Contradicting conventional wisdom, a new study published in Hypertension, a peer-reviewed journal of the American Heart Association, suggests that menopause may not be the driving force behind increased aortic stiffness and rising pulse pressure in women after midlife. The research, part of the long-running Framingham Heart Study, found that pulse pressure—the difference between systolic and diastolic blood pressure readings—starts to rise about two decades before menopause, challenging the long-held belief that falling estrogen levels are solely responsible.
The aorta, the body's largest blood vessel, delivers oxygen-rich blood from the heart to other organs. Over time, its walls can stiffen, leading to wider pulse pressure, which means the heart works harder and small vessels in organs like the brain and kidneys can be damaged. Wide pulse pressure is a major risk factor for cardiovascular disease, dementia, and kidney disease, and it may make high blood pressure less responsive to some medications.
Researchers analyzed data from 6,760 women and 3,248 men in the Framingham Heart Study, tracking pulse pressure over 14 years. They found that pulse pressure reached its lowest point and began to rise in women in their late 30s, about a decade earlier than in men, whose pulse pressure nadir occurred in their late 40s. Importantly, whether menopause occurred early, late, or at a typical age had no influence on the age at which pulse pressure began to rise. After midlife, pulse pressure increased faster in women than in men, resulting in higher average pulse pressure in women after age 60.
“To our huge surprise, our results suggest that factors other than the timing of the final menstrual period were likely involved in the accelerated increase in pulse pressure in women after midlife,” said study senior author Gary F. Mitchell, M.D., a longstanding NIH-funded investigator with the Framingham Heart Study and president of Cardiovascular Engineering, Inc., in Needham, Mass.
The findings have significant implications for clinical practice. “Healthcare professionals should definitely consider pulse pressure in middle-aged and older patients – especially women – with high blood pressure,” Mitchell said. “Because women’s overall heart disease risk is lower, they are often told that a blood pressure that is ‘borderline’ – for example an upper number of 130 mm Hg – can just be watched. However, women and their doctors should sound the alarm if pulse pressure is higher than 60 mm Hg [such as 130/70 mm Hg] and track it over time to see if pulse pressure is rising.”
Greater attention to pulse pressure could also guide treatment. High blood pressure with a wide pulse pressure is less likely to respond to usual therapies, so tailored treatment is important, Mitchell added.
Samar R. El Khoudary, Ph.D., M.P.H., FAHA, who chaired the writing group for a 2020 American Heart Association scientific statement on the menopause transition, emphasized that vascular aging may begin years before menopause. “We shouldn’t wait until menopause to start thinking about cardiovascular health. By the time a woman reaches her final menstrual period, vascular changes may already have been underway for years. Midlife is an opportunity to identify cardiovascular risk early and intervene before disease develops.”
The study’s limitations include its observational design, reliance on self-reported menopause age, and a predominantly white European descent participant group, which may limit generalizability. The Framingham Heart Study has been supported by the National Heart, Lung, and Blood Institute since 1948 and led by Boston University since 1971.
The American Heart Association, a relentless force for a world of longer, healthier lives, continues to fund groundbreaking research and provide critical resources to improve cardiovascular health. For more information, visit heart.org.
