’s Too Late

Dr. Cindy: So what I’m hearing is, going back a couple minutes, if a woman, even if she’s 25 and experienced some complications during pregnancy, 10 years later, that’s 35. So we’re talking really, really young women.

Are they already being screened? How do we get the word out to women, OBGYN? Maybe they’re already doing it. That may be me being naive.

Dr. Koshy: Part of the issue I always say is women typically, we see a pediatrician, and then 18, 19, we graduate. Often between college and pregnancy, our only doctor for women is our gynecologist.

That’s it. We know we go in for our Pap smears, and then we get pregnant, and then we see them for pregnancy. And then somewhere between, like, our last pregnancy and 50 years old, women only see their gynecologist once a year for their annual, which doesn’t often include a full physical. And sometimes, you know, your gynecologist may order things like lipids, knowing that they’re your only doctor.

But often we don’t have an internist. So definitely, you know, I think more and more gynecologists are aware that these are risks, but it often is, like, a gynecologist trying to refer you to a cardiologist, it is a difficult thing because the patient is not,

“Why are we going? I was just pregnant. Why would I be seeing a cardiologist?”

And I do feel like women need to be seeing an internist or family practitioner, someone that can kind of look at their whole risk assessment. They don’t always have to see the cardiologist, but at least someone is managing their risk further than what a gynecologist has the expertise in doing, or really wants to do.

But I do feel that gynecologists are definitely checking lipids, checking blood pressure. They’re doing all of those things because they know they are usually a woman’s only doctor. I think that that is just how we are as women. They are it. Our gynecologist is the one person that we probably see our entire lives, you know, compared to any other doctor that we have.

So getting the word out, and really getting the word out to women that these are things to keep in the back of their mind that, just because I’m not a diabetic, but if I had preeclampsia, this puts me at a higher risk.

Dr. Cindy: Yes. And you’re empowering the women and the patients so they can ask their doctor and start the conversation. And that’s why you’re here today too.

Dr. Koshy: Yes, absolutely.

Dr. Cindy: That’s exactly it.

Heart Attack Symptoms in Women Can Look Completely Different

Dr. Cindy: I think that many women assume that they would recognize an issue for themselves. It’s just,

“Oh, well, I’ll know it when it happens.”

But the symptoms in women can look very different than what we traditionally hear about for men.

And on top of that, women are conditioned to dismiss or explain away symptoms, or just push through. You may acknowledge them, but you’re still pushing through.

What are some of these symptoms or signs that women commonly brush off, in your opinion, that may be different from what you would see in a man?

Dr. Koshy: Firstly, most women expect that they won’t have cardiac disease until they’re in their 70s or 80s, so there’s this lack of expectation that it could happen when I’m 47 years old, where we think about men having their first cardiac event at about 45.

Women start asking their spouses to see a cardiologist for a baseline at approximately 45 years old, but we don’t do that for ourselves. So first, it doesn’t matter how old you are. At this point, I tell the women,

“If you have a heart, you’re at risk.”

So, you know, that’s really how that goes.

But the symptoms we see on television and everything, really the studies are done with men mostly, right? The women are not in a lot of these studies.

The expectation is you have chest pain at the top of your chest and it goes down your left arm. That is typically very true of men, but women don’t usually have that symptom at all. Less than 10% of women that have that left arm pain and pain up in the chest.

Most women experience their chest pain more in their epigastric or their stomach area, and so immediately assume that that is a stomach issue and not a heart issue. Women also, the studies have shown that women correlate pain with childbirth, so 10 out of 10, the worst pain of their life. Anything else, we’ve been conditioned to push through it.

And a heart attack, or a cardiac event, an acute event, is never, for a man or a woman, it is not a 10 out of 10 pain. Why God made this confusing, I don’t understand. But it is typically, like, a five or a six or, as I joke with my kids, and I know it’s not on trend, it’s like a six, seven. Like, that’s it.

They hate it when I say that, but that’s a good way to remember it. That’s where it is.

It’s just an uncomfortable feeling, and women will, in the throes of an MI, a heart attack in the ER, when anybody asks them,

“Tell me about your chest pain,”

a woman will always say,

“I’m not having chest pain. I never said chest pain. That’s not what I said. It’s just this pressure. It is this burning. It’s this uncomfortable, it’s discomfort. It is not pain.”

So I think people are looking, because we say chest pain, they’re looking for pain. It’s not, as far as I can tell from all the patients I’ve seen, it’s not that bad.

And so that is one of the things that we’re kind of told to push through. Also, women don’t get that left arm pain. They actually get it in both their shoulders or back between their shoulder blades, right where your bra hooks up.

A lot of women say they have the symptom, they come home, and they just want to take their bra off. Like, it just feels tight, which, I mean don’t we all experience that some days? And so the symptoms for us are a little bit more subtle.

What’s really interesting is women, two to three weeks before their heart attack, will have extreme fatigue out of the ordinary. And I will tell you that every woman, and I probably would do the same, will find every reason for why I have that fatigue.

We will justify it, well, there was… you know, it’s “Maycember”. It’s a million activities. There was graduation. There’s, you know, work. There were kid activities. And so I’m tired, because I haven’t had enough sleep.

But a telltale sign is two to three weeks you have extreme fatigue and then have a heart attack.

And then shortness of breath is typically the symptom that women come in with. 50% of women have any chest symptom, but the rest of the women all have just shortness of breath, which is never normal. No matter how old you are…no matter what other issues you have, shortness of breath should never be considered a normal symptom for a woman.

Dr. Cindy: Oof. So that is a strong distinction, shortness of breath. These other symptoms just feel like such a gray area.

Dr. Koshy: It’s so subtle.

Dr. Cindy: And I too would just push through that.

I’m imagining some women do get this overwhelming sense or a, maybe not overwhelming, a slight sense that something’s off, something’s not right.

Dr. Koshy: Yes.

Why Women Delay Getting Help Even When Something Feels Wrong

Dr. Cindy: How would you suggest that women advocate for themselves in a system that kind of brushes women off when they have that feeling and you can easily talk yourself out of it?

Dr. Koshy: Yes. So, and kind of the same as I said before, many women with a male partner who will come in the… You know, like my husband would come in and say,

“You know, I think I’ve got a hangnail on my left hand. We’re going to the ER ’cause it could be your heart. We just gotta get this checked out.”

We do take care of everybody else first. For women, what you said there is really important. That sixth sense, that woman’s intuition, if you feel like something is wrong, it’s not urgent care, it’s not your primary care visit, it really is the ER.

And in the majority of ERs in this country, any symptom a woman has, belly button and up, is an MI (a heart attack) until proven otherwise, and all of those women get an EKG.

And you know, and that’s usually our first test, and it’s easy, it’s cheap, you’ll get it in triage while you’re in the waiting room in the ER just to make sure that’s not what we’re missing. And the worst that it can happen is,

“Guess what? This is just heartburn, it is not your heart attack,”

right?

So, I mean, better to be safe than sorry, and it’s never a bother. I always talk about women will come in and they’re having a heart attack, and we’re telling them, you’re having a heart attack —

“Well, I mean, it could have just been I did lift up some heavy bags yesterday.”

“No, ma’am. You are actually having it.”

“Are you sure?”

Yeah. I mean, we will justify. And you know,

“And by the way, can we, like, take care of this at 3:00, ’cause I do have to pick up my kids?”

Right? I mean, this is all going on in our minds, but I always remind women, if we are doing all of that, we are taking care of everybody. If we are not there, guess what?

They can’t take care of themselves. It is not going to happen, so we have to take care of ourselves first. And that’s a good example to teach our children, if you have children, taking care of yourself is an important thing.

We would do it for our children. We would rush them off to an ER, to a doctor for anything we thought that was worrisome. We need to treat ourselves the same way.

So, advocating for ourselves means getting ourselves to the ER.

I really think that’s what it is. It’s just, it’s us. I don’t know that we’d be brushed off as often as we think because, like I said, belly button and up, any symptom, at least you’ll get yourself in the door.

It’s just us getting there. And the number of women that will, like, rather go to the urgent care or call their primary for a visit because they’re just not sure, but I think it’s because we really feel like we’re bothering somebody. And why we are either nurtured or our nature is that way, I really think it’s a nurture thing.

Like, we as women shouldn’t be a burden, shouldn’t bother somebody, but they come in as,

“I’m sorry, but I’m having this…”

Why are we sorry about that? There is no man that says,

“I’m sorry, but I’m having chest pain.”

That doesn’t happen.

Dr. Cindy: Wow, that, this is just such a, I just have to dwell on this for a second.

This is just such a mindset shift for myself because it was my own bias and assumption that, okay, if I get to the ER, they’re going to brush me off. But really, it’s myself making excuses.

Dr. Koshy: Yeah, there’s some kind of embarrassment, almost. And I think it’s really like what if I’m wrong?

Will they think I’m not smart enough, or I’m, you know, being silly or emotional or is it anxiety? But you know, the way I see it, women are typically late presenters, meaning they wait a lot longer than men to come in because of these things. Like,

“Let me first try the Tums. Let me just lay down for a bit. Let me wait two more days and not do anything and see if that helps before they show up.”

When you come in as a late presenter, it’s already too late for us to help you, you know? But I always say, if that was a man, and, you know, your husband walked in and said,

“I’m having this symptom, I’m not sure what it is,”

we are dragging them out of the house.

Like, it is a guarantee that we’re like,

“I am driving you or we’re calling 911.”

You know?

Know Your Numbers: The Most Important Step You Can Take for Your Heart

Dr. Cindy: Yes. Yes. So, if a woman wanted to take one step to really protect her heart health this year, what would you recommend she prioritize?

Dr. Koshy: I think the priority should be what I call knowing your numbers. And so not only go in for your annual physical and then let your clinician, your provider, your cardiologist, your internist, your family practice physician say,

“Everything looks good. See you next year.”

You now need to know what those numbers are because we have to play a role in… A physician is one thing, but we are the other part of it, right? So, we have to partner with our physician to make sure that we are understanding what our risk is.

Know your cholesterol, know what your goal is based on the risks that your doctor knows about you, and then how are we together going to get to the goal that we need to.

Know your blood pressure, what is my goal, and how are we together going to get to that goal? And so knowing those numbers, knowing the blood sugar, unfortunately knowing your weight, it is one of those things we have to know. You have to know what your weight is and know what your risks are, and how are we going to work together to get to our goal weight if that’s what’s necessary.

So, knowing some of those risk factors, and knowing where we stand is really important. And I think making sure that we don’t walk out blindly,

“Everything is good,”

is not a good enough answer. But that is really up to us to be saying,

“What are my numbers, and where should I be?”

Dr. Cindy: And what are the trends, too?

If you are seeing your doctor every year, what has been a slow trend and is there something that’s still good technically, but it’s been going up?

Dr. Koshy: Yes.

Dr. Cindy: Yes. Great advice. And know your numbers, know which direction you’re headed with your numbers, and partner with your doctor.

Dr. Koshy: Yeah. That’s so important.

Dr. Cindy: Your doctor is your friend.

Dr. Koshy: Your doctor is your friend, you know? And I always say I don’t want to be the parent scolding. Like, you’re not my child as a patient. We’re colleagues. We’re working together for your health. I mean, it doesn’t gain me anything to help you. I want to help you, and so we’ve got to work together.

Dr. Cindy: I’m hoping that the person listening today is feeling empowered, and I’m hearing hope that women get help sooner so that things don’t advance to heart disease.

Dr. Koshy: Yes, yes.

Why Dr. Koshy Is Hopeful About the Future of Women’s Heart Health

Dr. Cindy: So, what gives you hope right now when it comes to women being more informed and empowered?

Dr. Koshy: As I’m doing more of menopause and cardiology, I see women that are coming in to know what their cardiac risk is. So I mean, that’s what I’m seeing. So the fact that I have tons of new patients, and they are women, that are considering hormone therapy and have menopausal symptoms, but they want to know, do they have cardiac disease?

And it’s just refreshing to know that they’re 40 and 43 and 49 years old, and they’re already asking what their risk is. It’s wonderful.

You know, we were just talking with another group earlier, and I was just saying how the American Heart Association has now added your menopause transition or menopause timing as a female-specific risk factor to be discussing in a doctor visit.

So, other than the traditional risk factors that we use in all of our risk calculators, like your cholesterol, your blood pressure, smoking, and your family history, timing of menopause is now recognized as a risk factor for women.

Knowing that people now understand that women and men, although we have the same organ, they function differently and we have different disease and we have different risk factors is really important and gives me hope in the fact that people want to hear what cardiac disease is in women.

Just the fact that people want to hear it just tells me that people are interested in seeing that it’s a little bit different.

Dr. Cindy: Oh, I’m so, I’m so excited to hear you say all of that.

Dr. Koshy: Yeah.

Dr. Cindy: Do you have any final words of wisdom for the listeners?

Dr. Koshy: I really just want to say that don’t forget that taking care of yourself is the most important thing you can do for your family and your loved ones, because really it is.

If you’re not there, you know, you won’t be there to help other people, and everybody wants to be there for you, too. So don’t forget that you are not like this sole little island. Everybody that you are helping, they want to be there for you as well. And so that should hopefully empower you to seek the help that you need and understand your risk.

And don’t forget about knowing your family history and knowing what their risk is.

Dr. Cindy: Thank you. Thank you for that. How can people reach out to you?

Dr. Koshy: So, you can look for me, of course, on Instagram @skoshyMD. That’s one way. But I’m in a practice called Cardiovascular Consultants. We’re in Michigan, and I see men and women, but have a focus on women’s healthcare.

Dr. Cindy: Perfect. I will put those in the show notes. And I thank you so much for being here today and sharing your wisdom and spreading the empowerment and the hope that we need to hear.

Links for Dr. Koshy:

• Instagram: @skoshy_md
• Website: Cardiovascular Consultants