Strokes: Why Are Women More Prone?

Women are at a higher risk of having a stroke than men. In fact, strokes are the leading cause of disability for women, and they kill twice as many women as breast cancer. Women tend to have strokes at a later age than men, and nearly half of all strokes (45%) in women happen past the age of 80. This makes them less likely to recover and more likely to die as a result. While there are several general risk factors for stroke, such as family history, smoking, high cholesterol, high blood pressure, being overweight, and lack of exercise, women face additional risk factors. These include hormonal birth control, longer average lifespans, hormone replacement therapy, migraines, and atrial fibrillation.

Oral contraceptives and hormone replacement therapy

Modern combined oral contraceptives typically contain lower doses of estrogen (50 μg) and have a lower risk of stroke than older, high-dose formulations. The risk of ischemic stroke associated with combined oral contraceptives is influenced by the presence of additional stroke risk factors such as smoking, hypertension, and migraine with aura. The risk is also dependent on age, with older women having a higher risk.

Hormone replacement therapy (HRT), also known as hormone therapy or menopausal hormone therapy, is often used to treat menopause symptoms such as hot flashes, night sweats, vaginal dryness, and sleep disturbances. HRT can come in the form of pills, patches, gels, sprays, creams, or vaginal rings, containing estrogen, progesterone, or progestin. While HRT is the most effective treatment for menopause symptoms, it may increase the risk of endometrial cancer in women who take estrogen without progestin and still have their uterus.

Overall, the risk of stroke associated with oral contraceptives and hormone replacement therapy is influenced by various factors, including the type and dose of hormones, the route of administration, the presence of additional risk factors, and age. It is important for women to carefully consider the benefits and risks of these treatments in consultation with their healthcare providers.

Pregnancy and preeclampsia

Preeclampsia is a risk factor for stroke, both during pregnancy and later in life. It is estimated that preeclampsia/eclampsia accounts for about 47% of strokes during pregnancy. The risk of stroke is particularly high in the postpartum period, with fewer than 1% of women with preeclampsia suffering from stroke during the first six weeks after giving birth. However, this small proportion of women accounts for a high morbidity and mortality rate.

The relationship between preeclampsia and stroke is due to shared risk factors and pathophysiological mechanisms. These include endothelial dysfunction, dyslipidemia, hypertension, hypercoagulability, and abnormal cerebral vasomotor reactivity. Preeclampsia is also associated with long-term hypertension, which is a major risk factor for stroke. Additionally, aspirin, which is used to prevent ischemic stroke, has also been found to reduce the risk of preeclampsia when taken during early pregnancy.

In summary, preeclampsia is a significant risk factor for stroke in pregnant women and can have long-term implications for their health. The underlying pathophysiology involves similar mechanisms, including endothelial dysfunction and hypertension. Understanding this relationship is crucial for neurologists and obstetricians to provide appropriate care and prevent adverse outcomes.

Migraines with aura

Women are at a higher risk of stroke than men, and migraines with aura are a contributing factor. While migraines have not been shown to cause strokes, they are associated with an increased risk of ischemic stroke. People with migraines with aura have nearly twice the risk of ischemic stroke compared to those without migraines. This risk is higher in women, with a relative risk of 2.08 compared to 1.37 in men. The risk is particularly high in young women under the age of 45, with a relative risk of 3.7.

The exact mechanism linking migraines with aura to an increased risk of ischemic stroke is not fully understood. However, it is speculated that the risk may be independent of traditional cardiovascular risk factors. It is important to note that the overall risk of stroke associated with migraines is still very low, and other risk factors like smoking and high blood pressure play a more significant role.

Women with migraines with aura are advised not to take the combined oral contraceptive pill (combi pill) as it further increases the risk of stroke. Additionally, certain health conditions, such as CADASIL (a rare genetic disorder) and autoimmune conditions like antiphospholipid syndrome and lupus, are linked to both a higher risk of stroke and an increased likelihood of migraines.

Longer average life span

Women generally have a longer average life span than men. This is good news for women, but the risk of stroke increases with age, meaning that women typically have a higher stroke risk. This is why strokes are the leading cause of disability for women, and they kill twice as many women as breast cancer.

In 2016, about 55,000 more women than men had strokes in the US. More women than men die from strokes each year because older women outnumber older men. In fact, strokes are so common in some regions of the US that they are included in the "Stroke Belt", an area from Virginia down to Florida and west to Texas that has America's highest rates of morbidity and death from stroke.

Women tend to have strokes at a later age than men, and nearly half of all strokes (45%) in women happen past the age of 80. The risk of stroke doubles every decade after age 55. This also makes women less likely to recover and more likely to die as a result.

Women are also more likely to experience depression post-stroke, which research shows can impair post-stroke rehabilitation.

Postmenopausal changes

The risk of vascular diseases, including stroke, increases with age. Postmenopausal changes can further elevate this risk due to the development of conditions such as high blood pressure, high cholesterol, and diabetes. These conditions are known to contribute to the likelihood of experiencing a stroke. Therefore, addressing and managing these postmenopausal changes through medical treatment and a healthy lifestyle is crucial for reducing the risk of stroke in women.

Additionally, it is important to consider the impact of hormone replacement therapy (HRT) on postmenopausal women's stroke risk. HRT is a common treatment for menopausal symptoms like hot flushes. While HRT tablets may be unsuitable for women who have had a stroke, other forms such as patches, gels, or vaginal creams may be recommended. However, the use of HRT also depends on other health conditions and medications the patient may have.

Furthermore, oral contraceptives, or hormonal birth control pills, can also influence stroke risk in postmenopausal women. While these pills are effective in regulating hormone levels and preventing pregnancy, one of their side effects is the formation of blood clots, which can lead to deep vein thrombosis and stroke. The combination of oral contraceptives with other risk factors like smoking and diabetes can further increase the likelihood of stroke.

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