Menopause, Blood Pressure and Your Heart: The Numbers to Know

When we talk about menopause, we talk about hot flushes, sleep and mood. We don't talk much about the heart. But heart and circulation problems are one of the biggest health risks women face, and that risk goes up across and after the menopause.

Most of us still think of heart disease as something that happens to men. So the blood pressure that's been creeping up gets put down to stress, the cholesterol result gets filed as "a bit high", and nobody runs the numbers that would tell you where you actually stand.

So here's what changes for your heart around the menopause, the 4 numbers to know, how to check your blood pressure properly at home, and what HRT does and doesn't do for your heart.

Why the risk goes up after menopause

Oestrogen does a lot of quiet work for your blood vessels and your metabolism. As it falls, a few things tend to happen at once. LDL cholesterol (the type that builds up in artery walls) often goes up. Blood vessels can become a little less flexible. Fat tends to move from your hips to your tummy, around your organs. And your body handles blood sugar less well, so insulin has to work harder.

Blood pressure also tends to rise with age, and the menopause years are often when it first creeps over the line. None of this happens overnight, and none of it means something is wrong with you. It means the menopause is a good time to check where you are, while there's plenty you can do about it.

The risk is higher again if your menopause came early, before 45, and especially before 40. If that's you, your heart and bones need more attention, not less, and hormone treatment is usually recommended until around the natural age of menopause.

The 4 numbers to know

1. Your blood pressure. High blood pressure usually has no symptoms at all, which is why so many people don't know they have it. A clinic reading of 140/90 or more, or a home average of 135/85 or more, needs checking and confirming.

2. Your cholesterol. Not just "normal" or "a bit high". Ask for the numbers: total cholesterol, LDL, HDL (the protective type), non-HDL and triglycerides. They mean much more side by side than one total on its own.

3. Your HbA1c. This is your average blood sugar over the last 2 to 3 months. A result of 42 to 47 mmol/mol means higher risk of type 2 diabetes, which is the point where changes make the biggest difference. 48 or above suggests type 2 diabetes and needs a repeat test to confirm it.

4. Your QRISK3 score. This is a calculator that estimates your chance of a heart attack or stroke in the next 10 years. It uses your age, blood pressure, cholesterol, smoking, family history, weight and a few health conditions. Any clinician can run it, and it takes a few minutes. A score of 10% or more usually means a conversation about treatment as well as lifestyle. Ask for the number itself, not just "it's fine".

How to check your blood pressure at home

Home readings are often more useful than a single reading in a clinic, because some of us get higher numbers just from being there. Getting it right makes a big difference.

• Use an upper arm monitor, not a wrist one, and check it's a validated model. The cuff should fit your arm: too small gives a falsely high reading.
• Sit for 5 minutes first, back supported, feet flat on the floor, legs uncrossed. No coffee, exercise or cigarette in the 30 minutes before.
• Rest your arm on a table so the cuff is at the level of your heart, with bare skin under it, not a rolled-up sleeve.
• Take 2 readings, 1 minute apart. Do this morning and evening for 4 to 7 days.
• Ignore the first day, then take the average of the rest. That average is your number.

Write them down, or use my free Blood Pressure guide, which walks you through it and gives you somewhere to record them. Bring the readings with you to an appointment.

What you can change, and what each change does

Move most days, and lift something. 150 minutes a week of moderate activity, like a brisk walk where you can talk but not sing, plus strength work on 2 days. Walking helps blood pressure, blood sugar and mood. Strength training helps your muscles, your bones and how your body uses sugar. A 10-minute walk after meals is one of the easiest places to start.

Alcohol. No more than 14 units a week, spread over 3 or more days, with some days off. Cutting down can lower blood pressure, and it often helps sleep and hot flushes too.

Salt. About three-quarters of it is already in bread, cereals, sauces and ready meals. Cooking more from scratch is the simplest way to cut it.

Food. More vegetables, beans, lentils, wholegrains, nuts and oily fish, and fewer ultra-processed foods. Protein at each meal helps keep blood sugar steadier. If breakfast is the hard one, my free 30g Protein Breakfasts has plenty of ideas.

Smoking. Stopping is one of the biggest changes you can make for your heart, at any age.

Sleep. Short, broken sleep is linked with higher blood pressure. If you snore loudly, wake gasping or fall asleep in the day, sleep apnoea needs checking. It's more common after the menopause and it's easy to miss in women.

If you'd like to know your numbers, these are a good place to start.

What HRT does and doesn't do for your heart

Women hear a lot of mixed messages about this.

HRT isn't a heart treatment, and it isn't started to protect your heart. It's used for symptoms, and for bone. What matters for your heart is when you start and how you take it.

Timing. For women who start HRT within 10 years of their last period, or before 60, the overall balance of benefits and risks is favourable, and the effect on the heart looks neutral to slightly favourable. For women who start more than 10 years after their menopause, or over 60, the balance is less favourable and needs a more careful conversation.

Route. Oestrogen tablets can raise blood pressure in some women and carry a small extra risk of blood clots. Oestrogen through the skin, usually as a patch or gel, doesn't seem to do either. So for women with high blood pressure, a higher clot risk or a higher weight, the skin route is usually the one to use. High blood pressure on its own isn't usually a reason to avoid HRT, but it does need treating in its own right.

So if your blood pressure or cholesterol is high, HRT isn't the answer to that. The answer is the numbers above, the changes above, and treatment where it's needed. HRT can sit alongside all of that.

What about palpitations?

A racing or fluttering heartbeat is common in perimenopause and menopause, often alongside a hot flush or at night. Often it's harmless. But new palpitations still need checking, with your pulse, blood pressure and sometimes a heart tracing (ECG) and blood tests for thyroid and iron. Palpitations with chest pain, fainting or breathlessness are a different matter, and they're in the box below.

If you'd like help with it

The clinic's Menopause service starts on Sunday 18 October, World Menopause Day, for perimenopause, menopause and early menopause, online by video or in person in Milton Keynes. We go through your symptoms, your family history and your home blood pressure readings, and arrange blood tests where they'll change the plan, including cholesterol and HbA1c. There are around 40 clinics across the UK for the blood draw, so most women can have it done near home. We run your QRISK3 together, look at the results, and talk through your options, for your symptoms and your heart. If something needs NHS follow-up, I write to your GP the same day with what to ask for. And the clinic also works with women under 40 who want to get ahead: know what runs in your family and know what to watch.

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Every Sunday morning I send out my newsletter, Beyond Prescriptions, with 1 women's health lesson and what to do with it. You can sign up here.

Debora Tentis, Women's Health Pharmacist.