Together with the aging process, hypertension is the main risk factor contributing to the increase in cardiovascular morbidity and mortality in postmenopausal women, with a prevalence of around 60% in women older than 65 years. Considering that hypertension is a modifiable risk factor, the understanding of its epidemiology and pathophysiology and the development of appropriate therapeutic strategies are conceivably crucial in reducing cardiovascular risk. The high prevalence of hypertension in older women is largely due to the progressive stiffening of the arterial structure which accompanies the aging process in both sexes. However, the abrupt fall in circulating estrogen levels might independently contribute to the rise in blood pressure, through partly unknown mechanisms, such as a direct effect on the arterial wall, the activation of the renin-angiotensin system and of the sympathetic nervous system. Postmenopausal hypertension fosters the development of left ventricular hypertrophy and is the main factor contributing to coronary artery disease, chronic heart failure and stroke in older women. Recent analysis demonstrates that men and women receive a similar benefit from antihypertensive therapy in terms of reduction of cardiovascular morbidity and mortality and, considering that generally the response to different drugs is not different between the sexes, currently there is no need to use specific antihypertensive drug classes after menopause. Finally, although observational studies have shown that hormone replacement therapy is associated with lower cardiovascular risk and lower blood pressure values, randomized clinical trials have conversely denied this benefit and demonstrated rather that this therapeutical approach increases the risk of cardiovascular events.