First-time stroke prevention: What women should know
December 11, 2024
Every year 600,000 people have a first-time stroke and 200,000 have a recurrent stroke. About 20% of those people will die – and 57% of those fatal strokes occur in women.
Health situations that are unique to women, such as pregnancy, endometriosis, and menopause, or that are more common in women, such as migraine, have been shown to significantly increase the risk of stroke.
These are on top of the known risk factors for everyone, such as smoking, high blood pressure, sedentary lifestyle, and diabetes. About half of people who survive a stroke are left with permanent physical or cognitive disabilities.
But there is good news: 80% of first-time strokes can be prevented with proactive screening and patient-provider collaboration.
The 2024 Guideline for the Primary Prevention of Stroke by the American Heart Association/American Stroke Association has, for the first time, specifically recommended that women get regular screenings for gender- and sex-specific risk factors.
Three main goals of the 2024 Guideline are to:
- Help women become better-informed about sex- and gender-specific stroke risk factors.
- Alert health care providers to screen for unique risk factors that can help women avoid a first stroke.
- Emphasize the role of social determinants of health (SDOH) in stroke prevention and highlight strategies to close the gaps for all patients.
What are women’s unique stroke risk factors?
✔️ Endometriosis
About 1 in 10 women have endometriosis, a painful condition that causes tissue that is supposed to grow inside the uterus to attach elsewhere, such as in the pelvis or on the ovaries, fallopian tubes, bowel, and bladder.
Along with painful sex, severe cramps, heavy periods, and digestive and urinary problems, endometriosis is also associated with cardiovascular problems that are stroke risk factors, such as high blood pressure, high cholesterol, and heart disease.
Research shows that women with endometriosis are at 34% increased risk of stroke, possibly due to having higher levels of estrogen, which can drive blood clots.
What the 2024 Guideline says: Getting treatment for endometriosis can reduce life-disrupting symptoms and stroke risk. Hormone replacement therapy (HRT) may reduce stroke risk by 16%, and removing the uterus and ovaries may reduce stroke risk by 39%. UTSW offers medical management and fertility-sparing surgery to clear invasive endometriosis tissue.
✔️ Migraine
About 20% to 30% of women ages 15-49 have migraine, a neurological disorder that causes disabling headaches. Women are three times more likely than men to have migraine headaches, which can cause:
- Intense pain: It typically starts as mild pain on one side of the head and increases in intensity and becomes throbbing or pounding.
- Physical effects: Light, sound, or odor sensitivity, nausea, vomiting, or diarrhea.
- Neurological effects: Dizziness, speech difficulty, confusion, or numbness.
- Aura: Tingling of the hands or face or visual disturbances such as flashing lights, blurred or tunnel vision, light sensitivity, or blind spots. Having migraine with aura increases the risk of ischemic (clot-driven) stroke.
What the 2024 Guideline says: Women ages 18-64 should be screened and treated for migraine with aura. Providers should help patients manage the overlapping risk factors for migraine and stroke, which include:
- Tobacco and alcohol use
- Less nutritious diet
- Taking estrogen-driven birth control
Effective migraine treatments and preventive therapies can include trigger avoidance, medication, Botox injections, physical and behavioral therapy, or nerve stimulation.
✔️ Pregnancy and postpartum
While stroke in pregnancy or postpartum is not common, pregnant women are at three times greater risk of stroke than nonpregnant peers. Pregnancy strains the cardiovascular system. A woman’s blood volume can increase by 45% during pregnancy, making the heart work harder to pump blood.
The Centers for Disease Control and Prevention (CDC) estimates that 12% of women have high blood pressure in pregnancy – a major risk factor for stroke that typically doesn’t have noticeable symptoms. Preeclampsia, which is high blood pressure in pregnancy, can quickly become an emergency that requires early delivery to save the lives of the mother and baby. Left untreated, high blood pressure can cause a heart attack, kidney failure, or stroke – about half of pregnancy-related strokes are hemorrhagic, which typically have worse outcomes.
During the postpartum period, often called the “fourth trimester” of pregnancy, having high blood pressure remains a stroke risk, especially in the first two weeks after delivery. In this window, having blood pressure of 160/110 or higher is a medical emergency that could result in a fatal stroke.
What the 2024 Guideline says: Treating high blood pressure is safe and effective to reduce pregnancy-related stroke risk. Women should be screened regularly for high blood pressure, especially if they had pregnancy complications that can increase their lifetime risk of stroke, such as recurrent miscarriage, preterm delivery, preeclampsia, gestational diabetes, placental abruption, or stillbirth.
Several blood pressure medications are safe to take while pregnant or breastfeeding. For most women with a hypertensive disorder of pregnancy, 140/90 is an acceptable blood pressure reading. Talk with a doctor about the optimal blood pressure target for your overall health.
Related reading: Preeclampsia care: Research and prevention strategies
✔️ Menopause and estrogen
Going into perimenopause before age 40 or menopause before 45 is associated with increased stroke risk. Some treatment options for menopause symptoms such as hot flashes, night sweats, mood swings, and low libido can also increase the risk of stroke.
Estrogen is thought to thicken the blood and enable clot formation. Some research suggests that taking estrogen-based hormone replacement therapy can increase the risk of stroke in women by 40% and that estrogen-progestin hormone replacement therapy can increase the risk by 30%. However, taking lower-dose estrogen hormone replacement therapy may be safer.
What the 2024 Guideline says: Work with a hormone replacement therapy expert to get the appropriate medication and dosage. Women should be counseled about the risks and benefits of hormone replacement therapy based on their personal stroke risk factors. Hormone replacement therapy can be a safe and effective treatment for menopause symptoms when taken under the care of a board-certified specialist.
Related reading: Menopause is having a moment
✔️ Autoimmune conditions
Women are up to four times more likely than men to develop autoimmune conditions. Research suggests this could be estrogen-driven or because women’s bodies create more antibodies, which are meant to fight infection.
The 2024 Guideline specifically discusses systemic lupus erythematous (SLE) and antiphospholipid syndrome (APS), a clotting disorder.
Both conditions are more common in women, and both of them can increase the risk of ischemic stroke due to factors such as high blood pressure and vulnerability to blood clots.
What the 2024 Guideline says: Patients with lupus may benefit from daily aspirin, and those with APS may need vitamin K therapy to reduce the risk of blood clots.
Stroke prevention guidance for everyone
Social determinants of health
People living in the Stroke Belt in the southeastern United States and adjacent states, such as Oklahoma and Texas, are more at risk of stroke due to social determinants of health, such as:
- Access to health care, such as transportation and proximity to a stroke center
- Social and community support system
- Financial security
- Housing situation and security
- Experience with racism or discrimination in health care
- Access to nutritious food
- Understanding of medical terms and explanations (health literacy, language)
- Culture and preferences
The updated 2024 Guideline acknowledges the impact of social determinants of health on access to stroke prevention and the need for screening and tailored prevention strategies. It would be futile to recommend simply eating better and exercising more to patients who live in food deserts or feel unsafe walking in their neighborhood.
UTSW social workers can connect patients with support services to help with financial, social, and emotional support related to health care. Community-based support programs can connect patients with resources that enable stroke prevention.
For example, UTSW launched a series of culinary medicine shared visits in southwest Dallas County, in which 20% of participants reported food insecurity. Participants attend six sessions to get their vitals checked, learn how to make healthy meals, and collect kitchen tools and recipes to take home. These events are covered by most private and public health insurers.
What are the main risk factors for stroke?
According to the American Heart Association (AHA), all patients and providers should work together to identify and mitigate Life’s Essential 8 risk factors for stroke.
1. Healthy eating
Following the Mediterranean diet can reduce the risk of cardiovascular events such as stroke or heart attack by up to 30% for people at high risk and up to 10% for people at intermediate risk. This eating style minimizes processed foods, red meats, and butter/margarine and emphasizes whole foods such as:
- Green, leafy vegetables
- Nuts and beans
- Fruit
- Whole grains
- Seafood and poultry
- Olive oil in moderation
Taking a daily multivitamin or taking vitamin B3 or B6 independently has not been shown to reduce stroke risk. Talk with a doctor about whether taking supplements is advised for you.
2. Fitness
Living a sedentary lifestyle is a direct stroke risk. Research shows that stroke risk increases after 3.7 hours per day of sedentary behavior. Above 6.5 sedentary hours a day, stroke risk goes up 6% an hour; after 11 hours, the risk increases 21% an hour.
The American Heart Association recommends that adults participate in 150 minutes of moderate exercise a week, such as walking, biking, or light jogging, or 75 minutes of vigorous exercise in which your heart rate gets high enough that it's tough to talk. CDC estimates that only 20% of U.S. adults meet these criteria. The 2024 Guideline recommends that doctors screen patients about their physical activity and refer them to exercise counseling to help meet fitness goals.
3. Quit nicotine
Smoking or chewing tobacco and secondhand exposure have been shown to be a risk factor for stroke. It is likely that vaping is a risk factor as well, though researchers are still gathering long-term data to make that connection.
Quitting has been associated with a reduction in stroke risk. The 2024 Guideline shows that nicotine cessation support services are more effective than “going cold turkey” alone. UTSW offers free smoking cessation programs, with group and one-on-one support to help you quit for good. Medication-assisted support is also proven effective along with behavioral support.
4. Sleep
Normal life changes for women from teen years through menopause can disrupt sleep, resulting a range of health problems over time, including high blood pressure. About 15% of women and 30% of men in North America have obstructive sleep apnea (OSA), which is a major contributor to high blood pressure. Snoring, ceasing to breathe in one’s sleep, and waking fatigued or with a headache are signs of obstructive sleep apnea.
Continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea can help reduce daytime sleepiness by keeping oxygen flowing through the night, with fewer waking episodes. Your partner will appreciate the reduced snoring, too!
Related reading: Sleep disorders and obesity: A vicious cycle
5. Type 2 diabetes
About 37 million people in the U.S. have Type 2 diabetes – that's 11.3% of the population – and nearly one-fourth of these patients are undiagnosed. Another 96 million U.S. adults (38%) have prediabetes. Type 2 diabetes is strongly associated with obesity, heart disease, and chronic kidney disease – all of which significantly increase stroke risk.
The American Diabetes Association recommends screening for diabetes or prediabetes for all adults 35 and older at least every three years. You may need earlier screening based on your overall health.
Type 2 diabetes can be treated and cured through lifestyle changes and medication and/or bariatric surgery. New weight-loss medications are effective and may be covered by private or public health insurers:
- GLP-1 receptor agonists such as semaglutide (Ozempic), dulaglutide (Trulicity), or tirzepatide (Mounjaro) are FDA-approved for managing Type 2 diabetes. For some patients they can result in substantial weight loss. Some medications have also been shown to lower the risk of heart attack and stroke.
- SGLT2 inhibitor medications have not had the press that the GLP-1 RAs have received but can be highly effective in treating Type 2 diabetes. Research suggests these medications may protect the kidneys and reduce the risk of hospitalization due to heart failure.
6. Cholesterol
Managing high cholesterol can decrease heart attack and stroke risk. In fact, two UTSW physician-researchers won the 1985 Nobel Prize for discovering the underlying mechanisms of cholesterol metabolism and its impacts on heart attack and stroke.
People who are at particularly high risk of cholesterol-related stroke include those 40 and older and those with:
- South Asian ancestry
- Familial hypercholesterolemia, a genetic condition
- High blood pressure in pregnancy
- Early menopause
- History of diabetes
- Family history of heart attack or stroke before age 50
Patients with or at increased risk of high cholesterol should talk with a doctor about taking a statin oral pill or PCSK9-inhibitor injections, the latter of which was developed from award-winning research at UTSW. Statins can cut the risk of a first heart attack or stroke nearly in half; adding a PCSK9-inhibitor can reduce the risk of cardiovascular death, heart attack, or stroke by 20%.
7. Weight management
Obesity is a cardiometabolic condition that affects the hormones, blood pressure, insulin production and processing, and cardiovascular health. By 2030, nearly 50% of U.S. adults will have obesity. Working toward weight wellness can decrease the risk of stroke and heart attack. For every 11-pound increment of body weight, the risk of stroke increases by 10%.
Work with a doctor to create a sustainable plan that includes healthy diet, exercise, and support such as bariatric surgery or FDA-approved medications for weight management, such as:
- Semaglutide (Wegovy)
- Liraglutide (Saxenda)
- Tirzepatide (Zepbound)
These medications are found to also have heart-protective effects independent of weight loss. Ozempic and Mounjaro are not yet FDA-approved for weight loss but have contributed to weight loss in some patients.
8. Blood pressure
Managing blood pressure is one of the most effective ways to reduce stroke risk at any time of life. Everyone 18 and older should get screened regularly for high blood pressure, and some patients may benefit from checking their blood pressure at home.
Patients should aim for a target of less than 130/80. Randomized clinical studies have shown that most patients with high blood pressure need to take two or three hypertension medications to prevent a first-time stroke.
Knowledge is power
Understanding your stroke risk is essential to preventing a stroke. Just as important is to BE FAST and recognize the signs of stroke:
- Balance: Is there a sudden loss of balance or coordination?
- Eyes: Is there sudden blurred or double vision or sudden, persistent vision trouble?
- Face: Ask the person to smile. Is one or both sides of the face drooping?
- Arms: Ask the person to raise both arms. Does one side drift downward? Is there weakness or numbness on one side?
- Speech: Does the person have slurred or garbled speech? Can he/she repeat simple phrases?
- Time: Call 911 for immediate medical attention if you notice one or more of these signs. Also, take note of when symptoms began.
Once you have had a stroke, you are at increased risk of having another. If you do have a stroke, work with your care team to identify the source. Stroke is multifactorial, and the more you understand why it happened, the better prepared you will be to prevent future strokes.
To talk with an expert about stroke prevention, call 214-645-8300 or request an appointment online.
