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REFLECTIONS
Hypertension
Hypertension Global Newsletter #4 2023

Hypertension in women Hypertension
• Blood pressure trajectories during the life course of women are steeper than in men
• Hypertension control declines with age in women
• The association of blood pressure with poor CVD outcomes is stronger in women than in men
• Women and gender-specific aspects of hypertension are understudied and the existing evidence is poorly translated into
clinical guidelines

Pathophysiology of hypertension in women
• Obesity is strongly associated with hypertension in women
• Gynaecological disorders and adverse pregnancy outcomes are associated with cardiometabolic risk and hypertension in
women
• Physiological levels of estrogen are cardioprotective and promote vasodilation
• Pharmacological use of estrogen may increase blood pressure and CVD risk
• Progesterone promotes leptin-mediated endothelial dysfunction in obese premenopausal women
• Sodium sensitivity is more pronounced in women
• Greater occurrence of inflammatory disorders associated with hypertension and CVD in women

Risk factors for hypertension across the life course of women
• Female-specific factors associated with hypertension and CVD later in life, including timing of menarche, menstrual and fertility
disorders, uterine fibroids, PCOS, endometriosis, adverse pregnancy outcomes, premature ovarian dysfunction, and menopause
• Elevated risk during reproductive life could contribute to the perimenopausal or postmenopausal increase in CVD, with
perhaps overlooked opportunities in younger women to prevent CVD

Women-specific aspect of clinical hypertension management
• History taking should include gynaecological disorders, fertility and childbirth history, (adverse) pregnancy outcomes,
menopausal status, history of breast malignancy and treatment
• Clinical examination should include BP measurement and CV risk assessment, especially in women who are obese, have a
history of a gynaecological disorder, who wish to conceive, and with a history of adverse pregnancy outcomes
• Lifestyle intervention may include dietary sodium restriction, reduction of NSAIDs, replacement of oral contraceptives with
other means of contraception, and smoking cessation
• There are limited women-specific recommendations for pharmacological treatment:
- Earlier treatment is suggested for women with a history of pregnancy-induced hypertension and stage 1 hypertension
- Sparse data suggests BP lowering is greater with beta-adrenergic or calcium channel blockers
- Experimental evidence indicates that women with obesity may benefit from aldosterone antagonists
- For women with PCOS, metformin or antiandrogens may be indicated along with spironolactone and RAS blockers
- For women with fibroids or adverse pregnancy outcomes, metformin and RAS blockers have been proposed
• Women tend to experience more adverse effects of antihypertensive drugs, which may be due to understudied sex differences
in pharmacokinetic or pharmacodynamic properties

Cardiovascular health in women
• Patient, provider, health system level, and societal factors are implied in the blood pressure-related and cardiovascular
outcomes in women
• A healthy reproductive system is central to females’ cardiovascular health, as well as that of their offspring
• Earlier detection and better management of hypertension and cardiovascular risk factors in premenopausal women may
not only increase their healthy life expectancy but also support women in having healthier pregnancies, thus reducing
hypertension and CVD in future generations

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