Blood pressure difference between pre and post‐menopausal women and age‐matched men: A cross‐sectional study at a tertiary center

Abstract

Hypertension is a prominent risk factor for cardiovascular and cerebrovascular diseases. Gender differences and menopausal status contribute to blood pressure changes across the lifespan which have not been completely characterized. Our study aims to explore the impact of multiple factors on blood pressure levels in previously healthy women and men. Factors of interest included gender, menopausal status, age, and body mass index. Healthy women and men were recruited through healthcare facility announcements. Detailed menopausal history was obtained from females. The authors measured each participant's systolic and diastolic blood pressure at our outpatient clinics twice on the same day, and two different days, one week apart, and the authors included the mean of the averaged two readings for each participant. The study sample consisted of 313 participants. Female gender was a significant predictor of lower systolic and diastolic blood pressure (p < .001), while age significantly correlated with higher systolic blood pressure readings (p = .004). Although systolic blood pressure levels were significantly higher in postmenopausal females (124 mmHg) compared to premenopausal females (116 mmHg), our multiple linear regression analysis revealed that postmenopausal status did not significantly predict changes in either systolic or diastolic blood pressure. Our study demonstrates significant associations between blood pressure levels and various factors such as gender and age. This could emphasize the intricate interplay of demographic and clinical factors in blood pressure variations among individuals, highlighting the importance of a holistic approach to diagnosing hypertension, which considers various individual factors, including gender and age.

1. INTRODUCTION

Hypertension is a very common disease; around 31% of adults worldwide are affected by this illness. ¹ It is also considered a major, well‐established, and modifiable risk factor for both cardiovascular and cerebrovascular diseases in both men and women. ² , ³ , ⁴ It is a multiorgan disorder leading to cardiovascular diseases and stroke, which are the first and second leading causes of death in women respectively. ⁵ There are many factors linked to hypertension, including age, sex, body mass index, tobacco smoking, and family history. ⁶ At younger ages, the difference in blood pressure between men and women is evident, as hypertension is more common in men, ⁷ , ⁸ but this changes as women get older, where hypertension becomes more prevalent in older women than in men. ⁹

While multiple guidelines for hypertension management consistently acknowledge variations in its prevalence between men and women across their lifespans, they also agree that current evidence does not justify distinct blood pressure thresholds or treatment targets based on gender, nor the necessity for specific differences in the drugs used for treatment. ¹⁰ This paper highlights the effect of menopause on blood pressure in healthy women, not previously diagnosed with diabetes or hypertension. It also explores the relationship between systolic and diastolic blood pressure with gender, age, and BMI.

2. METHODS

This study was conducted in concordance with the Declaration of Helsinki's latest report and was approved by the University of Jordan Institutional Review Board committee approval number (2020/71). The study took place at Jordan University Hospital, a tertiary medical center in Jordan, spanning from September 2021 to August 2022. Informed consent was obtained from all participants.

This study was an observational cross‐sectional study. Our study has been conducted in accordance with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines. ¹¹

2.1. Participants

Our university hospital stands as a primary tertiary center in the country, encompassing all geographic regions of Jordan. We recruited participants via an announcement published at different locations at our healthcare facilities. We targeted healthy women and men visitors, who were not previously diagnosed with hypertension or diabetes mellitus. A thorough menstrual history was obtained from female participants, and comprehensive reviews of their medical records were conducted to categorize them as either premenopausal or postmenopausal women. The age of menopause was also recorded in postmenopausal women. All participants signed an informed consent form.

2.2. Assessment

Each eligible participant was instructed not to drink any caffeinated drinks for at least one hour before the blood pressure measurement. We measured each participant's systolic and diastolic blood pressure at our outpatient clinics twice on the same day, and two different days, one week apart, and we included the mean of the averaged two readings for each participant. We also measured each participant's height and weight.

For blood pressure measurement, we used an upper arm automated blood pressure device (Omron 705IT (HEM‐759‐E)); a validated blood pressure device. ¹² Two of the authors (LA and MA) were trained on blood pressure measurement, and they were instructed to rest the participant for five minutes before the measurement and choose the correct cuff size. We also investigated participants' histories of diabetes mellitus and cardiovascular diseases, as well as their smoking habits and family history of hypertension. The diagnosis and staging of undiagnosed hypertension among our sample was based according to the European Society of Hypertension guidelines. ¹³

2.3. Statistical analysis

Before performing statistical analysis, we checked relevant test assumptions including the Shapiro–Wilk normality test for normality assumption check and Bartlett's test for equality of variance. Data was presented as frequencies (percentage) or median (interquartile range). Mann–Whitney U test was used to compare the median (interquartile range) values as the data distribution was not normal. Spearman correlation was used to analyze the correlation between blood pressure levels and both age and BMI. A multiple linear regression analysis was conducted to develop a model exploring the effect of age, BMI, gender, and menopausal status on each of the systolic and diastolic blood pressure readings. The assumption of residual variance homogeneity and residual independency was assessed and confirmed by scatter plot of residuals versus predicted values and Durbin–Watson statistics, respectively. There was no collinearity among independent variables, which were assessed by variance inflation factor (values < 10). Further screening was performed to confirm no violations of the assumptions of normality, linearity, homoscedasticity, and no additivity. R 4.2.2 (R Foundation for Statistical Computing, Vienna, Austria), Python 3.12 (Van Rossum, G., & Drake Jr, FL (1995) Python reference manual Centrum voor Wiskunde en Informatica Amsterdam.), and Statistical Package for the Social Science software version 26 (SPSS Inc., Chicago, IL, USA) were used to perform the analyses. A threshold of p < .05 was used to determine statistical significance.

3. RESULTS

A total of 313 participants were included in this study with a mean age of 50 years (±10, ranging from 41 to 61 years). About 147 (46.9%) of the participants were men, while 166 (53%) were women. The frequency for premenopausal females was 92 (55%), while the frequency for postmenopausal females was 74 (45%). Table 1 shows the demographic and clinical characteristics of participants.

TABLE 1.

The demographic and clinical characteristics of participants.

	Count (percentage) or median (IQR). Size of sample: 313
Females	166 (53.1 %) were women	Pre‐menopausal: 92 (29.4%) of females
		Post‐menopausal: 74 (23.6%) of females
Males	147 (46.9%)
Age	50 (10.5)
BMI	27.1 (6.03)
Systolic blood pressure	124 (22) mmHg
Diastolic blood pressure	85 (14) mmHg
Active smoker	107 (34.2%)
Family history of diabetes mellitus (DM)	117 (37.4%)
Family history of hypertension	156 (49.8%)
Family history of cerebrovascular disease	38 (12.1%)
Undiagnosed hypertension	Males	Grade 1: 52 (35.4%) of males
		Grade 2/3: 24 (16.3%) of males
	Females	Grade 1: 29 (17.5%) of females
		Grade 2/3: 8 (5.0%) of females

According to the European Society of Cardiology and European Society of Hypertension (ESC/ESH); Grade 1 hypertension: Systolic blood pressure (SBP) equal or greater than 140 mmHg or diastolic blood pressure (DBP) equal or greater than 90 mmHg. Grade 2 hypertension: SBP equal to or greater than 160 mmHg or DBP equal to or greater than 100 mmHg.

There was a significant difference in systolic blood pressure between pre and postmenopausal females (p = .0096). The median (IQR) systolic blood pressure among premenopausal females was 116 (19.50) mmHg, while the median (IQR) systolic blood pressure among postmenopausal females was = 124 mmHg (18.75). On the other hand, there was no significant difference between the median (IQR) values of the diastolic blood pressure between premenopausal and postmenopausal women in which the median (IQR) readings were 83 (12.00) and 80.50 (11.75) for the premenopausal and postmenopausal groups respectively (p = .8991) (Table 2). Upon performing a multiple linear regression analysis, postmenopausal status did not significantly predict changes in either systolic or diastolic blood pressure levels (Table 3).

TABLE 2.

Comparison of systolic and diastolic blood pressure readings according to gender and menopausal status.

Group	Systolic blood pressure (mmHg)	p‐value	Diastolic blood pressure (mmHg)	p‐value
Males	128 (18.00)	<.001	89 (14.00)	<.001
Females	119 (20.00)		82 (11.75)
Pre‐menopausal females	116 (19.50)	.0096	83 (12.00)	.8991
Post‐menopausal females	124 mmHg (18.75)		80.50 (11.75)

Systolic blood pressure and Diastolic blood pressure values are depicted as Median (IQR‐rounded). Mann–Whitney U tests were performed to obtain p values.

TABLE 3.

Multiple linear regression analysis models to predict systolic and diastolic blood pressure readings according to age, gender, BMI, and menopausal status.

	Systolic blood pressure model				Diastolic blood pressure model
	Unstandardized B	95% confidence interval		p value	Unstandardized B	95% confidence interval		p value
Age	0.395	0.128	0.661	.004	−0.015	−0.197	0.166	.869
Gender (Female gender compared to male)	−9.996	−13.495	‐6.497	<.001	−5.948	−8.332	−3.564	<.001
BMI	0.081	−0.040	0.202	.190	0.028	−0.054	0.111	.498
Postmenopausal status (compared to premenopausal status) a	2.116	−5.200	9.431	.569	0.130	−4.771	5.031	.958

^a The model exploring menopausal status only included female participants.

We also found a significant difference in systolic blood pressure between males and females with a p‐value of <.001. The median (IQR) systolic blood pressure among men was 128 (18.00) mmHg, compared to 119 (20) mmHg among women. Also, there was a significant difference in diastolic blood pressure between males and females with a p‐value of <.001, in which the median (IQR) diastolic blood pressure values were 82 (11.75) mmHg in females and 89 (14) mmHg in males (Table 2). Furthermore, female gender significantly predicted lower systolic and diastolic blood pressure readings in the multiple linear regression model (p < .001), with a greater impact on systolic blood pressure (Table 3).

There was a statistically significant correlation between systolic blood pressure and age with a p‐value of .0065 and a Spearman's rank correlation coefficient of .15. On the other hand, there was no statistically significant correlation between diastolic blood pressure and age, with a p‐value of.99 (Figure 1A,B). Exact findings were replicated in our multiple linear regression model in which age significantly predicted higher systolic blood pressure readings (p = .004) but did not significantly predict changes in diastolic blood pressure readings (p = .869) (Table 3). With regards to BMI, there was a statistically significant correlation between systolic blood pressure and BMI with a p‐value of .038 and a Spearman's rank correlation coefficient of .117. On the other hand, there was no statistically significant correlation between diastolic blood pressure and BMI, with a p‐value of .113. (Figure 2A,B). However, BMI was not significantly associated with either systolic or diastolic blood pressure in the multiple linear regression model (Table 3).

FIGURE 1.

A and B: Correlation between blood pressure readings and age. Scatter plots depicting the correlation between systolic blood pressure readings (A) and diastolic blood pressure readings (B) with age. All participants, regardless of gender and menopausal status, were included.

FIGURE 2.

A and B: Correlation between blood pressure readings and BMI. Scatter plots depicting the correlation between systolic blood pressure readings (A) and diastolic blood pressure readings (B) with BMI. All participants, regardless of gender and menopausal status, were included.

There were no statistically significant associations between blood pressure readings and smoking status, family history of DM, family history of HTN, or family history of CVD.

4. DISCUSSION

Hypertension is the most common chronic disease in industrialized countries, affecting one‐quarter of the adult population and representing the most common major cardiovascular risk factor after the fifth decade of life in both men and women. ¹⁴ One important finding of our paper is the observation that postmenopausal women have higher systolic blood pressure than premenopausal women. Additional studies support this finding, as shown by Maas AH and colleagues, which have demonstrated that menopause affects both systolic and diastolic blood pressure. ¹⁵ Postmenopausal women typically exhibit higher blood pressure readings compared to their premenopausal counterparts. Furthermore, the association between age and blood pressure is more pronounced in postmenopausal women. ¹⁶ Another study showed that perimenopausal women (aged 45−54 years) appear to experience the most significant increase in the prevalence of hypertension. ¹⁷ Another finding of our study is the significant correlation between systolic blood pressure and age, whereas the correlation between diastolic blood pressure and age was not statistically significant.

Longitudinal cohort studies have demonstrated an increased prevalence of hypertension in postmenopausal females. A longitudinal cohort study of 315 women and age and BMI‐matched men showed a correlation between menopause and hypertension. The postmenopausal women had higher systolic blood pressure at baseline. Furthermore, systolic blood pressure increased by approximately 5 mm Hg over 5 years of follow‐up only in the pre and postmenopausal women. ¹⁸ Importantly, our study revealed that such observed significant differences in systolic blood pressure levels between premenopausal and postmenopausal females could be driven by other covariates, notably age, as postmenopausal status itself did not maintain as a statistically significant predictor of higher systolic blood pressure levels when included in a model adjusting for age, gender, and BMI.

The literature in this regard is inconclusive. Our finding aligns with previous studies, which highlighted that the apparent association between menopause and higher blood pressure levels could be explained by other factors, including age, metabolic syndrome, and arterial stiffness changes. ¹⁶ , ¹⁷ Additionally, an epidemiological study including 568 pre‐ and postmenopausal women, evaluated at two time periods separated by 16 years, showed that the higher systolic BP and cardiovascular morbidity and mortality seen in postmenopausal women were accounted for by age. ¹⁹

On the other hand, a cohort of over 18 000 Italian women aged 46–59 years revealed a statistically significant but clinically small increase in both systolic and diastolic blood pressure by 3.4/3.1 mm Hg in postmenopausal women, which was independent of factors such as age, BMI, smoking, contraception, or hormone replacement therapy (HRT). It was particularly noticeable in younger menopausal women (younger than 51). ²⁰

This could emphasize the intricate interplay of demographic and clinical factors in blood pressure variations among individuals, highlighting the importance of a holistic approach to diagnosing hypertension, which considers various individual factors, including gender and age.

Some earlier studies also reported a similar pattern of increased systolic and diastolic BP with aging, which was often followed by a decrease in diastolic BP later on. ²¹ , ²² It is worth noting that in the aging population, an isolated increase in systolic BP is the most prevalent pattern of hypertension, which aligns with our findings. This is primarily attributed to the increased arterial stiffness associated with aging. ²¹ Another Jordanian study also observed this pattern, with an isolated increase in systolic blood pressure. ²³

Additionally, we found other correlations of interest, such as systolic and diastolic blood pressure levels being significantly higher in males than females. Determining the role of sex hormones in the pathogenesis or progression of hypertension is complex given the effects of aging on the cardiovascular system and its relationship to other powerful risk factors such as body weight, family history of cardiovascular diseases, and others. ²⁷

While some studies showed that sex hormones play no role in hypertension development in females, ²⁸ interestingly, some studies have shown that estrogen has cured hypertension that was induced by surgical menopause, ²⁹ and a reduction in blood pressure was recorded following 17‐b estradiol therapy. ³⁰ There are also newer studies on the use of synthetic estrogen to prevent hypertension in animals. ³¹ However, other studies showed that hormone replacement therapy (HRT) has not been shown to lower BP consistently in postmenopausal women ³² , ³³

With this discussion, we encourage additional experimental studies to assess the effectiveness of estrogen as a treatment for hypertension in postmenopausal women. It is crucial to investigate the specific circumstances under which estrogen proves to be most beneficial and how it aligns with the primary pathophysiologic mechanisms of hypertension in the postmenopausal group. The inconsistencies in this field could suggest that estrogen may be effective in a subset of postmenopausal women but not in others.

Regarding BMI, our study revealed a significant correlation between BMI and systolic blood pressure levels, which did not maintain statistical significance when included in the adjusted multiple linear regression model. In this context, previous studies have shown that the occurrence of hypertension in postmenopausal women can be attributed to various factors. These include a higher prevalence of obesity in postmenopausal women and an increased sympathetic tone. ²⁴ Other contributing factors include the increased activation of the Renin–Angiotensin–Aldosterone System (RAAS) and an increased occurrence of endothelial dysfunction in postmenopausal females. ²⁵

A previous cross‐sectional study showed that an increase in BMI was associated with an increased incidence of isolated systolic hypertension, isolated diastolic hypertension, and combined systolic and diastolic hypertension. ²⁶ Also, another Jordanian study concluded that an increased BMI was associated with an increase in both systolic and diastolic BP. ²³ Such inconsistencies across studies could be due to the possible diverse mechanisms by which high BMI contributes to hypertension and could be partly explained by the observation that BMI is a significant but suboptimal measure of visceral adiposity, which plays a crucial role in driving hypertension by increasing sympathetic activity and releasing adipocytokines such as leptin, which lead to a state of vascular inflammation and atherosclerosis. ¹⁷ , ³⁴ , ³⁵

The study has limitations, such as a relatively small sample size; however, it successfully identified significant clinical and statistical findings. Obtaining blood pressure measurements and monitoring home readings posed challenges, and as a result, certain patients categorized as hypertensive may have experienced white‐coat hypertension. Longitudinal multicenter studies are essential for assessing the morbidity and mortality benefits of screening postmenopausal women for hypertension in a general context. Moreover, exploring different approaches to hypertension management based on individual characteristics is crucial.

5. CONCLUSIONS

Our study demonstrates significant associations between blood pressure levels and various factors such as gender and age. This could emphasize the intricate interplay of demographic and clinical factors in blood pressure variations among individuals, highlighting the importance of a holistic approach to diagnosing hypertension, which considers various individual factors, including gender and age.

AUTHOR CONTRIBUTIONS

Hussein Alhawari: Serving as an attending and consultant nephrologist, Hussein Alhawari, the corresponding and senior author, initiated and conceptualized the study. He conducted the literature review, supervised all stages of the study, and authored the main manuscript. Contact: h.alhawari@ju.edu.jo. Osama Alzoubi: Contributing as a postdoc research fellow, Osama Alzoubi focused on reviewing the statistical analysis, literature, and final manuscript editing. Sameeha Alshelleh: Functioning as an attending and consultant nephrologist, Sameeha Alshelleh actively participated in the literature review, patient recruitment, and the review of the final manuscript. Saif Aldeen AlRyalat: In the role of an ophthalmology resident at the University of Jordan, Saif Aldeen AlRyalat conducted the statistical analysis and contributed to the results section. Additionally, Saif Aldeen AlRyalat reviewed the final manuscript. Leen Alfaris and Mohamad Abdulelah: Both L.A. and M.A., as internal medicine interns, were responsible for measuring blood pressure and documenting data. They also contributed to the literature review and participated in the final manuscript review. Mohammad Alzoubi played a role in the literature review and contributed to the final manuscript review and editing.

CONFLICT OF INTEREST STATEMENT

All authors declare no competing interests.

Alhawari H, Alzoubi O, Alshelleh S, et al. Blood pressure difference between pre and post‐menopausal women and age‐matched men: A cross‐sectional study at a tertiary center. J Clin Hypertens. 2024;26:1368–1374. 10.1111/jch.14801

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available on request from the corresponding author, Hussein Alhawari, MD.