A new study published in Hypertension, a peer-reviewed journal of the American Heart Association, reveals that the midlife increase in pulse pressure and aortic stiffness in women may not be driven by menopause as previously thought. The research, part of the long-running Framingham Heart Study, found that pulse pressure—the difference between systolic and diastolic blood pressure readings—begins to rise about two decades before menopause, challenging conventional wisdom that links these changes to falling estrogen levels during menopause.
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 may be damaged. Wide pulse pressure is a major risk factor for cardiovascular disease, dementia, and kidney disease, and 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. They found that pulse pressure reached its lowest point and began rising about a decade earlier in women (late 30s) than in men (late 40s). The age at menopause—whether early, late, or typical—had no influence on when pulse pressure began to rise. After midlife, pulse pressure increased faster in women, resulting in higher average pulse pressure in women than men 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. “Healthcare professionals should definitely consider pulse pressure in middle-aged and older patients – especially women – with high blood pressure. Because women’s overall heart disease risk is lower, they are often told that a blood pressure that is ‘borderline’ can just be watched. However, women and their doctors should sound the alarm if pulse pressure is higher than 60 mm Hg and track it over time.”
The findings suggest that vascular aging may begin years before menopause, underscoring the need for early cardiovascular risk assessment in women. 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, noted, “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.”
Pulse pressure is not currently included in clinical guidelines for managing blood pressure, but the study authors argue it should be. Tailored treatment is important because high blood pressure with a wide pulse pressure is less likely to respond to usual treatments. The study’s limitations include its observational nature and reliance on self-reported menopause age, and most participants were of white European descent, so results may not apply to other groups.
The research was supported by the National Heart, Lung, and Blood Institute and led by Boston University. The findings highlight the importance of monitoring pulse pressure in midlife women to prevent cardiovascular disease and other conditions.
