Sex-specific differences in the epidemiology and pathophysiology of coronary artery disease and ischemic heart disease are now well recognized. Women with angina more often have nonobstructive coronary artery disease (NOCAD) compared with men. This patient population carries a significant risk of future cardiovascular events that is not commonly appreciated, often leading to delayed diagnosis and treatment. While coronary microvascular dysfunction plays a central role in the pathophysiology of NOCAD in women, other mechanisms of myocardial ischemia are now recognized. Risk factors such as hypertension and obesity disparately affect women and are likely to account for a significant proportion of NOCAD in the coming years. Vascular inflammation is an important pathophysiologic pathway in NOCAD and is a potential therapeutic target. Coronary CT angiography provides a comprehensive assessment of coronary anatomy and plaque morphology and is a reasonable screening test of choice for NOCAD.