Stroke in women presents unique challenges

Researchers are hoping to continue exploring presentation, evaluation, treatment and outcomes.

Stroke has recently emerged as a severe health risk among women, particularly elderly women.

According to some estimates, the burden of stroke in the United States will increase in both men and women by 2020, with a magnified projected increase in women. One systematic review of sex differences in stroke epidemiology published in Stroke suggested that although the disease is more common among men across the world, women appear to have more severe strokes and a higher mortality rate.

“We know that even though more strokes occur in men, about 60% of stroke deaths are in women. Stroke is a major women’s health issue,” Larry B. Goldstein, MD, a professor of medicine and director of the Duke Stroke Center in Durham, N.C., told Cardiology Today. “Stroke in women presents a complex series of issues, and with the high stroke mortality rates among older women and the aging population, this will be a growing problem. We need to get a better understanding of stroke as it particularly affects women.” Although research suggests that stroke is common in both women and men, stroke is currently understood, treated and studied differently in women.

Differences in presentation and evaluation

According to Chelsea S. Kidwell, MD, a professor in the department of neurology and the medical director of the Georgetown Stroke Center at Georgetown University in Washington, D.C., women may differ from men when it comes to the detection, treatment and reactions to stroke.

“There are gender differences that we were unaware of until recently,” Kidwell told Cardiology Today. “Gender differences in the evaluation, presentation, treatment, response to therapies and outcomes of women with stroke are just beginning to be discovered within the medical community, meaning there is more work to be done.”

Kidwell also suggested a potential problem for family members and even the patients themselves. The results of a study published in Stroke suggested that women were more likely than men to present with nontraditional or atypical stroke symptoms or warning signs (51.8% vs. 43.9%).

“If patients do not get to the hospital in time or their symptoms are not recognized as stroke, they are less likely to get tissue plasminogen activator, the one proven therapy for stroke,” Kidwell said. “The fact that women have more atypical or untraditional stroke symptoms makes it more difficult not only for the patients and their families to recognize but also the medical community.”

Sex-specific risk factors

Women face several sex-specific risk factors for stroke. Research suggesting that certain subgroups of women are at increased risk for stroke has been conducted, according to Tobias Kurth, MD, ScD, an epidemiologist at Brigham and Women’s Hospital in Boston and assistant professor of medicine at Harvard Medical School.

“One gender-specific difference is postmenopausal hormone use, which has been consistently associated with increased risk for stroke,” Kurth said in an interview. “There is also an increased risk for stroke for women with a specific migraine form and for some women during pregnancy.”

Kurth indicated that age is an important factor when assessing the burden of stroke in women, both in research and within the clinical setting.

“Part of the story one has to take into account is that women live longer than men,” Kurth said. “Women will face higher risk for stroke simply because when you live longer, you have a higher likelihood of having a stroke event.”

Kidwell pointed out another subgroup of women that recent research has suggested may also be at elevated risk — a subgroup consisting of younger women aged between 30 and 35 years.

“There is a category of younger women who are also at risk for stroke and may not know it,” Kidwell said. “If they are on oral contraceptives, smoke or have migraines or even all three of these factors combined, they are at significant risk, even though they are young.”

Differences in the vascular structure between men and women can also contribute to differences in stroke risk, according to C. Noel Bairey Merz, MD, director of the Women’s Heart Center at Cedars-Sinai Heart Institute in Los Angeles and a member of the Cardiology Today Editorial Board.

“Women, from a CV standpoint, have more microvascular dysfunction in their coronary arteries compared with age-matched men,” Bairey Merz said. “A leading underlying mechanism of this relatively greater threat for women probably has to do with this gender difference in microvascular disease.”

Bairey Merz also cited results from the Women’s Health Study that suggested low-dose aspirin may be an effective preventive therapy for stroke in women.

“We look through the lens of male-patterned disease, and we have too easily dismissed the benefits of low-dose aspirin in women, particularly relatively young to mid-life women, for prevention of stroke,” Bairey Merz said. “The Women’s Health Study demonstrated that it was effective — and statistically significant — at preventing first stroke at any age.” – by Eric Raible

For more information:

• Appelros P. Stroke. 2009;doi:10.1161/STROKEAHA.108.540781.
• Gargano J. Stroke. 2009;doi:10.1161/STROKEAHA.108.543116.
• Kurth T. Stroke. 2009;doi:10.1161/STROKEAHA.109.547471.