What PAD Is and How It Develops
Peripheral artery disease is a condition in which the arteries supplying blood to the legs and feet become narrowed or blocked, primarily due to atherosclerosis — the buildup of fatty plaque within the arterial walls. As plaque accumulates, the artery’s interior diameter decreases, and blood flow to the lower extremities becomes restricted. Muscles that are deprived of adequate oxygen and nutrients during activity cannot function normally, and tissue that is chronically underperfused is at risk for more serious complications.
PAD is, at its core, a manifestation of systemic cardiovascular disease. When I see a patient with significant PAD, I am not treating an isolated leg problem. I am evaluating a patient whose arteries throughout the body — including those supplying the heart and brain — may be affected by the same underlying process. This systemic reality is one of the reasons early recognition and treatment matter far beyond the legs themselves.
Globally, PAD affects over 200 million people. In the United States, research has shown that approximately 8 to 12 million Americans carry this diagnosis. What that figure does not reflect adequately is the disproportionate burden that falls on women — not because women develop PAD less often, but because women’s disease goes unrecognized at higher rates.
The Diagnostic Gap: Why PAD Is Underrecognized in Women
The clinical picture of PAD has been shaped largely by studies conducted predominantly in male populations. The result is a diagnostic framework built around symptoms that men are more likely to report. Women account for roughly 50 to 60 percent of PAD cases worldwide, yet they have been underrepresented in clinical research and trials for decades. This has produced a measurable and consequential gap between how the condition presents in women and how clinicians are trained to identify it.
The consequence of this gap is visible in clinical outcomes. Women are diagnosed at more advanced stages of PAD on average. By the time the diagnosis is confirmed, the disease has often progressed to a point where intervention is more complex, recovery is slower, and the risk of major adverse events — including limb loss — is higher. Clinical data suggests that women have higher rates of amputation compared to men, even when imaging shows less obstructive disease at the time of the procedure. This is a striking finding that points directly to delays in evaluation and treatment.
In my practice, I regularly see the effects of this gap. Patients come in having been reassured for months or years that their symptoms were due to arthritis, neuropathy, venous disease, or age-related deconditioning. Some of these diagnoses were partially correct. None of them explained the arterial component that had been quietly progressing. Earlier evaluation changes the trajectory of this disease, and that is the message I want women to take from this article.
How PAD Symptoms in Women Differ From the Classic Presentation
The textbook description of PAD symptoms centers on claudication: a cramping, aching pain in the calf, thigh, or buttock that occurs predictably during walking and resolves with a few minutes of rest. This pattern is reproducible; it follows a consistent anatomical distribution and makes intuitive sense as a description of muscle ischemia during exertion.
Women are less likely to report this specific pattern. Studies indicate that up to 40 to 50 percent of PAD patients have no classic claudication, and women are overrepresented in that group. What women describe more often includes:
- Leg fatigue or heaviness during activity, which may be attributed to poor fitness or aging
- Burning or aching sensations that do not follow a predictable walk-rest-walk cycle
- Non-exertional discomfort, meaning symptoms present at rest or in positions that have no obvious relationship to physical demand
- Rest pain, particularly in the foot or toes, that worsens at night or when lying flat and improves when the leg is lowered
- Slow-healing wounds on the lower leg or foot that may appear before the patient has ever identified leg pain as a concern
- Generalized lower extremity weakness that limits walking tolerance without producing the discrete, localized cramping that claudication implies
Other Conditions
Because these presentations do not fit the classic pattern, they are more likely to be attributed to other conditions. Venous insufficiency, peripheral neuropathy, musculoskeletal degeneration, and chronic venous insufficiency each produce symptoms that can overlap with atypical PAD. A thorough evaluation that includes objective vascular testing is the only way to reliably distinguish between them.
Women with PAD also demonstrate worse functional status than men at comparable disease stages. This is measured by walking distance, speed, and physical performance tests. This means that even when the degree of arterial obstruction appears similar on imaging, women experience more significant limitations in daily activity. The reasons for this are not fully understood, but the clinical implication is that symptoms alone may understate the severity of the underlying disease.
Who Is at Risk: Standard and Women-Specific Risk Factors
Standard Risk Factors
The risk factors that drive atherosclerosis and PAD in the general population include:
- Cigarette smoking (the single strongest modifiable risk factor for PAD)
- Diabetes mellitus
- Hypertension
- Hyperlipidemia (elevated LDL cholesterol, low HDL)
- Advancing age, particularly over 65
- Chronic kidney disease
- A personal or family history of cardiovascular disease
These factors apply equally to men and women, and their presence in any combination warrants consideration of vascular evaluation.
Women-Specific Risk Factors
Several risk factors carry particular significance for women and are not always discussed in the context of arterial disease.
Menopause. Estrogen has a protective effect on the vascular endothelium. After menopause, the loss of this hormonal protection is associated with accelerated atherosclerosis and increased cardiovascular risk. Women who experience early menopause, whether natural or surgical, carry a higher lifetime risk of vascular disease. This is a factor I discuss explicitly with female patients during risk assessment.
History of preeclampsia or eclampsia. Research has established that women who experienced hypertensive disorders of pregnancy carry significantly elevated lifetime cardiovascular risk, including PAD. Preeclampsia is now recognized as an independent vascular risk marker. If you had a pregnancy complicated by preeclampsia, that history is relevant to your vascular health and should be shared with your doctor.
Autoimmune diseases. Conditions such as systemic lupus erythematosus and rheumatoid arthritis are substantially more common in women than men and are associated with accelerated vascular disease through chronic inflammatory pathways. Women with these diagnoses warrant heightened surveillance for PAD.
Diabetes. Clinical data suggests that diabetes more than doubles PAD risk in women and appears to be a particularly strong risk factor in the female population compared to men. Diabetic women with any lower extremity symptoms deserve prompt evaluation rather than a watchful approach.
Hormonal contraception. Long-term use of certain hormonal contraceptives, particularly in women who also smoke or carry other cardiovascular risk factors, has been associated with increased arterial and venous thromboembolic risk. This is not an absolute contraindication, but it is relevant context when taking a vascular history.
Why Earlier Evaluation Matters
The consequences of delayed PAD diagnosis in women are not abstract. They are measured in wounds that do not heal, in procedures that could have been avoided, and in amputations that, in many cases, reflect a disease that was present and treatable years before the patient came to a vascular specialist.
PAD is also a marker for cardiovascular and cerebrovascular risk. Patients with established PAD have significantly elevated rates of myocardial infarction and stroke. Identifying PAD early allows for the implementation of medical therapy, risk factor modification, and cardiovascular surveillance, thereby reducing the probability of these events.
When I evaluate a patient with PAD, treatment is not limited to the legs. It encompasses antiplatelet therapy, lipid management, blood pressure control, smoking cessation support, and coordination with the patient’s primary care and cardiology teams when indicated. This integrated approach is possible only if the diagnosis is made.
The earlier I see a patient, the more options are on the table. Minimally invasive procedures can restore blood flow in many cases. Medical optimization can slow disease progression. Supervised exercise programs, when appropriate, can meaningfully improve walking capacity. Waiting until tissue loss has occurred eliminates many of these possibilities and yields uniformly worse outcomes.
How PAD Is Diagnosed: What to Expect From an Evaluation
A PAD evaluation is not complicated. When I evaluate a patient, I begin with a thorough history that covers symptom pattern, risk factors, and prior vascular history, followed by a physical examination that includes assessment of the pulses in the legs and feet.
Ankle-Brachial Index (ABI)
The primary objective screening test for PAD is the ankle-brachial index. I use the ABI as part of my initial evaluation for any patient with relevant symptoms or risk factors. The test measures blood pressure at the ankle and the arm, and the ratio of these two values indicates whether blood flow is restricted in the lower extremities.
A normal ABI is between 1.0 and 1.4. An ABI below 0.9 is diagnostic for PAD. Values between 0.7 and 0.9 indicate mild to moderate disease; values below 0.5 indicate severe disease. The test is non-invasive, requires no preparation, and can be completed in the office. Clinical data confirm that it is a reliable first-line screening tool, yet it is significantly underused among women, contributing directly to the diagnostic delay described earlier.
Additional Diagnostic Modalities
Depending on the ABI result and clinical findings, further evaluation may include:
- Segmental pressures and pulse volume recordings, which help localize the level and severity of arterial obstruction
- Duplex ultrasound imaging of the lower extremity arteries, which provides both anatomic and flow information without radiation or contrast
- CT angiography or magnetic resonance angiography, used when intervention is being planned and detailed arterial mapping is required
- Catheter-based angiography, which is both diagnostic and therapeutic in patients who are candidates for atherectomy.
The selection of testing depends on what the initial evaluation reveals and what clinical decisions are pending. The goal is to obtain the information needed to guide treatment without exposing the patient to unnecessary procedures.
Schedule a PAD Evaluation at Coastal Vascular Center
If you have leg symptoms that have not been clearly explained, or if you carry risk factors that place you at elevated risk for peripheral artery disease, schedule a formal vascular evaluation. Early diagnosis changes the outcome of this disease in a way that late diagnosis cannot recover.
Coastal Vascular Center serves patients in Pearland and Lake Jackson, Texas. To schedule an appointment, call 281-949-6020 or use our online appointment request to request an evaluation. A non-invasive examination in our office is the first step toward understanding what is happening in your arteries and what options are available to you.
Key Insights
- Peripheral artery disease affects approximately 8 to 12 million Americans, and women account for roughly 50 to 60 percent of total cases globally, yet women have historically been underrepresented in PAD research and clinical trials.
- Classic PAD symptoms, particularly claudication (leg pain during walking that resolves with rest), are far less reliable diagnostic markers in women. Studies suggest that up to 40 to 50 percent of PAD patients have no classic claudication at all.
- Women with PAD more frequently report atypical symptoms such as leg fatigue, heaviness, non-exertional discomfort, or pain at rest that does not follow a predictable pattern.
- Women are diagnosed at more advanced stages of PAD on average and face higher rates of major adverse limb events, including amputation, despite often showing less obstructive disease on imaging compared to men.
- Risk factors specific to women include menopause, a history of preeclampsia or eclampsia, autoimmune diseases such as lupus and rheumatoid arthritis, and the compounding effect of diabetes, which more than doubles PAD risk in women.
- The ankle-brachial index (ABI) is a non-invasive, widely available first-line screening tool for PAD. It is underused in women, and earlier use would reduce the diagnostic gap significantly.
- Women with PAD have higher rates of functional impairment and worse walking ability than men at comparable disease stages, which has direct consequences for independence and quality of life.
- If you have leg symptoms that concern you, or if you carry any of the risk factors described in this article, a formal evaluation is warranted regardless of whether your symptoms fit the classic description.
Frequently Asked Questions
Is PAD more common in women or men?
PAD affects both sexes at comparable rates overall. Women account for roughly 50 to 60 percent of PAD cases globally. The perception that PAD is a male disease is largely a product of research bias and underdiagnosis in women, not a reflection of actual disease prevalence.
What does PAD leg pain feel like in women?
In women, PAD pain often does not follow the classic pattern of cramping that begins with walking and stops at rest. Women more commonly report leg fatigue, heaviness, burning sensations, or diffuse aching that may not correlate reliably with activity level. Some women with significant PAD report no pain at all and present instead with slow-healing wounds or a change in skin color or temperature in the feet. These atypical presentations are one of the central reasons PAD is diagnosed later in women.
What tests are used to diagnose PAD?
The ankle-brachial index (ABI) is the primary non-invasive screening test. It compares ankle blood pressure with arm blood pressure and can quickly identify arterial obstruction without discomfort. Depending on findings, additional testing may include duplex ultrasound imaging, segmental pressure measurements, or CT or MR angiography for more detailed arterial mapping.
Does menopause increase PAD risk?
Yes. Estrogen has a protective effect on arterial walls, and its decline after menopause is associated with accelerated atherosclerosis. Women who undergo early menopause, whether naturally or through surgical removal of the ovaries, carry elevated lifetime cardiovascular and vascular risk. Menopause is one of several women-specific risk factors that should be factored into vascular risk assessment.
Can PAD be treated without surgery?
In many cases, yes. Medical therapy — which includes antiplatelet agents, statins, blood pressure management, and smoking cessation — forms the foundation of PAD treatment. Supervised exercise therapy can meaningfully improve walking distance and functional capacity. For patients with more significant obstruction, minimally invasive endovascular procedures including angioplasty and atherectomy can restore blood flow without open surgery. The appropriate approach depends on the severity of disease, the patient’s overall health, and the specific arteries involved.
What happens if PAD is left untreated?
Without treatment, PAD typically progresses. Mild disease can advance to critical limb-threatening ischemia, characterized by rest pain, non-healing wounds, or gangrene. At this stage, the risk of major amputation increases substantially. Beyond the legs, untreated PAD signals systemic cardiovascular disease that elevates the risk of heart attack and stroke. Early intervention — both medical and procedural when indicated — is significantly more effective than treating disease at an advanced stage.
