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The Fullness of Midlife

“Women need to feel entitled to care for themselves.”

by Dr. Barb DePree MD

Stacey Rosen MD with Dr. Barb

Dr. Stacey RosenDr. Stacey Rosen, a native Long Islander, is a graduate of the medical program at Boston University School of Medicine. Dr. Rosen completed training in Internal Medicine at Montefiore Medical Center in the Bronx, including an additional year as Chief Resident. She completed a fellowship in Cardiovascular Disease at The New York Hospital-Cornell University Medical College, which included advanced training in echocardiography. She is a fellow of the American College of Cardiology, the American College of Physicians, and the American Society of Echocardiography. Dr. Rosen served two terms as an American College of Cardiology councilor, serving Nassau and Suffolk counties. She has received numerous teaching awards including the Ann Gottlieb Award for Excellence in teaching from North Shore-LIJ, awards for volunteer service from the American Heart Association and was twice voted one of Long Island's Top 50 Most Influential Women. She received the Cardiovascular Science Award from the American Heart Association at the 48th annual American Heart Ball for the Long Island region. She is currently vice president, Women's Health, Katz Institute for Women's Health at North Shore-LIJ Health System and a practicing cardiologist and echocardiographer. She is the co-author, with Jennifer Mieres MD, of Heart Smart for Women: Six S.T.E.P.S. in Six Weeks to Heart-Healthy Living.


Dr. Barb: Today I’m happy to talk to Dr. Stacey Rosen, a cardiologist, health educator, and author, on the topic of women’s heart health. Stacey is a co-author of Heart Smart for Women: Six Steps in Six Weeks to Heart Healthy Living, which I suspect many of you will want to own by the end of our conversation. And we will have a link on our website. Welcome, Stacey. Thanks for taking the time to talk today.

Stacey: Thank you. It’s wonderful to be here.

Dr. Barb: So let’s start with the first reality, and that is that heart disease is the number one cause of death for women. Is that correct?

Stacey: Yes, that’s absolutely correct, and unfortunately there’s still too few of us who know that important fact.

Dr. Barb: And why do you think that is? Because I feel like it’s really been a pretty consistent message for quite some time. I assume that statistic has been true for quite some time.

Too few people think of heart disease as a women's disease.Stacey: That statistic has been true for as long as we’ve been accumulating data. But, equally important, from 1985 until just present, more women actually die of heart disease every year than men. We are, unfortunately, just about evening that out. But it’s really, for something that too few people think of as a woman’s disease, and it really is the number one killer. More women die than all forms of cancer combined actually. I think despite the fact that the message has been out there, we do know from some pretty interesting research, that only about 55 percent of women asked in some wonderful public health surveys, actually know that heart disease is the number one cause of death. And when we look at African American women, and Latinas, the knowledge is even less well known, the information less well known.

Dr. Barb: Interesting. So we have a lot of work to do yet.

Stacey: Absolutely!

Dr. Barb: So my area of medical focus is gynecology and menopausal women’s health and women’s healthcare from that aspect. I’ve heard you quoted as, “Women considering hearts as lady parts,” so I’d like to hear you speak into that a little bit more. I think that’s intriguing, and I like that phrase!

"The heart is a lady part" opens your eyes and ears to what we're talking about.

Stacey: So I must tell you, there was a wonderful panel that was sponsored by Woman's Day Magazine last fall, called “The Heart is a Lady Part.” And it was actually the beginning of a wonderful journey that I’m a part of that allows the cardiologists to partner with our OBGYN colleagues through initiatives that have been ongoing through the American Heart Association and the American College of Obstetrics and Gynecology.

You know, we know that the majority of women consider their gynocologist to be their primary care physician, and we also know that heart disease is preventable and starts in our twenties. So the opportunities to see the heart as an organ that also requires some fine tuning during your annual well-woman visit, became a real commitment of OBGYN throughout the country, and cardiologists. So to us, and using the cute term, “The Heart is a Lady Part” sort of opens up your ears and eyes to what we are talking about.

Dr. Barb: It is. I think that’s a great way to further a conversation with women. And I’m intrigued by your comment about the onset of heart disease starting for women as early as their twenties because, in my more traditional consideration of women and heart disease, we also see menopause as an at-risk time for more chronic conditions, including heart disease. But can you take a little bit of time and speak into this idea of women as early as in their twenties, and what those risk factors look like for those young women and what kind of conversation we might be having with women as young as twenty or thirty?

It's never too late to start doing things to lower your heart disease risk.

Stacey: No, no, absolutely. What’s so interesting, as two of us in the women’s health arena at large, the overlap between our specialties when it comes to women is critical. Because we know, as far as heart health goes, that there are female lifespan times where issues of cardiovascular health and prevention opportunities are most important. So, heart disease or the process whereby plaque lines our arteries, whether the arteries are in our heart or our kidneys or leg or the brain, we know begins in the twenties. And the latency period—the time from minor disease to those unlucky enough to show clinical presentation later on—still begins in our teens and twenties. So it is really never too young to ask at a well-woman visit, “Now what are my risk factors for heart disease?” “What things can I do over a lifetime to lower my risk?” “What testing, what evaluation?” “What should I be doing in my twenties, thirties, forties, and beyond?” For the record, it’s never too late to start doing these things, either, for some of our women who are far into menopause.

Dr. Barb: Sure. So am I right in seeing that menopause—the menopause transition, the absence of estrogen—does pose an additional risk for women in cardiovascular disease?

Stacey: Absolutely. It’s interesting because we’ve learned a lot about pregnancy-related issues that historically we thought of as being done with the delivery of a child—minor gestational diabetes or hypertension disorders during pregnancy. We now know that that marks a woman at being at higher risk for her lifetime, even if everything resolves. Then we get to menopause, and the loss of estrogen has an anatomic and physiologic impact on women’s cardiovascular health. Changes in blood pressure. Changes in lipid profiles, cholesterol profiles. Where we put our weight gain, you know, that sort of central apple-shaped woman that we all become in the menopausal time. Inability to sleep well, that’s so common in perimenopausal and menopausal women, also can have an impact on cardiovascular health. It actually goes on and on. So, that’s  sort of a second benchmark for us to sort of refocus our preventive strategies for women as they go through menopause.

Dr. Barb: Are there any menopausal-related symptoms that might actually be an indication of heart disease that women might confuse some of the symptoms they are experiencing that might represent actual symptoms of heart disease that are seen as “just blame it to hormones,” so to speak?

Stacey: That’s a wonderful question, because so much of our challenges earlier in health care were that we didn’t think women got heart disease, and we soon learned that when they presented with heart disease, they may not be having what we call, “the Hollywood Heart Attack”—the pressing in the chest, accompanied by nausea, radiating to the left arm. So women are more likely to present with heart disease with sort of what they call, “atypical symptoms”—increased fatigue, some indigestion, maybe just some muscle aches in the back or the chest. Sometimes a little bit of a palpitation or flutter. So if you’re not—as a patient—if you’re not attuned to the unusual or atypical way women may present with heart disease, and you’re going through your menopausal changes, you’re very likely to just attribute these symptoms to nothing serious and just menopause.

And unfortunately we have some education to do in the healthcare world as well. Because, too often physicians attribute some of these symptoms that women complain as “just their menopause, just their changes.” And that’s a real missed opportunity.

Dr. Barb: Interesting, because I think many women are seeking healthcare generally at that time of their life, so hopefully there is an opportunity for a healthcare provider to recognize that as a risk to maybe further pursue.

You talked earlier a little bit about some ethnic differences in recognition of the incidents of heart disease in women. But what about the actual process or condition of heart disease in different ethnicities. What should our listeners know about that?

One size doesn't fit all.Stacey: Yeah and that’s a wonderful question, and it’s part of the “one size doesn’t fit all.” You know, we all know that it doesn’t do that for our clothing, so certainly for our health care. And we’ve learned over the last 20 years for instance, that African American women hypertension is a more potent risk factor for them than for whites or Latinas. Whether or not that is anatomic and physiologic seems to be the case. There are some high blood pressure medicines that are less effective in blacks than in whites. So much of our work lately is sort of identifying more of a customized approach.

The Latina community have much more potency if they are diabetic. So, a Hispanic woman with diabetes is at far greater risk for heart disease than is a white or African American woman with the same level of diabetes. Certain Indian cultures from Southeast Asia have unusual forms of lipid abnormalities. So when you come to your well-woman visit, you know, learning more about what things are unique to you—your gender, your ethnicity, your race—to really optimize your best way to stay away from heart disease and stroke is really important. And some of the ongoing research is giving us even more information about the differences among different races and ethnicities.

Dr. Barb: Interesting, yeah, that’s fascinating. And again, it feels like really important information that should be more widely known and recognized.

Stacey: That’s for sure. Absolutely.

Dr. Barb: Speaking about research, I think historically we think about most of the cardiovascular research has been done in men and what’s been learned has been generally applied to women. And I think there’s been some progress in that area. Can you speak into that, whether or not that’s actually true. Are we actually seeing more research designed for women to better understand this disease and that population?

Stacey: Yes, that’s actually a very important point. I often joke when I’m doing community health education, that if I told a group of men to take a medication that had only been tested on tens of thousands of women, I would be laughed out of the office. But, in heart disease, we have done that historically for women. Initially women were specifically excluded, you know the quote “pesky hormones would get in the way of science.” Then women were brought into research studies in such small numbers as to be completely not helpful. And that harms both women and men actually.

Gender-based research and gender-based reporting are... critical for women's health.The National Institutes of Health, the Federal Drug Administration, they now require, in order to get funding or to have new drugs evaluated, a percentage of women included that reflects the percentage of women who get the disease. And that the data, the answers should be evaluated specifically for men and for women. One of the classic findings we realized when we did that is, probably all men or almost all men over the age of 40 should take a baby aspirin to prevent heart disease and stroke. But when we looked at that in a uniquely female population, the answer wasn’t as clear. So the importance of gender-based research and gender-focused reporting is absolutely critical for women’s health. And we’re all in this community fighting to be sure that we do the research the right way. Women are often reluctant to be included in clinical trials. Unfortunately one of the main reasons is that they are too busy taking care of everyone else in their family. So part of this is societal barriers that we need to address.

Dr. Barb: Sure. Interesting. So what area of women’s heart health research do you think really needs to expand—specifically around that further understanding for women?

Stacey: Well your first question was about, you know, we’ve sort of known about death rates for women from heart disease for so long, why are we still moving the needle on this? And I think things like partnerships with obstetricians, gynecologists, and primary care internists or cardiologists is really important. And the idea of advancing what we call, “implementation science,” you know, how do we expand our knowledge as clinicians and professionals and get it out to our community members, our patients, our women, their families, so that we really can further impact on preventing this disease? Because, we know it, and as you’ve said, we’re not doing an optimal job in getting the word out. And I think the partnership between American College of OBGYN and the American Heart Association is a really wonderful opportunity for us to move the needle for this prevention practices.

Dr. Barb: I think that’s exciting, I’m eager to hear more about that and where that might go in the future. But that probably brings us back to your book too, the Heart Smart for Women. As we talk about what individuals can know and understand, and understand that heart disease as you say is 80 percent preventable, what do women need to know about really moving the needle on how to impact their cardiovascular health?

Stacey: So, Jennifer Mieres and I have been practicing cardiologists and colleagues for decades. And we realized that it shouldn’t be so hard to get on the road to knowing your risk factors and making the small consistent changes that can really have a huge impact over a lifetime. So we wrote the book for our audience. We wanted this book to be something that you put sticky pads on, you highlight, you share tips with friends. And there’s no better patient than an engaged partner. So we really wanted to start by just teaching women and men about heart disease in a health-literate way, in a way that empowers them to go to every visit as a better partner with their doctor or nurse practitioner. And so the first part of the book is about that, you know, making everyone a mini-cardiologist in essence.

You don't have to be a marathon runner; you need to figure out a way to move more.And then we turn to a very practical six-week plan. Women have a tendency also to be somewhat perfectionists, so if we don’t do it perfectly, we don’t want to do it at all. But, you don’t have to be a marathon runner, you need to figure out a way to move more. You don’t have to never have a Girl Scout cookie, you know, maybe just don’t eat the whole sleeve of Girl Scout cookies. So we think that the book is a very practical road map to a lifetime of good health, good cardiovascular health.

Dr. Barb: So can you share with listeners where they might have access to this book?

Stacey: Sure, it’s available on Amazon. And we actually also have a heart-smart movement website, that we love to hear from people who are either involved in their cardiovascular health journey or who have read the book. But, right now it’s available to all on Amazon.

Dr. Barb: You mentioned an obstacle for women might be perfectionism. What other things do you think prevent women from really taking ownership? Do you think it’s a lack of understanding, or is it an inability to follow through on what they know they should do? What’s your perception of it in the trenches, seeing women regularly?

Women need to feel entitled to care for themselves.Stacey: A classic example, I predominately see women now, but I have these elderly couples that I’ve been caring for for so long, that I continue to do so. So, my saddest recent example is, an elderly couple that I’ve been seeing for a long time, he had a decompensation in his health, and each time they would make appointments for check ups, she was basically ignoring her worsening heart health, to take care of him. And by the time we realized how sick she had become, it was undeniable she had spent far too long being the caregiver, rather than focusing at all on her health. And I think women juggle so many balls in the air and it’s always, “I'm too busy for this.” “It’s okay, I can’t not take care of my father.” or “I can’t not get to the business meeting on time.”

So I think women really need to feel, I don’t know, entitled to care for themselves. You know, we joke that when we get on an airline, you put your mask on first, because if you’re not well, you can’t be the super woman for your family and colleagues and friends. So to me, that is the biggest barrier that we need to get past.

That’s why I think that engaging women, educating them, making them take care of themselves the same way that they take care of their family and loved ones and colleagues needs to be something that they’re not feeling guilty about, but should truly be a priority. And then I think partnering; every time in our health system when women go in for their mammograms is information about heart disease. You know, aligning along all the different opportunities that touch women, to educate, to empower, to advocate for them to do things for themselves. If we don’t do it, it’s a missed opportunity.

Dr. Barb: And it’s interesting that as you mention breast health, most women could tell you what the recommended screenings are for breast care and for breast health, and at what age you start mammograms and what the intervals should be. But, I think probably very few women could name many, really proactive steps in looking at cardiovascular health. And when you think about the prevalence and incidence and mortality rates to those two diseases, but yet, for the attention women put into it, as far as their worries or their concerns, it just is so disparate.

Stacey: Absolutely! I would say, once a month I will quote a middle-aged female patient of mine, who I asked, did she follow up on the stress test, or did she see the nutritionist. “No.” And I”ll joke if it’s someone I have a good relationship with, “When was your last mammogram?” “Oh, March 28.” And they know that immediately and they would never—and so as I said, it’s not an either or. So, to us these partnerships of clinicians working together and educating and using sound bites almost, that everything you do can move the needle on a little bit. And for heart disease, it is all incremental. It is the small things that you do to lower your risk over a lifetime.  You don’t need to be a marathon runner to move more.

Dr. Barb: And your practice focuses nearly entirely on women in cardiology, is that correct?

Stacey: Yes, I’ve been practicing for 25 years, but about 5 years ago, my clinical practice moved completely to women.

Dr. Barb: And how is it you decided to do that?

Stacey: Well, I guess my role overseeing the—we have the Katz Women’s Health Institute here at Northwell—I took over as the lead of that initiative, and have always spent my career focusing on women and heart disease. So I thought, in order to really show my commitment, I no longer see new male patients. Our women’s heart program partners with breast cancer, with high risk maternity, with our infertility colleagues, even with our rheumatologists, because women with rheumatologic diseases are at higher risk for heart disease. Women with migraines are at higher risk for heart disease and stroke.

So, we partner with our headache group to be sure that those women are aware of what they can do to lower their risk of heart disease. And listen, if you’re a younger middle-aged woman having regular migraines, the last thing you’re thinking of is doing more stuff. But if we can somehow partner that visit to your headache specialist with a little more education, a little more screening, then again, it’s those small opportunities to really change the end result. That commitment is what had me modify my practice.

Dr. Barb: Have there been any obstacles in your way to achieving a practice that is focused on women like this? Because it’s somewhat atypical for cardiology to be a focused practice, and I think it’s exciting that maybe yours would be a model for others. But I’m wondering, was it hard to achieve this?

Stacey: You know, I’ll tell you I’m very lucky here at Northwell Health. The physician partners that I work with—the neurologist, the breast doctors, the cancer folks, the OBGYN—they totally get the collaborative way we should be caring for women. So that, and I imagine in certain centers the territorial way doctors can be, could potentially be a roadblock, but for us here it wasn’t. I think the biggest challenge is getting the word out to women. You know, they still, everyone’s busy, everyone is fearful of breast cancer, everyone is taking care of their families. So that’s where we do a tremendous amount of community health education. We blog. I’m grateful to you for including me today. That’s where our challenge and our opportunities still exist, at least in my practice.

Dr. Barb: Good, well thank you for doing what you’re doing. I appreciate your focus, specifically to women in this condition, because I think we just need to have a louder, bigger voice—

Stacey: Absolutely, absolutely.

Dr. Barb: —to spread this. In conclusion with our time together, can you share with others, Stacey, where you find richness at this stage of your life?

Stacey: Oh sure. So I am the mother of three adult children and always worked full-time, always sort of enjoyed the balls in the air, and I am finding richness now in continuing my mission with women’s health. I get tremendous joy out of seeing women in our communities learn more, coming to educational conferences. I am enjoying watching my adult children become adults who I actually like, and who I am immensely proud of in their different life choices. And continuing to take better care of myself. You know, I have to walk the talk, as they say, and finding more opportunities to be active, to eat better. For me I’m sleeping better than ever before, not because I have less to do, but just because it was clearly never a priority for me as a younger woman and now it is. So for me those are my personal keys to richness and happiness.

Dr. Barb: Well, I’m smiling as you share each of those because I think I’m probably resonating with much of what you say. Just this week a friend who knows I struggle sometimes with the balance between busy-ness and finding appropriate down time, said to me a quote from someone she had read about, “Seeking exuberant rest in my life.”

Stacey: I love it, I love it! That will be on our quote board here in the women’s health office. That’s exactly the way life can be! Yeah!

Dr. Barb: Thanks again for taking this time today, Stacey. It was a delight to talk with you.

Stacey: Thank you so much, it was wonderful. I appreciate the time, Barbara.


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