Women’s Stroke Risks Get New Attention in Prevention Guidelines

Women face their own unique risks for stroke. New guidelines for preventing a first stroke highlight these factors while noting the importance of healthy lifestyle behaviors for everyone.

Pregnancy complications, including high blood pressure or premature birth, early menopause and use of certain oral contraceptives, are among the conditions that increase women’s stroke risk, according to the 2024 primary prevention of stroke guidelines from the American Stroke Association.

“It is now being appreciated that stroke risk factors are not identical for males and females,” said Alexandra Paul, MD, a neurosurgeon and associate professor of neurosurgery at Albany Medical Center.

A patient’s overall health and lifestyle should be considered when assessing stroke risk, and that individualized approach is reflected in the new guidelines, said Dr. Paul, a member of the Capital Region Board of Directors of the American Heart Association.

A stroke occurs when a blood vessel carrying oxygen and nutrients to the brain is blocked by a clot or the vessel bursts; these are known as ischemic and hemorrhagic strokes, respectively. Both types of stroke can lead to brain damage and disability.

Every year, about 610,000 people in the U.S. have a first stroke, 185,000 have a recurrent stroke and almost 163,000 die from a stroke. One in five women will have a stroke, and about 55,000 more women than men have a stroke each year.

Stroke is the nation’s fifth-leading cause of death. The good news is that 80 percent of strokes may be preventable.

Preventing a first stroke is crucial, Dr. Paul said. “Damage to blood vessels leading up to a stroke can take place over five to 10 years,” she said, explaining that “once an initial, or primary, stroke happens, physiological conditions for a subsequent stroke are already in place.”

“It is much easier to prevent a patient from having a stroke than trying to reverse the damage that has been done,” Dr. Paul said.

Risk factors among women have been known for some time; however, the new guidelines call more attention to them. For example, a pregnant woman’s risk for stroke is three times higher than a non-pregnant person of the same age, Dr. Paul noted. Even six weeks after delivery, a woman with high blood pressure faces a higher risk for stroke.

Prevention of pregnancy-related stroke can be achieved mainly by managing high blood pressure, also known as hypertension. High blood pressure during pregnancy and gestational diabetes also may impact stroke risk later in life.

Endometriosis, premature ovarian failure and early onset menopause are all associated with increased stroke risk, according to the new guidelines, which replace the 2014 version.

Migraines and the use of oral contraceptives with high levels of estrogen, especially among women who have migraines with aura, are associated with a higher stroke risk. Likewise, the use of estrogen for hormone replacement therapy in older women and the use of estrogen by transgender women for gender affirmation present risks.

These patients should have a conversation with their health care professional about how to boost stroke prevention in other ways, Dr. Paul said.

“You can offset the increase in risk,” she said. “It’s all about weighing the risks and benefits and optimizing other areas.”

The prevention guidelines urge health care professionals to screen patients for risk factors such as high blood pressure, elevated cholesterol, high blood sugar and obesity. The report emphasizes the behaviors outlined in the American Heart Association’s Life’s Essential 8, key measures for improving and maintaining ideal cardiovascular and brain health. These include being more physically active, eating better, managing weight, quitting tobacco, managing blood pressure, managing cholesterol, controlling blood sugar and getting a good night’s sleep.

Adhering to the Mediterranean diet is encouraged. That means plenty of fruits and vegetables, nuts, beans, and low to moderate amounts of fish and poultry, as well as olive oil as a primary fat source.

Also new in the guidelines is an emphasis on social drivers of health – non-medical factors such as economic stability, discrimination and neighborhood circumstances – that can impact the risk of having a stroke. Encouraging someone to eat more fresh fruits and vegetables or to exercise more is unrealistic if there’s no nearby grocery store or a place to exercise, Dr. Paul pointed out. Language barriers can interfere with conveying a message about stroke risk, she added.

Furthermore, the guidelines address the “robust data” on the benefits of new GLP-1 drugs used for managing Type 2 diabetes and weight loss and lowering the risk of cardiovascular disease and stroke.

The bottom line: Taking care of blood vessels today can help prevent a stroke in the future. Multiple medical and lifestyle factors are part of the equation, Dr. Paul said. “It’s the whole picture.”