Prof Angela Maas, Radboud UMC, The Netherlands

Gender differences in cardiovascular disease are well established, especially as women reach the menopause. However, much needs to be done to educate the physicians to help them distinguish between stress-related hypertension and severe cases of hypertension in these women.

Professor Angela Maas, Professor of Women’s Cardiac Health at Radboud University Medical Center in Nijmegen, The Netherlands, talks to Cardio Debate about the link between hypertension and the menopause, including strategies needed to tackle this issue on individual and national levels.

What is the connection between hypertension and the menopause?
The oestrogen hormones have an important regulatory effect on the renin-angiotensin system. When women are in their forties and the oestrogen levels decline, when the menopause starts, there are several dangers in the renin-angiotensin system.

At this point the renin and endothelin levels in the blood are higher. We see that vascular stiffness due to endothelial dysfunction develops more rapidly and more severely in women compared to men.

There is also an increase in salt sensitivity. We see a lot of women in their fifties having problems with fluid retentionwhich is also related to hormonal changes in the menopause.

So, in the older age groups we see more men with hypertension, but after the menopause transition – around 55 years – this changes into a predominance in women.

We often think that hypertension is asymptomatic, but it can give a lot of symptoms especially in women who are rather young, who are middle aged.

For instance chest pain, or chronic pain between the shoulder blades can be due to elevated blood pressure, and often when you treat the blood pressure these symptoms disappear. Also, there are symptoms on excursion, for example climbing the stairs, riding on a bicycle – we see this happening in women who are over 50. And if we treat the blood pressure to a lower level, between 120-130 systolic, you’ll see that exercise performance increases.

This applies especially in women who have had hypertensive pregnancy disorders – it is often easy to ask about their pregnancies – these women are certainly prone to developing hypertension at an earlier age than women who had normal pregnancies.

So I think in this age group it is easy to discriminate between stress-related elevated blood pressure and severe development hypertension. Just ask those questions about pregnancy, but also about family history. There is one serious risk factor which is genetic, and this is hypertension.

Does the cause of menopause (i.e., surgical versus biological) impact the risk of heart disease?
Yes, absolutely. It is a ‘chicken and egg’ discussion, but we tend to think that a younger onset of menopause is an indication of higher cardiovascular risk, whereas surgically-induced menopause – especially in women in their forties – doesn’t have a very large impact on cardiovascular risk.

An early menopause, before the age of 40, is certainly an indication of a higher, intrinsic genetic cardiovascular risk. And you also see in those women that they have more cardiovascular disease in their families. They have more pregnancy-related disorders like hypertension and gestational diabetes. So it is an important indication of a higher cardiovascular risk that we can see in women who are middle aged.

What strategies need to be employed on an individual and national scale to tackle post-menopausal hypertension?
In men it is taken more seriously, and often in women hypertension is called ‘stress’. Also women themselves tend to tell their doctor that they are busy, perhaps they have grandchildren or problems at work, all kinds of excuses for having elevated blood pressure.

Nowadays we can give patients the tools to measure blood pressure themselves, and I always advise women at middle age to buy a blood pressure monitor and to have a look at themselves in a home setting, and perhaps measure blood pressure once to twice a week. This gives a more serious idea about the real value of their blood pressure.

We have seen in the Systemic Blood Pressure Intervention Trial (SPRINT) in the US that levels of blood pressure should be lower than we used to, say below 140/90, and also we should take into account the different phases of life the women are in. So for example, blood pressure of 130 when you are in your thirties is too high, and 140 systolic in your forties is too high. We really need to relate blood pressure more seriously to the age group the patient is in.

It is very important to treat it annually, because women get more arterial stiffness, more myocardial stiffness when they age compared to men. Thus far, all those trials to reduce diastolic heart failure don’t success because it is too late. You need to start early, at middle age, to do your prevention.

It’s all in my book, a handbook on female-specific cardiology, we call it the Manual of Gynecardiology [1] and it’s also about female-specific risk factors, it’s about the difference between men and women in ischaemic heart disease, stable and unstable ischaemic heart disease. But it is also about female aspects of cardiomyopathies, differences between men and women in valve diseases – there are important differences.

We also look at cardio problems when treated for breast cancer. Breast cancer is a women’s disease, but we still underestimate the cardiotoxicity of the treatment that we currently give to women. And often women, when they have breast cancer treatment 10 years previously, they are getting tired and not feeling well, it’s not often attributed to their previous cancer treatment. I think we can perform better in preventing serious problems in breast cancer.


  1. Manual of Gynecardiology: Female-Specific Cardiology. Editors Maas, Angela H.E.M., Bairey Merz, C. Noel.