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 Program
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 one in 2.5 deaths among women, compared with breast cancer, which causes one 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 greater.
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 Antihypertensive 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 placebo.
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 in men.
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 Menopause and You, 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 health care provider with your specific concerns and questions.
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