Q&A: New stroke guidance highlights risk for women with endometriosis, early menopause
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Key takeaways:
- Women with endometriosis, early menopause or pregnancy complications have greater stroke risk.
- Clinicians should conduct a thorough risk assessment and tailor recommendations for higher-risk women.
New guidance on primary prevention of stroke from the American Heart Association and American Stroke Association states women with endometriosis and early menopause are at higher risk, requiring a thorough history and tailored management.
As Healio previously reported, the new guideline calls for more screening of risk factors such as high blood pressure, high cholesterol and high blood glucose, as well as focusing on primary prevention of stroke by promoting lifestyle changes such as improved diet, increased physical activity and better sleep. Other key recommendations of the new guidance include lowering BP if it is high in pregnant women; screening for pregnancy complications, premature ovarian failure, early-onset menopause (before age 45 years) and endometriosis; and screening for adverse social determinants of health.
Healio spoke with Alexis Simpkins, MD, PhD, MSCR, FAHA, FANA, FAAN, associate professor of neurology at Cedars-Sinai, about what might drive stroke risk in women with certain health conditions, how women can lower their stroke risk and the importance of taking a thorough health history. The updated guideline was recently published in Stroke.
Healio: Why are women with endometriosis or early menopause at higher risk for stroke? What might be driving this excess risk?
Simpkins: While several studies have consistently demonstrated that those with endometriosis have a higher risk for stroke, the exact cause is still unclear. We believe that inflammation and an imbalance in hormone levels may play a role. Individuals with endometriosis have been reported to be more likely to have high cholesterol and high blood pressure. Both high cholesterol and high blood pressure are well known to increase the risk for stroke.
Similarly, the reason for the increase in risk for stroke in patients with early menopause is still unclear. In addition to early menopause, patients that have more intense and frequent vasomotor symptoms — such as hot flashes and night sweats — during menopause seem to have a higher risk for stroke. Health care professionals seeing patients for management of vasomotor symptoms during menopause should assess stroke risk and consider any risk factors when deciding on the best medical options for managing symptoms associated with menopause.
Healio: Which other subgroups of women might be at higher risk for stroke and why?
Simpkins: Another important group to consider include pregnant people and those who have recently given birth. Having elevated blood pressure during pregnancy is associated with an increased immediate and long-term risk for stroke. Also, having complications during pregnancy is associated with long-term stroke risk. It is important for health care professionals to ask patients about any history of these types of conditions so that information can be factored into the approach used for primary stroke prevention.
It is also important to consider all of the other well-known risk factors for stroke, such as blood pressure control, diet, cholesterol control, exercise, diabetes, smoking, history of autoimmune disease, and heart conditions such as atrial fibrillation.
Healio: What do the new guidelines suggest these women do to reduce their risk? What are the roles of play, physical activity and weight loss or weight-loss medications?
Simpkins: The American Heart Association’s Life’s Essential 8 is a good tool patients can use to learn more about their overall risk of cardiovascular disease events such as stroke and ways that they can lower their risk. The Life’s Essential 8 includes information on targets for blood pressure, exercise, weight, cholesterol levels, diet, sleep, smoking cessation and glucose control. There are randomized controlled trials demonstrating that switching to a Mediterranean diet reduces stroke risk. In patients that have risk factors such as high blood pressure, it is also important to moderate salt intake. There is strong evidence showing that it is also important to avoid a sedentary lifestyle. It is generally recommended to either have moderate exercise at least 30 minutes a day for 5 days a week or more vigorous exercise such as jogging for 75 minutes a week. There is new evidence that people with diabetes and risk factors for or preexisting cardiovascular disease had a lower risk for stroke when treated with GLP-1 receptor agonists in addition to standard medical care.
Healio: Transgender women are also at greater risk for stroke compared with cisgender women. How should they be counseled about hormone therapy and follow-ups?
Simpkins: It is important that people taking estrogen for gender-affirming hormone therapy have an evaluation for stroke risk factors with their health care professional so these risk factors can be addressed. Several observational studies suggest higher incidence of stroke with estrogen gender-affirming hormone therapy.
Healio: How should clinicians assess women to see who is at higher risk?
Simpkins: In addition to the standard medical physical, it is also important that clinicians obtain a thorough medical, family and social history to identify the conditions we discussed above. They may also obtain blood pressure readings, order diagnostic tests and labs to confirm a new diagnosis such as diabetes or evaluate how well the current medical and lifestyle changes are working. Any evaluation must include an open dialogue so management is tailored to each person’s goals, preexisting conditions, current medical conditions and life experience.
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For more information:
Alexis Simpkins, MD, PhD, MSCR, FAHA, FANA, FAAN, can be reached at alexis.simpkins@cshs.org.