After the menopause the consequences of hypertension in women change. Their risks of myocardial infarction and stroke rise steeply, a rise that has been blamed in part on the loss of estrogen and the onset of menopausal metabolic syndrome, with endothelial dysfunction, hyperlipidemia, insulin resistance and derangement in coagulation. Hypertensive menopausal women have not had optimum treatment. They have poorer prognoses than men of the same age. Their antihypertensive management therefore merits special attention. Hormone replacement, aspirin prophylaxis and lipid-lowering drugs have their place. The antihypertensive drug chosen should not worsen the metabolic syndrome: angiotensin-II converting enzyme (ACE) inhibitors are therefore among the first-line drugs. Few drugs have been specifically aimed at menopausal hypertension and these are reviewed here.