Should women with hypertension avoid hormone replacement therapy?
Hormone therapy may improve cardiovascular health if initiated early in menopause.
So, do hormones increase or decrease the risks of heart disease in women with hypertension?This discussion is a complicated one, but here is what we do know and what still remains to be determined.
We know that hypertension is major risk factor for heart disease. We believe that if hypertension was eliminated, so would 38% of heart disease. Without hypertension, women might live an extra 5 years. We know that 56% of women ages 55 to 64 are hypertensive. That percentage increases to 66% for ages 65-74, and 81% over the age of 75.
The incidence of hypertension increases with menopause, and estrogen may protect women form hypertension until they go through menopause. Estrogen protects the cardiovascular system in a complex mechanism. On a molecular level, estrogen protects the inside lining of the blood vessels, as well as renal hormones which affect blood pressure. Before menopause, blood vessels are not as stiff.
The date regarding the effects of HRT on blood pressure are conflicting .Hormones are thought to have a neutral effect of blood pressure, and hypertension is not a contraindication to hormone replacement if blood pressure is well-controlled. The Women’s Health Initiative did demonstrate in 18% increase in hypertension in women on HRT, and an 29% increase in strokes in women who took estrogen alone, without progesterone. It is thought that if hormones are started early in menopause, within the first 10 years, there may be a cardiovascular benefit which is not found if hormones are started later. It is not recommended that HRT be given to prevent CV disease.
In younger, premenopausal women, oral contraceptive can increase BP. In premenopausal women, progesterone-only contraception does not increase blood pressure.
On the other hand, women with early menopause, or surgical menopause at ages 35-45, have an increased risk of ischemic heart disease which is not seen if the ovaries are preserved.
The reality is that probably half of women with hypertension really do not have good blood pressure control. The standard for normal blood pressure has been lowered to 130/80, and if your BP is >130/80 on two separate occasions, the diagnosis of hypertension is made. Automated blood pressure cuffs are now standard, and can be used at home. Blood pressure control strategies include weight loss, decreased sodium intake (<1500 mg/day), increased potassium intake, increased exercise, and moderation of alcohol intake (<1 drink on average per day). Medication therapy is indicated in anyone who has an elevated blood pressure, if life-style modifications are not successful.
In women who go through an early menopause, hormone therapy should be considered at least until the average natural age of menopause, which is age, 51.5 years of age. This is to prevent premature heart disease.
Marilyn C.Jerome, MD
NAMS Practice Pearl: Hypertension in Menopausal Women: The Effect and Role of Estrogen
Released December 11, 2019, K. Srivaratharajah, MD, MSc, FRCPC, and B. Abramson, MD, MSc, FACC