Contradicting long-held beliefs, a new study published in Hypertension, a peer-reviewed journal of the American Heart Association, suggests that menopause may not be the primary driver of increased aortic stiffness and pulse pressure in women after midlife. The research, based on data from the multi-generational Framingham Heart Study, found that the transition from falling to rising pulse pressure occurs about two decades before menopause, with women reaching their lowest pulse pressure in their late 30s—a decade earlier than men, who reach it in their late 40s.
Pulse pressure, the difference between systolic and diastolic blood pressure readings, is a critical indicator of aortic health. A wider pulse pressure means the aorta, the body’s largest blood vessel, is becoming stiffer and less flexible, forcing the heart to work harder and potentially damaging small vessels in organs like the brain and kidneys. This stiffness is a major risk factor for cardiovascular disease, dementia, and kidney disease, and it can make high blood pressure less responsive to standard medications.
The study analyzed 6,760 women and 3,248 men from the Framingham Heart Study over 14 years. Women were grouped by self-reported age at menopause: premenopausal, early, average, and late. Surprisingly, the timing of menopause—whether early, late, or typical—had no influence on when pulse pressure reached its lowest point. Instead, the shift occurred up to two decades before the final menstrual period, indicating that vascular aging begins well before menopause. After midlife, pulse pressure increased faster in women than in men, leading to higher average pulse pressure in women after age 60.
“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,” 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. “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.”
These findings have significant implications for clinical practice. Currently, pulse pressure is not included in clinical guidelines for managing blood pressure, but the study authors argue that healthcare professionals should pay greater attention to it, especially in middle-aged and older women. “Healthcare professionals should definitely consider pulse pressure in middle-aged and older patients – especially women – with high blood pressure,” Mitchell said. “Because women’s overall heart disease risk is lower, they are often told that a blood pressure that is ‘borderline’ - for example an upper number of 130 mm Hg - can just be watched. However, 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.”
Greater attention to pulse pressure could also guide individualized treatment approaches, as high blood pressure with a wide pulse pressure is less likely to respond to usual therapies. 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. Midlife is an opportunity to identify cardiovascular risk early and intervene before disease develops.”
The study’s limitations include its observational nature, reliance on self-reported menopause age, and a predominantly white European descent sample, which may limit generalizability. Nonetheless, the research underscores the importance of monitoring pulse pressure as a marker of vascular aging and a potential target for early intervention to reduce cardiovascular risk in women.
