A new study published in Hypertension, a peer-reviewed journal of the American Heart Association, indicates that the rise in pulse pressure and aortic stiffness that occurs in women during midlife may not be primarily driven by menopause. 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 increase about two decades before menopause, contradicting the long-held belief that falling estrogen levels at menopause are the main culprit.
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 must work harder and small vessels in organs like the brain and kidneys may be damaged. Wide pulse pressure is a known risk factor for cardiovascular disease, dementia, and kidney disease, and it can make high blood pressure less responsive to standard 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 rising in women in their late 30s, compared to late 40s in men. The timing of menopause—whether early, average, or late—had no influence on when this transition occurred. After midlife, pulse pressure increased faster in women than 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. “Healthcare professionals should definitely consider pulse pressure in middle-aged and older patients – especially women – with high blood pressure.”
The findings suggest that vascular aging may begin years before menopause, and that midlife is a critical window for early intervention. 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 cardiovascular health should be a focus long before menopause. “We shouldn’t wait until menopause to start thinking about cardiovascular health,” she said. “By the time a woman reaches her final menstrual period, vascular changes may already have been underway for years.”
The study’s implications are significant for clinical practice. Currently, pulse pressure is not included in blood pressure management guidelines, but Mitchell and colleagues argue it should be. Women with a pulse pressure higher than 60 mm Hg, such as 130/70 mm Hg, should be monitored closely, as this may indicate a need for tailored treatment approaches. The research also underscores the importance of recognizing sex differences in cardiovascular risk and the potential for early intervention to prevent disease progression.
Limitations of the observational study include the inability to prove cause and effect and reliance on self-reported menopause age. Most participants were of white European descent, so results may not apply to other racial or ethnic groups. The study was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health and led by Boston University since 1971.
