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 primary driver of increased aortic stiffness in women after midlife. The research, conducted as part of the long-running Framingham Heart Study, found that the transition from falling to rising pulse pressure—a key indicator of aortic stiffening—occurs about two decades before menopause, challenging the long-held assumption that hormonal changes during menopause are responsible.
Pulse pressure, the difference between systolic and diastolic blood pressure, is influenced by the stiffness and width of the aorta, the body's largest blood vessel. A wider pulse pressure indicates the heart is working harder and can damage small vessels in organs like the brain and kidneys. While high blood pressure is a known modifiable risk factor for cardiovascular disease, wide pulse pressure is increasingly recognized as an independent risk factor for heart disease, dementia, and kidney disease.
The study analyzed data from 6,760 women and 3,248 men in the Framingham Heart Study, tracking pulse pressure over 14 years. Researchers found that pulse pressure reached its lowest point and began rising in women in their late 30s, compared to late 40s in men. Importantly, the timing of menopause—whether early, average, or late—had no influence on when this transition occurred. After midlife, pulse pressure increased faster in women, leading to 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.
These findings have significant implications for clinical practice. Currently, pulse pressure is not included in clinical guidelines for managing blood pressure. However, the study authors argue that healthcare professionals should pay greater attention to pulse pressure, 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. He noted that women are often told that borderline high blood pressure can be monitored, but a pulse pressure higher than 60 mm Hg (e.g., 130/70 mm Hg) should prompt alarm and tracking over time.
The research also suggests that high blood pressure with a wide pulse pressure may be less responsive to standard treatments, making tailored approaches 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 vascular aging may begin years before menopause. "We shouldn't wait until menopause to start thinking about cardiovascular health," said El Khoudary, who was not involved in the study. "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 sample, which may limit generalizability. The Framingham Heart Study has been supported by the National Heart, Lung, and Blood Institute and led by Boston University since 1971. The findings underscore the need for earlier cardiovascular risk assessment in women and highlight pulse pressure as a critical metric for predicting heart disease, dementia, and kidney disease.
