Hypertension symptoms often mistaken for menopause in middle-aged women

One in 2 women may develop hypertension, or high blood pressure, before age 60. But a group of European doctors warn that many of these women may miss out on needed treatment to help prevent events like heart attacks and strokes because their hypertension symptoms are chalked up to menopause.

New research shows that many middle-aged women may be living with undiagnosed hypertension because symptoms of the condition — including chest pain, exhaustion, headaches, heart palpitations, and sleep disturbances — are mistakenly attributed to menopause.

Missed hypertension cases are part of a broader problem of overlooked cardiovascular disease among middle-aged women, according to a paper by a group of cardiologists, gynaecologists, and endocrinologists published in January 2021 in the European Heart Journal. Too often, these women have undiagnosed hypertension and other risk factors for cardiovascular disease because their doctors focus on signs common in men that aren’t as typical for women, the paper argues.

“The main reason for this confusion is that the pattern of aging of the coronary arteries is different among women and men, and this starts around menopause,” says Angela Maas, MD, PhD, lead author of the paper and a professor in women’s cardiac health at Radboud University Medical Center in Nijmegen, Netherlands.

Stenosis, or narrowing of the large arteries, typically doesn’t develop in women until about a decade later than in men and is unlikely to be present in women in their forties and fifties who are going through menopause, Dr. Maas says.

When cardiologists look for stenosis in middle-aged women and don’t find it, they may be too quick to conclude that women are experiencing symptoms of menopause — and not symptoms of hypertension or other risk factors for cardiovascular disease, Maas says.

The first signs of cardiac symptoms in middle-aged women tend to start around the same time as menopause and can include coronary spasms — a sudden, rapid narrowing of a blood vessel that can block blood flowing to the heart — and what’s known as microvascular disease, or damage to small arteries in the heart, Mass notes.

“Menopausal symptoms include night sweats, hot flashes, fast or irregular heartbeat, and even chest pain,” Maas says. “This can be difficult to distinguish from cardiac symptoms related to coronary spasm; an experienced cardiologist should know this.”

Heart risks of menopause

According to the North American Menopause Society, women reach menopause, on average, at age 51; for most it occurs between ages 45 and 55 and marks the permanent end of fertility. The run-up or transition stage lasts several years and involves the gradual reduction of the body’s production of reproductive hormones such as estrogen and progesterone.

Declining estrogen levels after menopause can contribute to increased weight gain around the midsection, a reduced ability to use the hormone insulin to convert sugars in the blood into energy, increased lipid levels, and elevated blood pressure, according to the new paper.

Women with severe menopause symptoms — particularly hot flashes and night sweats — are roughly 50 percent more likely to develop what’s known as subclinical atherosclerosis, slight narrowing and hardening of the arteries that might not produce any symptoms but can still increase the risk of heart attacks and other serious cardiovascular events, according to the paper.

Chest pain, however, is not a symptom of menopause, warns Stephanie Faubion, MD, director of the Mayo Clinic Center for Women’s Health in Rochester, Minnesota, and medical director for the North American Menopause Society.

“Any symptoms such as palpitations, shortness of breath, chest pain, or symptoms with exercise — even decreased exercise tolerance — should be evaluated before assuming they relate to menopause,” advises Dr. Faubion, who wasn’t involved in the new paper.

Menopause hormone therapy and heart risks

Hormone replacement therapy can be an effective way to ease menopause symptoms, particularly when symptoms are severe and interfere with daily life. While safety and effectiveness varies based on the type of hormone as well as how it’s delivered — such as a pill versus a skin cream — the heart benefits generally outweigh the risks for healthy women under age 60 who have gone through menopause within the past 10 years, says Faubion.

Among women under 60 who recently went through menopause, hormones can reduce the risk of developing cardiovascular disease, according to the new paper. The heart benefits are greatest when hormone therapy starts sooner after menopause, the paper notes.

Oral hormones, but not hormones delivered through the skin, can increase the risk of venous thromboembolism, blood clots that form in veins of the legs, thigh, and pelvis and can break loose and travel to the lungs.

“For women at higher risk of heart disease, such as those with diabetes, a transdermal route of administration of estrogen may be preferred over oral,” Faubion says.

Heart-healthy lifestyle choices after menopause

Reduced estrogen levels around menopause are associated with a slowed metabolism as well as the potential to eat meals that are bigger than necessary, contributing to an increased risk of obesity, according to the new paper. Obesity is associated with other risk factors for heart problems, including diabetes, stressdepression, sleep deprivation, and physical inactivity, the paper notes.

This makes it essential for middle-aged women to pay extra attention to the lifestyle choices that are known to reduce their risk for heart disease, says Yamnia Cortés, PhD, MPH, FNP-BC, of the School of Nursing at the University of North Carolina at Chapel Hill. Dr. Cortés, who wasn’t involved in the new paper, recommends the following heart-healthy lifestyle changes:

  • Stop smoking.
  • Maintain a healthy weight.
  • Get 150 minutes a week of moderate intensity exercise like brisk walking.
  • Sit less and move more; get up from your couch or desk often to move around.
  • Eat a heart-healthy diet that includes fruits, vegetables, whole grains, poultry, fish, nuts, and nontropical vegetable oils (such as olive, corn, or canola oil).
  • Limit intake of red meat, processed meat, dairy products made with whole milk, fried foods, sodium, and sugar-sweetened beverages.
  • Manage stress by doing things you enjoy, whether it’s going for a walk, making art, listening to music, practicing yoga, or taking a soothing bath.
  • Set a regular bedtime and wake-up time to help promote good quality sleep.