We recently had the world hypertension day and many awareness campaign were held. It has however been a feeling amongst many that vascular diseases including high blood pressure or hypertension (HT) is essentially a problem of men. This, however, is not true.
HT is equally prevalent in both sexes although till the age of 45 years men suffer from it more often. The situation equalizes after 55 years of age. With increasing longevity there will be more women with HT as compared to males in future. The life expectancy on an average is 5 years shorter in ladies with HT.
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, obesity and physical inactivity. Post-menopausal women have a high burden of sudden cardiac death, which accounts for around 10 to 15% of all deaths and about half of all heart attack deaths.
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 much 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. Uncontrolled hypertension while on treatment is a serious problem. We published our data (50% were females) recently highlighting it in 53% of those on medicines. These numbers are likely to increase as the longevity of our population increases. 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 very high quantity of salt in the form of salted tea, chutneys, pickles etc and lack of exercise are important contributors.
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.
Oral hormonal therapy induced HT:
These pills 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 continued usage leads to HT as compared to non-users. This is much more frequent if the person smokes, is in the higher age bracket and is obese. These agents can sometimes lead to very high blood pressures needing a very aggressive treatment.
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.
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 hip fracture, because of a gentle BP reduction and no giddiness as seen with stronger drugs.
Take home Message:
Normal BP in women like in men is 120/80 mms Hg. Beyond a BP level of 140/90 drug therapy is needed. The response to treatment and benefits are the same in both sexes.
There are some drugs which are forbidden to be taken during pregnancy and even during the lactation period. These are telmisartan, Olmesartan, ramipril etc (ARB’s /ACE’s) and spironolactone, eplerenone (Aldosterone antagonists).
Water pills are useful in elderly ladies with HT and produce much less limb fractures, however, one needs to caution against salt depletion. Life style measures of low salt intake, exercise and consuming fruits and vegetables is always the key whether or not needing drugs to treat HT.
DISCLAIMER: The views and opinions expressed in this article are the personal opinions of the author.
The facts, analysis, assumptions and perspective appearing in the article do not reflect the views of GK.