While this change is a perfectly normal part of aging, the loss of these hormones can have a systemic impact on health, especially cardiovascular health. Estrogen has a protective benefit to the heart and loss of it can impact some of the specific risk factors for heart health, which include high cholesterol, high blood pressure and weight gain.

Heart disease is the leading cause of death in women, and the risk continues to rise as they age. Therefore it’s important to be aware of red flags that might indicate current or future heart attack and stroke risk. Mitigating your risk for both also requires trusting your instincts.

“The most important thing, aside from signs, is an absolute awareness of your medical conditions and daily activities,” says Dr. Stacey Rosen, executive director of Northwell’s Katz Institute for Women’s Health and American Heart Association Go Red for Women volunteer expert. “Knowing what you’re able to do, so that when something feels different—anywhere in your chest, your abs, your back movement, smile—that you act on it and don’t ignore it.”

Additionally, it’s important to know your family health history, since research suggests women have an elevated risk of heart disease if an immediate family member—such as their mother or sister—had heart disease before age 65.

Knowledge is power. Here are five symptoms every woman in her mid-40s and older should take seriously.

1. Chronic fatigue

Life is exhausting, especially for many women, who are often balancing parenting, careers and other responsibilities. But there’s a difference between normal exhaustion and the type that could indicate a serious health problem.

Research finds in the weeks preceding a heart attack, the most common symptom for women is unusual fatigue. In one study, 70% of women who had a heart attack reported this.

“It is a significant fatigue that really feels different than just tiredness at the end of a busy day,” says Rosen.

It’s important to take unexplained exhaustion seriously. If the symptoms don’t resolve after getting additional rest and sleep, then reach out to your doctor, who can conduct further tests.

2. Hot flashes

Sudden intense flushing and sweating in the upper body—especially the face, neck, and chest—is a normal and frequent experience for women approaching and in menopause. However, excessive and severe hot flashes may indicate something isn’t right.

Recent research suggests that women who experience moderate-to-severe hot flashes and night sweats are three times more likely to develop heart disease and nonalcoholic fatty liver disease than those who experience less severe hot flashes. The study, which involved 106 peri- and post-menopausal women and was presented at the Endocrine Society’s annual meeting in May, indicates women should self-monitor their vasomotor symptoms and see a doctor if they become frequent and significantly interfere with daily activities.

“The FDA has come out with a definition that they use for hot flush trials, but I think it’s also clinically appropriate,” says Dr. JoAnn Pinkerton, a professor of obstetrics and gynecology and midlife health director at the University of Virginia Health. “Moderate hot flush is associated with sweating, and a severe hot flush stops you from functioning, whether it makes you pause when you’re giving a speech, or you wake up in the middle of the night because you’re overheated.”

She says clinical trials tend to admit women who experience seven or more hot flashes a day, and that is a good framework for knowing when to discuss the symptoms with a doctor, and consider treatment options.

3. Depression

It’s well known that our emotional health is intrinsically tied to our physical health. Therefore, it’s not surprising that research finds women with depression have a higher risk for cardiovascular disease later in life compared to men. In one study out of Japan, researchers analyzed database records from more than 4 million medical claims of patients who met the criteria for depression. The median age was 44. They found that the rate of subsequent heart attack, heart failure, stroke and chest pain were higher in women than men who were diagnosed with depression.

“If there’s truly a depression, it needs to be addressed and treated appropriately, either with counseling or combined with antidepressant medication, with or without hormones, depending on where they are in their menopausal stage,” says Pinkerton.

Every woman, regardless of her age, should speak with their doctor if they experience significant mood changes, frequent crying or thoughts of suicide. Pinkerton recommends starting with a basic depression screening tool through a primary care physician, who can then guide the next steps.

4. Chronic shortness of breath

When people imagine heart attacks, they often think of the portrayal in Hollywood films with the actor collapsing while clenching at his chest. But in women, heart attacks present differently and mostly lack that cinematic drama. They also tend to build up for a number of weeks.

Women are often unaware of this and may ignore subtle signs, especially shortness of breath. It can be easy to mistake breathlessness for a run-of-the-mill viral illness because as a heart attack sign, it is often accompanied by other symptoms such as nausea and fatigue. Experts say women should seek out care if the shortness of breath is unexplained or sudden.

“I like to tell people to have a feel for what they feel like in general when they walk up a flight of steps or walk around the block,” says Rosen. “Any change in how you feel with regards to breathing can be concerning. If you’ve never had asthma before, but you have multiple risk factors for heart disease, then you need to be increasingly attuned that this symptom may be related to your heart.”

After fatigue and sleep problems, shortness of breath is the most common heart attack warning sign in women. In one study on 515 women ages 29 to 97 who had heart attacks, shortness of breath occurred in more than 40%.

There is never any harm in seeing a doctor for your peace of mind. 

5. Migraines

Research suggests that migraines are three times more common in women than men. They can be crippling, so it’s not surprising that they’re the fourth leading cause of disability in women. Migraines in middle-aged women are primarily related to fluctuations in hormone levels; perimenopause causes a decline in estrogen, which triggers these very specific types of headaches in perimenopause and menopause. Migraines can also be related to factors such as stress, diet, anxiety, depression and sleep problems. 

One of the challenges is that symptoms of stroke in women have a number of overlapping symptoms with migraine. For example, both severe migraine and stroke may cause vision changes and dizziness. Other overlapping symptoms include disorientation and numbness and tingling. Even more, studies find migraines can double one’s risk for stroke.

If this is your first time experiencing any of these symptoms, it’s always best to seek out  immediate care. They are an emergency until a doctor says otherwise. Even if your migraines are unrelated to a more serious and insidious health problem, there are still treatments available that can prevent and alleviate them. When in doubt, it’s best to discuss any new neurological symptoms with a clinician.