Heart disease is the number one cause of death among women in the U.S. yet it remains woefully under-diagnosed. Part of the reason is that heart attacks were, from the 19th century well into the 20th, viewed as being caused by stress. It was a disease for “hard-working and ambitious men,” and dying of a heart attack, like sweating, was simply not something a proper woman did.

Nowadays we know differently, but it hasn't helped matters that the symptoms of a looming heart attack vary by gender. For men, it's chest pains. But women on the verge of cardiac arrest are more likely to experience discomfort in the neck, jaw, shoulder, back, or arm. Some women also experience nausea, vomiting, or a feeling similar to indigestion in the run-up to a heart attack.

Women under 55 years of age have a particularly difficult time when it comes to a swift and proper diagnosis of heart disease, as many may have symptoms that fall outside what’s currently considered typical. That is one of the conclusions of a 2017 study that included interviews with many women who felt they had to “sell” the idea that they might have something serious. Many complained to the researchers that their symptoms had been going on for a while but were neglected by the health-care system.

A 1999 survey unearthed the distressing fact that doctors are roughly half as likely to recommend cardiac catheterization (a test that determines the severity of heart disease) when the patient is female. The same survey also found that women are less likely than men to get bypass surgery or balloon angioplasty to unclog blocked arteries. And for whatever reasons, women are historically less likely to get tests to diagnose heart-related illnesses.

Since men and women are not created equal when it comes to heart disease, here are a few risk factors associated with female cardiovascular health that aren't talked about enough:

• Menopause — Heart disease can happen at any age, but it tends to increase in women around or after menopause
• Having started menstruating before 10 or after 17 years of age.
• Gestational hypertension/preeclampsia — Any elevation in blood pressure increases the risk for heart disease in women.
• Gestational diabetes during any pregnancy.
• Preterm delivery (before 37 weeks of gestation).
• Polycystic ovarian syndrome.