Premenstrual Syndrome and Increased Blood Pressure: A New Risk Factor for Cardiovascular Disease in Women?

Premenstrual syndrome (PMS) is an often debilitating and serious disorder characterized by moderate-to-severe symptoms occurring during the luteal phase of the menstrual cycle. Estimates of its prevalence are one-fifth or more of reproductive-aged women in the United States and abroad. ^1,2 Symptoms include abdominal bloating, breast tenderness, headache, hot flashes, palpitations, nausea, swelling in the extremities, fatigue, insomnia, and so on. ³ The recent article in the Journal of Women's Health by Bertone-Johnson et al. ⁴ considered whether there are differences in blood pressure between those who regularly experience these complaints compared with a group of women who do not. She conducted a cross-sectional study of 409 young women (mean age 21.0 years) exploring blood pressure and PMS symptoms during the period 2006 to 2014 on a campus in Massachusetts. Standardized questionnaires were administered to obtain information on PMS complaints as well as sociodemographic, anthropometric and personal health history, and habits. Standardized methods were also used to collect single blood pressure readings from these women, although more than one reading would have been ideal. A total of 78 women met the established criteria for PMS and there were 88 controls who reported few of the criteria. After adjustment for smoking, body mass index, hormone use, age at menarche, and physical activity, the mean diastolic blood pressure in cases was 72.3 versus 69.1 mmHg in controls (p < 0.02).

This observation may be important as a three-point shift in diastolic blood pressure in a large proportion of young women over time can have significant implications for future risk of heart disease. Kannel et al. in a recent article, “Hypertension: Reflections on Risks and Prognostication” (2009), ⁵ made an important statement concerning the status of the identification and treatment of hypertension: “It is now evident that it is the degree of blood pressure elevation that promotes cardiovascular disease, and not arbitrarily defined ‘hypertension stages.’ Cardiovascular risk increases incrementally with the blood pressure with no critical blood pressure values defining risk stages. Furthermore, blood pressure is best regarded as one component of a multivariable cardiovascular risk profile because at any level of blood pressure the cardiovascular disease risk varies widely in relation to the number of accompanying risk factors.” ⁶

Adding to the present study's findings is the recent work by the same author (2014) involving a nested case–control study within the Nurses' Health Study suggesting that women with PMS have a higher risk of subsequently developing hypertension. A total of 1257 women with clinically significant PMS (1991–2005) and 2463 age-matched comparison women with few menstrual symptoms were included in the follow-up for incident hypertension until 2011. After adjustment for age, smoking, body mass index, and other risk factors for hypertension, women with PMS had hazards ratio of 1.4 (95% CI: 1.2–1.6) compared with those without PMS. The risk was not changed by the use of oral contraceptives or antidepressants. ⁷

Several additional articles including one by Bertone-Johnson investigated the relationship of PMS symptoms and increases in inflammatory biomarkers such as CRP (C-reactive protein) and IL-6. ⁸ We have noted similar increases in women with PCOS who may also be at increased risk of heart disease and who are at increased risk of both hypertension and T2 diabetes. ⁹ This may offer additional evidence of the intermediary factors leading to increased blood pressure and future cardiovascular risk. Careful documentation within groups with PMS as to the use of over-the-counter or prescription pharmaceutical compounds and blood pressure would be important as well. ¹⁰ Women who take such medications to ameliorate their symptoms may increase their risk of elevated blood pressure. The finding by Bertone-Johnson et al. of an increased level of diastolic blood pressure among women at age 21 with PMS of a moderate-to-severe nature underscores the need for a larger studies of women prospectively followed to determine the relationship of PMS symptoms, inflammatory biomarkers of CVD risk, and systolic and diastolic blood pressure.