While coping with menopause, women should remember to address
other significant health issues as well. Dr. Leslie Poor of Bryn Mawr
Hospital reminds us that the number one health risk for women is heart
disease. Attention to all aspects of a woman's health will promote
healthier individuals for years to come. —Beverly
Vaughn, MD, Medical Coordinator,Menopause and You
Sixty-four million Americans suffer from cardiovascular disease (CVD),
and women make up 54 percent of these Americans. CVD is the leading
cause of death in women, accounting for 1 in 2.5 deaths among women,
compared with breast cancer, which causes 1 in 30 deaths.
Despite improved diagnostic and therapeutic tools, trends in mortality
among women have not improved in recent years. This trend may be
related to increases in the prevalence of several risk factors,
including obesity and diabetes. Hypertension is the most common
modifiable risk factor. Smoking trends and dyslipidemia have shown
limited improvement in the past 10 years.
Hypertension is defined as a blood pressure of greater than or
equal to 140mmHg systolic and greater than or equal to 90mmHg diastolic
(i.e., greater than or equal to 140/90). Women's risk for developing
hypertension increases with age due to increased stiffness and pulse
wave velocity in conduit vessels. Women have lower systolic blood
pressure than men do in early adulthood. After the fifth decade of
life, the incidence of hypertension increases more rapidly in women than
in men. Studies have found significantly higher blood pressure in
postmenopausal versus premenopausal women. The menopause-related
increase in blood pressure has been attributed to a variety of factors,
including estrogen withdrawal, weight gain and overproduction of
pituitary hormones. During the fifth decade, the prevalence of
hypertension in women exceeds that of men. In women older than age 75,
the prevalence of hypertension is 75 percent.
Women are more likely than men to know that they have hypertension and
to have it treated. However, women are less likely to have their blood
pressure controlled. Observational data from the Women's Health
Initiative (WHI) underscore the gravity of the hypertension problem in
menopausal women. The WHI is best known for its finding on the
effects of hormone replacement therapy on breast cancer and
cardiovascular disease among 98,705 menopausal women, ages 50 to
79. The prevalence of hypertension was 38 percent. Among the
hypertensives only 36 percent were controlled while 64
percent were on treatment. Prevalence rates were directly related
to age. Obesity and lack of moderate or strenuous physical activity were
major determinates of hypertension prevalence.
Systolic and Diastolic Blood Pressure
After age 65, systolic hypertension is highly prevalent. The
systolic blood pressure increases throughout the entire life span.
Diastolic blood pressure tends to fall after age 60. After
menopause, the increase in systolic blood pressure per decade is 5 mmHg
Evidenced-based guidelines recommend lifestyle interventions for all
women with hypertension. Aerobic exercise and weight loss are the most
effective in reducing blood pressure. Lifestyle modification helps to
prevent the progression to higher blood pressures and reduces the need
for pharmacologic treatment. Optimizing blood pressure to 120/80
reduces the potential for cardiovascular disease and improves long-term
outcomes and prognosis.
Pharmacotherapy is advised for women with blood pressure greater than
140/90 mmHg. Even lower blood pressure goals are advised for those
with diabetes or target-organ damage, such as renal insufficiency or
heart failure. Randomized controlled outcome trials indicate that
both women and men benefit from antihypertensive drug treatments.
Treatment Research Findings
There is strong evidence from multiple research trials for use of
antihypertensive treatment in the prevention of CVD in
women. Research trials such as the INDANA, HOPE, LIFE, ALLHAT and
JNC 6 trials have provided valuable information for physicians to most
accurately prescribe medications that best suit an individual’s need.
A subgroup meta-analysis from the randomized control trial INDANA (INdividual
Data ANalysis of Anithypertensive
intervention) showed significant treatment benefit for
women. Significant reduction in stroke and major cardiovascular
events was seen in women randomized to thiazide diuretic or
beta-blockers therapy, such as metoprolol or atenolol, compared with
The HOPE (Heart Outcomes Prevention Evaluation ) study evaluated the
effects of long-term ACE inhibitor (ramipril) use on CVD outcomes in
high-risk women and men older than 54 years with documented vascular
disease or diabetes. At the time of enrollment, only half of the
participants had controlled blood pressure. Ramipril treatment of
the 2,480 female participants was associated with a 23
percent reduction in cardiovascular events, including myocardial
infarction and stroke. There was a 38 percent relative risk
reduction in cardiovascular deaths.
The LIFE trial found greater benefit from treating women than men with
losartan compared with atenolol. Greater benefit was obtained in older
people (more than 70 years old) than in younger people.
The ALLHAT trial—the largest outcome study of antihypertensive
treatments ever conducted—enrolled 19,865 women at high
risk. Analysis demonstrated benefit from diuretic therapy. The
investigators concluded the thiazide-type diuretics should be preferred
for first-line antihypertensive therapy for high-risk older women, and
diuretics should be included in all multidrug antihypertensive regimens.
JNC 6 recommended diuretics and beta blockers, such as metoprolol and
atenolol, as first-line therapy for hypertension.
Determinates of aggressiveness of antihypertensive treatments are, in
addition to the extent of blood pressure elevation, the presence of
co-morbid conditions. Women with multiple risk factors or
target-organ damage, such as kidney disease or heart failure, should be
treated to a lower goal and often require combination
therapy. These factors play a role in determining a woman's risk
for having a cardiovascular event or death from CVD over time.
Physician follow-up for monitoring of both blood pressure and side
effects of pharmacotherapy is critical to the medical management and
treatment of hypertension in women. Some studies have reported more
side effects in women than in men. Women are more likely to develop
hyponatremia and hypokalemia associated with diuretic
therapy. Women develop a cough related to ACE inhibitors, such as
lisinopril and captopril, more than men. Leg edema related to
calcium channel blockers, such as norvasc, is more common in women than
Hypertension is the most common modifiable risk factor for
cardiovascular disease in women. Evidence-based guidelines
recommend both lifestyle interventions and pharmacotherapy for treatment
of hypertension. The growing public health problems of obesity,
diabetes, and hypertension underscore the need for prevention and
identifying these health problems in women. Optimal treatment of
hypertension offers significant hope for preventing cardiovascular
disease, the leading cause of death in American women.
This article is part of the Menopause and You library,
a Web-based program sponsored by Women’s Health Source.
It is intended as an information resource providing guidelines for
women. As always, check with your own healthcare practitioner with your
specific concerns and questions.
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