High blood pressure (hypertension) often creeps up silently during midlife.
Similar to cholesterol creeping up (see my previous blog post on cholesterol in midlife and PMOS), we can't FEEL mild to moderate increases in our blood pressure.
That's how it often goes unchecked for long periods of time.
As women enter perimenopause, and especially get close to and pass menopause, declining estrogen levels impact the behaviour of our blood vessels.
Estrogen is not just a reproductive hormone; it's an antioxidant with anti-inflammatory properties that protect our blood vessels.
Let's go through some of the changes that start to happen in perimenopause and beyond:
Stiffer arteries more prone to damage: The inner lining of your arteries (the endothelium) responds to estrogen. As estrogen decreases, the balance between relaxation and constriction in your blood vessels goes awry, leading to stiffer arteries.
Increased salt sensitivity: Women are naturally more sensitive to sodium than men, and this sensitivity increases as estrogen declines. This shift causes the kidneys to retain more fluid, increasing overall blood volume and pressure on arterial walls.
Exposure over time: Blood pressure rarely spikes overnight. What we see is a gradual incline through perimenopause followed by an accelerated steep rise post-menopause, after you've had your final period ever. You could also have a higher risk based on genetics, alcohol, past history like gestational hypertension or pre-eclampsia, or PMOS. Cardiovascular disease develops over decades, so we need to make sure we're monitoring over time, and having baselines established when you have regular estrogen exposure.
We care about high blood pressure because it can lead to cardiovascular disease and events like a stroke.
In Ontario and across Canada, healthcare systems are under immense strain. This means that routine and preventive screening often slips through the cracks, particularly for women in their late 30s and early 40s or those who are postpartum. This is unfortunate, but it's also why you need to make sure you're equipping yourself with some education and tools! And, that's exactly why I'm writing this post!
Relying solely on an annual blood pressure check at your clinic creates significant blind spots, like thinking your "white coat hypertension" isn't important. An elevated reading in a clinic (e.g., above 130/80 mmHg) is frequently brushed off as stress caused by the clinical setting. BUT, research shows that individuals with white coat hypertension carry a significantly higher risk of developing sustained, true hypertension at home over time. So, this could be an early warning sign, and I encourage you to check at home.
The other thing that sometimes gets missed with infrequent or MIA blood pressure checks: silent small-vessel damage. Unmanaged high blood pressure damages micro-vascular networks long before causing overt symptoms. Over time, elevated pressure forces the heart muscle to work overtime, increasing the risk of heart failure, arrhythmias, and damage in the kidneys and eyes. Again, I encourage you to check your BP.
The Heart & Stroke Foundation as well as Hypertension Canada are excellent resources on all things blood pressure including validated at-home devices.
To establish a true baseline, invest in a validated blood pressure monitor. Track your readings twice daily (morning and evening) over a seven-day period and bring those averages to your primary care provider.
Once you have that, you can check a few times per year at home (and store them on your machine or note them down somewhere) if your reading were normal. If they were abnormal or borderline, then check a bit more frequently.
The updated hypertension guidelines reflect an important reality we're recognizing more and more over time: cardiovascular impacts occur at lower blood pressure thresholds in women compared to men, and prolonged exposure to elevated blood pressure matters.
The top number is called the systolic blood pressure (when the heart contracts), and the bottom number is the diastolic blood pressure (when the heart relaxes).
Here are the categories:
If your blood pressure falls between 130-139/80-89 AND you do NOT have high-risk conditions (such as diabetes, established heart disease, or kidney dysfunction), Canadian guidelines allow a 3 to 6-month window to lower your numbers using diet and lifestyle levers before starting medication.
Unfortunately, many patietns are often told to "work on diet and lifestyle" without further clarity--this is the golden opportunity to make significant change and we need to use evidence-based strategies! I'll lay out a few of them below (remember: this is not medical advice!).
There's lots that can be done here! The sooner you start, the longer of a runway you have and the sooner you can understand how much lifestyle is having an impact.
Improve sodium to potassium ratio: Reducing sodium intake and decrease high-sodium foods is important AND increasing dietary potassium is equally critical because potassium relaxes vessel walls and helps excrete excess sodium. Aim for >3,500mg of dietary potassium daily through foods like leafy greens, avocados, sweet potatoes, squashes, beans, and lentils (note: check with your medical team re: potassium as kidney health and current medications need consideration here). Plant foods are inherently high in potassium.
Adopt a plant-predominant dietary pattern: Follow plant-forward models like the DASH (Dietary Approaches to Stop Hypertension) or Mediterranean diets. These patterns naturally emphasize whole grains, legumes, vegetables, nuts, seeds, lean proteins, and low-fat dairy, delivering the exact combination of potassium, calcium, magnesium, and lower sodium needed for optimal arterial health. They also de-emphasize saturated fat containing foods like red meat and butter, which contribute to overall heart disease risk.
Move your body: Combine aerobic and resistance exercise, aiming for a minimum of 150 to 300 minutes per week of moderate-intensity aerobic activity (like brisk walking, cycling, or swimming), which directly enhances vascular health. Pair this with 2 to 3 days of resistance training to build muscle, manage visceral fat, and improve metabolic health, and you've got a robust plan for your heart, brain, and bones.
Manage your stress: Chronic stress affect blood pressure and overall health. Daily stress-reduction practices, like breathing exercises, mindfulness, spending time in nature, moving your body, spending time with loved ones, and prioritizing sleep, help with your heart (and mental) health! Consider counselling, acupuncture, and herbs here too.
Prioritize sleep & check for sleep apnea: Sleep is crucial for overall health, and it's important for appetite regulation as well. Sleep apnea in midlife women often goes under-diagnosed, presenting more with daytime fatigue and brain fog versus loud snoring. Unmanaged sleep apnea can lead to high(er) blood pressure. Get a sleep study!
Identify and remove hidden triggers: Check daily things that silently drive up blood pressure, like frequent over-the-counter NSAIDs (like ibuprofen or naproxen), decongestants containing stimulants, and regular alcohol intake, all of which impair kidney function or constrict blood vessels.
There are many tools that we can use to help manage blood pressure. Sometimes, this can be temporary to "buy" some time to implement lifestyle modifications while minimizing the effects of high blood pressure on your vessels.
Lifestyle modification works really well for some. However, the goal is to prevent future events that can totally derail your life. So, remember: medication or supplementation is not a failure, simply tools to protect your health. Medication has way more long-term scientific data on safety and effectiveness than supplements (as of right now).
Taking control of your blood pressure in perimenopause is about imporving your healthspan--the years you have to live doing the things you want, being independent, etc. Identifying subtle changes early gives you decades of runway to protect your heart, brain, and kidneys for the long run.
Thank you to my colleague, Dr. Olivia Greenspan, ND RN MSCP, who inspired this post after speaking at The Perimenopause Summit, which runs Sept 21 to 24, 2026 virtually--it's free to attend. Sign up now!
If you're looking for support with your heart health like your blood pressure and/or cholesterol, feel free to to book an appointment with Dr. Olivia Greenspan (virtual or Newmarket) or myself (virtually in Ontario, in Newmarket or Innisfil).
References: Hypertension Canada
