What is Angina?
Angina refers to the chest pain we experience when our heart muscles become damaged or weakened due to a lack of oxygenated blood, which is due to a blockage in our coronary arteries. It is one of the leading causes of mortality worldwide, affecting approximately 17 million people worldwide and 2 million people in the UK. According to the American Heart Association, angina is one of the main symptoms of coronary heart disease.1 Angina can lead to heart disease or even heart failure over time by myocardial ischemia.
What are the symptoms of Angina?
Symptoms of this disease include discomfort in the chest, dizziness and even fatigue. However, symptoms differ based on whether patients have stable or unstable angina.2 Stable angina is normally triggered by physical activity and tends to go away as soon as the person rests and can be managed with the use of medication. On the other hand, unstable angina may last for longer periods and may result in a heart attack..2
What are the risk factors?
There are many risk factors that contribute to the rise of angina. Some of these include lifestyle factors like smoking and lack of exercise, as well as pre-existing conditions including diabetes, high blood pressure and obesity.3 The American Heart Association recommends that angina patients should treat unstable angina as an emergency as new, worsening or persistent chest pain may be the result of a heart attack.4 Some of these symptoms are prolonged pain in the chest, shoulder and arms, shortness of breath and nausea.5
Angina in women
Angina is slightly different in women than in men. Women also experience chest pain but tend to have increased nausea, shortness of breath and abdominal pain, with the latter being highly prevalent. Despite this, women tend to be diagnosed and treated for angina far less than men. To understand angina in women, we must consider menstruation and hormone balances.
What is menstruation?
The menstrual cycle is the changes a woman’s body experiences in order to prepare for fertilisation. It is split into four phases: menstrual phase; follicular phase; ovulation phase; luteal phase.6 It consists of the maturation and release of eggs and bleeding if fertilisation hasn’t taken place. During menstruation, women experience vaginal bleeding resulting from the breakdown of the lining of the uterus. Menstruation is an extremely important part of women’s health.
What are the symptoms of menstruation?
During menstruation, women experience vaginal bleeding resulting from the breakdown of the lining of the uterus. Symptoms during menstruation can include cramping in the pelvis, headaches, tender breasts, irritability, and food cravings.7 These symptoms are generalised and can vary from person to person.
What does the cycle consist of?
The menstruation phase occurs between 3 and 7 days. During the follicular phase, maturing of the eggs occurs, which is predominantly caused by follicle-stimulating hormone (FSH). FSH is made in the pituitary gland in the brain and travels through the bloodstream to reach the ovaries. Its role is not only to mature eggs in the ovaries but also to stimulate the production of the hormone oestrogen. During ovulation, oestrogen helps release an egg from the ovaries and into the fallopian tube to make it ready for fertilisation. The follicular phase generally occurs between 10 and 22 days. The increase in FSH release means that oestrogen is increasing rapidly.
The final stage is the luteal stage. This is where luteinizing hormone (LH) is released to reduce the stimulation of FSH and oestrogen. Here, the lining of the uterus is thick and ready for fertilisation. However, if the egg is unfertilised, the endometrial tissue lining breaks down, and vaginal bleeding begins.
What are the main hormones in menstruation?
The three hormones of the menstrual cycle are FSH, oestrogen and LH. Progesterone is also an important hormone, but it is more of a concern following fertilisation. Oestrogen is arguably the most important hormone when relating to diseases. For example, it plays a large role in breast cancer, osteoporosis, neurodegenerative disorders and even angina. Oestrogen tends to have a cardioprotective effect in women: it can protect the heart and heart muscles from most types of injury such as cardiovascular disease and heart attacks.
Pre-menopausal women tend to produce between 30 and 400 pg/ml of oestrogen compared to the 0-30pg/ml of oestrogen produced by post-menopausal women and 10-40 pg/ml of oestrogen produced by men in their lifetimes. This means men have an overall increased risk of heart diseases than women. Also, as oestrogen is cardioprotective, many pre-menopausal women have reduced heart conditions or symptoms overall.8 This ultimately reduces the overall mortality of women by heart conditions, including angina, where many women do not have chest pain as their predominant source of pain.
How are menstruation and angina linked?
The association between angina and menstruation is a reasonably new subject to research in science. Therefore, there are only three main notable studies published about the links between angina in women and menstruation.9
According to a research paper with case studies published in 2009, a woman with south Asian heritage complained of chest pains that collided with her menstruation cycle.9 These symptoms became worse with increased pain, radiating from her chest, through her jaws and arms and lasting for longer periods of time (unstable angina). The patient also experienced supraventricular tachycardia and heart palpitations. According to her healthcare provider, the patient’s previous medical records indicated that she suffered from anaemia and had previous attempts of in vitro fertilisation but did not take any medication on a regular basis or have a family and genetic history of heart disease. Her levels of oestrogen and progesterone were relatively the same; however, doctors did find an increase in troponin T. Increased levels of troponin T indicate a high level of muscle damage which may cause a heart attack. The cause of the patient’s heart damage was unclear. It can be concluded that the pains appeared during menstruation due to the lack of oestrogen available and its inability to have a protective effect on the heart.9
Women living with Angina
A website set up to help women living with heart disease says that the rate of heart attacks in women increases for post-menopausal women due to the lack of oestrogen produced by their body, as it is no longer needed for menstruation. 11
Is there a treatment?
There is also a common misconception that hormone replacement therapies could work to reduce the chances of heart attacks in women. However, hormone replacement therapies are only an appropriate method to reduce the symptoms of menopause. In hormone replacement therapies, there are concerns of increased risks for breast cancer as well, so it is better to always consult with a GP before making a decision.
The relationship between angina and menstruation appears to be proportional. A lack of oestrogen can cause major symptoms; however, the occurrences are quite rare in premenopausal women which is why there is a deficiency in the research. Moreover, angina itself is more prevalent in post-menopausal women; however, due to the low occurrence of angina in women, it is not researched enough to make a definite conclusion.
Angina can be caused by many different factors which can lead to symptoms of the stable or unstable version of coronary artery disease. Although it is less prevalent in women, there have been previous correlations of women experiencing angina during menstruation. Further research must be done in order to make sure that women with angina are treated safely and effectively.
- Angina(Chest pain) [Internet]. www.heart.org. [cited 2022 Jun 2]. Available from: https://www.heart.org/en/health-topics/heart-attack/angina-chest-pain
- Kloner RA, Chaitman B. Angina and its management. J Cardiovasc Pharmacol Ther [Internet]. 2017 May [cited 2022 Jun 2];22(3):199–209. Available from: http://journals.sagepub.com/doi/10.1177/1074248416679733
- Angina [Internet]. nhs.uk. 2017 [cited 2022 Jun 2]. Available from: https://www.nhs.uk/conditions/angina/
- Unstable angina [Internet]. www.heart.org. [cited 2022 Jun 2]. Available from: https://www.heart.org/en/health-topics/heart-attack/angina-chest-pain/unstable-angina
- Symptoms of a heart attack [Internet]. nhs.uk. 2017 [cited 2022 Jun 2]. Available from: https://www.nhs.uk/conditions/heart-attack/symptoms/
- Stages of menstrual cycle: menstruation, ovulation, hormones, mor [Internet]. Healthline. 2018 [cited 2022 Jun 3]. Available from: https://www.healthline.com/health/womens-health/stages-of-menstrual-cycle
- PMS (Premenstrual syndrome) [Internet]. nhs.uk. 2018 [cited 2022 Jun 3]. Available from: https://www.nhs.uk/conditions/pre-menstrual-syndrome/
- Simpson ER. Sources of estrogen and their importance. J Steroid Biochem Mol Biol. 2003 Sep;86(3–5):225–30.
- Choo WK. Menstruation angina: a case report. J Med Case Reports [Internet]. 2009 Dec [cited 2022 Jun 3];3(1):6618. Available from: https://jmedicalcasereports.biomedcentral.com/articles/10.1186/1752-1947-3-6618
- Supraventricular tachycardia (Svt) [Internet]. nhs.uk. 2017 [cited 2022 Jun 3]. Available from: https://www.nhs.uk/conditions/supraventricular-tachycardia-svt/
- Thomas ~ Carolyn. Heart sisters [Internet]. Heart Sisters. [cited 2022 Jun 3]. Available from: https://myheartsisters.org/
- Hormone replacement therapy (Hrt) [Internet]. nhs.uk. 2017 [cited 2022 Jun 3]. Available from: https://www.nhs.uk/conditions/hormone-replacement-therapy-hrt/