Gensini score and Friesinger score are effective tools used to evaluate the severity of coronary artery disease (CAD). The risk of CAD in women after menopause rises sharply in contrast to that in women before menopause, due to the loss of hormonal protection against atherosclerosis. Postmenopausal women present with more severe CAD along with multiple comorbidities. However, there are limited data describing the sensitivity and specificity of Gensini and Friesinger scores in distinguishing between pre- and postmenopausal women with acute coronary syndrome (ACS). This study aimed to assess the sensitivity and specificity of the Gensini and Friesinger scores between pre- and postmenopausal women with ACS.

 In this cross-sectional observational study, a total of 140 female patients with ACS were enrolled. They were divided into Group I (premenopausal) and Group II (postmenopausal) based on menopausal status. Clinical data and coronary angiographic characteristics, including severity assessed by Gensini and Friesinger scores, were compared between the two groups, and sensitivity and specificity were analyzed.The Gensini Score, first described in 1975 by Goffredo G. Gensini, is a widely used angiographic scoring system for quantifying the severity of CAD. It considers the geometrical severity of the lesion, the cumulative effect of multiple obstructions, and the significance of the affected myocardium. For each coronary lesion, three parameters are considered: severity score, region multiplying factor, and collateral adjustment factor. A non-linear score is first assigned according to the degree of lumen diameter reduction. This score is then multiplied by a factor depending on the functional significance of the affected myocardial region, with further adjustment for collateral circulation. The final score is the sum of all lesion scores.The Friesinger Index ranges from 0 to 15, with each of the three main coronary arteries scored separately from 0 to 5:

• Score 0: No arteriographic abnormality
• Score 1: Trivial irregularities (1–29% narrowing)
• Score 2: Localized 30–68% luminal narrowing
• Score 3: Multiple 30–68% luminal narrowings in the same vessel
• Score 4: 69–100% luminal narrowing without total occlusion of proximal segments
• Score 5: Total obstruction of a proximal segment

The mean age of premenopausal ACS patients was 41.53 ± 5.45 years, while postmenopausal ACS patients had a mean age of 57.23 ± 7.45 years, which was statistically significant (P = 0.001). Normal coronary angiograms and single-vessel disease were more prevalent in the premenopausal group (31.4% vs. 17.1%, p = 0.04; and 31.4% vs. 15.7%, p = 0.002, respectively), while triple-vessel disease was more common in the postmenopausal group (48.6% vs. 20%, p = 0.001).The mean Gensini score was significantly higher in the postmenopausal group compared to the premenopausal group (56.1 ± 43.4 vs. 33.5 ± 36.9; p = 0.001). High to intermediate Friesinger scores (11–15) were also more common in postmenopausal women than in premenopausal women (72.9% vs. 50%, p = 0.003). Sensitivity and specificity of the Gensini and Friesinger scores were 95.9% vs. 97.3%, and 73.7% vs. 64.2%, respectively.

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• This study reflects that while the risk of ACS during the premenopausal period is lower, it is not negligible.
• Coronary angiographic findings in premenopausal women revealed less severe lesions, predominantly single-vessel involvement, most commonly affecting the LAD, and lower Friesinger scores compared to postmenopausal women.
• For severity assessment, the Friesinger score was found to be more sensitive, whereas the Gensini score was more specific.
• Large-scale community-based studies are needed to provide further insights. Social awareness regarding primary and secondary prevention, early diagnosis, and timely treatment are essential for reducing the morbidity, mortality, and overall burden of CAD.