Stroke in women: 5 risk factors that are specific to women
The lifetime risk of stroke is higher in women than in men, mainly due to their longer life expectancy. Here are 5 stroke risk factors specific to women
Globally, stroke remained the second-leading cause of death and the third-leading cause of disability and death combined in 2019.
Recent studies indicate that stroke incidence in women is greater or comparable to that of males in younger age groups but afterward, men have a higher incidence of stroke than women in middle age. In an interview with HT Lifestyle, Dr Kranthi Mohan, Consultant Neurologist at Gleneagles Hospital in Bengaluru, shared, “The difference in stroke incidence between men and women narrows as the incidence increases in postmenopausal women. Eventually, stroke incidence in women is close to or even higher than in men in the eighth decade. It is generally considered that the LTR of stroke is higher in women than in men, mainly due to their longer life expectancy.”
Dr Kranthi Mohan highlighted the stroke risk factors that are specific to women -
- Pregnancy: Pregnancy-related stroke, commonly known as maternal stroke, refers to ischemic or hemorrhagic strokes occurring during pregnancy and the postpartum period (up to 12 weeks after delivery).
Various physiological changes occur during pregnancy. Following are the three primary changes related to stroke: changes in the (1) hemodynamic/vascular system, (2) coagulation system, and (3) immune system.
- During pregnancy and the postpartum period, a hypercoagulable state is induced with a 4- to 10-fold increased thrombotic risk.The hypercoagulable state results from an increase in procoagulant activity and a decrease in physiological anticoagulants. During pregnancy, the concentrations of coagulation factors VII, VIII, X, and XII and von Willebrand factor increase significantly accompanied by a pronounced increase in fibrinogen levels.
- Etiology of maternal stroke: Hemorrhagic strokes account for almost 60% of strokes in pregnancy and the postpartum period, which is much higher than the rate in the general population.
- Pregnancy-induced hypertension(PIH) is one of the most common causes of hemorrhagic stroke during the antepartum and peripartum period.
- Various vasculopathies can cause maternal stroke. Reversible cerebral vasoconstriction syndrome (RCVS) is a prevalent cause of maternal stroke, and most commonly develops after childbirth.
- CVT( cerebral venous thrombosis)is a common etiology of maternal stroke and occurs mainly during the postpartum period.
- Due to the five times higher risk of deep vein thrombosis during pregnancy and the postpartum period, paradoxical embolism through a patent foramen ovale (PFO) can cause embolic stroke.
2. Exogenous estrogen use of oral contraceptive pills (OCPs) is associated with an increased risk of stroke.In women with current OCP use were at a ≈2.5-fold increased risk of ischemic stroke and a ≈1.4-fold increased risk of hemorrhagic stroke.
- The risk of stroke increases as the estrogen dose increases, but progestin-only pills are not associated with an increased risk of ischemic stroke.
- The stroke risk in women with current OCP use is further increased by additional risk factors such as migraine, HTN, and current smoking. A recent study discovered that the first year of OCP usage was riskier for stroke in women who used it, presumably as a result of abrupt changes in hemostatic balance.
- Oral menopausal hormone replacement therapy (HRT) also increases the risk of ischemic stroke.
- Regarding the initiation of HRT, the “timing hypothesis” has been suggested that age and time since menopause influence the relationship between HRT and CVD. Starting HRT might be more harmful when started more than 10 years after the onset of menopause or in women older than 60 years of age.
- Useof transdermal therapy containing low doses of estrogen has a lower stroke risk than oral HRT.
3. Lifetime endogenous estrogen exposure
- The reproductive lifespan (defined as the time from menarche to menopause), which reflects endogenous estrogen exposure, is closely related to stroke risk.
- Recent study suggestwomen with a reproductive life span less than 30 years had a 75% higher risk of stroke than those with a reproductive life span of 36–38 years.
- Compared with women with menarche at age 13 years, those with early menarche (≤10 years) and late menarche (≥16 years) had 27% and 25% increased risk of stroke, respectively.
- Compared with women aged 50–51 years at menopause, those with premature menopause (<40 years) and early menopause (40–44 years) had 98% and 49% higher risk of stroke, respectively.
- In addition to natural menopause, surgical menopause by oophorectomy (with or without hysterectomy) is also associated with a higher risk of stroke.
4. Atrial fibrillation: The prevalence of atrial fibrillation is higher in men, but the risk of stroke due to atrial fibrillation is higher in women.
Migraine is more prevalent in women than in men.Migraine, particularly migraine with aura, is associated with an increased risk of ischemic stroke. Possible mechanisms explaining the migraine-stroke connection include genetic predisposition, endothelial dysfunction, coagulation abnormalities, arterial dissection, and paradoxical embolism via a patent foramen ovale (PFO).
Common risk factors:
- Diabetes mellitus
- Smoking and alcohol consumption.
Mortality and Morbidity in women with stroke :
a) Women have poorer functional recovery and lower quality of life (QOL) than men after stroke.
b) Post-stroke depression (PSD) is more common in women than in men.A previous systematic review suggested that the prevalence of PSD is 78% higher among women than among men.
c) Post stroke cognitive impairment and dementia is more prevalent in women than in men due to various factors.
Dr Kranthi Mohan concluded, “Women bear a disproportionate burden of stroke, being more susceptible to experiencing a stroke in their lifetime and facing poorer post-stroke outcomes. The risk factors specific to women for stroke are modifiable; therefore, early attention and prevention are crucial in both preventing and improving the prognosis of stroke.”