Contrary to long-held assumptions, menopause may not be the primary trigger for the rise in aortic stiffness and pulse pressure that occurs in women after midlife. A new study published in Hypertension, a peer-reviewed journal of the American Heart Association, found that pulse pressure—the difference between the upper (systolic) and lower (diastolic) numbers in a blood pressure reading—begins to increase about two decades before menopause, with the lowest point occurring in women's late 30s, compared to late 40s in men.
The research, led by Gary F. Mitchell, M.D., a senior investigator with the Framingham Heart Study, analyzed data from 6,760 women and 3,248 men across three health visits spanning 14 years. Women were grouped by self-reported age at menopause: premenopausal, early, average, and late. The timing of menopause—whether early, late, or typical—had no influence on when pulse pressure reached its lowest point and began to rise. This finding challenges the conventional belief that falling estrogen levels during menopause drive the increase in aortic stiffness.
“Many people believe that the change in pulse pressure is linked to the hormonal shifts caused by menopause. Here, we are evaluating whether the timing of this change, from falling to rising pulse pressure, is connected to menopause timing in a long-term study,” Mitchell said. The results suggest that other factors are at play, and that vascular aging may begin years before the final menstrual period.
The aorta, the body's largest blood vessel, delivers oxygen-rich blood from the heart to other organs. As the aorta stiffens, pulse pressure widens, forcing the heart to work harder and potentially damaging small vessels in the brain and kidneys. Wide pulse pressure is an independent risk factor for cardiovascular disease, dementia, and kidney disease. However, it is not currently included in clinical guidelines for managing blood pressure.
“Healthcare professionals should definitely consider pulse pressure in middle-aged and older patients – especially women – with high blood pressure,” Mitchell said. He advised that women and their doctors should be alarmed if pulse pressure exceeds 60 mm Hg, such as 130/70 mm Hg, and should track it over time. This is particularly important because high blood pressure with a wide pulse pressure is less likely to respond to usual treatments, making tailored approaches essential.
The study also noted that after midlife, pulse pressure increased faster in women than in men, leading to higher average pulse pressure in women after age 60. 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 heart health should be addressed long 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,” said El Khoudary, who was not involved in the current study.
Limitations of the observational study include the inability to prove cause and effect, reliance on self-reported menopause age, and a predominantly white European descent sample, which may limit generalizability. The study was supported by the National Heart, Lung, and Blood Institute and has been led by Boston University since 1971. The findings underscore the need for earlier monitoring of pulse pressure in women and may influence future clinical guidelines, potentially improving prevention of cardiovascular and related diseases.
