Hypertension and cardiovascular disease during perimenopause and menopause

What you need to know – and how to safeguard your heart health

• Women have a higher risk of cardiovascular disease than men post-menopause
• Why healthy blood pressure is important during and after the menopause
• Advice on HRT and lifestyle approaches to reduce your risk of hypertension and cardiovascular disease

Atherosclerotic cardiovascular disease (ASCVD) is caused by plaque buildup in arterial walls and refers to conditions that include myocardial infarction (heart attacks), angina, and coronary artery stenosis.

ASCVD is the leading cause of death in men and women and its incidence continues to increase. Although in adults under 65 years, men have a greater incidence of heart attacks than women, in Europe and USA, the fastest relative increase in death from ASCVD is in middle aged women aged 45-64 years [1].

The cardiovascular disease advantages in women up to the age of menopause gradually disappears thereafter, which leads to a higher risk of CVD in postmenopausal women than men of the same age. This trend is largely attributed to the role of female oestrogen in this process [2].

During the perimenopause and menopause, women suffer from blood vessel ageing, decreased diastolic ability, reduced insulin sensitivity, and increased blood pressure due to decreased ovarian function and changes in hormone secretion, which increase the risk of ASCVD occurring [3].

Hypertension: raised blood pressure

Your blood pressure is the force of your blood pushing against your blood vessel walls as it flows away from your heart and around your body. We all have blood pressure, but high blood pressure puts a strain on your heart and blood vessels and increases risk of heart disease, heart attack, stroke and many other diseases. Blood pressure tends to rise with age and it’s very common to have high blood pressure – known as hypertension – by the age of 60. An estimated 46% of adults with hypertension are unaware that they have the condition, and less than half of adults (42%) with hypertension are diagnosed and treated [4].

Blood pressure tends to rise with age, and high blood pressure increases the risk of heart attacks and stroke. Checking your blood pressure regularly, looking after your overall health and taking HRT can all help lower your risk of heart disease.

What is a healthy blood pressure?

The higher your blood pressure, the greater the risks to future health. In the UK, if your blood pressure consistently raises to 140/90mmHg or over, this would be diagnosed as high.

What raises blood pressure?

Hypertension is usually caused by a combination of risk factors. As well as your age, your blood pressure can be raised by your genes (this means hypertension can run in some families), being overweight, not exercising enough, eating a diet which is high in processed food and saturated fat, smoking, drinking excess alcohol.

Why is healthy blood pressure important during and after the menopause?

Oestrogen allows your blood vessels to relax and widen so that blood can flow through them easily, helping to keep your blood pressure normal.

Oestrogen and heart health

The hormone oestrogen plays an important role in protecting your cardiovascular health, and it helps to reduce your risk of a heart attack in the following ways [5]:

• It increases levels of nitrous oxide, which is a chemical known to relax and widen blood vessels, so that blood can flow through them easily – this helps to keep your blood pressure down, but oestrogen is not a substitute for blood pressure medication if you need it
• It reduces the levels of ‘bad’ cholesterol in your blood. This is a type of fat that can clog the arteries and increase the risk of heart attack and stroke, but it isn’t a substitute for cholesterol lowering medication if you need it
• It reduces inflammation in the lining of your blood vessels
• It increases levels of nitrous oxide, which is a chemical known to relax and widen blood vessels
• It supports the conducting system of the heart, the network of cells and signals that control your heartbeat
• Oestrogen can also reduce inflammation by reducing oxidative stress in the cardiovascular system. Oxidative stress can cause damage which can lead to cardiovascular disease.

Palpitations

As levels of oestrogen fluctuate and fall, you might notice symptoms such as racing or irregular heartbeats or palpitations, or an increased awareness of your heart beating – this sometimes happens during a hot flush. Palpitations can be worst at night time, which is when oestrogen levels are usually at their lowest.

While palpitations can feel alarming, in most cases they are usually harmless. Still, it is worth seeing a healthcare professional to rule out any other cause. Also seek help if your palpitations:

• Last for several minutes
• Are accompanied by shortness of breath or chest pain
• Get worse over time or become more frequent
• If they do not improve within three months of starting HRT.

Many women with no history of heart disease become worried when they first experience palpitations and see a healthcare professional for further investigation and reassurance. In some cases, they may be referred to a cardiologist as a result of these symptoms and be prescribed medications that later turn out to be unnecessary as the palpitations can often resolve when oestrogen is replaced by taking HRT. A growing body of evidence has associated the presence of vasomotor symptoms with future risk for CVD events [6,7]. Besides quality of life, vasomotor symptoms should be treated being a marker of cardiovascular disease.

When oestrogen levels fall, the protective effects of oestrogen can be lost. Studies have shown that women who are at a younger age when they are menopausal have a greater risk of developing heart disease as they have longer without their hormones (unless they take HRT)[8,9].

In addition, menopause-related symptoms such as reduced stamina, fatigue and reduced motivation can lead to women being less likely to exercise and eat healthy foods.

Can I take HRT if I have hypertension?

For most women, it is safe to take body identical hormones if you have hypertension or you are taking medicines to lower your blood pressure. You will need to monitor your blood pressure regularly and you may need to adjust your medicines if needed.

There is sometimes confusion around taking HRT in women who have hypertension and some women are needlessly advised against taking HRT. However, taking body identical HRT can either make no difference to blood pressure or can actually lower blood pressure for some people.

Oestrogen taken as a tablet has the potential to raise blood pressure. However, using oestrogen through your skin as a patch, gel or spray allows your blood vessels to widen – so it can lower your blood pressure rather than raise it.

Progestogens have different effects and while the older synthetic progestogens could raise blood pressure, body identical progesterone, called micronised progesterone, has either no effect or can lower blood pressure.

This means that women with raised blood pressure can still usually take body identical HRT and it is safe to take blood pressure lowering medication with HRT [10]. Some women find that they can reduce or even stop their blood pressure lowering medication when they take body identical HRT.

HRT and heart disease

Evidence shows that if you start taking HRT during your perimenopause, or within 10 years of your menopause, you have a lower risk of developing heart disease and also lower risk of death from heart disease than those who don’t take HRT. Taking HRT to reduce the risk of a heart attack is actually more effective than taking statins [12].

Many people who have a history of heart disease such as a heart attack or blocked arteries, or have had a stroke, assume or have been told that they can’t take HRT but this isn’t usually the case.

Oestrogen taken through the skin in a patch, gel or spray does not have an increased risk of clot or stroke. If you need to take a progesterone as part of your HRT, micronised progesterone – known under the brand name Utrogestan – is recommended and this does not increase your risk of clot either.

The synthetic progestins, such as medroxyprogesterone acetate, can be associated to deleterious cardiovascular effects so are usually avoided as much as possible [13]. The natural micronised progesterone also has beneficial effects also on sleep disorders – this is also important as poor sleep is an independent risk factor for both hypertension and cardiovascular disease [14,15].

Synthetic oestrogen taken in tablet form can slightly increase the risk of blood clots, deep vein thrombosis and stroke, but the overall risk of stroke in women under 60 is low and the increased risk is greater if you are overweight and don’t exercise.

The impact of starting HRT more than 10 years after menopause on the risk of heart disease is likely to be neutral or possibly beneficial if you use oestrogen through the skin and take micronised progesterone.

If you have an early menopause or surgical menopause before the age of 40, you are at higher risk of cardiovascular disease, as the longer a woman is without her hormones, the greater her future risk of developing heart disease.

It’s important to discuss possible treatments with your healthcare professional and perhaps a menopause specialist. Taking body identical HRT is usually recommended until you are at least 51 years old, which is the average age for menopause. Many women then continue to take HRT after this age as there are more benefits than risks for the majority of women.

What else can you do to look after your heart health?

Taking care of your blood pressure and your overall health will help you lower your risk of heart disease and stroke after the menopause and into later life.

Remember to:

• Have your blood pressure checked regularly
• Take your blood pressure medicines if you are prescribed them
• Be active
• Eat a healthy and balanced diet trying to avoid or reduce processed food intake
• Try to maintain a healthy body weight
• Limit or reduce alcohol intake
• Stop smoking
• Consider doing yoga and meditation regularly.

Avoiding HRT in menopausal women can actually be detrimental to their future health in terms of cardiovascular disease and also osteoporosis as well as other diseases.

Authors

Dr Louise Newson BSc(Hons) MBChB(Hons) MRCP FRCGP, GP and Menopause Specialist

Dr Rebecca Lewis MBBS FRCA DRCOG MRCGP, GP and Menopause Specialist

Dr Penny Ward BM MRCGP DFSRH PGCert MedEd, GP and Menopause Specialist

Dr Sarah Glynne MB BS(Hons) BSc (Hons) MRCP MRCGP MSc, GP with a special interest in menopause

Dr Marco Gambacciani, Italian Menopause Society president

Professor James Simon, MD, CCD, MSCP, IF, FACOG, Clinical Professor, George Washington University, past-President, International Society[KK1] [LN2]  for the Study of Women’s Sexual Health, past-President, North American Menopause Society

References

1. Timmis, A. et al. (2022), ‘European Society of Cardiology: cardiovascular disease statistics 2021’, European Heart Journal vol. 43,8: 716-99. doi:10.1093/eurheartj/ehab892
2. Newson, L. (2018), ‘Menopause and cardiovascular disease’, Post Reproductive Health vol. 24,1: 44-49. doi:10.1177/2053369117749675
3. Xiang, Du et al. (2021), ‘Protective effects of estrogen on cardiovascular disease mediated by oxidative stress’, Oxidative Medicine and Cellular Longevity. doi:10.1155/2021/5523516
4. World Health Organization (2023), Hypertension
5. Roeters van Lennep J.E., Tokgözoğlu L.S., Badimon L., et al. (2023), ‘Women, lipids, and atherosclerotic cardiovascular disease: a call to action from the European Atherosclerosis Society’, European Heart Journal vol. 44(39):4157-73. doi:10.1093/eurheartj/ehad472
6. Biglia, N. et al. (2017), ‘Vasomotor symptoms in menopause: a biomarker of cardiovascular disease risk and other chronic diseases?’, Climacteric vol. 20,4: 306-12. doi:10.1080/13697137.2017.1315089
7. Carson, M.Y., Thurston R.C. (2023), ‘Vasomotor symptoms and their links to cardiovascular disease risk’, Current Opinion in Endocrine and Metabolic Research vol. 30: 100448. doi:10.1016/j.coemr.2023.100448
8. Honigberg, M.C. et al. ‘Association of Premature Natural and Surgical Menopause With Incident Cardiovascular Disease.’ JAMA vol. 322,24 (2019): 2411-21. doi:10.1001/jama.2019.19191
9. Honigberg, M.C. et al. (2021), ‘Premature menopause, clonal hematopoiesis, and coronary artery disease in postmenopausal women’, Circulation vol. 143,5 (2021): 410-23. doi:10.1161/CIRCULATIONAHA.120.051775
10. Mueck, A.O., Seeger. H (2004), ‘Effect of hormone therapy on BP in normotensive and hypertensive postmenopausal women’, Maturitas vol. 49,3: 189-203. doi:10.1016/j.maturitas.2004.01.010
11. Lobo R.A. et al. (2016), ‘Back to the future: hormone replacement therapy as part of a prevention strategy for women at the onset of menopause’, Atherosclerosis, 254:282-90. doi:10.1016/j.atherosclerosis.2016.10.005
12. Hodis H.N., Mack W.J. (2022), ‘Menopausal hormone replacement therapy and reduction of all-cause mortality and cardiovascular disease: it is about time and timing’, Cancer, 28(3):208-23. doi: 10.1097/PPO.0000000000000591
13. Clarkson T.B. (1999),’Progestogens and cardiovascular disease: a critical review’, Journal of Reproductive Medicine, 44(2 Suppl):180-4.
14. Mirkin S., (2018), ‘Evidence on the use of progesterone in menopausal hormone therapy’, Climacteric, 21:4, 346-354. doi: 10.1080/13697137.2018.1455657
15. Nolan et al. (2021), ‘Efficacy of micronized progesterone for sleep: a systematic review and meta-analysis of randomized controlled trial data, The Journal of Clinical Endocrinology & Metabolism vol. 106 (4) 942-51. doi:10.1210/clinem/dgaa873