For decades, cardiovascular disease was thought to mainly affect men. In fact, it claims the lives of both men and women in equal numbers, according to the Centers for Disease Control and Prevention. And for women with diabetes, there are a number of gender-specific risk factors that make the likelihood of developing of heart disease even greater.

If you’re a woman with diabetes, you should be aware of the following facts regarding how heart disease might affect you.

Women with diabetes are three to four times more likely to develop heart disease than women without diabetes. It’s an even higher percentage than that for men with diabetes.

Men often get heart disease in their 40s and 50s, typically about a decade sooner than it develops in women. But for women with diabetes, that doesn’t hold true. When diabetes is present, the premenopausal protection against heart disease that women normally receive from estrogen is no longer effective. This means that women with diabetes are more prone to suffer heart-related complications than women without diabetes, essentially putting them at the same risk as men their age.

For women with diabetes, a number of risk factors for heart disease are generally more prevalent than they are in men with diabetes. Women with diabetes have a higher rate of abdominal obesity, which increases their chances of having high blood pressure, high cholesterol, and imbalanced blood sugar levels, compared to men.

Some women with diabetes are also particularly at risk for heart disease, such as those who have hypoestrogenemia, which is a deficiency of estrogen in the blood. Research has found that women living with diabetes who’ve already had a heart attack have an increased risk of experiencing a second heart attack. They also have a greatly increased risk of heart failure.

The way the symptoms of heart disease present themselves also seems to be different in women than in men. When describing their symptoms, men commonly cite chest pain, pain in their left arm, or excessive sweating. Women, on the other hand, often describe symptoms of nausea, fatigue, and jaw pain.

This difference in warning signs, particularly chest pain, could mean that women with diabetes are more prone to silent myocardial infarctions, which are heart-related complications that can happen without the person even knowing that a myocardial event has occurred. This means women may be more likely to suffer a heart attack, or episode related to heart disease, without being aware that something is wrong.

The correlation between stress and heart disease is another issue that is different for women than it is for men. In general, family-related stress is a higher risk factor for heart disease in women. A condition called broken heart syndrome, a temporary heart episode that can be brought on by stressful events like the death of a loved one, occurs almost exclusively in women.

If you’re a woman with diabetes, it’s important that you take time whenever possible to de-stress. Consider using deep breathing exercises, progressive muscle relaxation techniques, or meditation.

In general, heart disease goes underdiagnosed in women at an alarmingly high rate. Although heart disease is the leading cause of death among women, many women are more concerned about getting breast cancer. That’s despite the fact that heart disease claims the lives of six times more women each year than breast cancer.

Heart disease is typically thought of as something that affects older women, so those who are younger may not see it as a threat. Its symptoms are often misdiagnosed as panic disorder or stress.

In terms of treatment, women’s coronary arteries are smaller than men’s, which can make surgery more difficult. Women may also be at risk for more postsurgery complications than men. Research suggests women are also twice as likely to continue experiencing symptoms in the years following heart surgery.

If you’re a woman living with diabetes, it’s important to talk to your doctor about your risk of heart disease. You and your health care provider can work together to create a plan to reduce your risk as much as possible. Managing your diabetes effectively and making healthy lifestyle changes can make a difference.