Can Perimenopause Cause High Blood Pressure?

For many women, perimenopause—the four to 10 years leading up to menopause—ushers in surprises: hot flashes, brain fog, mood swings. But here’s one most women don’t expect: high blood pressure.

“We see a lot of issues with blood pressure in the perimenopause transition, likely due to hormonal changes,” explains cardiologist Kayle Shapero, M.D., Ph.D.

Estrogen plays a key role in keeping blood vessels flexible and supporting circulation. As levels decline during perimenopause, arteries become stiffer, increasing the risk of hypertension (high blood pressure).

The link between perimenopause and high blood pressure is complex. Studies show that up to 50% of women develop high blood pressure before the age of 60, but the symptoms— like hot flashes and palpitations—happen gradually and are often attributed to menopause. ¹ What that means: Some women may need aggressive blood pressure treatment in their 40s in order to avoid serious heart problems later on. ²

About the Experts:

Kayle Shapero, M.D., Ph.D, assistant professor of medicine at The Warren Alpert Medical School of Brown University

Candace Knight, M.D., an integrative physician and CEO of Knight Wellness

Angela Maas, M.D., Ph.D., cardiologist and author of A Woman’s Heart: Why Female Heart Health Really Matters

Umesh A. Patel, M.D., a cardiologist at Louisiana Heart Center

What Exactly Is High Blood Pressure?

High blood pressure, or hypertension, happens when your blood pushes too forcefully against your artery walls. Over time, this extra pressure strains your heart and damages blood vessels, increasing the risk of heart disease, stroke, and other serious health issues.³

High blood pressure, for the most part, is a symptom-less condition—about 46 percent of adults with hypertension aren’t aware that they have it, and fewer than half of them are diagnosed and treated. “You don’t know you have high blood pressure unless someone’s checking it,” says integrative physician Candice Knight, M.D.

Here’s how the American Heart Association categorizes healthy and unhealthy blood pressure ranges:

Can Perimenopause Cause High Blood Pressure?

The primary driver of high blood pressure in perimenopause is declining estrogen levels. Before the menopause transition, estrogen helps keep women’s blood vessels flexible and functional. As levels of the hormone decline, blood vessels lose elasticity, making it harder for them to expand and contract. This stiffening increases resistance in the arteries, which raises blood pressure. ^{4 5}

Other changes in perimenopause increase the risk of developing high blood pressure, including:

• Weight gain and fat redistribution. As fat accumulates around the abdomen in perimenopause (aka menopause belly), it may increase blood pressure. ⁶ Experts suspect this is because as visceral fat builds up, the kidneys become compressed, forcing the heart to work harder. ⁷
• Stress. Juggling work, teens, and aging parents? Chronic stress in perimenopause is a pervasive, underappreciated contributor to high blood pressure and cardiovascular disease risk. ⁸
• Sleep disturbances. Night sweats, insomnia, and sleep apnea are common perimenopause sleep thieves. ⁹, ¹⁰ Recent data suggests that the less a woman sleeps, the more likely she is to develop high blood pressure.¹¹
• High cholesterol. As estrogen levels decline in perimenopause, LDL “bad” cholesterol levels go up and HDL good levels of HDL cholesterol go down, which can contribute to heart risks by allowing fat and cholesterol to build up in the arteries. ¹²
• Common midlife diseases. A woman’s risk for other diseases related to high blood pressure—such as diabetes, metabolic syndrome, thyroid problems, or kidney disease— increases with age. ¹³

Are hot flashes and high blood pressure related?

A 2024 study published in Women’s BMC found strong correlations between perimenopause symptoms like hot flashes and high blood pressure. ¹⁴ Other research links vasomotor symptoms (VMS) like hot flashes and night sweats to cardiovascular risk factors like high cholesterol, diabetes, and underlying atherosclerosis—a dangerous buildup of fat in the arteries. ¹⁵

That doesn’t mean hot flashes cause high blood pressure. A 2023 study published in Menopause suggests both conditions may be driven by shared risk factors like alcohol, weight gain, and lack of exercise. ¹⁶

What Are the Risks of High Blood Pressure in Perimenopause and Menopause?

Unchecked high blood pressure in perimenopause is a major risk factor for heart disease, stroke, and dementia. Some research calls high blood pressure the most deadly risk factor for women’s heart health.

Research suggests that women with stage 1 hypertension in their 40s are at a higher risk for acute coronary syndromes than men with the same blood pressure levels. ¹⁷ “Aging is the main reason that blood pressure rises,” says cardiologist Angela Maas, M.D., Ph.D. “But in women, the climb to higher levels is more steep than in men.”

High blood pressure in perimenopause also increases the risk of cardiovascular problems including:

• Heart attack
• Stroke
• Heart failure
• Heart disease
• Atherosclerosis

Some research also links hypertension with

• Osteoporosis (age-related bone loss). The conditions are caused by similar dietary deficiencies, and high blood pressure may slow bone resorption and rebuilding. ¹⁸
• Accelerated brain aging and increased risk for cognitive decline and dementia. Researchers note that managing high blood pressure in midlife could be an opportunity to postpone potential cognitive troubles down the road. ¹⁹

How to Monitor High Blood Pressure in Perimenopause and Menopause

Self-measured blood pressure (SMBP) devices are a convenient, reliable way to monitor your blood pressure at home in perimenopause.

“You can keep a journal of your readings to show your doctor or buy one that connects to your smartphone, which averages your measurements for you,” says Patel. He notes that automatic arm cuff monitors are more reliable than wrist or finger monitors.

That said, home monitors shouldn’t replace physician monitoring. Talk to your doctor about testing frequency, as yours will depend on your age and other variables. “Women in perimenopause with a history of gestational diabetes may test levels at least once a month,” says Patel.

If you get a home monitor, bring it to your doctor’s office to confirm you’re using it correctly. Patel says common mistakes—like using the wrong cuff size, talking during the test, or drinking coffee beforehand—can skew results.

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Can HRT Help Women with High Blood Pressure in Perimenopause?

Although decreasing estrogen and perimenopause symptoms contribute to high blood pressure, hormone replacement therapy (HRT, also called menopause hormone therapy or MHT) might not lower it. In fact, some research suggests oral estrogen-only may increase blood pressure (non-oral estradiol, such as transdermal patches and vaginal estrogen cream, was associated with the lowest risk). ²⁰

If you’ve already been diagnosed with high blood pressure, your physician may still prescribe HRT, but they’ll consider your overall health first and make sure the high blood pressure is controlled before starting. ²¹

HRT supports overall perimenopause heart health

Blood pressure aside, evolving research suggests HRT has other heart-protective benefits. A study presented at the 2024 Annual Meeting of The Menopause Society suggested that certain estrogen-based hormone therapies may offer long-term cardiovascular benefits including improving cholesterol levels, reducing insulin resistance, and lowering lipoprotein(a), a key cardiovascular risk factor. ²²

That may be true even if you already have heart risks. For years, women with a history of cardiovascular disease were advised to avoid HRT. However, newer research suggests it may actually help prevent heart disease in some women. For example, a 2023 review in Circulation concluded that HRT is appropriate for some women with hot flashes—even those with certain cardiovascular risk factors like diabetes. ²³

Timing also matters. Research suggests that starting HRT before age 60 and within 10 years of menopause may provide a cardioprotective effect, without increasing cardiovascular risks like high blood pressure. ²⁴

On birth control pills? Some forms of estrogen-based birth control raise blood pressure. If you’re using the Pill for mood or hot flash relief, switching to HRT—particularly transdermal estrogen—may provide similar benefits with lower estrogen exposure. ²⁵

Other medications for high blood pressure

Several medications–or combinations of medications–can help women in perimenopause manage blood pressure. Your doctor will determine the best option based on your overall health, symptoms, and risk factors. Common options include:

• Water pills or diuretics: these help the body eliminate excess sodium and water, lowering blood pressure.
• Angiotensin-converting enzyme (ACE) inhibitors: These medications relax blood vessels by preventing a hormone that narrows them.
• Angiotensin II receptor blockers (ARBs): Work similarly to ACE inhibitors but with fewer side effects.
• Calcium channel blockers. These prevent calcium from entering heart and blood vessel walls, keeping arteries relaxed.

How to Help Improve Blood Pressure Naturally

Lifestyle changes can significantly lower blood pressure—and, in some cases, may reduce the need for medication.

1. Exercise. The AHA recommends 150 minutes of moderate-intensity aerobic exercise per week, plus some strength training at least twice a week.
2. Cut back on salt. If you have high blood pressure, the DASH diet (Diet to Stop Hypertension), which emphasizes salt reduction, is proven to help lower it. ²⁶ “Salt increases blood pressure, and salt restriction can help,” says Shapero, adding that women may get more sensitive to salt around menopause.
3. Don’t smoke, vape, or use any tobacco products. Nicotine increases heart rate, constricts blood vessels, and raises blood pressure. It’s also a huge contributor to atherosclerosis which increases blood pressure by narrowing and stiffening arteries. ²⁷
4. Limit or avoid alcohol. Drinking any type of alcohol can increase blood pressure significantly.
5. Maintain a healthy body weight. Your heart won’t have to work as hard if you lose even a small amount of weight, says cardiologist Umesh A. Patel, MD. ²⁸ Preliminary research suggests that GLP-1 medications like Ozempic may reduce cardiometabolic risk factors in older women with obesity or who are overweight—especially those on HRT. ²⁹
6. Manage stress. Women in perimenopause are more vulnerable to anxiety and mood disorders. ³⁰ Yoga, mindfulness, and therapy can help regulate the nervous system and reduce blood pressure. Some women benefit from HRT, antidepressants, or other medications to support mental health ³¹
7. Prioritize sleep. A lack of sleep raises blood pressure, and obstructive sleep apnea is a major but overlooked cause.“The first thing I ask patients is ‘Do you snore?’ because treating sleep apnea can lower high blood pressure a lot,” says Shapero.