High Blood Pressure in Women

There is a common myth that high Blood pressure is less prevalent and less dangerous for health in women. While this may be true before the menopause but later in life the prevalence and associated risks becomes equal. In fact, after the ages of 65 years more women have hypertension (HT) as compared to men. It should be remembered that the life expectancy in women with HT is shortened by an average of 5 years. Women dying of strokes, heart attacks and heart failure have a 65 to 75 % chance of having HT as one of the important causes besides diabetes and obesity.

Awareness of HT is fairly low in women because of not getting it checked unless symptomatic which is quite late. Around half of those diagnosed have BP readings more than the target of 140/90 mms Hg in spite of treatment. Although HT treatment has improved over the years this figure still is not showing any significant change. This could be either because of sub-optimal treatment, non-compliance or true resistance. Adverse life style is common in urban women. Staying indoors, consuming high quantity of salt in the form of chutneys, pickles etc and lack of exercise are important contributors. The problem of HT when combined with diabetes and high bad cholesterol levels increases the risk of heart attacks and strokes several folds.

 Women Specific Causes of HT 

Post-Menopausal HT:

BP always rises by up to 5 mms Hg after menopause and hormonal imbalance is the main reason for this. It is mainly related to increased salt sensitivity and stiffness of the arteries of the body and the inner lining becoming rough due to reduction in the release of protective substances. The withdrawal of oestrogens is the chief culprit leading to excessive retention of salt in the body.

Hormone replacement therapy in low doses (oestrogen progesterone combinations) has been advocated to get over the symptoms of hot flushes, swings of mood and vaginal dryness etc. However, it should be avoided in ladies with previous history of heart disease and strokes etc because of the data showing more strokes and heart attacks in them.

Hormone Pills and HT:

These pills often used as contraceptives or for treatment for missed periods or excessive bleeding (menorrhagia) contain a combination of oestrogen and progesterone and are associated with small but significant risk of HT and vascular events, particularly stroke, in the population of women consuming it. The main reason being stiffening of the arteries because of salt retention secondary to hormone effects. Their prolonged usage leads to HT as compared to non-users. This is much more frequent in smokers, obese and relatively older women. These agents can sometimes lead to very high blood pressures which becomes difficult to treat.

 HT Related to Pregnancy:

High BP during pregnancy can be seen in a number of situations: Chronic HT, gestational HT, Pre-Eclampsia and Eclampsia. All these can be responsible for a high maternal, foetal and neo natal (new born) morbidity and mortality.

Management of a lady with pre-existent HT is directed to protect the mother from getting into problems like heart failure, stroke and kidney damage which can be at times be fatal. The foetus by far is not affected. The choice of drugs is however, important because some agents used to lower BP can harm the foetus.

Life style modification especially exercise and diet rich in fruits and vegetables etc. are very important initial measures. For ladies with BP more than 160/100 mms Hg drug treatment using a combination of 2 different class of drugs is recommended. Even in those with a BP between 140/90 to 150/95 mms Hg during gestation drugs are needed. This is important if there is asymptomatic target organ damage like protein in the urine or features of hypertrophy of the left ventricle as seen by echo cardiography or ECG.

The drugs recommended are labetalol, methyldopa or nifedipine, which are time tested agents for foetal safety. When BP has to be reduced rapidly in a hypertensive emergency intravenous labetalol is the agent of choice and other options are intravenous nitroprusside or nitro-glycerine. These drugs should always be administered in a hospital setting under expert supervision.

While the beneficial effects of treating HT are similar in both men and women, the side effects of commonly used drugs for treating HT in women are often different. Women get 3 times more cough with ACEI (ramipril, enalapril) and more oedema with calcium channel blockers (amlodipine).

Drugs of the group of ACEI and ARB’S (ramipril, enalapril and losartan, telmisartan or Olmesartan etc) are absolutely contraindicated during pregnancy or even in ladies planning a pregnancy. These are known to produce foetal developmental abnormalities. Same is true for drugs like spironolactone and eplerenone. Women are more prone to get electrolyte deficiency with diuretics while men get high uric acid with these agents.

Thiazide and thiazide-like diuretics (water pills) are particularly attractive for use in elderly women because of decreased risk of falls leading to hip fracture and other injuries because of a gentle BP reduction.

Author is Cardiologist, Founder Director Gauri Kaul Foundation