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 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—begins to rise about two decades before menopause, indicating that vascular aging starts much earlier than previously thought.
The aorta, the body's largest blood vessel, stiffens with age, leading to wider pulse pressure. 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. The study analyzed data from 6,760 women and 3,248 men, tracking pulse pressure changes over 14 years. Results showed that pulse pressure reached its lowest point and began rising in women in their late 30s, compared to late 40s in men. Notably, the timing of menopause—whether early, late, or average—had no influence on when this transition occurred.
"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. The findings imply that healthcare professionals should pay greater attention to pulse pressure in middle-aged and older women, especially those with high blood pressure. "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," Mitchell added.
The study's implications extend to clinical practice. Currently, pulse pressure is not included in clinical guidelines for managing blood pressure, but the researchers argue it should be. High blood pressure with a wide pulse pressure is less likely to respond to usual treatments, so tailored approaches are important. 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. 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.
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. However, the findings underscore the importance of early monitoring and intervention. As Mitchell noted, "Vascular aging may begin years before menopause, but that doesn't mean menopause is irrelevant. The trajectory may accelerate as women enter perimenopause." The research supports the need for increased awareness and proactive management of pulse pressure to reduce cardiovascular risk in women.
