# The "Women's Heart Bus": the first french initiative for the prevention of cardiovascular and gynaecological risk in women, prospective multicentre analysis of 4,300 participants

Manon Jouffroy, Patrick Devos, Thierry Drilhon, Claire Mounier-Vehier

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Manon Jouffroy, Patrick Devos, Thierry Drilhon, Claire Mounier-Vehier. The "Women's Heart Bus": the first french initiative for the prevention of cardiovascular and gynaecological risk in women, prospective multicentre analysis of 4,300 participants. Journal of Gynecology Obstetrics and Human Reproduction, 2025, Journal of Gynecology Obstetrics and Human Reproduction, 54 (7), pp.102983. 10.1016/j.jogoh.2025.102983. hal-05248108

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Original Article

# The “Women’s Heart Bus”: the first french initiative for the prevention of cardiovascular and gynaecological risk in women, prospective multicentre analysis of 4,300 participants

<figure><img src="image_3.png" /></figure>

Manon Jouffroy<sup>a,∗</sup> ◦, Patrick Devos<sup>b</sup>, Thierry Drilhon<sup>c</sup>, Claire Mounier-Vehier<sup>a</sup>

ARTICLE INFO

Keywords:

Women-cardiovascular disease

Cardiovascular risk factors

Metabolic risk factors

Ob-gyn risk factor

Prospective multicentre study-France

Medical follow-up - national

Observatory on Women's Health

Women's cardiovascular health—screening –
prevention campaign

A B S T R A C T

**Objective:** To assess the cardiovascular and gynaecological health status of women in France, based on data collected through the Women's Heart Bus screening and prevention campaign.

**Methods:** A mobile screening campaign was carried out in 20 cities across France between September 2021 and November 2022. The initiative aimed to establish the cohort of the National Women's Health Observatory (ONSF) and included 4300 women. A structured assessment booklet was used to collect information on cardiovascular, metabolic, and gynaecological-obstetric risk factors, as well as on medical follow-up by general practitioners and cardiologists. Gynaecological screening practices were also analysed in relation to age and national screening guidelines.

**Results:** Among the women included, 90.2 % had at least two cardiovascular or metabolic risk factors, and 48.9 % had two or more gynaecological-obstetric risk factors. More than 70 % had never received cardiovascular follow-up, and fewer than half were up to date with gynaecological screening.

**Conclusion:** The findings underscore the urgent need to improve cardiovascular and gynaecological health in women in France. The Women's Heart Bus enabled many women to be reintegrated into appropriate care pathways.

Introduction

Cardiovascular disease (CVD) remains the leading cause of death globally, accounting for approximately 15.2 million deaths annually [1]. In both Europe and the United States, it is the primary cause of death among women, surpassing cancer [2].

In France, women are eight times more likely to die from CVD than from breast cancer, with a threefold increase in myocardial infarctions among women under 50 observed over the past 15 years [2]. These trends are partly explained by gender disparities in screening, diagnosis, and treatment: women are less likely to be screened, more frequently underdiagnosed, and often receive suboptimal treatment compared to men, resulting in missed opportunities for prevention and care [3].

Although the major cardiovascular risk factors are largely shared between men and women, women present specific sex-related features [4] that are still insufficiently recognised and inadequately integrated

into current risk assessment models. Cardiovascular risk in women is further influenced by hormonal status [4], differs in the relative impact of risk factors [3], and often manifests through atypical symptoms, contributing to diagnostic delays. Furthermore, both patients and healthcare professionals frequently lack awareness of cardiovascular warning signs in women [5]. Emerging evidence also points to social vulnerability [6] as a newly recognised, yet significant, cardiovascular risk factor.

Evidence-based guidelines, such as those presented in the 2007 up-
date of the "Evidence-Based Guidelines for Cardiovascular Disease Pre-
vention in Women", offer specific recommendations to mitigate these
risks. These include the promotion of regular screening, interventions
adapted to hormonal phases throughout a woman's life, and the inte-
gration of psychosocial determinants into cardiovascular risk manage-
ment. A personalised prevention approach tailored to women's
biological and socioeconomic profiles is strongly encouraged [7].

<footnote><sup>a</sup> Univ. Lille, CHU Lille, ULR 2694 -METRICS: Évaluation des technologies de santé et des pratiques médicales F-59000 Lille, France</footnote>

<footnote><sup>b</sup> Univ. Lille, CHU Lille, Lillometrics F-59000 Lille, France</footnote>

<footnote><sup>c</sup> Agir Pour Le Cœur Des Femmes, 22 Rue De Londres 75009 Paris, France</footnote>

<footnote>* Corresponding author.</footnote>

<footnote>E-mail address: manon.jouffroy@gmail.com (M. Jouffroy).</footnote>
Several international organisations actively promote cardiovascular disease prevention in women. In Europe, the British Heart Foundation [8] and the European Society of Cardiology [9] support large-scale screening initiatives. Similarly, awareness campaigns in the United States and Canada, such as “Go Red for Women” [10], “World Heart Day” [11], and those led by the Heart and Stroke Foundation [12], focus specifically on the female population.

Despite rising rates of smoking, hypertension, obesity, psychosocial stress, and sedentary behaviour among women in France, there is currently no national programme dedicated to the screening and management of both cardiovascular and gynaecological risk factors. To address this gap and reduce health inequalities, the “Women’s Cardiovascular Healthcare Foundation” launched the nationwide initiative “Le Bus du Cœur des Femmes” (The Women’s Heart Bus) in September 2021. This campaign aims to save 10,000 women’s lives over five years through systematic screening, prevention, and education regarding cardiovascular disease [13].

This study aimed to analyse cardiovascular and gynaecological health data collected in 2021 and 2022 as part of the “Women’s Heart Bus” campaign based on the National Women’s Health Observatory (ONSF) registry.

## Methods

### Study design

This was a prospective, observational, multicentre study conducted using data from the ONSF cohort. All participants provided written informed consent prior to data collection. The study was carried out in accordance with French regulations on data protection and confidentiality.

### Patient selection

As part of the National Women’s Heart Bus programme, a mobile unit equipped for cardiovascular, metabolic, and gynaecological screening visited 20 cities across France between September 2021 and November 2022. The campaign was implemented in collaboration with local partners, including volunteer healthcare professionals, associations, municipalities, and the National Health Insurance Fund (CNAM), the institution responsible for healthcare reimbursement and policy formulation in France. The aim was to assess cardiovascular, metabolic, and gynaecological-obstetric risk factors and to provide medical check-ups to participating women.

The Heart Bus initiative was first presented to local city councils during informational meetings, after which municipalities were invited to apply. Applications were reviewed by the “Agir pour le Cœur des Femmes” team, and selection was based on the availability of financial support, logistical infrastructure, and sufficient volunteers to host the bus for three days. The estimated cost per city was €10,000, covering technical and security requirements. Once selected, municipalities were included in the campaign schedule, and a general mailing was sent to local women, without specific eligibility criteria, to invite participation.

Additional participants were recruited through the OSMOZ campaign, which used the CPAM database to identify women aged 40–65 who were socially vulnerable, specifically those without supplementary health insurance or a designated primary care physician, and beneficiaries of State Medical Aid or Complementary Health Insurance. These programmes cover all healthcare expenses for low-income individuals. The OSMOZ cohort comprised approximately 15,000 women, of whom around 150 accepted screening appointments arranged by CPAM.

Women were also recruited through other means, including unlicensed applications in response to local radio advertisements. Furthermore, a broad outreach campaign was conducted, a large scale mailing was sent out with no age limit or specific criteria by various

organisations, including city social centres, Territorial Professional Health Communities (CPTS), and regional branches of CPAM. The only inclusion criteria were female sex, age ≥ 18 years, residence in a screening area, and having signed informed consent.

The screening process consisted of 10 sequential steps (Supplemental Table 1), each overseen by qualified healthcare professionals. Written consent was obtained before initiating the screening. Data were recorded on paper using a structured assessment booklet (Supplemental File 1), and included cardiovascular, metabolic, gynaecological, and obstetric risk factors, as well as information on ongoing follow-up with general practitioners, gynaecologists, or cardiovascular specialists.

The selection of risk factors for analysis was based on the publication “Trends in Cardiovascular Risk Factors in US Adults by Race and Ethnicity and Socioeconomic Status, 1999–2018” (JAMA Network) [14], which emphasised the role of sociodemographic determinants in cardiovascular risk stratification, particularly in women [14].

At the conclusion of each screening, a physician provided a summary of the findings to the participant, along with a written report outlining identified cardiovascular risk factors and recommended follow-up, intended for their general practitioner. Women with more than two cardiovascular risk factors or with signs of cardiovascular disease, and no prior cardiology follow-up, were referred to local specialists such as cardiologists or vascular physicians. A set number of appointments had been pre-scheduled for these referrals.

Women who lacked an up-to-date gynaecological evaluation were offered appointments with a local gynaecologist, midwife, or general practitioner with gynaecological expertise. Similarly, when mammography was not current, CPAM staff present at the Heart Bus issued updated screening invitations. Anonymity was strictly maintained throughout the entire process.

Once completed and anonymised, all assessment booklets were sent to a professional data entry service. The resulting Excel files were centralised at Lille University Hospital for statistical analysis. Quality control checks were performed by the lead biostatistician and the head physician overseeing the screenings, in order to identify and correct any inconsistencies or abnormal data entries.

### Data management

All data were imported into SAS statistical software for verification and analysis. The initial step involved checking for internal consistency (e.g., instances where the age at menopause was recorded but the menopause status field was left blank) and generating indicators for further analysis.

From the 160 variables included in the assessment booklet, new derived variables were created to define key analytical parameters. These included clinical criteria (e.g., age, hypertension, obesity), follow-up indicators (e.g., visits with a general practitioner, cardiovascular specialist, or gynaecologist), and the presence of cardiovascular, metabolic, and gynaecological-obstetric risk factors. For each woman screened, the number of cardiovascular risk factors (ranging from 0 to 4) and gynaecological-obstetric risk factors (ranging from 0 to 5) was estimated. Full definitions of these indicators are provided in Supplemental Tables 2 and 3.

In addition, each woman was asked to report the date of her most recent gynaecological consultation, pap smear, and mammogram. Gynaecological follow-up was considered up to date if at least one of these examinations had been performed during the year of screening or the preceding calendar year.

### Statistical analysis

Data analysis was performed using SAS version 9.4 (Cary, NC, USA). A descriptive analysis was conducted, with qualitative variables reported as frequencies and percentages, along with 95 % confidence intervals calculated using the Clopper-Pearson method. The normality of
numerical variables was assessed using the Shapiro-Wilk test. As most numerical variables did not follow a Gaussian distribution, they were summarised using medians and interquartile ranges. Categorical variables were compared using the chi-square test, or Fisher's exact test when appropriate. Numerical or ordinal variables were compared using the Wilcoxon or Kruskal-Wallis test. Analyses related to cardiovascular and gynaecological obstetric risk factors were adjusted for menopausal status.

## Results

The analysis was conducted in 20 cities across France and included a total of 4300 women: 1066 were screened in 5 cities in 2021, and 3234 in 15 cities in 2022. Participants ranged in age from 14 to 95 years, with a median age of 54 years (interquartile range: 46.0-65.0). However, the median age varied considerably across centres, ranging from 46 to 65 years (Supplemental Table 4).

**Table 1** summarises the main characteristics of the study population, including cardiovascular and metabolic profiles, medical follow-up, and gynaecological history and follow-up. For each variable, the number of available observations, absolute frequencies, and corresponding percentages with 95 % confidence intervals were reported. The minimum and maximum values observed across the 20 centres were also presented, along with the p-value for heterogeneity across centres.

### Cardiovascular characteristics

In the study population, 68.3 % of women reported experiencing stress. A high-sodium diet was reported by 33.7 % of participants, while 26.0 % described themselves as sedentary (self-reported data).

The prevalence of diagnosed hypertension was 25.9 %, and among these women, 81.7 % reported receiving treatment. During the screening, elevated blood pressure values (≥140/90 mmHg) were observed in 38.6 % of participants. The above results refer to both

<table><caption>**Table 1**
Characteristics, risk factors and follow-ups.</caption><thead><tr><th rowspan="2">Label</th><th colspan="4">Total population</th><th colspan="3">By city</th></tr><tr><th>N</th><th>No. of Cases</th><th>Percentage</th><th>95 % CI</th><th>Min</th><th>Max</th><th>p</th></tr></thead><tbody><tr><td>Smoking</td><td>3941</td><td>585</td><td>14.8</td><td>[13.8 - 16]</td><td>6.2</td><td>24.8</td><td>&lt;0.0001</td></tr><tr><td>Stress</td><td>4200</td><td>2868</td><td>68.3</td><td>[66.9 - 69.7]</td><td>40.9</td><td>77.6</td><td>&lt;0.0001</td></tr><tr><td>High sodium diet</td><td>4154</td><td>1400</td><td>33.7</td><td>[32.3 - 35.2]</td><td>17.0</td><td>65.9</td><td>&lt;0.0001</td></tr><tr><td>Sedentary lifestyle</td><td>4180</td><td>1088</td><td>26.0</td><td>[24.7 - 27.4]</td><td>11.7</td><td>39.2</td><td>&lt;0.0001</td></tr><tr><td>Diagnosed hypertension</td><td>4174</td><td>1081</td><td>25.9</td><td>[24.6 - 27.3]</td><td>18.7</td><td>32.9</td><td>0.021</td></tr><tr><td>Treated hypertension</td><td>1035</td><td>846</td><td>81.7</td><td>[79.3 - 84.1]</td><td>69.8</td><td>91.8</td><td>0.274</td></tr><tr><td>SBP ≥ 140 or DBP ≥ 90 mm Hg</td><td>4233</td><td>1633</td><td>38.6</td><td>[37.1 - 40.1]</td><td>23.0</td><td>52.1</td><td>&lt;0.0001</td></tr><tr><td>Inherited heart disease</td><td>4114</td><td>1819</td><td>44.2</td><td>[42.7 - 45.8]</td><td>26.3</td><td>68.3</td><td>&lt;0.0001</td></tr><tr><td>Cardiovascular warning symptoms (shortness of breath, etc.)</td><td>3411</td><td>2090</td><td>61.3</td><td>[59.6 - 62.9]</td><td>27.9</td><td>84.3</td><td>&lt;0.0001</td></tr><tr><td>BMI > 30 (kg/m<sup>2</sup>)</td><td>4186</td><td>1333</td><td>31.8</td><td>[30.4 - 33.3]</td><td>11.8</td><td>48.0</td><td>&lt;0.0001</td></tr><tr><td>Abdominal circumference ≥ 88 cm</td><td>4073</td><td>2791</td><td>68.5</td><td>[67.1 - 70]</td><td>45.4</td><td>83.2</td><td>&lt;0.0001</td></tr><tr><td>Dyslipidaemia</td><td>3446</td><td>819</td><td>23.8</td><td>[22.4 - 25.2]</td><td>13.0</td><td>32.3</td><td>&lt;0.0001</td></tr><tr><td>Treated dyslipidaemia</td><td>743</td><td>351</td><td>47.2</td><td>[43.6 - 50.9]</td><td>30.8</td><td>71.9</td><td>0.0611</td></tr><tr><td>Diabetes</td><td>3536</td><td>337</td><td>9.5</td><td>[8.6 - 10.6]</td><td>3.6</td><td>21.2</td><td>&lt;0.0001</td></tr><tr><td>At least 2 cardiac/metabolic risk factors</td><td>4300</td><td>3877</td><td>90.2</td><td>[89.2 - 91]</td><td>84.8</td><td>94.5</td><td>0.0098</td></tr><tr><td>Regular check-up by a general practitioner</td><td>4263</td><td>3735</td><td>87.6</td><td>[86.6 - 88.6]</td><td>76.8</td><td>96.1</td><td>&lt;0.0001</td></tr><tr><td>Regular check-up by a cardiologist or vascular specialist</td><td>4212</td><td>876</td><td>20.8</td><td>[19.6 - 22.1]</td><td>12.6</td><td>28.5</td><td>&lt;0.0001</td></tr><tr><td>Age of Menstruation (11 or) 15 years</td><td>3606</td><td>548</td><td>15.2</td><td>[14 - 16.4]</td><td>9.6</td><td>20.2</td><td>0.212</td></tr><tr><td>Combined oral contraceptive</td><td>1599</td><td>173</td><td>10.8</td><td>[9.3 - 12.5]</td><td>3.8</td><td>32.0</td><td>0.0002</td></tr><tr><td>History of cardiovascular disorders or hypertensive disorders during pregnancy</td><td>3740</td><td>431</td><td>11.5</td><td>[10.5 - 12.6]</td><td>4.5</td><td>19.3</td><td>&lt;0.0001</td></tr><tr><td>History of gestational diabetes</td><td>3744</td><td>459</td><td>12.3</td><td>[11.2 - 13.4]</td><td>2.5</td><td>23.0</td><td>&lt;0.0001</td></tr><tr><td>Menopause</td><td>4300</td><td>2830</td><td>65.8</td><td>[64.4 - 67.2]</td><td>43.0</td><td>89.6</td><td>&lt;0.0001</td></tr><tr><td>Hormone replacement therapy</td><td>2685</td><td>730</td><td>27.2</td><td>[25.5 - 28.9]</td><td>12.2</td><td>61.3</td><td>&lt;0.0001</td></tr><tr><td>At least two gynaecological and obstetric risk factors</td><td>4300</td><td>2103</td><td>48.9</td><td>[47.4 - 50.4]</td><td>35.5</td><td>61.5</td><td>&lt;0.0001</td></tr><tr><td>Gynaecological check-up in the current or previous year</td><td>3642</td><td>1865</td><td>51.2</td><td>[49.6 - 52.8]</td><td>29.6</td><td>66.4</td><td>&lt;0.0001</td></tr><tr><td>Mammogram in the current or previous year</td><td>2791</td><td>1534</td><td>55.0</td><td>[53.1 - 56.8]</td><td>43.3</td><td>67.4</td><td>0.0002</td></tr><tr><td>Pap smear in the current or previous year</td><td>3233</td><td>1485</td><td>45.9</td><td>[44.2 - 47.7]</td><td>25.9</td><td>59.1</td><td>&lt;0.0001</td></tr><tr><td>At least one gynaecological examination in the current or the previous year (Consultation/ Mammogram/Pap smear)</td><td>4300</td><td>2553</td><td>59.4</td><td>[57.9 - 60.8]</td><td>50.3</td><td>72.1</td><td>&lt;0.0001</td></tr></tbody></table>
women with known but uncontrolled hypertension and those in whom high blood pressure was newly identified. Among women with elevated blood pressure, 61.3 % reported experiencing cardiovascular warning symptoms within the previous three months.

## Metabolic characteristics and medical follow-ups

In the cohort, 31.8 % of women had a body mass index (BMI) >30 kg/m², and 68.5 % had a waist circumference >88 cm. The prevalence of diabetes was 9.5 %. Dyslipidaemia was reported in 23.8 % of participants, with 47.2 % of those affected receiving treatment.

Overall, 90.2 % of women had at least two cardiovascular and/or metabolic risk factors. Despite this heavy burden, only 87.6 % reported having a general practitioner, and just 20.8 % were regularly followed by a cardiovascular specialist.

## Gynaecological characteristics and follow-ups

Among the women surveyed, 11.5 % reported a history of cardiovascular events during pregnancy or hypertensive disorders of pregnancy. Approximately one tenth (10.8 %) of the 1599 women who answered the relevant question, reported current use. of combined hormonal contraception. Among menopausal women, 27.2 % (n = 730) reported the use of hormone replacement therapy.

Overall, 48.9 % of participants presented at least two gynaecological and obstetric risk factors.

Regarding gynaecological follow-up, only 51.2 % of women had undergone a consultation with a gynaecologist in the current or preceding year. In the same period, 55.0 % of the surveyed population had received a mammogram, and 45.9 % had undergone a pap smear. Across the overall population, regardless of age, 59.4 % had received at least one of the above mentioned three examinations within the last two years.

Substantial variability was observed among centres with respect to

cardiovascular, metabolic, and gynaecological-obstetric indicators. Statistically significant differences were found for most variables, with the exception of two related to therapeutic management: hypertension and dyslipidaemia (Table 1).

## Gynaecological follow-ups by age

Fig. 1 illustrates the rates of gynaecological follow-up by age group. Overall, 51.2 % of women had not consulted a gynaecologist in the past two years. The proportion of recent consultations declined with age: 54.8 % of women aged 25–29 had seen a gynaecologist in the current or preceding year, compared to only 9.2 % of women over 80. The highest rate of recent consultations was observed in the 35–39 age group (59.2 %).

Among women aged 50–74, the age group eligible for organised mammography screening in France, 50.4 % had undergone a mammogram within the recommended interval. For pap smears, 43.1 % of women aged 25–65, the target population for organised cervical cancer screening, reported a recent test.

When defining adequate gynaecological follow-up as having undergone at least one of the three key examinations (gynaecological consultation, mammogram, or pap smear) in the current or preceding year, the highest coverage was observed in women aged 35–69. However, even in this group, the rate did not exceed 65 %.

## Menopause

In the total population, 65.8 % of women were postmenopausal. Substantial variability was observed across centres, with the proportion of menopausal women ranging from 47.1 % to 89.6 %. Hormone replacement therapy was reported by 27.2 % of postmenopausal women.

The median age at menopause in the overall population was 50 years (interquartile range: 47–53). Figs. 2 and 3 illustrate the number of

<figure><img src="image_4.png" /><figcaption>**Fig. 1.** Gynaecological check-up by age group. Gynaeco Check-up: Gynaecological consultation in the current or previous year. Mammo Check-up: Mammogram in the current or previous year. PapSmear Check-up: Pap smear in the current or previous year. Gynaeco Exam: At least one gynaecological examination in the current or previous year.</figcaption></figure>
<figure><img src="image_5.png" /><figcaption>Fig. 2. Number of cardiovascular risk factors in menopausal and non-menopausal women. Chi-square = 155.77, DF = 4, *p* < 0.0001.</figcaption></figure>

<figure><img src="image_6.png" /><figcaption>Fig. 3. Number of gynaecological and obstetric risk factors in menopausal and non-menopausal women. Chi-square = 1329.51, DF = 4, *p* < 0.0001.</figcaption></figure>

cardiovascular and gynaecological-obstetric risk factors, stratified by menopausal status. After adjusting for menopausal status, menopausal women were found to have a significantly higher burden of both cardiovascular (traditional) and gynaecological-obstetric (emerging) risk factors compared to non-menopausal women (*p* < 0.0001). Among menopausal woman, 91.0 % had more than two cardiovascular risk factors and 18.0 % had more than two gynaecological-obstetric risk factors. In contrast, among non-menopausal women, these rates were 88.0 % and 26.0 %, respectively. The majority of menopausal women predominantly presented with three cardiovascular risk factors (39.0 %) and one gynaecological-obstetric risk factor, excluding 'menopause' itself (42.0 %). Among non-menopausal women, the most common profile was three cardiovascular risk factors (43.0 %) and no gynaecological-obstetric risk factors (38.0 %).

Discussion

This prospective multicentre study included 4300 women from 20 cities across France and aimed to describe the cardiovascular, metabolic, gynaecological-obstetric characteristics, and medical follow-ups of women participating in a population screening programme. In our cohort, we observed a higher prevalence of several cardiovascular risk factors compared with national estimates. More than 90 % of participants had at least two cardiovascular or metabolic risk factors. Reported

stress levels were four times higher than in the general population [15], and abdominal obesity was 1.5 times more frequent [16]. In some centres, over 65 % of women reported excessive sodium intake, exceeding national averages by 1.5 times [17]. The prevalence of diabetes reached 10 % overall and up to 20 % in some cities, significantly surpassing the national average of 5.3 % [18]. Dyslipidaemia affected approximately one-third of participants, consistent with national data [19], although rates varied across centres.

These findings reflect a population at elevated cardiovascular risk: obesity is associated with a 64 % increase in coronary artery disease risk [20], chronic stress with a 2.5-fold increased risk of myocardial infarction, and diabetes with a 9 to 10 fold increase in mortality from ischaemic heart disease.

Our results also revealed shortcomings in the prevention and treatment of cardiovascular, metabolic, and gynaecological-obstetric risk factors in women. Excessive sodium intake varied widely between centres and has been rising in France over the past decade [17], representing a major prevention issue. Regarding hypertension, a significant proportion of known hypertensive women were not receiving treatment, and over one-third of participants had elevated blood pressure at screening. These findings are consistent with national data [21], where 17 % of hypertensive women are untreated and 55 % have uncontrolled blood pressure. For dyslipidaemia, fewer than 50 % of affected women in our cohort were receiving treatment, echoing the findings of the ESTEBAN study [19], which reported gender disparities in statin use. A similar pattern is seen in diabetes management, where women are less likely to be prescribed beta-blockers, aspirin, or statins [22].

The high prevalence and variability of cardio-metabolic risk factors across centres may reflect underlying socioeconomic vulnerability in certain cities, which may contribute to inequalities and promote high-risk behaviours [23]. Older age in some centres may also partially explain the uneven distribution of specific risk factors such as hypertension [24].

Regarding gynaecological and obstetric risk factors, more than 50 % of participants had at least two such factors, a prevalence comparable to that of the general population. A history of gestational diabetes or hypertensive disorders of pregnancy was reported by one in ten women, in line with published data [25,26]. Other risk factors [24] such as polycystic ovary syndrome, early or late menarche, and combined hormonal contraception use were also present in proportions consistent with national data.

These findings are of particular concern as gestational diabetes is
associated with a 35 % increased risk of developing type 2 diabetes, a fivefold increased risk of metabolic syndrome, and a 1.7 higher incidence of cardiovascular disease [25]. Hypertensive disorders of pregnancy, especially pre-eclampsia, increase the risk of heart failure by 2.3 times and the risk of cerebrovascular events by three times [27].

Exposure to hormonal fluctuations throughout a woman's life contributes to a sex-specific evolution of cardiovascular risk [24], highlighting the need for regular medical follow-ups. However, our findings indicate that these follow-ups are inadequate: the proportion of women without a general practitioner was 10 % higher than the national average [28], and more than 80 % of participants had never undergone cardiovascular assessment. Gynaecological follow-up was also insufficient, with over one-third of women lacking a recent consultation. Less than 50 % of eligible women had undergone a pap smear, compared with 58.7 % at the national level [29]. Among women aged 50-74, only 50 % had undergone recent mammogram, slightly higher than the 2020 national average of 42.8 % [30].

These missed opportunities may be explained by social and behavioural factors. According to a French survey by Axa Prévention Santé [31], eight in ten women delay medical appointments due to time constraints and prioritising the health of others. In addition, health literacy remains a challenge: 25 % of women were unaware of the impact of hormonal changes on cardiovascular risk [32]. Socioeconomic vulnerability and limited healthcare access may also contribute to inadequate follow-up, with 30 % of the French population living in areas characterised by medical undersupply [28].

The analysis of menopausal women, who represented 65.8 % of our cohort, revealed that although they had similar cardiovascular risk burdens as non-menopausal women, they exhibited more gynaecological and obstetric risk factors. Since menopause is itself considered a gynaecological-obstetric risk factor, adjustment for menopausal status was necessary to avoid potential bias in the analysis. The prevalence and incidence of cardiovascular disease increase with age across all populations, but in women this increase becomes more pronounced during menopause due to changes in lipid profile, abdominal adiposity, and blood pressure [33]. Although the American Heart Association [34] issued specific guidelines for female cardiovascular risk in 2020, there is currently no dedicated risk score for women in France. However, the French Hypertension Society recently published recommendations to guide cardiovascular and metabolic screening at menopause onset [35]. New approaches, such as coronary artery calcium scoring and coronary CT angiography, are increasingly being considered for comprehensive risk assessment in peri- and postmenopausal women [24]. This study has several strengths. It is one of the largest prospective multicenter screening studies in France and includes a diverse population. Data collection was standardised and conducted in collaboration with a professional data entry service. Nonetheless, the study has limitations. Selection bias is possible due to recruitment through social services, insurance databases, and voluntary participation. The use of the OSMOZ database to recruit patients, likely increased the proportion of socially vulnerable women and those lacking medical follow-up, potentially distorting age distribution. Recall bias may also have affected data accuracy, as some variables were self-reported. Interpretation of gynaecological. follow-up data was age-stratified due to the age-specific nature of national screening recommendations, which led to missing data for non-targeted women. A large number of women were referred to cardiology, vascular, or gynaecological follow-up as a result of screening, and many were reintegrated into the national mammography programme via CPAM. However, because this was a cross-sectional study and not a follow-up programme, no outcome data were collected after screening. Finally, a significant amount of missing data was due to incomplete forms, either because of missing answers by participants or incomplete data entry by healthcare professionals. To address this issue, training webinars were delivered to healthcare professionals, who were required to review the booklet before the conclusion of the screening.

## Conclusion

The study highlights the critical need to address cardiovascular, metabolic, and gynaecological health among women in France, revealing substantial gaps in prevention, screening, treatment, and follow-up. These findings emphasise the importance of further investigating the role of social vulnerability in shaping health disparities and developing targeted strategies to improve women's cardiovascular health. This will be the focus of a subsequent study. Beyond its quantitative impact, the Women's Heart Bus represents a key initiative in targeted cardiovascular screening, offering an opportunity to reintegrate women into appropriate care pathways, reduce health inequalities, and foster a more proactive approach to disease prevention and management.

Although cardiovascular disease remains the leading cause of death among women in France, women continue to be under-screened, under-diagnosed, and under-treated. This study aims to evaluate the overall health status and the cardiovascular and gynaecological follow-up of women in France, to raise awareness of the critical gaps in care. By doing so, it seeks to inform clinical practice, promote widespread screening, and support the reintegration of women into appropriate, tailored care pathways.

## Ethics approval statement

All participants provided written informed consent prior to inclusion in the study. Following the screening, a summary letter was sent to each participant's general practitioner to support medical care coordination.

The study was approved by the French National Commission for Information and Freedom (CNIL), declaration number: 2021-5229, and by the Ethics Committee of Lille University Hospital, declaration number: DEC21-337bis.

## Funding statement

The Women's Cardiovascular Healthcare Foundation received funding for its national cardiovascular and gynaecological screening campaign for women in France from the following organisations:

Marc Ladreit de la Charrière's Foundation and various health establishments, mutual insurance groups, and pharmaceutical companies, including: Korian Foundation, Ramsay Foundation, Orpéa, Hôpital de la Tour at Geneva, Henner, VYV Group, Harmonie Mutuelle, Axa Prévention, Aesio mutuelle, Synlab biological aboratory, Fitbit society, Crédit Mutuel Bank, Alliance BMS/Pfizer France, Boehringer Ingelheim France, Bayer France, Exeltis santé France, and AMGEN France.

## Declaration of competing interest

Claire Mounier-Vehier and Thierry Drilhon are co-founders of the Women's Cardiovascular Healthcare Foundation.

Additional disclosures for Claire Mounier-Vehier are publicly available at: https://dpi.sante.gouv.fr/dpi-public-webapp/app/home/ (last update: 2 November).

The other authors declare no conflicts of interest. Any potential connections or financial disclosures can be consulted via the official transparency platform: https://www.transparence.sante.gouv.fr.

## Acknowledgement

The authors gratefully acknowledge the support of the Marc Ladreit de la Charrière Foundation and Health establishments, mutual health group and pharmaceutical companies: Korian foundation, Ramsay foundation, Orpéa, Hôpital de la Tour at Genève, Henner, VYV group, Harmonie Mutuelle, Axa prevention, Aesio mutuelle, Synlab biological laboratory, Fitbit society, Crédit Mutuel bank, Alliance BMS / Pfizer France, Boehringer Ingelheim France, Bayer France, Exeltis santé
France, AMGEN France.

They also thank ITC Translation for their assistance with manuscript translation, as well as Dr A. Huillet and Dr R. Adafer for their involvement in the study.

## Supplementary materials

Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.jogoh.2025.102983.

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