A new study published in Hypertension, a peer-reviewed journal of the American Heart Association, challenges the long-held belief that menopause is the main cause of increased aortic stiffness and pulse pressure in women after midlife. The research, conducted as part of the Framingham Heart Study, indicates that the rise in pulse pressure—the difference between systolic and diastolic blood pressure readings—begins about two decades before menopause, suggesting that vascular aging starts much earlier than previously thought.
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 a wider pulse pressure, which means the heart must work harder and small vessels in organs like the brain and kidneys may be damaged. This is significant because 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. They found that pulse pressure reached its lowest point and began to rise about a decade earlier in women (late 30s) than in men (late 40s). Importantly, the timing of menopause—whether early, late, or average—had no influence on when this transition occurred. The increase in pulse pressure was also 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."
Mitchell emphasized that women and their doctors should be alert if pulse pressure exceeds 60 mm Hg, such as 130/70 mm Hg, and track it over time. He also noted that high blood pressure with a wide pulse pressure is less likely to respond to standard treatments, making tailored approaches crucial.
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, commented that vascular aging may begin years before menopause, but menopause remains relevant. "We shouldn’t wait until menopause to start thinking about cardiovascular health," she said. "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 pool, which may limit generalizability. The research was supported by the National Heart, Lung, and Blood Institute and led by Boston University. The findings underscore the need for healthcare providers to monitor pulse pressure in women long before menopause and to consider it as an independent risk factor in clinical guidelines.
