by Bianca Garilli, ND, IFMCP
Stroke is the 5th leading cause of death in the US and a major cause of serious disability for adults.1 Up to age 75 the incidence of stroke is higher in men, and from years 75-84 both men and women’s risk are equal; after age 84, however, the risk of stroke in women surpasses that of their male counterparts.2 Overall, the lifetime risk of stroke is actually higher in women than men, with a 21% lifetime risk in women age 55 and a 17% risk in men of the same age.2 The reason behind this difference is multifactorial and should take into account the longer life span of women in addition to understanding the impact of the biological differences between the two genders, particularly the variance in sex hormones (both endogenous and exogenous), pregnancy and parity, age of menarche and menopausal factors.3
A review published in Stroke explored these gender variances in a much needed examination of female-specific contributions to the increased lifetime risk of stroke.3 The review of literature to date revealed the following findings:3
Endogenous Hormone Exposure: Increased risk of stroke in women was associated with early menarche (<10 years old), early age of menopause (<45 years old), and low dehydroepiandrosterone (DHEA) levels. There was also a potential association between the length of reproductive lifespan (shorter length leading to increased risk of stroke), underscoring the need for additional research in this area. Levels and length of exposure to estradiol and testosterone also warrant further investigation, although there does not seem to be a clear relationship between testosterone levels and risk of stroke in women.3
Exogenous Hormone Exposure: Use of oral estrogens found in postmenopausal hormone therapy, use of combined oral contraceptives and use of transgender exogenous estrogens were all associated with increased risk of stroke in women. Progestogen-only contraceptives and transgender exogenous testosterones were not found to be associated with a higher risk. Further research is indicated to more closely examine the relationship between increased stroke risk in women and transdermal estrogens in postmenopausal hormone therapy, progestogen-only contraceptives, and transgender exogenous estrogen and testosterone administration.3
Pregnancy-Related Exposures: Interestingly, there is an increase in ischemic stroke and intracerebral hemorrhage in the peripartum period, from 2 days before to 1 day after delivery, with a lesser risk up to 6 weeks postpartum. Factors associated with this elevated risk include eclampsia, preeclampsia and gestational diabetes mellitus. There is some evidence indicating increased stroke risk in women who have pregnancies resulting in pre-term births or small-for-gestational age infants. Prior occurrence of stroke also increases recurrent stroke risk in women during peri- and postpartum time periods.3
Why this is Clinically Relevant?
- Women have unique risk factors for stroke, a leading cause of morbidity and mortality in the US
- Healthcare providers should be aware of these female-specific risks
- Women should be screened for stroke risk factors throughout their adult life, particularly during times of fluctuating hormone levels (i.e. HRT, pregnancy/postpartum, hormonal contraceptive use, transgender estrogen use)
- Increased education regarding risk factors should be communicated through healthcare providers’ offices and public health programs
- CDC. Stroke. https://www.cdc.gov/stroke/. Accessed May 2, 2018.
- Falcone G. Gender differences in stroke among older adults. Geriatrics and Aging. 2007;10(08):497-500.
- Demel S, Kittner S, Ley S, McDermott M, Rexrode K. Stroke Risk Factors Unique to Women. Stroke. 2018;49:518-523.
