- Email: [email protected]
Risk factors for high blood pressure in women attending menopause clinics in Italy
Maturitas 53 (2006) 83–88
Risk factors for high blood pressure in women attending menopause clinics in Italy Gruppo di Studio Progetto Menopausa Italia1,2 Associazone Osterici E Ginecologi Ospedalieri Italia, Via Abanonti 3, Milan, Italy Received 6 April 2004; received in revised form 1 March 2005; accepted 1 March 2005
Abstract Objective: We analysed risk factors for high blood pressure (BP) among women around menopause. Methods: Eligible women were consecutively attending first-level outpatient menopause clinics in Italy for general counseling or treatment of menopausal symptoms. During the visit BP was measured three times. The mean of second and third of the three diastolic BP values for women was >90 mm of mercury and/or reporting any current pharmacological treatment for high BP were considered hypertensive. Out of 45,204 women who entered the study with information on blood pressure, 12,150 had high BP. Results: The odds ratios (OR) of high BP increased with age: in comparison with women aged <50 years, the multivariate OR were 1.44 (95% confidence interval (CI), 1.34–1.55), 1.61 (95% CI, 1.50–1.74) and 1.91 (95% CI, 1.77–2.06) in women aged 51–53, 54–57 and ≥58, respectively. Women with high BP were less educated than those without (OR education >12 versus <7 years, 0.79, 95% CI, 0.74–0.84). In comparison with women with a body mass index (BMI) <24, the multivariate ORs were 1.48 (95% CI, 1.39–1.57) and 2.56 (95% CI, 2.41–2.71) for women with BMI 24–26 and >26. In comparison with women reporting no regular physical activity, the multivariate OR of high BP was 0.93 (95% CI, 0.87–0.99) for women reporting regular activity. In comparison with peri-menopausal women, post-menopausal women were at increased risk (OR 1.14, 95% CI, 1.03–1.24) and the risk tended to increase with age at menopause. Current use of hormonal replacement therapy (HRT) was associated with a lower risk of high BP (OR 0.88, 95% CI, 0.84–0.94). Conclusions: This large cross-sectional study suggests that, after taking into account the effect of age, post-menopausal women are at greater risk of high BP, but current HRT use slightly lowers the risk. Other determinants of high BP were low level of education, overweight, and low level of physical activity. © 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: Women; Menopause; Risk factors; Elevated blood pressure
1
Corresponding author: Fabio Parazzini. Tel.: +39 02 390141; fax: +39 02 33200231. E-mail address: [email protected]. The following clinicians are co-authors of this paper: Participating centres: Cento (P. Di Donato); Cattolica (N.A. Giulini); Parma (A. Bacchi Modena); Forl`ı (G. Cicchetti); Reggio Emilia (G. Comitini); Bologna (G. Gentile); S. Lazzaro di Savena (P. Cristiani); Sassuolo (A. Careccia); 2
0378-5122/$ – see front matter © 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.maturitas.2005.03.002
84
Gruppo di Studio Progetto Menopausa Italia / Maturitas 53 (2006) 83–88
1. Introduction High blood pressure (BP) is among the main determinants of cardiovascular disease risk. There are some suggestions that hormonal factors play a role [1–4]. In biological terms non-diseased coronary artery vessels dilate in response to the administration of estrogen. Thus, it was interesting to analyse the characteristics of subjects with high BP among women around
menopause, a period of important changes, when the frequency of hypertension tends to rise. Epidemiological data on women around menopause are scant and in particular the relationship between menopausal status and hypertension is unclear [5]. Further, evidences is inconsistent on the effect of estrogen replacement therapy, some studies showing an increase, others a decrease or no change of BP in users [1,4,6,7].
Lugo di Romagna (E. Esposito); Reggio Emilia (F. Gualdi); Bazzano (S. Golinelli); Scandiano (E. Bergamini); Carpi (G. Masellis); Rimini (S. Rastelli); Gorizia (C. Gigli); Trieste (A. Elia); Udine (D. Marchesoni); Udine (F. Sticotti); S. Daniele del Friuli (G. Del Frate); Palmanova (C. Zompicchiatti); La Spezia (L. Marino); Genova (M.R. Costa); Genova Voltri (P. Pinto); Lavagna (D. Dodero); Genova (A. Storace); Genova (G. Spinelli); Milano (S. Quaranta); Como (C.M. Bossi); Mantova (A. Ollago); Brescia (U. Omodei); Milano (M. Vaccari); Lodi (M. Luerti); Treviglio (F. Repetti); Magenta (G. Zandonini); Milano (F. Raspagliesi); Sondrio (F. Dolci); Milano (G. Gambarino); Sondalo (B. De Pasquale); Vimercate (G. Polizzotti); Saronno (G. Borsellino); Melegnano (P. Alpinelli); Lecco (N. Natale); Sesto S. Giovanni (D. Colombo); Como (C. Belloni); Brescia (A. Viani); Paderno Dugnano (G. Cecchini); Bollate (G.W. Vinci); Brescia (B.A. Samaja); Manerbio (E. Pasinetti); Milano (M. Penotti); Como (F. Ognissanti); Cremona (P. Pesando); Ivrea (C. Malanetto); Torino (M. Gallo); Torino (G. Dolfin); Moncalieri (P. Tartaglino); Bra (D. Mossotto); Alessandria (A. Pistoni); Alba (A. Tarani); Cuneo (P.D. Rattazzi), Novara (D. Rossaro); Pinerolo (M. Campanella); Trento (E. Arisi); Rovereto (M. Gamper); Aosta (D. Salvatores); Soave-Tregnago (E. Bocchin); Trecenta (G. Stellin); Treviso (G. Meli); S. Don`a di Piave (V. Azzini); Isola della Scala (F. Tirozzi); Mestre (G. Buoso, R. Fraioli); Treviso (V. Marsoni); Pieve di Cadore (C. Cetera); Vicenza (R. Sposetti); Vittorio Veneto (E. Candiotto); Portogruaro (R. Pignalosa); Motta di Livenza (L. Del Pup); Chieti (U. Bellati); Atri (C. Angeloni); Lanciano (M. Buonerba); Vasto (S. Garzarelli); Pescara (C. Santilli); Ortona (M. Mucci); Penne (Q. Di Nisio), L’Aquila (F. Cappa); Pescara (I. Pierangeli); Teramo (A. Cordone); Agnone (L. Falasca); Campobasso (D. Ferrante); Roma (G.B. Serra); Roma (E. Cirese); Roma (P.A. Todaro); Roma (C. Romanini); Roma (L. Spagnuolo); Roma (A. Lanzone); Roma (C. Donadio); Roma (M. Fabiani); Alatri (E. Baldaccini); Roma (S. Votano); Latina (P. Bellardini); Velletri (W. Favale); Anzio (V. Monti); Roma (A. Bonomo; C.E. Boninfante); Roma (P. Pietrobattista); Senigallia (L. Massacesi); Pesaro (G. Donini); Ancona (F. Del Savio); Macerata (L. Palombi); Ascoli Piceno (P. Procaccioli); Fabriano (A. Romani); Osimo (G. Romagnoli); Pisa (A.R. Genazzani, M. Gambacciani); Firenze (G. Scarselli); Prato (P. Curiel); Siena (V. De Leo); Pescia (A. Melani); Montevarchi (V. Levi D’Ancona); Borgo S. Lorenzo (G. Giarr`e), Poggibonsi (E. Di Gioia); Lucca (P. Ceccarelli); Firenze (G.B. Massi); Livorno (S. Cosci); Bagno a Ripoli (G. Gacci), Sansepolcro (A. Cascianini); Perugia (C. Donati Sarti); Foligno (S. Bircolotti); Citt`a di Castello (P. Pupita); Perugia (M. Mincigrucci); Narni (A. Spadafora); Iglesias (G. Santeufemia); Oristano (G. Marongiu); Sassari (G.R. Lai); Olbia (R. Lai); Sassari (S. Dessole); Potenza (S.A. D’Andrea); Villa d’Agri (Coppola); Napoli (A. Chiantera); Napoli (De Placido); Napoli (R. Arienzo); Solofra (A.R. Pastore); Napoli (A. Tamburrino); Napoli (A. Cardone, N. Colacurci); Benevento (S. Izzo); Napoli (R. Tesauro); S. Maria Capua Vetere (A. Pascarella); Nocera Inferiore (M.G. De Silvio); Napoli (L. Di Prisco); Napoli (N. Lauda); Napoli (F. Sirimarco); Aversa (C. Agrimi), Mercogliano (G. Casarella); Eboli (G. Senatore); Oliveto Citra (S. Ronzini); Caserta (G. Ruccia); Giugliano (G. De Carlo); Battipaglia (G. Pisaturo); Castellammare di Stabia (F. Carlomagno); Salerno (A. Fasolino); Napoli (F. Fiorillo); S. Bartolomeo in Galdo (R. Sorrentino); Vico Equense (V.B. Ercolano); Napoli (S. Panariello); Pozzuoli (A. Brun); Reggio Calabria (P. Tropea); Castrovillari (C.M. Stigliano); Cosenza (A. Amoroso); Soveria Mannelli (P. Vadal`a); Oppido Mamertina (A. Coco); Soriano Calabro (G. Galati); Lamezia Terme (G. Barese); Crotone (G. Masciari); Corigliano (P. Pirillo); Soverato (T. Gioffr`e); Catanzaro (P. Mastrantonio); Catanzaro (A. Cardamone); Trebisacce (N. D’Angelo); Paola (G. Valentino); Crotone (R. Barretta); Gioia Tauro (G. Ferraro); Mesagne (C. Ferruccio); Terlizzi (D. Agostinelli); Cerignola (G. Corrado); Foggia (A. Scopelliti); Bari (S. Schonauer, V. Trojano); Taranto (F. Bongiovanni); Lecce (F. Tinelli); Brindisi (E.R. Poddi); Poggiardo (F. Scarpello); Altamura (L. Colonna); Castellaneta (G. Fischetti); Carbonara (R. Doria); Barletta (G. Trombetta); Grottaglie (E.B. Cocca, A. D’Amore); Castellana Grotte (M. Di Masi); Acquaviva delle Fonti (R. Liguori); Francavilla Fontana (A. Dimaggio); Taranto (M.R. Laneve); Martina Franca (M.C. Maolo); San Severo (G. Gravina); S. Pietro Vernotico (G. Nacci); Catania (F. Nocera); Palermo (A. Lupo); Palermo (C. Giannola, R. Graziano); Palermo (M. Mezzatesta); Palermo (G. Vegna); Enna (G. Giannone); Catania (G. Palumbo); Messina (F. Cancellieri); Milazzo (A. Mondo); Messina (A. Cordopatri); Caltanisetta (M. Carrubba); Leonforte (V. Mazzola); Caltagirone (L. Cincotta); Comiso (S. D’Asta); Mazara del Vallo (A. Bono); Canicatti (L. Li Calsi); Catania (S. Cavallaro Nigro); Vittoria (S. Schilir`o); Messina (A. Repici); Palermo (D. Gullo); Mussomeli (A. Orlando); Grammichele (F. Specchiale); Piazza Armerina (A. Papotto). Regional coordinators: Angeloni (Abruzzo), D’Andrea (Basilicata), Stigliano (Calabria), Arienzo (Campania), Di Donato (Emilia), Giulini (Romagna), Gigli (Friuli Venezia Giulia), Todaro (Lazio), Marino (Liguria), Luerti (Lombardia), Donini (Marche), Ferrante (Molise), Dolfin (Piemonte), Poddi (Puglia), Santeufemia (Sardegna), Nocera (Sicilia), Melani (Toscana), Arisi (Trentino Alto Adige), Mincigrucci (Umbria), Salvatores (Valle D’Aosta), Bocchin (Veneto). National coordinators: A. Massacesi, A. Chiantera, C. Donati Sarti, P. De Aloysio, U. Omodei, F. Ognissanti, C. Campagnoli, M. Penotti, A. Gambacciani, A. Graziottin, C. Baldi, N. Colacurci, G. Corrado Tonti. Data analysis: F. Parazzini, L. Chatenoud.
Gruppo di Studio Progetto Menopausa Italia / Maturitas 53 (2006) 83–88
Overweight, low physical activity, history of diabetes, hypercholesterolemia, and less consistently smoking and alcohol consumption have been associated with an increased risk of hypertension. However, the data on women around menopause are scanty [8–14]. Further, most studies in peri-menopausal women have been conducted in North American and northern European populations. Determinants may differ in countries with different lifestyles and prevalence of use of hormonal replacement therapy (HRT) [15]. In order to give information on the determinant of high BP in women around menopause in a southern European population, we analysed data from a large Italian study including about 50,000 women attending menopause clinics in Italy for counselling about menopause [15–18]. In 1999, we published a paper analysing determinants of high BP in post-menopausal women observed by their general practitioners [19]. Data presented here refered to a different study based on a totally difficult population. Women not included in the previous paper was included in the present analysis.
2. Methods Between 1997 and 2000, we conducted a large cross-sectional study on the characteristics of women around menopause attending a network of first-level outpatient menopause clinics in Italy for general counseling or treatment of menopausal symptoms [16–19]. Women consecutively observed during the study were eligible. The study protocol did not set any exclusion criteria. All women who agreed to participate underwent a gynecological examination. During the visit they were asked about their general characteristics and habits, reproductive and menstrual history, and a selected medical history were taken. During the visit weight (kg) and height (cm) were measured and recorded. During the interview, BP was measured three times on the right arm, with the participant seated. The woman for whom the mean of the second and third of the three diastolic BP values was >90 mm of mercury and/or women reporting any current pharmacological treatment for high BP were considered hypertensive. The finding of high BP was checked by the gynecologist against clinical records.
85
The study started in 1997 in 25 centers. The number of centers increased to 268 in 1999. Of these, 63 were in the North, 81 in the Center and 124 in the South of Italy. A total of 49,122 women (mean age 53 years, range 45–75 years) entered the study. The mean number per center was 98. Less than 3% of eligible women refused to participate. Information on blood pressure was available on 45,204 (92.0%) subjects. Body mass index (BMI, kg m−2 ) was classified as the best possible approximation of tertiles of BMI in the whole population. Post-menopausal women were defined as those with surgical menopause (i.e. bilateral oophorectomy with or without hysterectomy), women aged >55 years who had undergone hysterectomy without bilateral oophorectomy, and those whose menstrual cycles had stopped more than one year before interview. Women with a history of cardiovascular disease were those reporting any medical treatment for cardiovascular conditions. Level of physical activity was self-reported. The woman was asked to answer ‘Yes’ or ‘No’ to the following question: “Do you usually spend three or more hours per week in intense physical activity for leisure or work?” Housekeeping activity was not considered. 2.1. Data analysis Odds ratios (ORs) of high BP and the corresponding 95% confidence intervals (CIs) were computed after allowance for age. To take into account the potential reciprocal confounding effect of the variables considered, factors significantly related with high BP risk in the age-adjusted analysis were subsequently included in multiple logistic regression models fitted by the method of maximum likelihood [20]. The terms included are indicated as the footnotes in Table 1.
3. Results A total of 12,150 (26.8%) women had high BP. The distribution of women with and without high BP according to selected general characteristics is shown in Table 1. The OR of elevated blood pressure increased with age. In comparison with women aged <50 years, the multivariate OR were 1.44 (95% CI, 1.34–1.55), 1.61 (95% CI, 1.50–1.74), and 1.91 (95%
Gruppo di Studio Progetto Menopausa Italia / Maturitas 53 (2006) 83–88
86
Table 1 Odds ratios of high blood pressure according to selected factorsa High blood pressure No Age (years) <50 51–53 54–57 ≥58
OR (95%
Yes 1863 2665 3318 4279
1c 1.44 (1.34–1.55) 1.61 (1.50–1.74) 1.91 (1.77–2.06)
Education (years) <7 7–11 ≥12
11714 9213 8824
5428 3129 2481
1c 0.90 (0.85–0.96) 0.79 (0.74–0.84)
BMI (kg m−2 ) <24 24–26 >26
12222 9612 9698
2647 3164 5675
1c 1.48 (1.39–1.57) 2.56 (2.41–2.71)
Smoking habits Never smoker Ever smoker
25123 7662
9935 2123
1c 0.82 (0.77–0.87)
3306 3100 1256
956 813 354
0.84 (0.77–0.91) 0.79 (0.72–0.86) 0.86 (0.75–0.99)
24806 8006
9063 2998
1c 1.05 (0.98–1.11)
Regular physical activity No 26513 Yes 6263
10137 1914
1c 0.93 (0.87–0.99)
Family history of cardiovascular diseases No 20364 6903 Yes 8780 4006
1c 1.41 (1.34–1.48)
Diabetes No Yes
Alcohol drinking No Yes
29377 735
10717 468
1c 1.24 (1.09–1.42)
Serum cholesterol (mg/dl) <210 6232 210–250 6137 251–290 2474 >290 714
2070 2368 1125 376
1c 1.07 (0.99–1.16) 1.25 (1.13–1.38) 1.42 (1.22–1.65)
Triglycerides (mg/dl) <180 12127 180–215 1125 216–250 363 >250 355
4363 498 2008 228
1c 1.12 (0.99–1.27) 1.33 (1.09–1.62) 1.55 (1.28–1.83)
1882 10268
1c 1.14 (1.05–1.24)
Menopausal status Peri-menopause Post-menopause
6311 26743
OR (95% CI)b
High blood pressure
CI)b
8199 7670 8311 8813
Cigarettes day <10 10–20 >20
Table 1 (Continued )
No Age at menopause (years) ≤49 12871 50–52 7492 ≥53 3469 Current use of HRT No 27374 Yes 5680
Yes 4470 3180 1715
1.03 (0.96–1.09) 1.06 (0.98–1.14) 1.14 (1.04–1.24)
10209 1941
1c 0.88 (0.84–0.94)
a
In some cases the sum does not add up the total because of missing values. b OR, odds ratios; CI, confidence intervals. Multivariate estimates include terms for age, education, BMI, physical activity, family history of cardiovascular diseases, diabetes, serum cholesterol, triglycerides menopausal status, current use of HRT. c Reference category.
CI, 1.34–1.55) in women aged 51–53, 54–57 and ≥58 years, respectively. Women with high BP were less educated than those without (OR education >12 versus <7 years, 0.79, 95% CI, 0.74–0.84). Overweight was associated with an increased risk of high BP (OR BMI >26 versus <24 2.56, 95% CI, 2.41–2.71). Regular physical activity was associated with a lower risk of high BP: in comparison with women reporting no physical activity, the multivariate OR of elevated blood pressure was 0.93 (95% CI, 0.87–0.99) for women reporting regular activity. A family history of cardiovascular disease in first-degree relatives (OR Yes versus No 1.41, 95% CI, 1.34–1.48), a personal history of diabetes (OR Yes versus No 1.24, 95% CI, 1.09–1.42), hypercholesterolemia (OR > 290 mg/dl versus <210 mg/dl 1.42 95% CI, 1.22–1.65) and hypertryglyceridemia (OR > 250 mg/dl versus <180 mg/dl 1.55, 95% CI, 1.28–1.83), were all associated with the risk of high BP. No association emerged with smoking habits or alcohol drinking. The OR of high BP was 1.14 (95% CI, 1.05–1.24) in post-menopausal in comparison with peri-menopausal women and the risk increased with age at menopause. Among post-menopausal women, the multivariate OR of high BP for HRT use was 0.88 (95% CI, 0.84–0.94). We then analysed the effect of BMI, physical activity, family history of cardiovascular disease, diabetes, ipercholesterolemia and ipertriglyceridemia in strata of
Gruppo di Studio Progetto Menopausa Italia / Maturitas 53 (2006) 83–88
pre- and post-menopausal women and, among postmenopausal women, in HRT and non-HRT users no marked differences emerged (data not shown).
4. Discussion Before discussing the results of this study, potential limitations should be carefully considered. First of all, the women analysed were part of a large study whose main goal was to describe the characteristics of women attending first-level outpatient menopausal clinics in Italy. Thus, they cannot be considered representative of the Italian population but are clearly particularly interested in health problems, specifically menopauserelated questions. This is a selected population, and in fact the prevalence of high BP was about 25%, slightly higher than in the general population in the same strata of age [21]. In any case, the aim of this analysis was to evaluate the determinants of high BP in women around menopause. Thus, any inference from the present analysis must be made in strictly comparative terms. For the purpose of this analysis we defined hypertension on the basis of BP measurements at a single visit for women not treated with anti-hypertensive drugs. Measurement at a single visit is not probably accurate, but the diagnosis of hypertension was checked with information in the clinical record. In order to confirm on data we have also analysed determinants of high BP in women treated with an anti-hypertensive drug versus not hypertensive one: no marked differences emerged in the OR estimates (data not shown). In any case, any misclassification of hypertensive and non-hypertensive women should tend to reduce the differences in epidemiological characteristics of two groups. Data were collected at 268 centres and by different observers. This may be a problem with regard to the unifornity of the clinical measurements. We have included in the analysis term for centre. Further, as previously suggested, any not systematic misclassification should tend to reduce the observed differences. The strength of the study includes the fact that it provides an opportunity to analyse the determinants of high BP in a large series of women, using standard methods of diagnosis. This should strengthen the reliability of the difference in the frequency in the various groups of menopausal status and other covariates. Further, participation was practically complete.
87
Body weight is a recognised determinant of BP [14,22]. It has been suggested that its role, however, can differ in pre- and post-menopausal women [23]. We did not find any difference in the OR estimates of high BP for hypertensive women in strata of menopausal status. Studies conducted in different populations have shown that a low level of physical activity is related to a higher frequency of hypertension [19,23]. This study confirmed this finding. A limitation of the analysis is the fact that physical activity was self-reported; however, any misclassification should tend to underestimate the ORs. Alcohol consumption and smoking have been associated with high BP [24]. The effect can be different in young or older subjects [25]. We did not find any association between alcohol consumption, smoking and risk of high BP; in either pre- or post-menopausal women. The effect of smoking on BP may be transient, so smokers can have similar or lower BP during abstention (i.e. during a physical examination) than non-smokers. Otherwise, under-reporting of alcohol consumption and smoking might explain the lack of association with high BP in epidemiologial studies. Epidemiological evidence on the role of menopause in hypertension is not completely consistent. For example, in a comparative analysis of data collected in the MONICA study in the US and Poland, postmenopausal women were at high risk of hypertension in urban and rural populations in the US, but only in urban populations in Poland [26]. In a study conducted in Italy among women consulting their general practitioners, post-menopausal women were at increased risk [19]. Similarly, the effect of HRT on BP is controversial [1,4,6,7]. In this study, we observed an increased risk of high BP, after taking into account the confounding effect of age in post-menopausal women. Among these, HRT users were at a slightly lower risk, but the role of selection bias cannot be ruled out. In conclusion, this large cross-sectional study suggests that, after taking into account the effect of age, post-menopausal women are at higher risk of high BP, though current HRT use slightly lowers it. Other main determinants of risk of high BP among women around menopause were overweight, scant physical activity, a family history of cardiovascular disease in first-degree relatives, and a history of diabetes, and hyperlipidemia. The effect of these factors was not different in pre- and post-menopausal women.
88
Gruppo di Studio Progetto Menopausa Italia / Maturitas 53 (2006) 83–88
References [1] Luoto R, Rutanen EM, Auvinen A. Fibroids and hypertension. A cross-sectional study of women undergoing hysterectomy. J Reprod Med 2001;46:359–64. [2] Pang SC, Williams DB, Huang T, Wang C. Long-term effects of transdermal estradiol with and without medroxyprogesterone acetate. Fert Steril 1993;59:76–82. [3] Chen FP, Lee N, Wang CH, Cherng WJ, Soong YK. Effects of hormone replacement therapy on cardiovascular risk factors in post-menopausal women. Fert Steril 1998;69:267–73. [4] Campisi R, Nathan L, Pampaloni MH, et al. Non-invasive assessment of coronary microcirculatory function in postmenopausl women and effects of short-term and long-term estrogen administration. Circulation 2002;105:425–30. [5] Lindquist O. Intra-individual changes of blood pressure, serum lipids and body weight in relation to menstrual status: results from a prospective population study of women in Goteborg, Sweden. Prev Med 1982;11:162–72. [6] Hassager C, Riis BJ, Storm V, Guyene TT, Christiancen C. The long-term effect of oral and percutaneous estradiol on plasma renin substrate and blood pressure. Circulation 1987;76:753–8. [7] Cheang A, Sitruk-Ware R, Samsioe G. Transdermal oestradiol and cardiovascular risk factors. Br J Obstet Gynaecol 1994;101:571–81. [8] Levenstein S, Smith MW, Kaplan GA. Psychosocial predictors of hypertension in men and women. Arch Intern Med 2001;161:1341–6. [9] Cushman WC. Alcohol consumption and hypertension. J Clin Hypertens 2001;3:166–70. [10] Fuchs FD, Chambless LE, Whelton PK, Nieto FJ, Heiss G. Alcohol consumption and the incidence of hypertension: the atherosclerosis risk in communities study. Hypertension 2001;37:1242–50. [11] Tozawa M, Oshiro S, Iseki C, et al. Family history of hypertension and blood pressure in a screened cohort. Hypertens Res 2001;24:93–8. [12] Okosum IS, Chandra KM, Choi S, Christman J, Dever GE, Prewitt TE. Hypertension and type 2 diabetes comorbidity in adults in the United States: risk of overall and regional adiposity. Obes Res 2001;9:1–9. [13] Dyer AR, Elliott P, Shipley M. For the intersalt cooperative research group. Body mass index versus height and weight in relation to blood pressure. Am J Epidemiol 1990;131: 589–96.
[14] Kaufman JS, Durazo-Arvizu R, Rotimi CN, McGee DL, Cooper RS. Obesity and hypertesion prevalence in populations of African origin. The investigators of the international collaborative study on hypertension in blacks. Epidemiology 1996;7:398–405. [15] Parazzini F, La Vecchia C, Negri E, Bianchi C, Fedele L. Determinants of estrogen replacement therapy use in northern Italy. Rev Epidemiol Sant`e Publique 1993;41:53–8. [16] Progetto Menopausa Italia Study Group. Determinants of hysterectomy and oophorectomy in women attending menopause clinics in Italy. Maturitas 2000;36:19–25. [17] Progetto Menopausa Italia Study Group. General and medical factors associated with hormone replacement therapy among women attending menopause clinics in Italy. Menopause 2001;8:290–5. [18] Progetto Menopausa Italia. Risk of low bone density in women attending menopause clinics in Italy. Maturitas 2002;42:105–11. [19] Amigoni S, Morelli P, Parazzini F, Chatenoud L. Determinants of elevated blood pressure in women around menopause: results from a cross-sectional study in Italy. Maturitas 2000;34:25–32. [20] SAS Institute Inc., SAS/STAT user’s guide, Version 6, vol. 2, 4th ed., Cary, NC: SAS Institute Inc., 1989. [21] ISTAT. Condizioni di salute e ricorso ai servizi sanitari (Anno 1994). Indagine Multiscopo sulle famiglie. (A cura di: A Urbano, R Vivio). Informazioni n., 54, 1997. [22] Grobbee DE, Van Hemert AM, Vandenbrouke JP, Hofman A, Valkemburg HA. Importance of body weight in determining rise and level of blood pressure in post-menopausal women. J Hypertens 1988;6:614–6. [23] Ekelund LG, Haskell WL, Johnson JL, Whaley FS, Criqui MH, Sheps DS. Physical fitness as a predictor of cardiovascular mortality in asymptomatic North American men. N Engl J Med 1988;319:1379–84. [24] Bots ML, Grobbee DE, Hofman A. High blood pressure in the elderly. Epidemiol Rev 1991;13:294–314. [25] Mann SJ, James GD, Wang RS, Pickering TG. Elevation of ambulatory systolic blood pressure in hypertensive smokers. J Am Med Assoc 1991;265:2226–8. [26] Rywik SL, Davis CE, Pajak A, et al. Poland and US collaborative study on cardiovascular epidemiology hypertension in the community: prevalence, awareness, treatment, and control of hypertension in the pol-MONICA project and the US atherosclerosis risk in communities study. Ann Epidemiol 1998;8:3–13.
Risk factors for high blood pressure in women attending menopause clinics in Italy Gruppo di Studio Progetto Menopausa Italia1,2 Associazone Osterici E Ginecologi Ospedalieri Italia, Via Abanonti 3, Milan, Italy Received 6 April 2004; received in revised form 1 March 2005; accepted 1 March 2005
Abstract Objective: We analysed risk factors for high blood pressure (BP) among women around menopause. Methods: Eligible women were consecutively attending first-level outpatient menopause clinics in Italy for general counseling or treatment of menopausal symptoms. During the visit BP was measured three times. The mean of second and third of the three diastolic BP values for women was >90 mm of mercury and/or reporting any current pharmacological treatment for high BP were considered hypertensive. Out of 45,204 women who entered the study with information on blood pressure, 12,150 had high BP. Results: The odds ratios (OR) of high BP increased with age: in comparison with women aged <50 years, the multivariate OR were 1.44 (95% confidence interval (CI), 1.34–1.55), 1.61 (95% CI, 1.50–1.74) and 1.91 (95% CI, 1.77–2.06) in women aged 51–53, 54–57 and ≥58, respectively. Women with high BP were less educated than those without (OR education >12 versus <7 years, 0.79, 95% CI, 0.74–0.84). In comparison with women with a body mass index (BMI) <24, the multivariate ORs were 1.48 (95% CI, 1.39–1.57) and 2.56 (95% CI, 2.41–2.71) for women with BMI 24–26 and >26. In comparison with women reporting no regular physical activity, the multivariate OR of high BP was 0.93 (95% CI, 0.87–0.99) for women reporting regular activity. In comparison with peri-menopausal women, post-menopausal women were at increased risk (OR 1.14, 95% CI, 1.03–1.24) and the risk tended to increase with age at menopause. Current use of hormonal replacement therapy (HRT) was associated with a lower risk of high BP (OR 0.88, 95% CI, 0.84–0.94). Conclusions: This large cross-sectional study suggests that, after taking into account the effect of age, post-menopausal women are at greater risk of high BP, but current HRT use slightly lowers the risk. Other determinants of high BP were low level of education, overweight, and low level of physical activity. © 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: Women; Menopause; Risk factors; Elevated blood pressure
1
Corresponding author: Fabio Parazzini. Tel.: +39 02 390141; fax: +39 02 33200231. E-mail address: [email protected]. The following clinicians are co-authors of this paper: Participating centres: Cento (P. Di Donato); Cattolica (N.A. Giulini); Parma (A. Bacchi Modena); Forl`ı (G. Cicchetti); Reggio Emilia (G. Comitini); Bologna (G. Gentile); S. Lazzaro di Savena (P. Cristiani); Sassuolo (A. Careccia); 2
0378-5122/$ – see front matter © 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.maturitas.2005.03.002
84
Gruppo di Studio Progetto Menopausa Italia / Maturitas 53 (2006) 83–88
1. Introduction High blood pressure (BP) is among the main determinants of cardiovascular disease risk. There are some suggestions that hormonal factors play a role [1–4]. In biological terms non-diseased coronary artery vessels dilate in response to the administration of estrogen. Thus, it was interesting to analyse the characteristics of subjects with high BP among women around
menopause, a period of important changes, when the frequency of hypertension tends to rise. Epidemiological data on women around menopause are scant and in particular the relationship between menopausal status and hypertension is unclear [5]. Further, evidences is inconsistent on the effect of estrogen replacement therapy, some studies showing an increase, others a decrease or no change of BP in users [1,4,6,7].
Lugo di Romagna (E. Esposito); Reggio Emilia (F. Gualdi); Bazzano (S. Golinelli); Scandiano (E. Bergamini); Carpi (G. Masellis); Rimini (S. Rastelli); Gorizia (C. Gigli); Trieste (A. Elia); Udine (D. Marchesoni); Udine (F. Sticotti); S. Daniele del Friuli (G. Del Frate); Palmanova (C. Zompicchiatti); La Spezia (L. Marino); Genova (M.R. Costa); Genova Voltri (P. Pinto); Lavagna (D. Dodero); Genova (A. Storace); Genova (G. Spinelli); Milano (S. Quaranta); Como (C.M. Bossi); Mantova (A. Ollago); Brescia (U. Omodei); Milano (M. Vaccari); Lodi (M. Luerti); Treviglio (F. Repetti); Magenta (G. Zandonini); Milano (F. Raspagliesi); Sondrio (F. Dolci); Milano (G. Gambarino); Sondalo (B. De Pasquale); Vimercate (G. Polizzotti); Saronno (G. Borsellino); Melegnano (P. Alpinelli); Lecco (N. Natale); Sesto S. Giovanni (D. Colombo); Como (C. Belloni); Brescia (A. Viani); Paderno Dugnano (G. Cecchini); Bollate (G.W. Vinci); Brescia (B.A. Samaja); Manerbio (E. Pasinetti); Milano (M. Penotti); Como (F. Ognissanti); Cremona (P. Pesando); Ivrea (C. Malanetto); Torino (M. Gallo); Torino (G. Dolfin); Moncalieri (P. Tartaglino); Bra (D. Mossotto); Alessandria (A. Pistoni); Alba (A. Tarani); Cuneo (P.D. Rattazzi), Novara (D. Rossaro); Pinerolo (M. Campanella); Trento (E. Arisi); Rovereto (M. Gamper); Aosta (D. Salvatores); Soave-Tregnago (E. Bocchin); Trecenta (G. Stellin); Treviso (G. Meli); S. Don`a di Piave (V. Azzini); Isola della Scala (F. Tirozzi); Mestre (G. Buoso, R. Fraioli); Treviso (V. Marsoni); Pieve di Cadore (C. Cetera); Vicenza (R. Sposetti); Vittorio Veneto (E. Candiotto); Portogruaro (R. Pignalosa); Motta di Livenza (L. Del Pup); Chieti (U. Bellati); Atri (C. Angeloni); Lanciano (M. Buonerba); Vasto (S. Garzarelli); Pescara (C. Santilli); Ortona (M. Mucci); Penne (Q. Di Nisio), L’Aquila (F. Cappa); Pescara (I. Pierangeli); Teramo (A. Cordone); Agnone (L. Falasca); Campobasso (D. Ferrante); Roma (G.B. Serra); Roma (E. Cirese); Roma (P.A. Todaro); Roma (C. Romanini); Roma (L. Spagnuolo); Roma (A. Lanzone); Roma (C. Donadio); Roma (M. Fabiani); Alatri (E. Baldaccini); Roma (S. Votano); Latina (P. Bellardini); Velletri (W. Favale); Anzio (V. Monti); Roma (A. Bonomo; C.E. Boninfante); Roma (P. Pietrobattista); Senigallia (L. Massacesi); Pesaro (G. Donini); Ancona (F. Del Savio); Macerata (L. Palombi); Ascoli Piceno (P. Procaccioli); Fabriano (A. Romani); Osimo (G. Romagnoli); Pisa (A.R. Genazzani, M. Gambacciani); Firenze (G. Scarselli); Prato (P. Curiel); Siena (V. De Leo); Pescia (A. Melani); Montevarchi (V. Levi D’Ancona); Borgo S. Lorenzo (G. Giarr`e), Poggibonsi (E. Di Gioia); Lucca (P. Ceccarelli); Firenze (G.B. Massi); Livorno (S. Cosci); Bagno a Ripoli (G. Gacci), Sansepolcro (A. Cascianini); Perugia (C. Donati Sarti); Foligno (S. Bircolotti); Citt`a di Castello (P. Pupita); Perugia (M. Mincigrucci); Narni (A. Spadafora); Iglesias (G. Santeufemia); Oristano (G. Marongiu); Sassari (G.R. Lai); Olbia (R. Lai); Sassari (S. Dessole); Potenza (S.A. D’Andrea); Villa d’Agri (Coppola); Napoli (A. Chiantera); Napoli (De Placido); Napoli (R. Arienzo); Solofra (A.R. Pastore); Napoli (A. Tamburrino); Napoli (A. Cardone, N. Colacurci); Benevento (S. Izzo); Napoli (R. Tesauro); S. Maria Capua Vetere (A. Pascarella); Nocera Inferiore (M.G. De Silvio); Napoli (L. Di Prisco); Napoli (N. Lauda); Napoli (F. Sirimarco); Aversa (C. Agrimi), Mercogliano (G. Casarella); Eboli (G. Senatore); Oliveto Citra (S. Ronzini); Caserta (G. Ruccia); Giugliano (G. De Carlo); Battipaglia (G. Pisaturo); Castellammare di Stabia (F. Carlomagno); Salerno (A. Fasolino); Napoli (F. Fiorillo); S. Bartolomeo in Galdo (R. Sorrentino); Vico Equense (V.B. Ercolano); Napoli (S. Panariello); Pozzuoli (A. Brun); Reggio Calabria (P. Tropea); Castrovillari (C.M. Stigliano); Cosenza (A. Amoroso); Soveria Mannelli (P. Vadal`a); Oppido Mamertina (A. Coco); Soriano Calabro (G. Galati); Lamezia Terme (G. Barese); Crotone (G. Masciari); Corigliano (P. Pirillo); Soverato (T. Gioffr`e); Catanzaro (P. Mastrantonio); Catanzaro (A. Cardamone); Trebisacce (N. D’Angelo); Paola (G. Valentino); Crotone (R. Barretta); Gioia Tauro (G. Ferraro); Mesagne (C. Ferruccio); Terlizzi (D. Agostinelli); Cerignola (G. Corrado); Foggia (A. Scopelliti); Bari (S. Schonauer, V. Trojano); Taranto (F. Bongiovanni); Lecce (F. Tinelli); Brindisi (E.R. Poddi); Poggiardo (F. Scarpello); Altamura (L. Colonna); Castellaneta (G. Fischetti); Carbonara (R. Doria); Barletta (G. Trombetta); Grottaglie (E.B. Cocca, A. D’Amore); Castellana Grotte (M. Di Masi); Acquaviva delle Fonti (R. Liguori); Francavilla Fontana (A. Dimaggio); Taranto (M.R. Laneve); Martina Franca (M.C. Maolo); San Severo (G. Gravina); S. Pietro Vernotico (G. Nacci); Catania (F. Nocera); Palermo (A. Lupo); Palermo (C. Giannola, R. Graziano); Palermo (M. Mezzatesta); Palermo (G. Vegna); Enna (G. Giannone); Catania (G. Palumbo); Messina (F. Cancellieri); Milazzo (A. Mondo); Messina (A. Cordopatri); Caltanisetta (M. Carrubba); Leonforte (V. Mazzola); Caltagirone (L. Cincotta); Comiso (S. D’Asta); Mazara del Vallo (A. Bono); Canicatti (L. Li Calsi); Catania (S. Cavallaro Nigro); Vittoria (S. Schilir`o); Messina (A. Repici); Palermo (D. Gullo); Mussomeli (A. Orlando); Grammichele (F. Specchiale); Piazza Armerina (A. Papotto). Regional coordinators: Angeloni (Abruzzo), D’Andrea (Basilicata), Stigliano (Calabria), Arienzo (Campania), Di Donato (Emilia), Giulini (Romagna), Gigli (Friuli Venezia Giulia), Todaro (Lazio), Marino (Liguria), Luerti (Lombardia), Donini (Marche), Ferrante (Molise), Dolfin (Piemonte), Poddi (Puglia), Santeufemia (Sardegna), Nocera (Sicilia), Melani (Toscana), Arisi (Trentino Alto Adige), Mincigrucci (Umbria), Salvatores (Valle D’Aosta), Bocchin (Veneto). National coordinators: A. Massacesi, A. Chiantera, C. Donati Sarti, P. De Aloysio, U. Omodei, F. Ognissanti, C. Campagnoli, M. Penotti, A. Gambacciani, A. Graziottin, C. Baldi, N. Colacurci, G. Corrado Tonti. Data analysis: F. Parazzini, L. Chatenoud.
Gruppo di Studio Progetto Menopausa Italia / Maturitas 53 (2006) 83–88
Overweight, low physical activity, history of diabetes, hypercholesterolemia, and less consistently smoking and alcohol consumption have been associated with an increased risk of hypertension. However, the data on women around menopause are scanty [8–14]. Further, most studies in peri-menopausal women have been conducted in North American and northern European populations. Determinants may differ in countries with different lifestyles and prevalence of use of hormonal replacement therapy (HRT) [15]. In order to give information on the determinant of high BP in women around menopause in a southern European population, we analysed data from a large Italian study including about 50,000 women attending menopause clinics in Italy for counselling about menopause [15–18]. In 1999, we published a paper analysing determinants of high BP in post-menopausal women observed by their general practitioners [19]. Data presented here refered to a different study based on a totally difficult population. Women not included in the previous paper was included in the present analysis.
2. Methods Between 1997 and 2000, we conducted a large cross-sectional study on the characteristics of women around menopause attending a network of first-level outpatient menopause clinics in Italy for general counseling or treatment of menopausal symptoms [16–19]. Women consecutively observed during the study were eligible. The study protocol did not set any exclusion criteria. All women who agreed to participate underwent a gynecological examination. During the visit they were asked about their general characteristics and habits, reproductive and menstrual history, and a selected medical history were taken. During the visit weight (kg) and height (cm) were measured and recorded. During the interview, BP was measured three times on the right arm, with the participant seated. The woman for whom the mean of the second and third of the three diastolic BP values was >90 mm of mercury and/or women reporting any current pharmacological treatment for high BP were considered hypertensive. The finding of high BP was checked by the gynecologist against clinical records.
85
The study started in 1997 in 25 centers. The number of centers increased to 268 in 1999. Of these, 63 were in the North, 81 in the Center and 124 in the South of Italy. A total of 49,122 women (mean age 53 years, range 45–75 years) entered the study. The mean number per center was 98. Less than 3% of eligible women refused to participate. Information on blood pressure was available on 45,204 (92.0%) subjects. Body mass index (BMI, kg m−2 ) was classified as the best possible approximation of tertiles of BMI in the whole population. Post-menopausal women were defined as those with surgical menopause (i.e. bilateral oophorectomy with or without hysterectomy), women aged >55 years who had undergone hysterectomy without bilateral oophorectomy, and those whose menstrual cycles had stopped more than one year before interview. Women with a history of cardiovascular disease were those reporting any medical treatment for cardiovascular conditions. Level of physical activity was self-reported. The woman was asked to answer ‘Yes’ or ‘No’ to the following question: “Do you usually spend three or more hours per week in intense physical activity for leisure or work?” Housekeeping activity was not considered. 2.1. Data analysis Odds ratios (ORs) of high BP and the corresponding 95% confidence intervals (CIs) were computed after allowance for age. To take into account the potential reciprocal confounding effect of the variables considered, factors significantly related with high BP risk in the age-adjusted analysis were subsequently included in multiple logistic regression models fitted by the method of maximum likelihood [20]. The terms included are indicated as the footnotes in Table 1.
3. Results A total of 12,150 (26.8%) women had high BP. The distribution of women with and without high BP according to selected general characteristics is shown in Table 1. The OR of elevated blood pressure increased with age. In comparison with women aged <50 years, the multivariate OR were 1.44 (95% CI, 1.34–1.55), 1.61 (95% CI, 1.50–1.74), and 1.91 (95%
Gruppo di Studio Progetto Menopausa Italia / Maturitas 53 (2006) 83–88
86
Table 1 Odds ratios of high blood pressure according to selected factorsa High blood pressure No Age (years) <50 51–53 54–57 ≥58
OR (95%
Yes 1863 2665 3318 4279
1c 1.44 (1.34–1.55) 1.61 (1.50–1.74) 1.91 (1.77–2.06)
Education (years) <7 7–11 ≥12
11714 9213 8824
5428 3129 2481
1c 0.90 (0.85–0.96) 0.79 (0.74–0.84)
BMI (kg m−2 ) <24 24–26 >26
12222 9612 9698
2647 3164 5675
1c 1.48 (1.39–1.57) 2.56 (2.41–2.71)
Smoking habits Never smoker Ever smoker
25123 7662
9935 2123
1c 0.82 (0.77–0.87)
3306 3100 1256
956 813 354
0.84 (0.77–0.91) 0.79 (0.72–0.86) 0.86 (0.75–0.99)
24806 8006
9063 2998
1c 1.05 (0.98–1.11)
Regular physical activity No 26513 Yes 6263
10137 1914
1c 0.93 (0.87–0.99)
Family history of cardiovascular diseases No 20364 6903 Yes 8780 4006
1c 1.41 (1.34–1.48)
Diabetes No Yes
Alcohol drinking No Yes
29377 735
10717 468
1c 1.24 (1.09–1.42)
Serum cholesterol (mg/dl) <210 6232 210–250 6137 251–290 2474 >290 714
2070 2368 1125 376
1c 1.07 (0.99–1.16) 1.25 (1.13–1.38) 1.42 (1.22–1.65)
Triglycerides (mg/dl) <180 12127 180–215 1125 216–250 363 >250 355
4363 498 2008 228
1c 1.12 (0.99–1.27) 1.33 (1.09–1.62) 1.55 (1.28–1.83)
1882 10268
1c 1.14 (1.05–1.24)
Menopausal status Peri-menopause Post-menopause
6311 26743
OR (95% CI)b
High blood pressure
CI)b
8199 7670 8311 8813
Cigarettes day <10 10–20 >20
Table 1 (Continued )
No Age at menopause (years) ≤49 12871 50–52 7492 ≥53 3469 Current use of HRT No 27374 Yes 5680
Yes 4470 3180 1715
1.03 (0.96–1.09) 1.06 (0.98–1.14) 1.14 (1.04–1.24)
10209 1941
1c 0.88 (0.84–0.94)
a
In some cases the sum does not add up the total because of missing values. b OR, odds ratios; CI, confidence intervals. Multivariate estimates include terms for age, education, BMI, physical activity, family history of cardiovascular diseases, diabetes, serum cholesterol, triglycerides menopausal status, current use of HRT. c Reference category.
CI, 1.34–1.55) in women aged 51–53, 54–57 and ≥58 years, respectively. Women with high BP were less educated than those without (OR education >12 versus <7 years, 0.79, 95% CI, 0.74–0.84). Overweight was associated with an increased risk of high BP (OR BMI >26 versus <24 2.56, 95% CI, 2.41–2.71). Regular physical activity was associated with a lower risk of high BP: in comparison with women reporting no physical activity, the multivariate OR of elevated blood pressure was 0.93 (95% CI, 0.87–0.99) for women reporting regular activity. A family history of cardiovascular disease in first-degree relatives (OR Yes versus No 1.41, 95% CI, 1.34–1.48), a personal history of diabetes (OR Yes versus No 1.24, 95% CI, 1.09–1.42), hypercholesterolemia (OR > 290 mg/dl versus <210 mg/dl 1.42 95% CI, 1.22–1.65) and hypertryglyceridemia (OR > 250 mg/dl versus <180 mg/dl 1.55, 95% CI, 1.28–1.83), were all associated with the risk of high BP. No association emerged with smoking habits or alcohol drinking. The OR of high BP was 1.14 (95% CI, 1.05–1.24) in post-menopausal in comparison with peri-menopausal women and the risk increased with age at menopause. Among post-menopausal women, the multivariate OR of high BP for HRT use was 0.88 (95% CI, 0.84–0.94). We then analysed the effect of BMI, physical activity, family history of cardiovascular disease, diabetes, ipercholesterolemia and ipertriglyceridemia in strata of
Gruppo di Studio Progetto Menopausa Italia / Maturitas 53 (2006) 83–88
pre- and post-menopausal women and, among postmenopausal women, in HRT and non-HRT users no marked differences emerged (data not shown).
4. Discussion Before discussing the results of this study, potential limitations should be carefully considered. First of all, the women analysed were part of a large study whose main goal was to describe the characteristics of women attending first-level outpatient menopausal clinics in Italy. Thus, they cannot be considered representative of the Italian population but are clearly particularly interested in health problems, specifically menopauserelated questions. This is a selected population, and in fact the prevalence of high BP was about 25%, slightly higher than in the general population in the same strata of age [21]. In any case, the aim of this analysis was to evaluate the determinants of high BP in women around menopause. Thus, any inference from the present analysis must be made in strictly comparative terms. For the purpose of this analysis we defined hypertension on the basis of BP measurements at a single visit for women not treated with anti-hypertensive drugs. Measurement at a single visit is not probably accurate, but the diagnosis of hypertension was checked with information in the clinical record. In order to confirm on data we have also analysed determinants of high BP in women treated with an anti-hypertensive drug versus not hypertensive one: no marked differences emerged in the OR estimates (data not shown). In any case, any misclassification of hypertensive and non-hypertensive women should tend to reduce the differences in epidemiological characteristics of two groups. Data were collected at 268 centres and by different observers. This may be a problem with regard to the unifornity of the clinical measurements. We have included in the analysis term for centre. Further, as previously suggested, any not systematic misclassification should tend to reduce the observed differences. The strength of the study includes the fact that it provides an opportunity to analyse the determinants of high BP in a large series of women, using standard methods of diagnosis. This should strengthen the reliability of the difference in the frequency in the various groups of menopausal status and other covariates. Further, participation was practically complete.
87
Body weight is a recognised determinant of BP [14,22]. It has been suggested that its role, however, can differ in pre- and post-menopausal women [23]. We did not find any difference in the OR estimates of high BP for hypertensive women in strata of menopausal status. Studies conducted in different populations have shown that a low level of physical activity is related to a higher frequency of hypertension [19,23]. This study confirmed this finding. A limitation of the analysis is the fact that physical activity was self-reported; however, any misclassification should tend to underestimate the ORs. Alcohol consumption and smoking have been associated with high BP [24]. The effect can be different in young or older subjects [25]. We did not find any association between alcohol consumption, smoking and risk of high BP; in either pre- or post-menopausal women. The effect of smoking on BP may be transient, so smokers can have similar or lower BP during abstention (i.e. during a physical examination) than non-smokers. Otherwise, under-reporting of alcohol consumption and smoking might explain the lack of association with high BP in epidemiologial studies. Epidemiological evidence on the role of menopause in hypertension is not completely consistent. For example, in a comparative analysis of data collected in the MONICA study in the US and Poland, postmenopausal women were at high risk of hypertension in urban and rural populations in the US, but only in urban populations in Poland [26]. In a study conducted in Italy among women consulting their general practitioners, post-menopausal women were at increased risk [19]. Similarly, the effect of HRT on BP is controversial [1,4,6,7]. In this study, we observed an increased risk of high BP, after taking into account the confounding effect of age in post-menopausal women. Among these, HRT users were at a slightly lower risk, but the role of selection bias cannot be ruled out. In conclusion, this large cross-sectional study suggests that, after taking into account the effect of age, post-menopausal women are at higher risk of high BP, though current HRT use slightly lowers it. Other main determinants of risk of high BP among women around menopause were overweight, scant physical activity, a family history of cardiovascular disease in first-degree relatives, and a history of diabetes, and hyperlipidemia. The effect of these factors was not different in pre- and post-menopausal women.
88
Gruppo di Studio Progetto Menopausa Italia / Maturitas 53 (2006) 83–88
References [1] Luoto R, Rutanen EM, Auvinen A. Fibroids and hypertension. A cross-sectional study of women undergoing hysterectomy. J Reprod Med 2001;46:359–64. [2] Pang SC, Williams DB, Huang T, Wang C. Long-term effects of transdermal estradiol with and without medroxyprogesterone acetate. Fert Steril 1993;59:76–82. [3] Chen FP, Lee N, Wang CH, Cherng WJ, Soong YK. Effects of hormone replacement therapy on cardiovascular risk factors in post-menopausal women. Fert Steril 1998;69:267–73. [4] Campisi R, Nathan L, Pampaloni MH, et al. Non-invasive assessment of coronary microcirculatory function in postmenopausl women and effects of short-term and long-term estrogen administration. Circulation 2002;105:425–30. [5] Lindquist O. Intra-individual changes of blood pressure, serum lipids and body weight in relation to menstrual status: results from a prospective population study of women in Goteborg, Sweden. Prev Med 1982;11:162–72. [6] Hassager C, Riis BJ, Storm V, Guyene TT, Christiancen C. The long-term effect of oral and percutaneous estradiol on plasma renin substrate and blood pressure. Circulation 1987;76:753–8. [7] Cheang A, Sitruk-Ware R, Samsioe G. Transdermal oestradiol and cardiovascular risk factors. Br J Obstet Gynaecol 1994;101:571–81. [8] Levenstein S, Smith MW, Kaplan GA. Psychosocial predictors of hypertension in men and women. Arch Intern Med 2001;161:1341–6. [9] Cushman WC. Alcohol consumption and hypertension. J Clin Hypertens 2001;3:166–70. [10] Fuchs FD, Chambless LE, Whelton PK, Nieto FJ, Heiss G. Alcohol consumption and the incidence of hypertension: the atherosclerosis risk in communities study. Hypertension 2001;37:1242–50. [11] Tozawa M, Oshiro S, Iseki C, et al. Family history of hypertension and blood pressure in a screened cohort. Hypertens Res 2001;24:93–8. [12] Okosum IS, Chandra KM, Choi S, Christman J, Dever GE, Prewitt TE. Hypertension and type 2 diabetes comorbidity in adults in the United States: risk of overall and regional adiposity. Obes Res 2001;9:1–9. [13] Dyer AR, Elliott P, Shipley M. For the intersalt cooperative research group. Body mass index versus height and weight in relation to blood pressure. Am J Epidemiol 1990;131: 589–96.
[14] Kaufman JS, Durazo-Arvizu R, Rotimi CN, McGee DL, Cooper RS. Obesity and hypertesion prevalence in populations of African origin. The investigators of the international collaborative study on hypertension in blacks. Epidemiology 1996;7:398–405. [15] Parazzini F, La Vecchia C, Negri E, Bianchi C, Fedele L. Determinants of estrogen replacement therapy use in northern Italy. Rev Epidemiol Sant`e Publique 1993;41:53–8. [16] Progetto Menopausa Italia Study Group. Determinants of hysterectomy and oophorectomy in women attending menopause clinics in Italy. Maturitas 2000;36:19–25. [17] Progetto Menopausa Italia Study Group. General and medical factors associated with hormone replacement therapy among women attending menopause clinics in Italy. Menopause 2001;8:290–5. [18] Progetto Menopausa Italia. Risk of low bone density in women attending menopause clinics in Italy. Maturitas 2002;42:105–11. [19] Amigoni S, Morelli P, Parazzini F, Chatenoud L. Determinants of elevated blood pressure in women around menopause: results from a cross-sectional study in Italy. Maturitas 2000;34:25–32. [20] SAS Institute Inc., SAS/STAT user’s guide, Version 6, vol. 2, 4th ed., Cary, NC: SAS Institute Inc., 1989. [21] ISTAT. Condizioni di salute e ricorso ai servizi sanitari (Anno 1994). Indagine Multiscopo sulle famiglie. (A cura di: A Urbano, R Vivio). Informazioni n., 54, 1997. [22] Grobbee DE, Van Hemert AM, Vandenbrouke JP, Hofman A, Valkemburg HA. Importance of body weight in determining rise and level of blood pressure in post-menopausal women. J Hypertens 1988;6:614–6. [23] Ekelund LG, Haskell WL, Johnson JL, Whaley FS, Criqui MH, Sheps DS. Physical fitness as a predictor of cardiovascular mortality in asymptomatic North American men. N Engl J Med 1988;319:1379–84. [24] Bots ML, Grobbee DE, Hofman A. High blood pressure in the elderly. Epidemiol Rev 1991;13:294–314. [25] Mann SJ, James GD, Wang RS, Pickering TG. Elevation of ambulatory systolic blood pressure in hypertensive smokers. J Am Med Assoc 1991;265:2226–8. [26] Rywik SL, Davis CE, Pajak A, et al. Poland and US collaborative study on cardiovascular epidemiology hypertension in the community: prevalence, awareness, treatment, and control of hypertension in the pol-MONICA project and the US atherosclerosis risk in communities study. Ann Epidemiol 1998;8:3–13.