Hormone therapy and high blood pressure

Why blood pressure comes up so often

Blood pressure tends to rise across midlife, and the menopause transition is when many women first see higher numbers. At the same time, hormone therapy is associated with a higher risk of stroke while it's taken, according to the National Cancer Institute's summary of the Women's Health Initiative. High blood pressure is itself a major stroke risk factor, so the two need to be considered together.

That's why your clinician will want good blood pressure numbers before recommending hormone therapy, and why MedlinePlus lists high blood pressure among the conditions to tell your doctor about before starting estrogen.

If you've never had your blood pressure checked properly, a week of home readings is one of the most useful things you can bring to a hormone therapy conversation.

'Controlled' is the key word

If your blood pressure is well controlled, with or without medication, hormone therapy is usually still an option. If it's high and not yet treated, the usual order is to bring it under control first. That's a question of sequence, not a permanent exclusion.

Very high or poorly controlled blood pressure, especially with other heart risks or a history of stroke, may tip the balance toward non-hormonal treatments for hot flashes.

Why transdermal estrogen is usually preferred

Estrogen taken by mouth goes through the liver before reaching the rest of the body, which affects the production of several proteins, including some involved in clotting and blood pressure regulation. Transdermal estrogen, from a patch, gel or cream, goes directly into the bloodstream and avoids that first pass.

The Menopause Society notes that oral estrogen raises blood clot risk while transdermal estrogen may carry a lower risk. For women with high blood pressure, who often have other cardiovascular risk factors, transdermal estradiol is generally the first choice. Progestogens differ from one another too, and your clinician will pick one with your blood pressure in mind.

Getting accurate readings at home

One reading in a clinic isn't enough to judge blood pressure. The American Heart Association recommends home monitoring with these basics:

• Use a validated, automatic upper-arm cuff in the right size. Wrist and finger monitors are less reliable.
• Avoid caffeine, smoking and exercise for 30 minutes beforehand, and empty your bladder.
• Sit with your back supported, feet flat and arm resting at heart level on a table, cuff on bare skin.
• Rest quietly for five minutes, without talking or using your phone.
• Take two readings one minute apart, at the same time each day, and record both.

Before and during treatment

• Before: several properly measured readings, plus a look at cholesterol, blood sugar, weight, smoking and family history.
• Before: a review of clot history and migraines, since these also affect route choice.
• During: home readings after starting and at follow-ups, especially in the first months.
• During: if readings rise, your clinician may adjust the dose or route rather than stopping altogether.

Migraine with aura and other overlapping risks

Women with migraine with aura, smokers and women with diabetes or high cholesterol have extra stroke and heart considerations. Each pushes the decision toward transdermal estrogen at the lowest effective dose and makes blood pressure control even more important. Stopping smoking does more for stroke risk than any choice of hormone route.

Vaginal estrogen is a different question

Low-dose vaginal estrogen, used for dryness, painful sex and some urinary symptoms, has very little absorption into the bloodstream, according to The Menopause Society. Blood pressure considerations are therefore much less significant. Genitourinary symptoms tend to get worse over time without treatment, so they're worth addressing even if systemic therapy isn't right for you.

When to get help right away

A single high home reading isn't an emergency; recheck it and follow up with your clinician if readings stay high. The American Heart Association advises calling 911 for readings above 180/120 mm Hg with symptoms such as chest pain or trouble speaking.

How HealifyMD handles it

Your clinician will ask for recent readings, and may ask you to take a week of home measurements before deciding. If your pressure needs treatment, they'll recommend you see your primary care clinician first. Hormone Therapy for Women at HealifyMD is listed at $349 for the first month, including baseline labs, then $99/month, with estradiol (topical, cream or patch), estriol vaginal cream and progesterone included in the program rather than priced separately. Pricing is confirmed at your eligibility review and other labs are priced separately. Some of these, such as compounded estradiol cream, estriol vaginal cream and compounded progesterone, are compounded medications: they are not FDA-approved, FDA doesn't verify their safety, effectiveness or quality, and they aren't equivalent to branded products.