Research Highlights:
- Increasing pulse pressure (the gap between the upper and lower numbers in blood pressure readings), long attributed to falling estrogen levels caused by menopause, begins about two decades before women enter menopause, according to an analysis from the large and multi-generation Framingham Heart Study.
- The study suggests that healthcare professionals should pay greater attention to women with a wide (higher number) pulse pressure because it is a sign that the body's largest blood vessel (the aorta) is becoming stiffer and less flexible, therefore, increasing the risk of heart disease.
- Wide pulse pressure is a major risk factor for cardiovascular disease, dementia and kidney disease and may make high blood pressure less responsive to some medication treatments.
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DALLAS, Sept. 14, 2026 — Contradicting conventional wisdom, menopause may not be the driving force behind an increase in aortic stiffness in women after midlife, according to new, independent research published today in Hypertension , a peer-reviewed scientific journal published by the American Heart Association journal.
The largest blood vessel in the body, the aorta, receives oxygen-rich blood from the heart to deliver to other organs throughout the body. In many people, particularly after midlife, the walls of the aorta stiffen. Pulse pressure is influenced by the stiffness and width of the aorta and is quantified by the difference between the upper (systolic) and lower (diastolic) numbers in the blood pressure measurement. A wider pulse pressure (higher number) means the heart is working harder, and it can also create damage in the small vessels of other organs, such as the brain or kidneys.
Between early adulthood and midlife, pulse pressure usually falls because the internal space in the aorta increases in diameter, easing blood flow. After midlife, pulse pressure widens or rises, as the aorta diameter stops increasing and the aorta walls stiffen. This midlife transition is particularly marked in women, who start life with a smaller volume of elastic fibers in the aorta. With fewer elastic fibers in the aorta among women, the transition from having a lower pulse pressure than men prior to midlife results in a much higher pulse pressure among women after midlife.
"Many people believe that the change in pulse pressure is linked to the hormonal shifts caused by menopause. Here, we are evaluating whether the timing of this change, from falling to rising pulse pressure, is connected to menopause timing in a long-term study," said study senior author Gary F. Mitchell, M.D., a longstanding NIH-funded investigator with the Framingham Heart Study and president of Cardiovascular Engineering, Inc., in Needham, Mass.
Researchers analyzed data from the Framingham Heart Study, which has conducted health exams and collected information for up to three generations of families living in Massachusetts, to investigate heart disease risk factors.
What are the study's findings?
- Pulse pressure reached its lowest point and changed from a falling to a rising profile about a decade earlier in women than men: in their late 30s among women rather than late 40s in men.
- Whether menopause (date of last menstrual period) occurred early, late or at a typical time had no influence on the age when women had the lowest point in pulse pressure, which occurred up to two decades before the onset of menopause.
- Pulse pressure increased with age in both men and women after midlife, although the increase was faster in women, resulting in average pulse pressure that was higher in women than in men after age 60.
"To our huge surprise, our results suggest that factors other than the timing of the final menstrual period were likely involved in the accelerated increase in pulse pressure in women after midlife," Mitchell said.
While high blood pressure is the most modifiable risk factor for cardiovascular disease, there is strong evidence that wide pulse pressure is an independent risk factor for various cardiovascular conditions, as well as dementia and kidney disease. However, pulse pressure is currently not included in clinical guidelines for managing blood pressure.
"Healthcare professionals should definitely consider pulse pressure in middle-aged and older patients – especially women – with high blood pressure," Mitchell said. "Because women's overall heart disease risk is lower, they are often told that a blood pressure that is 'borderline'—for example an upper number of 130 mm Hg—can just be watched. However, women and their doctors should sound the alarm if pulse pressure is higher than 60 mm Hg [such as 130/70 mm Hg] and track it over time to see if pulse pressure is rising."
Greater attention to pulse pressure may also help guide individual treatment approaches. High blood pressure with a wide pulse pressure is less likely to respond to the usual treatments, so tailored treatment is important, Mitchell added.
"Vascular aging may begin years before menopause, but that doesn't mean menopause is irrelevant. The trajectory may accelerate as women enter perimenopause," said Samar R. El Khoudary, Ph.D., M.P.H., FAHA, who chaired the writing group for a 2020 American Heart Association scientific statement on the menopause transition.
El Khoudary was not involved in the current study and is chair and professor of epidemiology at the School of Public Health and director of Women's Public Health Research Initiatives at the Institute of Women's Health at Virginia Commonwealth University in Richmond, Va. She added that women and healthcare professionals should be thinking about heart health long before menopause.
"We shouldn't wait until menopause to start thinking about cardiovascular health. By the time a woman reaches her final menstrual period, vascular changes may already have been underway for years. Midlife is an opportunity to identify cardiovascular risk early and intervene before disease develops."
Study details, background, design and limitations:
- Participants included 6,760 adult women who were assessed in three health visits spanning 14 years as part of the Framingham Heart Study. They were divided into four groups based on self-reported age at menopause:
- Premenopausal (average age 33 at first study visit);
- Early menopause (average age 53 at first study visit and 44 at menopause);
- Average menopause (average age 54 at first study visit and 51 at menopause); and
- Late menopause (average age 57 at first study visit and 56 at menopause).
- Women were excluded from the analysis if their menopause was induced by surgery or medication.
- To evaluate sex differences, researchers also analyzed data from 3,248 adult male participants in the Framingham Heart Study (average age 51 at first study visit).
- The Framingham Heart Study is an ongoing, long-term, community-based study of risk factors for the development of heart disease, involving participants over three generations. The study has been supported by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health since just after its 1948 beginning, and it has been led by Boston University since 1971.
- Limitations of this observational study include not being able to prove cause and effect, and its reliance on participants' self-reported information about their age at menopause rather than measurements of estrogen levels. Because most participants in this analysis were of white European descent, these results might not apply to people in other racial or ethnic groups.
Co-authors, disclosures and funding sources are listed in the manuscript.
