High Blood Pressure During Menopause: Why an Undiagnosed Hormonal Imbalance Might Be the Cause

When blood pressure rises in middle age, menopause, stress, or lifestyle changes are often suspected as possible causes. But sometimes a treatable disorder of the adrenal glands is to blame. A new study shows why conventional blood tests may overlook this hormonal disorder—and why nighttime hormonal changes could provide important clues.

Why Blood Pressure Becomes a More Frequent Concern Around Menopause

As people age, the risk of high blood pressure increases for many. During perimenopause and after menopause, many women notice changes they had rarely experienced before: blood pressure rises, sleep becomes more restless, the heart occasionally beats faster, or physical stamina changes. Younger women can also be affected, as some studies associate early menopause—before age 45—with an increased risk of high blood pressure.

Such symptoms can have various causes. That is why it is important not to automatically attribute every change to menopause. In particular, newly occurring high blood pressure or high blood pressure that is becoming increasingly difficult to control should be evaluated by a doctor. In addition to age-related changes in the cardiovascular system, underlying conditions that have not yet been diagnosed may also be to blame.

A study published in the journal Science Translational Medicine draws attention to one such cause: primary aldosteronism. This is a hormonal disorder of the adrenal glands in which too much aldosterone is produced. What makes this condition unique is that the abnormal hormonal activity can fluctuate throughout the day and become particularly pronounced at night. For women, a great deal changes around the time of menopause. During menopause, estrogen production in the ovaries decreases significantly. This hormonal transition is accompanied by changes in various bodily functions, including processes that are important for vascular health and metabolism.

Among other things, estrogen influences the function of the inner lining of blood vessels and various mechanisms involved in regulating vascular tone. After menopause, vascular function and the elasticity of the arteries may change. At the same time, factors such as an unfavorable distribution of body fat, insulin resistance, or weight gain become more significant for many women. Sleep problems, lack of physical activity, and a family history of high blood pressure can also influence blood pressure. These individual factors often interact.

However, this does not mean that the decline in estrogen alone is responsible for rising blood pressure. High blood pressure usually results from a combination of various factors. Furthermore, it can go unnoticed for a long time because it often does not cause any clear symptoms. This is precisely why it makes sense to monitor blood pressure regularly during midlife and to have any persistent changes evaluated by a doctor.

When it’s Not Menopause But the Adrenal Glands That are Involved

In addition to the well-known influences of age and menopause, there are hormonal disorders that can directly affect blood pressure. One of these is primary aldosteronism. Aldosterone is produced in the adrenal cortex. This hormone causes the kidneys to retain sodium and water and to excrete more potassium. In this way, it affects the volume of fluid in the circulatory system and helps regulate blood pressure. If too much aldosterone is produced over a long period, the body may retain too much sodium and water. Blood volume increases and blood pressure rises. At the same time, the potassium level in the blood may drop, which can cause further symptoms in severe cases.

The condition can have various causes. Sometimes a single adrenal gland produces excessive amounts of aldosterone, for example, due to a benign hormone-producing nodule. In other cases, both adrenal glands are involved. The tricky part is that primary aldosteronism does not necessarily go hand in hand with a noticeably low potassium level. A normal potassium level therefore does not rule out the condition.

According to the Endocrine Society, primary aldosteronism affects an estimated 5 to 14 percent of people with high blood pressure in primary care. In specialized facilities, the prevalence may be even higher. The condition is considered a common but often unrecognized cause of secondary high blood pressure. This is an important point for women in midlife: Even if the rise in blood pressure coincides with menopause, appropriate signs should prompt an investigation into whether there is an additional or alternative cause.

What the New Study Reveals About Nighttime Hormone Surges

An international research team from the United Kingdom, Norway, Sweden, and Greece investigated how the activity of certain hormones changes over the course of a full day and night in people with primary aldosteronism. The results were published in Science Translational Medicine. The study included 60 patients whose hormone activity was monitored over a 24-hour period.

A wearable device called U-RHYTHM was used. The lightweight device is worn on the body and enables repeated sampling through the skin. This allowed participants to continue their normal daily routines rather than having to stay in a clinic for the duration of the measurements. Hormone levels were recorded every 20 minutes. In addition to aldosterone, the scientists examined two related steroid hormones, 18-hydroxycortisol and 18-oxocortisol. Thanks to the frequent measurements, the researchers were able to observe changes that would have been barely detectable in a single blood sample.

Why a Single Blood Test is Not Always Sufficient

The study showed that aldosterone production in the participants was not simply elevated throughout the day. Instead, there were recurring spikes in secretion, which were particularly noticeable during the night and in the early morning hours. This is significant for diagnosis. If a hormone is measured at a time when its concentration happens to be lower, the result may appear less striking than at another time. Even in some patients with severe disease, the levels were at times below the thresholds typically used for diagnostic evaluation.

The results therefore suggest that it is not only the absolute level of a hormone that is important. The temporal course of hormone production can also provide crucial information. The researchers thus describe a possible reason why primary aldosteronism remains undiagnosed in some people: the hormonal dysregulation does not necessarily manifest itself with the same clarity in every single measurement.

What This Could Mean for Women Going Through Menopause

The study was not specifically conducted on women in perimenopause or postmenopause. Its results therefore cannot be directly interpreted as evidence of a specific link between menopause and primary aldosteronism. Nevertheless, the topic is relevant to this stage of life. High blood pressure becomes more common with age. At the same time, women may experience various physical changes during menopause that make it more difficult to clearly identify the cause of new symptoms.

Heart palpitations, sleep disturbances, or restlessness, for example, can occur in connection with hormonal changes. However, these symptoms are nonspecific and, on their own, do not indicate whether a woman has high blood pressure or an adrenal gland disorder. Primary aldosteronism, too, cannot be reliably diagnosed based on individual symptoms. It is often not noticed until repeatedly elevated blood pressure readings are recorded or blood pressure does not decrease sufficiently despite multiple medications.

A thorough medical evaluation is therefore advisable, especially for women whose blood pressure begins to rise in midlife or becomes increasingly difficult to control. In this evaluation, menopause should be considered as a possible contributing factor without prematurely ruling out other causes.

Signs That May Indicate a Hormonal Cause

Primary aldosteronism does not always cause clearly recognizable symptoms. Many affected individuals initially notice only elevated blood pressure. However, certain findings may prompt a targeted search for a hormonal cause:

• High blood pressure that is difficult to control: Blood pressure levels remain elevated despite multiple antihypertensive medications.
• Severe high blood pressure: Particularly high readings may warrant further investigation.
• Low potassium levels: A low potassium level may be a clue, although many affected individuals have normal levels.
• An abnormal adrenal gland: If an abnormality in the adrenal gland is discovered incidentally during imaging, hormonal testing may be advisable.
• High blood pressure associated with certain comorbidities or a relevant family history: Such circumstances may also be relevant to the medical assessment.

These findings do not automatically indicate the presence of primary aldosteronism. However, they may suggest that the cause of the high blood pressure should be investigated more closely. The Endocrine Society’s guidelines, updated in 2025, recommend that screening for primary aldosteronism be considered as a matter of course in people with high blood pressure. Implementation depends, among other things, on the clinical situation and the available diagnostic options.

How has Primary Aldosteronism Been Diagnosed to Date?

The current initial evaluation is generally based on blood tests. These tests measure aldosterone levels and renin—a hormone and an enzyme, respectively, involved in regulating blood pressure. The aldosterone-renin ratio is calculated from these two values. Additionally, potassium levels may be tested. Depending on the results and the clinical situation, further tests may be necessary to confirm the diagnosis and pinpoint the cause more precisely.

If primary aldosteronism is diagnosed, it must then be determined whether one or both adrenal glands are responsible for the excessive hormone production. To do this, imaging studies and specialized procedures to assess hormone production by the adrenal glands may be used, among other methods.

This precise determination is important because it influences the choice of treatment. The new study does not call these established procedures into question, but it does show that additional information about the temporal course of hormone production could be helpful in the future.

Can the New Measurement Technique Improve Diagnosis?

Continuous monitoring opens up the possibility of more accurately recording hormonal changes under realistic everyday conditions. The nighttime period is of particular focus here, because sample collection at this time is comparatively rare in normal clinical practice.

The researchers were able to show that the abnormal hormone patterns in patients with unilateral disease disappeared following surgical removal of the affected adrenal gland. This supports the assumption that these patterns are directly related to the disease. However, this was a so-called proof-of-concept study. Its primary purpose was to demonstrate that continuous measurement is technically feasible and can provide additional information.

It remains unclear how reliable the method is in larger and more diverse patient groups, what diagnostic thresholds can be derived from it, and whether it can actually improve current diagnostic practices. The technology should therefore not yet be considered a generally established replacement for conventional diagnostics. Further studies are needed to confirm its utility in everyday clinical practice.

Why a Timely Diagnosis is So Important

Primary aldosteronism is significant not only because of elevated blood pressure. The condition can also be associated with additional risks to the heart and kidneys, regardless of blood pressure levels. Studies show that, compared to people with ordinary high blood pressure, those affected have an increased risk of certain cardiovascular complications. These include, among others, atrial fibrillation, strokes, and heart failure.

If the hormonal cause is identified, treatment can be more targeted. In cases of unilateral overproduction, surgical removal of the affected adrenal gland may be considered under appropriate conditions. In cases of bilateral disease or when surgery is not an option, medications that block the effects of aldosterone can be used. Early detection can thus help improve blood pressure control and prevent long-term health complications.

This is particularly relevant for women during and after menopause, as various risk factors for cardiovascular disease can change during midlife. Elevated blood pressure should therefore not be accepted as an inevitable part of aging.

High Blood Pressure During Midlife Warrants a Thorough Evaluation

Rising blood pressure during menopause may be linked to age-related vascular changes, hormonal shifts, and other risk factors. Sometimes, however, it is caused by a specific condition that can be treated directly. The new study on primary aldosteronism shows that pathological hormonal changes do not necessarily manifest with the same intensity at all times. Recurring nocturnal spikes in hormone levels could provide additional clues when conventional measurements do not yield a clear picture.

Further studies are needed to determine whether wearable devices for continuous hormone monitoring will be used in medical diagnostics in the future. However, one thing is already clear today: Newly occurring, severe, or difficult-to-control high blood pressure should be evaluated by a doctor—even if the symptoms coincide with menopause.

After all, not every change during midlife is solely attributable to menopause. The correct diagnosis can be crucial for enabling appropriate treatment and protecting cardiovascular health in the long term.