When Symptoms become INVISIBLE.
Diagnostic overshadowing and the systemic dismissal of women's health concerns: what it is, why it happens, and why it matters.
She has been to her GP three times in as many months. Each time, she leaves with a prescription for anxiety or is told to "give it time." What no one has yet properly considered is that her racing heart, breathlessness, and overwhelming fatigue might be her body telling her something entirely different.
I have met women like this more times than I can count. In my work as a cardiology nurse specialist, I see the consequences of this pattern all too often. This phenomenon, diagnostic overshadowing, is one of the most common and biggest failures in healthcare that I see. Diagnostic overshadowing occurs when a clinician attributes a patient's symptoms to a pre-existing condition (or an assumed one) rather than investigating them independently. The result is that new, potentially serious pathology is missed and attributed to a more familiar, easier, or socially convenient explanation.
The term was originally used in the context of learning disabilities, where physical symptoms in patients with intellectual impairments were routinely attributed to their disability rather than investigated properly. Over time, it has come to describe a far broader pattern: one that affects women, people from ethnic minority backgrounds, those with mental health diagnoses, and anyone whose presentation does not fit the accepted clinical template.
For women, the "shadow" most commonly cast is that of anxiety, stress, or hormones.
"She's just anxious." "It's probably her hormones." "This is what menopause feels like." These phrases, often spoken with the best intentions by overworked healthcare professionals, can be devastating, both psychologically and physically. Closing the door for further investigations and leaving a person feeling like they are wasting time or overreacting.
To understand why women's symptoms are so frequently overshadowed, we need to look at how medicine itself was built. Medical knowledge, including its research base, diagnostic criteria, and textbook illustrations, was constructed predominantly around male bodies. Heart disease, for decades, was studied almost exclusively in men. The classic presentation of a heart attack, crushing chest pain radiating to the left arm, reflects male symptoms.
In cardiology practice, I see how this plays out far too often, and it makes me really cross. Women's cardiac presentations are frequently atypical. Jaw pain (even toothache), nausea, profound fatigue, breathlessness without obvious chest discomfort, upper indigestion, pain between the shoulder blades, a sensation that a bra is too tight, palpitations that come and go. These symptoms are real, they are cardiac in origin, and they are routinely attributed to something else. Anxiety is the most common offender, followed by gastrointestinal causes, musculoskeletal issues, and hormonal fluctuations.
Women wait 50% longer to receive a heart disease diagnosis compared to men.
Women are 3 times more likely to be misdiagnosed following a heart attack
On average, women with autoimmune diseases wait for up to 7 years for a diagnosis.
It is estimated that women are disproportionately affected by autoimmune diseases (up to 90%)
These are not anomalies. They are patterns sustained by unconscious bias, insufficient research diversity, and a cultural tendency to read women's distress as emotional rather than physical.
For women in their forties and fifties, the risks intensify. Perimenopause and menopause produce a genuinely bewildering array of symptoms: palpitations, insomnia, cognitive change, mood disturbance, joint pain, breathlessness, and fatigue. They are hormonally mediated. And they are also, at exactly this life stage, capable of masking serious underlying pathology.
The problem arises when "menopause" becomes a diagnosis, without any consideration of other causes. When a healthcare professional hears "52-year-old woman with palpitations," the menopause explanation is often applied before a thorough differential diagnosis is even considered. Thyroid dysfunction, arrhythmia, anaemia, cardiac amyloidosis, and hypertensive heart disease can all present with symptoms that overlap significantly with perimenopause, and all of them require proper investigation.
I have cared for women in my nurse specialist role, and close family members, who had been told that their symptoms were hormonal, only to eventually receive a diagnosis of paroxysmal atrial fibrillation, or autonomic dysfunction, or, in rarer and more sobering cases, a structural cardiac condition that had been silently progressing. As nurses, we are often the ones spending the most time with patients, and that time matters. It is frequently in those longer conversations, while taking a history or running through a care plan, that a woman finally feels safe enough to describe what has really been going on.
Symptoms commonly attributed to anxiety or hormones that may warrant further investigation
Palpitations, especially those that wake you from sleep or occur at rest
Breathlessness on exertion that is new or progressively worsening
Chest tightness, pressure, or discomfort, however mild or atypical
Profound fatigue not explained by sleep quality alone
Dizziness, presyncope (feeling faint), or episodes of feeling "not quite there"
Swelling of the ankles or legs (oedema)
Cognitive change that is sudden, or accompanied by other neurological features
Weight loss or gain that is unexplained and significant
A Mental Health Diagnosis
Women are diagnosed with anxiety and depression at significantly higher rates than men. Some of this reflects genuine epidemiology, but some of it reflects the ease in which distress, including the legitimate distress of living in a body that is not being taken seriously, can be diagnosed as a psychiatric condition.
Once a woman has an anxiety or depression diagnosis in her records, it can become the lens through which all subsequent presentations are viewed. New symptoms are read as manifestations of existing anxiety. The possibility that the anxiety itself might be secondary, a response to an undiagnosed physical condition or to the experience of not being believed, is rarely entertained. Receiving a diagnosis of depression can also affect life insurance policies, access to mortgages and loans. Once in your medical records, a diagnosis is almost impossible to remove. I have had personal experience of this, with my life insurance policy being altered compared to my husband’s because of a diagnosis of depression in my medical records. This, of course, can be relevant for men, but the problem disproportionately affects women.
Women who are repeatedly told that their symptoms are "just stress" begin to believe it. They stop advocating for themselves. They apologise for attending appointments. They begin consultations with: "I know it's probably nothing, but..." It is a phrase I hear so often (and one I have used myself) that it has become a signal for me to slow down and listen even more carefully.
The Cardiovascular Picture
Cardiovascular disease remains the leading cause of death in women in the UK, yet women are less likely to be referred for cardiac investigations, less likely to be prescribed cardioprotective medications, and more likely to present later in the course of their illness precisely because earlier symptoms were not taken seriously. As a nurse specialist working in this field, the gap between what women experience and what gets acted upon is something I witness regularly.
Conditions such as MINOCA (myocardial infarction with non-obstructive coronary arteries), spontaneous coronary artery dissection (SCAD), and Takotsubo cardiomyopathy (broken heart syndrome) disproportionately affect women and are still poorly understood across the wider healthcare system. Women with these conditions are frequently told initially that nothing is wrong with their heart, because the investigations performed were designed to detect the type of disease more commonly seen in men.
Cardiovascular risk in perimenopausal and postmenopausal women is also underappreciated. Oestrogen protects the heart by keeping good levels of cholesterol (HDL) up. When oestrogen declines, so does HDL, which is associated with a marked increase in cardiovascular risk. This is why generally younger men are more affected by heart disease than younger women (but not always!). Women who should be on statins are not receiving them. Women whose blood pressure is creeping upward are monitored but not treated. Women wait longer for preventive intervention and hear statements such as: "let's see how things go", appointment after appointment, to the point where the woman stops going to appointments altogether.
What Needs to Change
Diagnostic overshadowing in women is not the result of malice; no one in healthcare sets out to be dismissive or get things wrong. The problem is built out of systemic bias embedded in how medicine was taught, how research was conducted, and how clinical time is structured. Acknowledging this is not about assigning blame; it is about understanding the conditions that allow harm to persist. Nurses are not immune to these biases either, and honest self-reflection is part of good practice for all of us.
Better education and awareness
Clinicians and nurses at all levels need training in gender-specific symptom presentation, implicit bias, and the dynamics of the clinical encounter. This must be embedded in medical and nursing curricula from the outset, not offered as an optional afternoon workshop years into practice.
Research that includes women
The historical exclusion of women from clinical trials, justified for decades on grounds of hormonal "complexity," has left medicine with diagnostic frameworks that simply do not reflect female physiology. This is beginning to change, but it is changing slowly.
Structural changes in clinical practice
Longer appointment times, multidisciplinary review for complex presentations, and policies around re-investigation when symptoms persist would all reduce the rate at which serious conditions are attributed to a convenient alternative diagnosis.
Women advocating for themselves, and being supported to do so
This should not fall on patients. A system that requires women to fight for adequate assessment has already failed them. But until structural change catches up, self-advocacy remains one of the most important tools available. In my work, I actively encourage women to keep a symptom diary, to ask questions, to request specific investigations where appropriate, and to seek a second opinion if something does not feel right. These are not acts of "being difficult." They are rational, reasonable responses to a system with known gaps. Women's symptoms are not inherently mysterious, psychosomatic, or hormonal. They deserve the same thorough, open-minded clinical assessment afforded to anyone who walks through a healthcare door.
If you are a woman who has felt dismissed, who has been told "it's probably just anxiety" or "it's your age," I want you to know this: your symptoms deserve to be taken seriously. You are not imagining it. Push for answers. Return when things do not resolve. Bring someone with you if it helps. And if the door isn’t opening, find another one.
This article is written for educational purposes and does not constitute individualised medical advice. If you have a specific health concern or are managing a chronic condition, please speak with your healthcare provider before making significant dietary changes or beginning a new exercise programme or before beginning any supplementation.