Prevention and management of stroke in women

Abstract

Stroke is the leading cause of acquired disability and the third leading cause of death in women worldwide. Sex differences in risk factors, treatment response and quality of life after stroke complicate stroke management in women. Women have an increased lifetime incidence of stroke compared to men, largely due to a sharp increase in stroke risk in older postmenopausal women. Women also have an increased lifetime prevalence of stroke risk factors, including hypertension and atrial fibrillation in postmenopausal women, as well as abdominal obesity and metabolic syndrome in middle-aged women. Controversy continues over the risks of oral contraceptives, hormone therapy and surgical intervention for carotid stenosis in women. Pregnancy and the postpartum period represent a time of increased risk, presenting challenges to stroke management. Recognition of these issues is critical to improving acute care and functional recovery after stroke in women.

Keywords:

• atrial fibrillation
• carotid stenosis
• hormones
• hypertension
• obesity
• pregnancy
• sex
• stroke
• women

Financial & competing interests disclosure

The authors were supported by NIH funding to LDM RO1 NSO55215. LD McCullough was part of a speaker’s panel for Genentech. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Key issues

• Women have a distinct risk factor profile compared to men.

• Lifestyle approaches are critical to the prevention of stroke in men and women alike. The DASH diet, exercise and smoking cessation have all been shown to reduce stroke risk in women.

• Monitoring for atrial fibrillation and screening for embolic risk (CHA₂DS₂VASc) is critical to the prevention of stroke in older populations, and women over the age of 80 especially should be aggressively treated with anticoagulants.

• Oral contraceptive pills are safe in the general population, but may increase stroke risk in women who suffer from complex migraines, smoke or are over the age of 40.

• Hormone therapy may be safe in healthy, recently postmenopausal women.

• Pregnant women must be monitored for pre-eclampsia, as it greatly enhances lifetime stroke risk for both mother and fetus.

• Depression is more common in women before and after stroke and should be treated with antidepressants to improve quality of life.

Notes