Systemic hypertension in postmenopausal women: a clinical approach

Gender-specific differences in the incidence of cardiovascular disease have long been known, and estrogens have been considered to be responsible for this dissimilarity. Recently, the steep increase in cardiovascular risk in the no longer fertile woman has become evident. The postmenopausal metabolic syndrome is very frequent, with obesity, insulin resistance, and hyperinsulinemia, which convey increased sodium reabsorption, stimulation of the sympathetic nervous system, and smooth muscle growth. The clinical corollary of these overall changes is hypertension. Gender differences in components of the renin-angiotensin system have been shown to exist, and may play a central role in blood pressure control. In normotensive populations, plasma renin activity is significantly higher in men than in women, and is higher in postmenopausal versus premenopausal women. Two angiotensin-converting enzyme inhibitors, ramipril and moexipril, have undergone trials aimed specifically at older people with cardiovascular risk and with postmenopausal hypertension, and could be the first therapeutic choice. However, a comprehensive treatment should include nonpharmacologic measures with strong emphasis on weight normalization and regular physical activity, prevention of osteoporosis, as well as decisions on the use of estrogen replacement therapy and treatment of the menopausal metabolic syndrome. Finally, education of both patients and physicians on the nature and prognosis of untreated hypertension is crucial.