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New guidelines for preventing strokes spell out for the first time the risks faced by women, noting that pre-term births and conditions like endometriosis and early menopause can raise the risk.
“Prior guidelines tended to be sex-agnostic,” said Dr. Brian Snelling, director of the stroke program at Baptist Health South Florida’s Marcus Neuroscience Institute, who was not involved in writing the guidelines.
“Now we have more data about sex-specific subgroups, so you’re able to more appropriately screen those patients.”
The focus of the recommendations by the American Stroke Association, published on Monday in the journal Stroke, is primary prevention — the effort to prevent strokes in individuals who have never had one. It represents the first such update in a decade, and it’s the playbook by which millions of Americans will be cared for.
A stroke is a sudden blockage of blood flow to the brain, or sudden bleeding in the brain. It is a leading cause of the death in the United States, and the incidence has been rising even among adults 49 and younger, stoked by increases in obesity, high cholesterol, diabetes and — perhaps most significantly — high blood pressure.
Nearly 800,000 strokes occur each year, leading to severe disability and more than 160,000 deaths. Some 57 percent occur in women. At least 60 percent are preventable.
For the first time, the guidelines cautioned that trans women and other gender-diverse individuals who take the hormone estrogen for gender affirmation may face a higher stroke risk and should be screened for related risk factors by their doctors.
The report also called attention to the role played by poverty, limited access to healthy food, difficulty obtaining health care, and exposure to racism, discrimination and stress.
These life circumstances — often referred to as the social determinants of health — are particularly pertinent when it comes to strokes, which disproportionately affect people who are economically disadvantaged.
That group includes residents of the so-called Stroke Belt, a contiguous group of states in the Southeast that stretches from North Carolina to Louisiana, sometimes said to include Texas.
Younger adults are now affected much more often, said Dr. Cheryl Bushnell, the lead writer of the new report and a vice chair of research for the department of neurology at Wake Forest University School of Medicine in Winston-Salem, N.C.
“We’re seeing much more complex patients with stroke, and much younger patients with strokes,” Dr. Bushnell said.
Pregnancy and the postpartum period after childbirth are a critical time, during which the risk of stroke is approximately triple that of nonpregnant adults at the same ages, according to the report.
Though still comparatively rare, stroke is a leading cause of maternal death and disability. Significant racial disparities place Black women at even greater risk.
Most strokes occur after the delivery; the first two weeks after childbirth are the most dangerous period. Women in these circumstances are more likely to have strokes if they are older, used assisted reproductive technology, or had obesity, heart disease, infections, migraines or lupus.
Women who experience preterm deliveries, recurrent miscarriages and other poor outcomes of pregnancy are more likely, the report noted, to develop cerebrovascular disease (conditions that affect blood flow to the brain), and at an earlier age.
The list of pregnancy outcomes linked to stroke also includes hypertensive disorders, gestational diabetes, stillbirths, babies small for their gestational age, and a condition called placental abruption, which occurs when the placenta separates from the inner wall of the uterus before delivery.
The number of Americans affected is vast. One in five pregnancies in the United States ends in one of these adverse outcomes. A woman who develops pre-eclampsia — serious pregnancy-related high blood pressure — is four times more likely to have a stroke, compared with a pregnant woman without the condition.
The health risks extend beyond stroke. “There’s evidence for an increased risk of heart disease, for development of atherosclerosis, and it really spans a lot of other diseases, like kidney disease and even dementia later on,” Dr. Bushnell said.
The guidelines encourage providers to screen these women for all stroke risk factors, and to treat them aggressively for high blood pressure. They should be counseled about lifestyle changes that reduce risk, such as physical activity, a healthy diet, and quitting smoking and other substances, such as cannabis, whose frequent use has been linked to stroke.
Women should know about the risks, the report added: “These discussions may help patients make informed decisions about future pregnancies.”
New stroke treatments and management strategies are available. Drugs like semaglutide, the active ingredient in a new wave of GLP-1 weight loss and diabetes drugs, also reduce the risk of stroke, Dr. Bushnell noted.
Other risk factors that are unique to women are early menopause, before age 45, and endometriosis, a condition that occurs when endometrial tissue grows outside the uterus.
Hormonal contraception that includes both estrogen and progestin, and oral estrogen hormone therapy after age 59, also may increase the risk of a stroke, the report said.
Trans women taking estrogen face an increased risk of stroke, and the report called for more research to understand the risk.
“Women should be prescribed the lowest doses of estradiol possible,” Dr. Bushnell said, referring to a type of estrogen. “These can still be very effective for contraception, but lower the risk of stroke.”
Women at higher risk for stroke — including those over the age of 35, smokers, those with high blood pressure or migraines with auras — should avoid estrogen and use non-hormonal or progestin-only contraception.
Postmenopausal hormone therapy should “be reserved for women with moderate to severe hot flashes, night sweats or both” who are under 60, she said. “If somebody doesn’t have those, they really are not a candidate for hormone therapy.”
Those with a history of breast cancer, liver disease, heart attack, other hormone-driven cancers or blood clots “should really never take hormone therapy,” she added.
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