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Neurology and Women's Health, Part 4: Stroke

Wednesday, March 28, 2018

For women, stroke is both more dangerous and more complicated than it is for men. Women are at greater risk than men for having and dying from a stroke. Being a woman also brings unique health concerns, such as risk spiking during certain life events, and having to balance questions about risk with quality of life and family planning concerns. In the fourth entry in our Neurology and Women’s Health series, Jodi Dodds, MD, talks about these issues and what women can do about them. She also discusses recent improvements in diagnosing stroke in women and trends in stroke that affect both genders, such as increases in strokes among younger populations.

How much of a concern is stroke for women?
Women should be concerned about stroke, not only because they live longer and the risk of stroke increases with age, but because women are particularly vulnerable during specific times in their lives. These can include pregnancy, the postpartum period, and menopause (when many women turn to hormone replacement therapy to manage very uncomfortable symptoms). Having migraine with aura, a condition that disproportionately affects women, also increases the risk of stroke.

What issues do women who have survived a stroke face? What can be done to help them recover their health and live happier, productive lives?
It is more common for women to be full-time caregivers for their spouses than the other way around. Additionally, because women do have longer life expectancies, it is not unusual for a woman to lack a built in caregiver after a stroke if adult children are not available. Optimizing recovery means very early, intensive rehabilitative therapy. Regardless of whether the patient is a woman or a man, every day that the person lies in a hospital bed awaiting the start of rehabilitation can have long-lasting consequences to that person’s independence.

While stroke is often perceived as something that only happens to older people, many strokes occur among people in their thirties, forties, or even twenties. What health issues affect younger women with stroke, rehabilitation, and life after stroke?
Women in the postpartum state and in the third trimester of pregnancy are at a higher risk for stroke than they are at their baselines. Young women taking estrogen-based birth control pills are at a relatively higher risk for stroke as well, although the absolute risk in the overall population remains small. Younger patients are more vulnerable to vascular injuries that can result in stroke, such as carotid and vertebral artery dissections. We are also seeing more strokes in young women due to traditional risk factors we would expect in older patients, such as high blood pressure, diabetes, and high cholesterol. With the inactivity and obesity we are seeing in children and adolescents now, I believe the rate of stroke in young adults will continue to rise.

There has been recent controversy about birth control pills and hormone therapy as risk factors for stroke. How large are these risks, and how much should they influence women's decisions to use birth control or hormone therapy?
All other things being equal, women on estrogen-based birth control pills or hormone replacement therapy are much more likely NOT to have strokes than to have them. The absolute risk is pretty low. However, the risk is increased compared to what it would be otherwise if estrogen-based birth control pills or hormone replacement therapy were not being used. I usually advise my patients towards progesterone-based birth control, or other forms of non-hormonal birth control if needed.

When it comes to hormone replacement therapy, I truly believe it is a quality of life discussion to have. It’s easy for a healthcare provider to tell a menopausal woman not to use it, but if she is awake all night every night because night sweats are making her miserable, then that’s a pretty awful way to live, and perhaps compromise is needed as long as there is an understanding of the potential risk on her part. There is a risk of dying in a car accident every time I make the decision to drive, but I still drive, because the benefit to my quality of life outweighs that risk in my mind.

What can be done to improve how we treat, detect or research stroke among women?
I think we should start with listening to women when they present for medical attention with sudden neurological symptoms potentially concerning for stroke. I have been pleased with the outstanding job our residents and providers at Duke do in listening to and empathizing with women presenting with neurological symptoms. As is the case with any neurological disorder, at least 80% of the journey to diagnosing and treating stroke is through observation, listening, and asking the right questions.

What can women do to reduce their risk for stroke?
Women frequently have a difficult time putting themselves first. In general, they feel a need to take care of everyone else – their spouses/partners, children, aging parents, communities. Regular exercise, routine nighttime sleep, eating healthily, minimizing stress – finding balance and tending to one’s own needs is of utmost importance in the prevention of disease, including stroke. Having annual visits with a primary care provider is important in the detection of many stroke risk factors, so making the time for these visits is part of good self-care.

Read more about strokes, and how you can reduce your risks for strokes, here.