How Blood Pressure Affects Women

An omnipresent metric, blood pressure serves as an indicator of our cardiovascular well-being, which affects all aspects of our lives.

However, as we delve into this fascinating world of pulsating forces, an intriguing discovery surfaces: There is a distinct gender disparity when it comes to blood pressure.

"Many women are unaware cardiovascular disease (CVD) kills twice as many women as breast cancer every year," said Deborah Lee, M.B. Ch.B., a sexual and reproductive health specialist at Dr Fox, an online doctor and pharmacy service in the United Kingdom. "Looking after your blood pressure is vital for women for good health and longevity."

Women navigate a distinct physiological landscape, such as hormonal fluctuations, which can impact their cardiovascular health. Understanding these gender-specific dynamics is crucial for women's individual well-being and remains essential for developing targeted interventions and providing personalized healthcare.

Women differ from men in part because of their reproductive hormones. Between the ages of adolescence and menopause, hypertension is less common in women than men in the same age group. After menopause, the incidence of high blood pressure rises steeply, Lee said. Plus, there are differences between sexes regarding how blood pressure affects health.

"Women are more sensitive to the harmful effects of blood pressure than men," she said, adding that a 10 mmHg (millimeters of mercury) rise in blood pressure in women increases the risk of cardiovascular disease by 25 percent.

In contrast, the same rise in blood pressure in men only increases CVD risk by 15 percent.

This is because men and women appear to have different "types" of high blood pressure. The exact cause of hypertension is not clearly defined, but men have raised blood pressure with normal vascular resistance. Women, on the other hand, can have raised vascular resistance and increased arterial stiffness as evidenced by abnormal pulse wave velocity (a measurement of arterial stiffness).

Premenopausal women are largely protected from hypertension by their estrogen levels. Lee explained this is because estrogen, a steroid hormone, is responsible for the following:

• It depresses the renin-angiotensin-aldosterone system (RAAS), a unique hormone system that regulates blood pressure via hormones produced in the kidney that increase or decrease sodium reabsorption into the bloodstream. Estrogen lowers the effects of the RAAS, lowering levels of angiotensin 2, thus lowering blood pressure.
• It increases levels of nitric oxide (NO), which is a powerful vasodilator that lowers blood pressure.
• It reduces levels of endothelin 1, a peptide that causes vasoconstriction and raises blood pressure.

"In women, testosterone levels are lower than those of men," Lee said. "Testosterone is known to stimulate the RAAS system."

After menopause, women are more at risk of high blood pressure.

"High blood pressure, or hypertension, is a common illness that many women have, especially as they age," said Robert Pilchik, M.D., a board-certified cardiologist with Manhattan Cardiology in New York City. "It's crucial to frequently check your blood pressure and take action to keep it within a healthy range because high blood pressure can increase the risk of heart disease, stroke and other health issues."

Pilchik said high and low blood pressure can present various symptoms for women.

Signs of high blood pressure in women include the following:

• Blurry vision
• Chest pain
• Dizziness or lightheadedness
• Fatigue or weakness
• Headaches, particularly at the back of the head
• Irregular heartbeat
• Nausea or vomiting
• Nosebleeds
• Shortness of breath
• Swelling in the feet, ankles or legs

Signs of low blood pressure in women include:

• Blurry vision
• Cold, clammy or pale skin
• Depression or anxiety
• Dizziness or lightheadedness, especially when standing up from a seated or lying position
• Fainting or feeling faint
• Fatigue or weakness
• Nausea or vomiting
• Pale or clammy skin
• Rapid or shallow breathing
• Thirst

"It's crucial to remember that not everyone who has high blood pressure exhibits any symptoms," Pilchik noted.

Unless it originates from an underlying medical issue or has symptoms, low blood pressure is not always a cause for concern.

If you're wondering how often you should get your blood pressure checked, Lee recommended the following:

• Adults age 40 and older should have their blood pressure measured at least once every five years.
• If a woman has risk factors for high blood pressure, it should be checked more often. This includes women who are on a combined oral contraceptive pill—containing synthetic female hormones, estrogen and progestogen—or who have polycystic ovary syndrome (PCOS) or who have other medical conditions such as diabetes and/or obesity.
• Women who smoke or drink more than the recommended amount of alcohol should undergo more frequent blood pressure checks.

Speak with your primary healthcare provider if you have concerns about your blood pressure and, together, you'll come up with a suitable testing period.

Young women with hypertension have a secondary cause for their raised blood pressure more often, Lee noted, which can include:

• Coarctation of the aorta, a congenital narrowing of a short section of the aorta, the largest artery of the body, which carries blood from the heart to the circulatory system
• Congenital adrenal hyperplasia, a genetic disorder where the two adrenal glands (located at the top of the kidneys) don't function properly
• Cushing's syndrome, when a pituitary adenoma—a benign tumor on the pituitary gland—makes too much adrenocorticotropic hormone (ACTH)
• Diabetes
• Fibromuscular dysplasia, an abnormal growth of cells in the walls of arteries that can cause the vessels to narrow or bulge
• Phaeochromocytoma, a rare tumor of the adrenal glands, typically found in adults
• Renal artery stenosis, or the narrowing of one or more renal arteries that carry blood to your kidneys
• Thyroid dysfunction, which includes a number of disorders that can result in the thyroid gland producing too little (hypothyroidism) or too much (hyperthyroidism) of the thyroid hormone

High blood pressure is common in women age 65 and older; this may be due to the lack of endogenous estrogen.

Other reasons include chronic inflammation, oxidative stress, lifestyle factors—obesity, smoking, lack of exercise and too much alcohol—and increased arterial stiffness. It's difficult to disassociate what is due to being female and what is caused by natural aging.

"Blood pressure tends to be more severe in older women and more difficult to treat," Lee said.

Women may experience a variety of female-specific medical conditions that can affect their blood pressure.

• Assisted reproduction techniques (ART). Many studies have shown that women going through ART—in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI)—are at increased risk of preeclampsia, but the reasons for this are unknown.
• Endometriosis. Pilchik noted this disorder raises the risk of high blood pressure by causing inflammation and chronic pain.
• Menopause. Blood pressure in women often rises sharply after menopause. In the United States, 65 percent of women age 60 and older have high blood pressure.
• Polycystic ovary syndrome (PCOS). Lee noted women who have PCOS produce too many androgens (testosterone) and may fail to ovulate. It is characterized by irregular or absent periods, unwanted hair, obesity, acne and infertility. In general, higher testosterone and lower estrogen levels, plus a tendency to obesity, increase the risk of high blood pressure.
  In addition, PCOS sufferers are at increased risk of diabetes, which also raises blood pressure.
• Pregnancy. The reasons for high blood pressure in pregnancy are complex and not fully elucidated. A woman's blood volume increases by as much as 45 percent in pregnancy, meaning the heart must pump harder to maintain blood circulation.
  "Preeclampsia, or pregnancy-induced hypertension, can raise blood pressure and lead to other pregnancy issues," Pilchik said, adding the fetus's growth and development could be impacted by high blood pressure during pregnancy.
• Taking the combined oral contraceptive pill (COC). Known as "the pill," COCs contain synthetic estrogen (17 beta-estradiol), which is known to increase blood pressure. Small numbers of women taking the pill develop high blood pressure, in which case, they should stop taking it. However, modern COCs contain a much lower dose of 17 beta-estradiol than was used years ago; thus, the risk of raised blood pressure is minimized.

  For most women, the benefits of taking the pill outweigh the risks. They should, though, have their blood pressure measured before starting COCs and regularly while taking them. However, the guidelines set out by the Faculty of Sexual and Reproductive Health in 2019 state COCs should not be prescribed for women with hypertension, aged 35 or older who smoke, or for people with multiple risk factors for CVD.

Sexual health is an integral component of overall well-being, and any disruption in this delicate balance can significantly impact a woman's quality of life.

Physiologically, issues stemming from blood pressure impede healthy blood flow throughout the body, affecting the vascular system responsible for arousal and sexual response.

In the case of hypertension, narrowed and stiffened blood vessels can lead to reduced blood flow to the pelvic region. This can result in diminished sexual sensation, difficulties in achieving arousal, and even anorgasmia, which is best described as regular difficulty having an orgasm even after sufficient sexual stimulation.

"Blood vessels and organs important for sexual and reproductive health can be harmed over time by hypertension," Pilchik said. "High blood pressure in women can cause a decrease in libido and vaginal lubrication, which can make sexual activity uncomfortable or painful."

On the other hand, hypotension, characterized by low blood pressure, can cause dizziness, fatigue and a lack of energy, leading to decreased sexual desire and performance.

The psychological impact of blood pressure problems on sexual health should not be underestimated. Women may experience heightened stress, anxiety or depression due to the challenges of managing their blood pressure, which can cause a diminished interest in sexual activity, body image concerns, and difficulties in establishing and maintaining intimate connections.

Lee and Pilchik offered several tips for looking after your blood pressure.

Get regular exercise

Exercise has numerous positive effects on lowering blood pressure. It works the heart muscle so it pumps more efficiently. It lowers peripheral vascular resistance, decreases the sympathetic nervous system's stress response and reduces oxidative stress levels. Women should aim for at least 150 minutes of moderate-intensity exercise or 75 minutes of vigorous-intensity exercise every week.

Eat a balanced diet

Eating a diet rich in fruits, vegetables, whole grains, lean proteins and low-fat dairy products can help keep blood pressure in check.

Reduce your salt intake

Most people take in 9 to 12 grams of salt per day—about twice the recommended daily amount of less than 5 grams per day. You can do this by cooking from scratch with more fresh produce and eating less processed food. Don't add salt to food and try to avoid eating salty snacks.

Maintain a healthy weight

Work with a healthcare professional to figure out a healthy weight for you and then do your best to maintain that.

Limit alcohol intake

Alcohol stimulates the RAAS system and increases blood pressure. As we age, our ability to metabolize alcohol reduces, meaning our alcohol levels get higher and stay elevated for longer. Alcohol is full of calories and is a contributor to obesity, which raises blood pressure.

Manage stress

Engage in relaxation techniques such as deep breathing exercises, meditation, yoga or Tai Chi.

Quit smoking

Each cigarette you smoke causes a spike in blood pressure. Smoking results in the production of acrolein, which is needed in the transport of HDL (good) cholesterol. As a result, smoking is directly linked to accelerated atherosclerosis—the deposition of fatty plaques in the arteries, which underpins the occurrence of major cardiac events such as heart attacks and strokes.

Get regular blood pressure monitoring

In order to monitor blood pressure levels and detect possible problems early, women should undergo frequent blood pressure checks. If you haven't had your blood pressure checked in a while, let this serve as a reminder to contact your healthcare provider.

Don't assume that cardiovascular disease won't affect you just because you don't hear about it as often as you hear about other women's health issues. It's a silent killer but one that is largely preventable and manageable. Talk with your doctor.