Blood pressure, the menopause and HRT

8 February 2021

Female sex hormones such as estrogen play vital roles in our bodies, so it’s surprising how little most of us know about them. Blood Pressure UK caught up with GP and menopause specialist Dr Louise Newson on what you need to know about your hormones, the changes that happen at menopause, and how hormone replacement therapy (HRT) could help – even if you have high blood pressure.

Go straight to 'Can you take HRT if you have high blood pressure?'

Why do women need to know about their female sex hormones?

We have estrogen (oestrogen) receptors throughout our bodies, which means estrogen has various roles in our health. It has protective effects on our bones, cardiovascular system (that’s your lungs, heart and blood vessels) brain, vagina, joints and skin, for example.

We have other sex hormones including progesterone and testosterone which play their roles too, and can affect your mood and energy levels.

During the menopause, our ovaries (where our eggs and sex hormones are made) stop making these hormones. This causes symptoms like hot flushes, palpitations (where you can feel your heart beat), headaches, low mood, memory problems, fatigue, urinary symptoms and lower libido.  

The low hormone levels can have long-term effects too. The risk of heart attacks is five times higher after menopause than before. This is really important, especially as outcomes for women after a heart attack are worse than for men. The risk of stroke, dementia and osteoporosis (weak bones) and other conditions all rise as well. 

After the menopause, female hormone levels will stay low, they won’t rise again. Menopause is a natural process, it’s not a condition or a health problem, but the reduction in hormones mean the risk of health problems rises after menopause. In this way, it’s a bit like high blood pressure – it’s not a disease but it does raise the risk of diseases.

 

How does the menopause affect your blood pressure and heart health?

Estrogen helps to keep your blood pressure down because it has a vasodilative effect, meaning it allows your blood vessels to widen so that blood can flow more easily. It also helps keep your cholesterol levels down. Like high blood pressure, high cholesterol can lead to heart disease, as it can be laid down in the artery walls, clogging them up.  

Estrogen has other roles in your blood vessels too. It reduces inflammation and does all the ‘good things’ like improving nitrous oxide levels, a chemical which is known to relax and widen blood vessels.

These effects are the reason women have a low risk of heart disease before menopause then it suddenly rises afterwards. Plus, the change in hormones can make you feel tired or low, so women sometimes turn to things like unhealthy eating, which raises the risks too.  

There are other factors involved in disease development too – simply growing older and the changes in lifestyle – but it’s surprising how little known the roles of female sex hormones are, even among many GPs.

How do you know when you are going through the menopause?

The medical definition of menopause is when your periods have stopped for one year. But this doesn’t happen suddenly, it can take many months and even years. The time from when your hormones start to reduce until you reach menopause is known as perimenopause. It typically starts around the age of 45, but this does vary.

Some effects are well-known, like hot flushes and periods becoming less regular. Other are less obvious and you won’t necessarily know what’s causing them, such as brain fog, hair and skin changes, feeling tired, low or anxious, and sleeping badly. These could simply be caused by life, but it’s helpful to be aware that they could be down to a drop in your hormones.

What is HRT and how can it help? 

Hormone replacement therapy (HRT) is where women are prescribed hormones to replace the ones which are no longer being made by their bodies. HRT can come as a tablet, or through the skin in patches, gels, or sprays. It can include estrogen alone if you have had a hysterectomy, or estrogen with progestogens or micronised progesterone – this is a newer type of progestogen and is known as the body identical progesterone. Sometimes testosterone is also prescribed.

Taking the right dose and type of HRT can improve symptoms of menopause and perimenopause and improve quality of life – many women on HRT say they feel like their old self again.

It can help prevent illnesses too. Good evidence shows that HRT can preserve bone strength and protect against broken bones. Some research also shows it can help protect against heart disease, heart attacks and type 2 diabetes.

For heart disease in particular, some research shows that starting the right type of HRT within 10 years of the menopause is associated with a lower risk of developing coronary heart disease – the main cause of heart attacks – compared to women who don’t take it. But starting later still leads to many benefits for most women. 

Can you take HRT if you have high blood pressure?

There has been a lot of confusion around HRT and heart health and some women are needlessly advised to stop taking HRT if they have high blood pressure. In fact, estrogen prescribed as a patch, gel or spray allows your blood vessels to widen, so it does not raise your blood pressure and can actually work to lower it. Progestogens have differing effects, but the newer type, micronised progesterone, seems to have no effect on blood pressure or even lowers it. 

In a nut shell, if you have high blood pressure or you’re taking medicines to lower your blood pressure, you can still take HRT. Your doctor will need to keep an eye on your blood pressure and adjust your medicines if needed.

Professor Gareth Beevers, Trustee of Blood Pressure UK, encountered patients in his blood pressure clinic at Birmingham City Hospital who had been advised not to have HRT because of their high blood pressure. So, he ran a study to see if HRT raised it further. The results from 161 women, published in 2005, showed that, with careful monitoring and adjustments where needed, it did not.

 

Are there any risks with HRT? 

There is a lot of fear around HRT which comes from a study done in the 1990s called the Women’s Health Initiative. It received a great deal of press coverage, and the way the results were presented in the media was very misleading and made the risks seem bigger than they are. It’s a shame because many women have had to suffer through menopause symptoms unnecessarily, and missed out on preventive effects on heart disease, osteoporosis, type II diabetes and dementia. These problems have even become more common in some groups of women with the drop in HRT use.

There are some small risks to be aware of with some types of HRT, and these are a small increase in the risks of blood clots, strokes and breast cancer.

What these risks look like for you as an individual depends on many things including your age, family history, your general health, your weight, if you smoke, and whether you still have a uterus (womb), as well as the type of HRT. That’s why it’s always worth having a conversation with your GP or a menopause specialist, as they can weigh up all these factors and see what’s suitable for you.

Breast cancer is the one that worries women the most. Estrogen only HRT, usually taken by women who have had a hysterectomy, is actually associated with a lower future risk of developing breast cancer. Women taking estrogen and micronised progesterone do not have an increased risk of developing breast cancer in the first five years of taking it, and after this time the risk is very low. As a comparison, women who drink a couple of glasses of wine most nights have a higher future risk of developing breast cancer than women taking HRT containing estrogen and a progestogen.

For most women, HRT is safe and effective and the benefits outweigh the risks.

What are the risks of blood clots and stroke with HRT?

HRT taken as a tablet is linked to a higher risk of blood clots, known as venous thrombolembolism, which includes deep vein thrombosis in the legs and pulmonary embolism in the lungs). There is a small increased risk of strokes but the overall risk of stroke in women under 60 is low.

Often the solution is simply to prescribe estrogen through the skin as a patch, gel or spray. These bypass the liver, which produces the clotting factors needed for blood clots to form. So, they don’t raise the risk of blood clots.

With progestogen, older types have a slightly higher risk of blood clots but the new type, micronised progesterone (Utrogestan), does not.

So, for most women, there are options. For example, if a woman is at higher risk because she reached menopause ten years ago and has atherosclerosis, doctors usually prescribe a lower dose and estrogen through the skin.

What advice would you give to women with high blood pressure who are peri- or post-menopausal? 

Prevention is key when it comes to health problems like heart disease. Take care of your health in the ways that we all need to – exercise, eat well, avoid processed foods, and limit alcohol and cigarettes – and find ways to look after yourself, such as yoga and meditation.

 The effects of changing hormones can happen little by little, so they sneak up on you. You might gain weight very slowly and feel gradually less and less like yourself, then by the time you’re told you have high blood pressure or high cholesterol you might feel so down and lethargic that exercise feels impossible. It’s much easier to start early and maintain a routine than it is to start a new one when you don’t feel like it.

Wherever you are now, just start with something small that makes you feel a bit better, and build up from there.

What else do women need to know about menopause and their heart health?

The more knowledge you have, the more you will understand what’s going on in your body and how to look after it. This means you’ll have the information you need to have constructive discussions with your GP.

Menopause can be a positive experience, don’t suffer unnecessarily. The more you understand about your body and what you need, the better.

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Dr Louise Newson is a GP and Menopause Specialist. She is founder of consultancy Newson Health and Wellbeing Centre in Stratford-upon-Avon, who provide information and treatment to women during and after menopause. She has developed a menopause education programme with www.fourteenfish.com to provide training to healthcare professionals about the menopause and the appropriate treatments.

You can find more information on Dr Newson’s website www.menopausedoctor.co.uk and use her new app balance, which provides free evidence-based and unbiased information and a health journal and community features, allowing you to take control of your menopause wellbeing.