Sexism in Medicine: Not All Hearts Beat the Same

V Three years ago, Laura Juntersdorf first felt that something in her chest was tearing apart. It was, as she describes, as if someone had taken her heart, held it at both ends and pulled hard.

When she recalls it today, her face tightens, her eyes narrow into slits. With both hands, Laura Juntersdorf tries to show where the pain was, without touching herself. She says the area around her heart has become sensitive, because there is the certainty that the pain will come back. It is a cold Tuesday afternoon in December, wearing tight jeans, a dark sweater and with straight black hair, Juntersdorf sits in a meeting room in the Women’s Heart Center of the Rhein-Maas Clinic in Würselen near Aachen. Here she received her diagnosis and a prescription for three different medications.

Laura Juntersdorf has a heart condition that, in the worst case, if left untreated for years or decades and with other risk factors added, can end in a heart attack. She only learned this a few months ago—and she is still ahead of many other women in that sense.

Because cardiovascular diseases and heart attacks often remain undetected in women until it is too late. Their symptoms differ from textbook descriptions; complaints are repeatedly attributed to psychological causes. When looking at 30-day mortality, i.e., the rate of deaths shortly after a heart attack, women die twice as often as men. But there are also professionals who are working to close this diagnostic gap.

When, three years ago, the burning pain first spread through her chest, Laura Juntersdorf was on the couch in her living room, as she tells it. Her heart was beating so fast that she could hear her pulse all over her body. She became very scared and called her partner; together they drove to the emergency department. There, Juntersdorf’s heart was deemed healthy, and the doctor responsible attributed her symptoms to muscular tension. He told her to warm the area and rest, then it would go away again.

Juntersdorf trusted the doctor, but quickly realized that the diagnosis must be wrong. For, she says, the complaints returned, first once a month, and for about a year they have come daily. Some days the pain taps lightly and goes away after a few minutes. On other days it spreads, reaches into the right arm or slowly climbs up the collarbone. In addition, Juntersdorf often has trouble catching her breath – even when she is sitting at her desk or lying tired in bed.

The episodes of chest pain that occur in waves and can radiate to other parts of the body have a name: angina pectoris. They are caused by a disturbance of the heart’s blood supply, which can have different origins. The most common heart disease is coronary artery disease, which the German Heart Foundation estimates affects around five million people in Germany alone. Each year in Germany, about 120,000 patients die from it. The coronary vessels become narrowed by deposits of blood lipids, calcification, and connective tissue. They often arise from an unhealthy lifestyle, though some are genetic. When the blood supply to the heart muscle at a single point is completely interrupted, a heart attack occurs.

Looking at health portals and medical guides, one often only hears about deposits as the cause of angina pectoris. The at-risk groups are typically older, smoking, overweight people and, above all, men.

Michael Becker, chief physician of the Clinic for Cardiology, Nephrology and Internal Intensive Care Medicine at the Rhein-Maas Clinic in Würselen, sits at his desk in a white coat, photos of his children on it. In 2018, he founded the Women’s Heart Center in Würselen, the first of its kind in Germany. Whenever Becker thinks it might get a bit too medical, he takes up his pen. He draws the coronary arteries that supply the heart muscle with oxygen and nutrients, then makes jagged lines in several places. “That’s roughly what it often looks like for men with angina pectoris during a heart catheter examination,” he says.

Men’s hearts calcify, women’s hearts constrict

What he means: The blood vessels, which should be smooth tubes, often appear in X-ray images like pearls with varying widths and narrow sections—because calcification narrows the vessels and makes them less elastic. If that is the case, medications can be prescribed to slow the progression of the califications.

When the heart is not being supplied with blood as it should be, however, there can be other triggers that are not visible in regular heart catheter examinations. Especially in women, the coronary arteries are often free of cholesterol and calcifications, explains Michael Becker. More common are sudden spasms of the large coronary vessels, a condition also known as vasospastic angina pectoris. It also leads to the heart muscle receiving too little oxygen at times. The symptoms often occur during rest, in the evening in bed or while driving a car.

Even heart attacks are described by many women more complexly than in the movies or textbooks, says Lena Seegers. The 35-year-old cardiologist heads the Women’s Heart Center at Goethe University in Frankfurt. “We now know that women have more accompanying symptoms and that chest pain is not necessarily the symptom women report first,” she says. Many notice a general feeling of unease, fatigue, nausea and pain in the abdomen and back – often early, before abnormalities appear in the ECG or in the labs.

Because of the abundance of symptoms and the often gradual onset, affected patients and doctors tend to react later than men, who typically have only chest pain, Seegers adds. The consequences of this under-supply are well documented, even if exact numbers are hard to determine. Studies show, however, that women after a cardiac arrest are more likely to receive an ECG only later or a venous access later, are less likely to be brought to a hospital, and are less often, and for shorter periods, resuscitated with less intensity.

At Laura Juntersdorf’s appointment in mid-December, four months after the diagnosis, her medications are to be stopped. In the meeting room, she sits opposite Michael Becker. Next to her is her father, and she says she now only goes to medical appointments with someone accompanying her, because she has “simply had too many negative experiences with doctors.” She looks subdued when she says this, and when she elaborates what that means, she sometimes laughs out of disbelief.

Juntersdorf comes from nursing, she knows many diseases by their Latin names and knows what a healthy heart looks like. Time and again she told doctors of her suspicions, and about a year ago she even mentioned angina pectoris herself. It was said that for women her age this was far too rare a diagnosis. Maybe her bra was too tight and pressing on the pain, another time. Or: she should try losing weight, her symptoms could come from the stomach. One sentence she particularly remembers: “If you hear galloping in the courtyard, it’s usually a horse, not a zebra.”

Many times doctors had sent her home over the years, at most prescribing physical therapy or psychotherapy. Stress tests, emergency examinations and heart ultrasounds with cardiologists never yielded results. The Women’s Heart Center in Würselen was able to diagnose her condition within 20 minutes and without elaborate procedures—thanks to a so-called provocation test that can detect spasms of the coronary arteries.

The provocation test is considered more time- and cost-intensive than simple catheterizations and, because many doctors do not think of spasm, is offered only rarely, explains Michael Becker. A thin wire is inserted into the coronary arteries and a hormone naturally produced by the body is injected into the vessel, which normally causes the vessels to widen and the heart to receive more blood when needed, for example during exercise. For patients like Laura Juntersdorf, the vessels spasm at that moment. They then function like poorly controlled sluice gates and react out of sync. The consequence: the heart does not get what it needs and cries out for help.

Menopause can also be a risk factor

More and more clinics in Germany are aiming to recognize and treat cardiovascular diseases and heart attacks in women earlier. More than a hundred women’s heart centers, such as the one run by Michael Becker and Lena Seegers, now offer gender-specific examinations and inquire about risk factors such as menopause or illnesses during pregnancy, which usually play no role in regular cardiology examinations. “The problem is that many doctors do not know the specifics of women’s hearts,” says Seegers. “We want to change that.” That is why the cardiologist also gives gender medicine lectures at the Frankfurt university hospital. This could also help spread knowledge beyond women’s heart centers.

Until women find their way to the Women’s Heart Center in Würselen, it took an average of eight years and 17 doctor visits, says Michael Becker. Of around 1,200 female patients per year in 2024, 60 percent received the diagnosis of vasospastic angina pectoris. Becker has known these figures by heart for years, has collected his patients’ data, written the women’s heart guide “Herzenssache” and gives talks at conferences or to general practitioners. Many of his patients come from far away, from Brussels, from Lake Constance. For Laura Juntersdorf, who only has a 20-minute drive to the hospital, he says: “Her stories nearly match those of my other patients one-to-one. What I can say with absolute certainty is: I know what she has. And with the right therapy, it’s not something to be afraid of.”

With her diagnosis in the early 30s, the probability of having a heart attack is very low for Juntersdorf. This is because female sex hormones have a protective effect on the coronary vessels. After menopause, the probability then rises disproportionately because cholesterol levels and blood pressure increase and fewer hormones are produced.

Why spasm of the coronary vessels occurs even in young people and women are more affected than men is still not clarified. Neither smoking nor overweight are considered triggers. Whether the disorder is congenital is unknown. This is also because large, cross-generational studies are lacking. For a long time vasospastic angina was considered harmless. But if the heart muscle is repeatedly deprived of blood for years and decades, long-term damage can occur, and the likelihood of other diseases increases.

All these risks can be addressed early. The disorder can be treated with active substances that also help men with calcifications in the coronary arteries. Substances like Diltiazem are intended to dilate the blood vessels and relieve the heart.

That women remain underserved despite good treatment options is more due to the fact that they are often not taken seriously and have to wait significantly longer for medications, after years of misdiagnoses, explains Michael Becker. The image of the supposedly less burdened woman still persists in many minds. Even today diagnoses and therapies are largely based on the male body, gender-specific symptoms are rarely recognized. To change this, politics must be roused as well, Becker says: “Women are not small men. Gender medicine is vital for survival.”

Laura Juntersdorf has been taking her medications for a month, she says, and she hasn’t felt overly drained yet, though she looks worried. “We aren’t at high doses yet; there is still room to increase,” reassures her Michael Becker, and he picks up his pen again, this time to write the milligram amounts of the medications on a slip of paper which he will hand to Laura Juntersdorf shortly.

Being in a place at last where her symptoms are taken seriously gives her a lot of hope, Laura Juntersdorf says, even though she was disappointed at first that the medications had not yet had a large effect. She stands at the main entrance of the clinic, her father by her side. “I don’t want to hate my heart anymore,” she says, small lines returning to her forehead. Over the years it has become a foreign object inside her.

In the meantime she is in therapy; she wants to get rid of her fear and be brave again. Recently she has started exercising again to really challenge her heart. And at some point she wants to ride roller coasters again, she says, looking at her father. They used to love doing that together.