Stroke the discriminator

Stroke in women is a major health issue that until recently was one of the great neglected medical problems. Only now is the incidence of stroke in females beginning to get the warranted attention.

Despite the historical neglect of stroke in women, more women than men die of it, and more women are as a result disabled and demented because of suffering a stroke.

There is no gender difference in terms of the presenting symptoms of stroke, the neurological examinations required, and for the most part the epidemiological data.

One of the reasons stroke is more prevalent in women is that women on average live 10 years longer than men and the incidence of stroke rises with age. More women die of stroke. One in five women and one in six men die of stroke. One and a half times more women get strokes by age 80 and nearly three times more by age 90.

There is evidence from prediction models indicating the rates of stroke are likely to increase in the future at a faster rate in women than men, especially in the over 85s.

Stroke exerts a considerable burden on society, but there seems to be an inequality in the impact. After a stroke women have poorer functional outcomes, suffer more confusion and depression, a greater reduction in quality of life and suffer more social isolation.

More women live alone. In the US, it is estimated that 8 million women live alone, while only 2.7 million men do so.

Even when all other outcomes are taken into consideration women will have a worse quality of life after a stroke. Three times more women end up in an institution after their stroke.

The frequency of stroke aetiologies seen in men and women tend to be similar. There are some strokes that are related to oral contraception and pregnancy that are more common in women.

Before the menopause stroke is rare in young women. Most are rare causes; some of them hormone-related.

For 20-30 years, women were told to take HRT after the menopause as it was thought to be protective against stroke. Now the evidence shows the opposite and taking HRT actually significantly increased the risk of a stroke event. The risk is low but it is there.

The benefit seen previously may have something to do with socioeconomic status. The rich had much healthier style of life and could afford to take HRT. When the socioeconomic status was taken into account and the studies adjusted for that the beneficial effect disappeared completely.

Oestrogen skin patches don’t seem to pose the same risk of a clot in the veins.

HRT is no longer recommended carte blanche for stroke prevention.

It can still be prescribed on a case per case basis taking into account the risks and the benefits, quality of life, and if the woman has low or high vascular risk.

For women already on HRT it is a balance of risk and quality of life that needs to be determined before stopping it.

This increased risk also extends to the Pill. Any oral contraceptive with high oestrogen content increases the risk of all strokes. For low oestrogen pills the results are conflicting and there may be a small risk.

The risk of a stroke from taking oral contraceptives is increased by smoking, hypertension, hypercholesterolaemia, obesity and diabetes.

If a woman has thrombophilia, a genetic clotting disorder, and takes oral contraceptives then this also greatly increases the risk. There is not enough evidence on the use of progestogen only pills.

High oestrogen doses given for ovarian induction therapy there is the risk of ovarian hyperstimulation syndrome and this can trigger a stroke is some women.

There is increased risk of stroke in women when they are pregnant. It tends to occur postpartum and there is some overlap with pre-eclampsia.

Stroke risk is increased in women with migraine with aura and not increased in those without aura. Although the absolute risk is slight, if a young woman experiences migraines it is usually recommended that she quits smoking.

In general, there are no major gender differences in terms of how stroke is treated.

However, in hospital emergency departments women are one third less likely to receive thrombolysis and don’t seem to undergo as many tests as men.

In terms of primary prevention women are less likely to be on aspirin. The major aspirin prevention studies were in US and UK physicians in the 1990s.

Women were not included in these studies as most doctors were men.

These studies showed that low dose aspirin decreases by 35% the risk of a myocardial infarction.

The use of aspirin for primary prevention in men decreased the risk of myocardial infarction by 30%, but it does not prevent stroke. In women aspirin does not prevent myocardial infarction, whereas it reduces by 20% the risk of stroke.

Stroke in women will remain a major health issue, especially as the population gets older and the fact that women live 10 years longer than men.  There is a specific increased risk in women due to oral contraceptive use, HRT therapy, and post-partum. The risk is increased by the presence of vascular risk factors. The mechanism is unknown, but the absolute risk is still very low.

In acute care, it is within hospital that delays in treating and testing women are higher than in men.


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