Change of Heart: Understanding Cardiovascular Disease in Women with ADHD

What’s the leading cause of death among women worldwide?

No, it’s not cancer. In fact, the number of worldwide deaths from all types of cancer combined is equivalent to half the number of fatalities caused by heart disease in women.

More than 60 million women in the United States have heart disease — and for the large majority, serious cardiac problems begin in perimenopause when estrogen, which protects the heart, decreases dramatically.

While the risk for cardiovascular disease increases in all women during perimenopause, women with ADHD may face an even greater risk than their non-ADHD peers. Research has revealed that the prevalence of heart disease is higher among adults with ADHD of both genders compared to adults without ADHD: 38% vs 23%.¹

While research investigating the prevalence of heart disease among women with ADHD, specifically, remains incomplete, it is reasonable to hypothesize that rates are high because this population faces myriad heart disease risk factors including chronic stress, anxiety, depression, substance use disorders, sleep disorders, obesity, and diabetes.

To test this hypothesis, I partnered with the HeartLife Cardiology Clinic in the Netherlands. Included in the study were 300 women, the majority of whom were of perimenopausal age, as this is commonly the age at which women seek treatment for cardiac complaints.²

[Read: Let’s Talk About Perimenopause and ADHD]

We found that 35% of these patients met criteria for lifetime ADHD symptoms: a rate that is nearly 10 times that found among women in general. We also found that the women with ADHD symptoms experienced cardiac complaints two years earlier than their non-ADHD peers, suggesting that their cardiac problems may be relatively more severe.

This exploratory study indicated to us that further research is needed. To that end, my colleagues and I have launched the Women with ADHD Health Study, which has enrolled more than 3,000 female participants from across the world and is investigating the relationship between female hormones and cardiovascular issues, among other physical conditions. The ongoing research survey is accepting responses until the end of June 2025, and all women with ADHD or who identify as having ADHD symptoms are invited to participate.

Today, research shows that just 44% of women in the U.S. correctly identify heart disease as the greatest threat to their health.³ This lack of awareness is due, in part, to the fact that women often experience significantly different symptoms of cardiovascular disease than men. If patients, and their doctors, aren’t educated about how heart disease presents in women, potentially deadly health repercussions may result.

[Download: Free Guide to Hormones & ADHD in Women]

So, while we wait for research to be completed, we seek to equip at-risk women with the information necessary to protect their hearts from harm.

The Big Impact of Small Vessel Disease

When people think of heart disease, what usually comes to mind is coronary artery disease (CAD). In this disorder, plaques build up in the larger coronary arteries, causing a narrowing that may lead to an obstruction and possible heart attack. CAD is associated with risk factors such as high cholesterol, high blood pressure, obesity, diabetes, smoking, and lack of exercise.

Seldom discussed is another type of coronary heart disease that predominantly affects women, called coronary microvascular disease (CMD). Unlike CAD, which affects the heart’s large arteries and reduces blood flow due to obstruction, CMD also affects the heart’s smallest blood vessels, and reduces blood flow due to spasms.

Symptoms of CAD tend to occur after physical effort, whereas signs of CMD are more erratic in nature. Symptoms frequently occur during rest, even during sleep. They are also more commonly associated with chronic stress, depression, and anxiety.

Heart Attacks in Women Look Different

We are all familiar with the “classic” symptoms of a heart attack; sudden pain in the chest, often after physical effort, sometimes accompanied by pain in the left arm and jaw. These symptoms are real and serious, for women as well as men — but they are not the only signs of a heart attack.

For many women, signs of a heart attack include:

• tightness in the chest, the feeling of being in a harness or too-tight bra
• shortness of breath
• pain in the back
• indigestion
• nausea or vomiting

Though these symptoms are sometimes called “atypical,” the truth is that they are only atypical for men. They are quite common, and often under-recognized, in women.

Microvascular disease is much more difficult to diagnose than is CAD. Because it involves the heart’s smallest vessels, it’s not visible via routine angiography. Unlike blockages in the arteries that are fixed and persistent, the spasms associated with CMD come and go. It can be diagnosed through a provocative acetylcholine challenge test, however this is an invasive and uncomfortable procedure that is not often used.

Women with cardiac complaints frequently report going to the emergency room, where an angiogram is performed and finds no evidence of blockage in the arteries. These women are often misdiagnosed with anxiety, and told the problem is not in their heart, but in their head. They’re sent home, their cardiovascular disease unrecognized and untreated.

Female-Specific Risk Factors for Heart Disease

In addition to heart disease risk factors that impact both men and women (high cholesterol, hypertension, smoking, obesity), there are several heart disease risk factors specific and exclusive to women. These include:

• gestational diabetes
• a history of preeclampsia
• endometriosis
• polycystic ovarian syndrome
• autoimmune disorders
• oral contraceptive use
• premature menopause

Menopause most commonly occurs when a woman is in her early 50s. When it occurs before the age of 40, it’s considered premature menopause, which is a risk factor for cardiovascular disease. This is because the early drop in estrogen exposes the heart to more harm over a longer period.

Women with ADHD may experience premature menopause at relatively higher rates, according to a recent study in Nature Genetics.⁴ While the reasons for early menopause remain largely unclear, we do know that smoking can be a contributing factor. Surgeries that impact the ovaries can also result in early menopause.

Tailoring Treatment to ADHD Patients

When treating patients with cardiac problems, doctors often start with lifestyle changes. This can prove especially challenging for patients with ADHD. Unless their ADHD, sleep problems, and mood disorder are treated first, they will likely be too exhausted, forgetful, or disorganized to make changes to their lifestyle. For this reason, I advise addressing ADHD and other symptoms first to lay the groundwork for successful changes to diet, exercise, and other habits. Blood pressure and heart rate should be monitored during ADHD treatment, as stimulants may increase both.

I also urge perimenopausal women to address hormonal complaints that may be at play and to consider the protective effect of estrogen on heart function.

Heart Disease in Women: Next Steps

• Read: Falling Estrogen, Soaring ADHD: Menopause Care for Neurodivergent Women
• Read: Hormonal Changes in Women with ADHD: 4 Gaping Holes in Research
• Learn: Menopause, Hormones & ADHD – What We Know, What Research is Needed

The content for this article was derived, in part, from a plenary address at the 2025 Annual Conference of the American Professional Society for ADHD and Related Disorders (APSARD) delivered by prof. J.J. Sandra Kooij, M.D., Ph.D., titled, “Gender & Endocrine Issues in ADHD.” J.J. Sandra Kooij is a professor on Adult ADHD at Amsterdam UMC/VUMc, the Netherlands.

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