7 things to know about how stroke is different for women

By Michael Merschel, American Heart Association News

Shidlovski/iStock via Getty Images
(Shidlovski/iStock via Getty Images)

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Stroke can be devastating for anyone. But the risks and symptoms of a stroke are not always the same in women and men.

American Heart Association News asked experts to explain a few of the most significant differences – and what women can do to protect themselves.

Women have more risk from high blood pressure

Women and men share many classic risk factors for stroke, said Dr. Tracy Madsen, an associate professor of emergency medicine and epidemiology at Brown University in Providence, Rhode Island. Such factors include high blood pressure, diabetes and a type of irregular heartbeat called atrial fibrillation.

Of all factors, high blood pressure influences stroke risk the most. And "for a given level of high blood pressure, the risk of stroke may be actually higher for women than men," Madsen said.

Guidelines from the American Heart Association and American College of Cardiology define high blood pressure as a systolic (top number) of 130 or higher or a diastolic (bottom number) of 80 or higher. A reading of less than 120/80 is considered normal.

Research has shown that a woman with a systolic blood pressure of 120 to 129 – a range defined as elevated blood pressure – has the same risk of stroke as a man with a systolic reading of 140 to 149, said Dr. Cheryl Bushnell, a professor of neurology and vice chair of research at Wake Forest University School of Medicine in Winston-Salem, North Carolina.

"I think that brings up a lot of questions, obviously, about how whether men and women should be treated" differently for elevated blood pressure, she said.

Pregnancy complications can pose a lifelong risk

Some risk factors affect only women. "Probably one of the most important is pregnancy," Bushnell said.

Pregnancy is often likened to a stress test for the heart. Blood volume and the heart's output increase by about 45% compared with pre-pregnancy levels.

Complications during pregnancy can raise the risk of stroke. Preeclampsia, a condition that causes high blood pressure and can cause organs to not function normally, can lead to an immediate stroke. It also raises a woman's lifelong stroke risk.

As many as 1 in 5 pregnant women have problems such as premature labor, gestational diabetes and other conditions that are labeled as adverse pregnancy outcomes. All those conditions can lead to an increased risk of stroke later in life. That includes ischemic stroke, where a clot blocks blood flow to the brain, or hemorrhagic stroke, where a vessel in the brain ruptures and bleeds.

Early menopause is another risk unique to women, Bushnell said. A woman who stops having periods before age of 45, and especially before 40, has a higher stroke risk than a woman who has menopause at the usual age of 50 to 54.

A 2020 study in the journal Stroke suggests that stroke risk is higher among young women ages 25 to 44 than their male peers. "It's certainly not lower," said Madsen, a co-author of the study. To her, the bottom line is "strokes do happen in that age group, and people should be aware of their own risk factors and the warning signs."

Stroke can look different in women

Traditional stroke symptoms are the same for women and men and can be remembered through the acronym FAST: "F" for face drooping; "A" for arm weakness; "S" for speech difficulty; and "T" for time to call 911.

But women are more likely to have additional symptoms, including nausea, loss of consciousness or appearing confused.

Women also are more likely to have migraines, which can double their risk of clot-caused strokes, according to a 2023 review of research in the Journal of Stroke co-authored by Bushnell. She said migraines with aura are particularly associated with increased stroke risk and can include flashing lights or even a loss of vision.

Such symptoms of migraine with aura, along with numbness or weakness, can overlap with stroke, Madsen said, which "can make the diagnosis more challenging and lead to possible delays in diagnosis."

Ethnic and racial comparisons

Among most racial and ethnic groups in the U.S., the death rate for stroke is similar between men and women, according to AHA statistics. Black women, however, have a notably lower death rate than Black men. But even so, the death rate for both was significantly higher than for other races and ethnicities.

Disparities also exist between women. For example, Black women are twice as likely to have a stroke as non-Hispanic white women, says the Office of Minority Health at the U.S. Department of Health and Human Services.

Bushnell said Black women also have higher rates of pregnancy complications related to high blood pressure compared to Hispanic and non-Hispanic white women.

Such issues, Madsen said, reflect problems with access to health care and other social factors that influence health.

What happens after a stroke

According to the latest data from the National Center for Health Statistics, stroke ranked fourth among the leading causes of death for women in 2021. Among men, it was fifth.

Because women live longer than men, they are more likely to have a stroke during their lives. "Women tend to be somewhere around six years older at the time that they have their first stroke compared to the men," Madsen said. "That might be part of why stroke tends to be more debilitating in women."

Studies have found that after a stroke, women have a lower quality of life than men and are less likely to recover full abilities.

How women can protect themselves

Women need to know their blood pressure and, if it's high, make sure they're working with a doctor to manage it, Madsen said.

She and Bushnell both said the best way to prevent a stroke is to follow Life's Essential 8 – a checklist from the AHA that encourages not smoking, maintaining a healthy weight, staying physically active, eating a healthy diet, getting enough sleep and maintaining blood pressure, blood glucose and cholesterol levels within the normal range.

Pregnant women should be especially aware of the risks of high blood pressure, Bushnell said, and work with their OB-GYN to monitor and, if necessary, treat it.

"Some women may be reluctant to take medications because of fear for the baby, which I totally understand," she said. "But there are safe medications." And, Bushnell emphasized, the risks of high blood pressure related to pregnancy don't end when the pregnancy does.

'There's a lot that we don't know'

Women have been underrepresented in studies about stroke, Bushnell said, but researchers are working to remedy that.

"There's a lot of active work going on trying to understand the reasons for some of these sex differences," Madsen said, such as the role of hormones in stroke risk. "There's a lot that we don't know. But the community of stroke researchers are working very hard."

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