What are the causes of acute hypertension in a 38‑year‑old woman?

Causes of Acute Hypertension in a 38-Year-Old Female

In a 38-year-old woman presenting with acute severe hypertension, the most critical immediate distinction is whether acute target organ damage is present—defining a hypertensive emergency requiring ICU admission—versus hypertensive urgency managed with oral agents and outpatient follow-up. 1

Primary vs. Secondary Hypertension

Essential (Primary) Hypertension

• Most common cause in this age group, typically accompanied by family history of hypertension and often associated with overweight or obesity 1
• Acute exacerbations are frequently triggered by medication non-adherence, the single most common precipitant of hypertensive emergencies 1
• White-coat hypertension (office BP ≥140/90 mmHg but normal home BP <135/85 mmHg) accounts for up to 25% of elevated clinic readings and should be confirmed with home BP monitoring or 24-hour ABPM before accepting a diagnosis of true hypertension 1

Secondary Causes (5-10% of cases, but higher in young women)

Pregnancy-Related (Critical in reproductive-age women)

• Gestational hypertension: New-onset hypertension after 20 weeks gestation without proteinuria 1
• Preeclampsia: Hypertension with proteinuria (>300 mg/24h or ACR >30 mg/mmol), predisposed by preexisting hypertension, diabetes, renal disease, first or multiple pregnancy 1
• Eclampsia: Hypertension with seizures, severe headaches, visual disturbance, abdominal pain—requires immediate treatment and delivery 1
• HELLP syndrome (hemolysis, elevated liver enzymes, low platelets): Requires immediate treatment and delivery 1

Renal Causes (Most common secondary cause in young adults)

• Fibromuscular dysplasia of renal arteries: Accounts for >90% of cases in women and affects 3.3% of the general population; most common secondary cause in young women 1, 2, 3
• Renal parenchymal disease: Reflux nephropathy, glomerulonephritis 1, 2
• Atherosclerotic renal artery stenosis: Less common in this age group 1, 2

Endocrine Causes

• Primary aldosteronism: Most common secondary cause in middle-aged adults; screen with aldosterone/renin ratio 2, 3
• Pheochromocytoma: Presents with sudden severe hypertension, palpitations, diaphoresis, headache 1, 4
• Cushing syndrome: Associated with central obesity, striae, moon facies 2
• Thyroid disease: Both hyperthyroidism and hypothyroidism can cause hypertension 2

Medication and Substance-Induced

• Combined hormonal contraceptives: Can cause BP elevation, particularly in women with preexisting hypertension 1
• NSAIDs and steroids: Common culprits affecting BP control 1
• Sympathomimetics: Cocaine, methamphetamine, decongestants 1, 4
• Immunosuppressants and antiangiogenic therapy 1

Obstructive Sleep Apnea

• Increasingly recognized cause, particularly in overweight patients 2

Clinical Clues Suggesting Secondary Hypertension

Screen for secondary causes when any of the following are present: 1, 2, 3

• Severe or resistant hypertension (BP >180/120 mmHg or failure to control on 3 agents including a diuretic)
• Age of onset <30 years, especially before puberty
• Malignant or accelerated hypertension (BP commonly >200/120 mmHg with bilateral retinal hemorrhages, cotton wool spots, papilledema) 1
• Acute rise in BP from previously stable readings
• Increase in serum creatinine ≥50% within one week of starting ACE inhibitor or ARB therapy (suggests renovascular disease) 2
• Unilateral smaller kidney or kidney size difference >1.5 cm 2
• Recurrent flash pulmonary edema 2
• Hypokalemia (suggests aldosteronism) 3

Essential Diagnostic Workup

For all women with newly diagnosed or acutely elevated hypertension, obtain: 1

• Complete blood count (hemoglobin, platelet count)
• Liver enzymes (AST, ALT, LDH) and function tests (INR, bilirubin, albumin)
• Serum creatinine, electrolytes, and uric acid
• Urinalysis and microscopy, plus protein-to-creatinine ratio or albumin-to-creatinine ratio
• Pregnancy test (mandatory in all reproductive-age women)
• Renal ultrasound if serum creatinine or urine testing abnormal

Additional testing based on clinical suspicion: 1, 2

• Aldosterone/renin ratio if hypokalemia or resistant hypertension
• 24-hour urine or plasma metanephrines if episodic symptoms suggest pheochromocytoma
• Renal artery imaging (MRA or CTA) if clinical features suggest renovascular disease
• TSH if thyroid symptoms present
• Home sleep apnea testing if snoring, daytime somnolence, or obesity

Common Pitfalls to Avoid

• Do not assume essential hypertension in a young woman without first excluding fibromuscular dysplasia, the most common secondary cause in this demographic 1, 2, 3
• Never overlook pregnancy as a cause—always obtain a pregnancy test in reproductive-age women presenting with acute hypertension 1
• Do not dismiss white-coat hypertension—confirm with home BP monitoring or ABPM, as up to 25% of elevated office readings are spurious 1
• Recognize that secondary causes are found in 20-40% of patients with malignant hypertension, making screening essential after stabilization 1
• Avoid ACE inhibitors, ARBs, and aldosterone antagonists in women of childbearing potential without reliable contraception due to teratogenicity 1