Systolic BP significantly increases with HT for postmenopausal women: Perspective from Holly L. Thacker, MD
Posted on February 13, 2023
Holly L. Thacker, MD
Menopausal hormone therapy has complex cardiometabolic effects. Age, time since menopause, type and route of administration of HT and concomitant disease are all factors in the response to HT and the risk-benefit equation.
In general, both estradiol and progesterone are vasodilatory but when given orally can lead to activation of the renin-angiotensin-aldosterone system. Activation of the RAAS system can lead to vasoconstriction with some fluid retention and resultant increase in BP. Estradiol can increase the production of renin while simultaneously reducing the effects of renin. Estradiol has positive effects on calcium channel blocking, nitric oxide, lipids and body composition. Conversely oral HT can increase clotting proteins and triglyceride levels and can affect MMP9 levels, which can destabilize atherosclerotic plaque.
In this study of the WHI using oral conjugated estrogens (women who had had hysterectomy) or oral conjugated estrogens with medroxyprogesterone acetate (women with a uterus), a small, clinically insignificant increase in BP was noted.
The WHI age-stratified data showed that for women under age 60 years and/or within 10 years of menopause who took oral HT, there was a reduction in death rate and CV morbidity and mortality.
My takeaway is that for women with hypertension and/or worsening BP control, transdermal HT should be considered; however, in most recently menopausal women within 10 years of menopause the benefits of HT outweigh the risks. I would not summarily favor transdermal over oral HT even if the BP increases by a few points as other factors — patient preference, cost, convenience, comorbidities — also factor into shared patient-physician decision-making of selecting oral HT, transdermal HT or nonhormonal alternatives.
Holly L. Thacker, MD
Professor of Medicine and OBGYN and Reproductive Biology
CCLCM at Case Western Reserve
Director, Center for Specialized Women's Health