A stroke can be devastating for anyone. But the risks and symptoms of a stroke, or cerebrovascular accident, are not always the same in women and men.
American Heart Association News asked two experts to explain some of the most significant differences – and what women can do to protect themselves.
Women are more at risk of high blood pressure
Women and men share many of the classic risk factors for stroke, said Dr. Tracy Madsen, 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 the factors, the one that has the greatest influence on stroke risk is high blood pressure, also known as hypertension. And “for a given level of high blood pressure, the risk of stroke may actually be higher for women than for men,” Madsen said.
The American Heart Association and American College of Cardiology guidelines define high blood pressure as a systolic measurement (the top number) of 130 or more or a diastolic measurement (the bottom number) of 80 or more. Readings less than 120/80 are 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, Dr. Cheryl said. Bushnell, professor of neurology and vice president for research at Wake Forest University School of Medicine in Winston-Salem, North Carolina.
“I think that, of course, raises a lot of questions about whether men and women should be treated” differently for high blood pressure, she said.
Pregnancy complications can pose a lifelong risk
Some risk factors only affect women. “Probably one of the biggest is pregnancy,” Bushnell said.
Pregnancy is often compared to a stress test for the heart. Blood volume and cardiac output increase by approximately 45% compared to prepregnancy levels.
Complications during pregnancy can also increase the risk of stroke. Preeclampsia, a condition that causes hypertension and can cause organs to not function normally, can lead to an immediate stroke. It also increases a woman’s lifetime risk of stroke.
Up to one in 5 pregnant women experience problems, such as preterm birth, gestational diabetes, and other conditions that are identified as adverse pregnancy outcomes. All of those conditions can lead to an increased risk of stroke later in life. This includes an ischemic stroke, which occurs when a clot blocks blood flow to the brain, or a hemorrhagic stroke, which occurs when a blood vessel ruptures and bleeds into the brain.
Early menopause is another risk unique to women, Bushnell said. A woman whose periods stop before age 45, and especially before age 40, has a higher risk of stroke than a woman who goes through menopause at the normal age of 50 to 54.
A 2020 study published in the medical journal Stroke suggests that the risk of stroke is higher among young women ages 25 to 44 than their male peers. “It’s certainly not minor,” said Madsen, a co-author of the study. For her, the bottom line is that “strokes happen in that age group and people should be aware of their own risk factors and warning signs.”
Stroke May Look Different in Women
The traditional symptoms of a stroke are the same for women as for men and can be remembered by the acronym FAST: “R” for droopy face; “A” for balance disturbance; “P” for loss of strength in the arm or leg; “I” for sudden visual impairment; “D” for slurred speech and “O” for get help and call 911.
But women are more likely to have additional symptoms, including nausea, loss of consciousness, or appearing confused.
Women are also more likely to get migraines, which can double their risk of strokes caused by clots, according to a 2023 research review in the Journal of Stroke, of which Bushnell co-authored. She said migraines with aura are particularly associated with increased risk of stroke and can include flickering lights or even vision loss.
Such symptoms of migraines with aura, accompanied by numbness or weakness, can overlap with stroke, Madsen said, something that “can make diagnosis more difficult and cause possible delays in diagnosis.”
Ethnic and racial comparisons
Among most racial and ethnic groups in the United States, the death rate from stroke is similar between men and women, according to AHA statistics. However, black women have a significantly lower mortality rate than black men. But even so, the mortality rate for both is significantly higher than for other races and ethnicities.
There are also disparities among women themselves. For example, black women are twice as likely to suffer a stroke as non-Hispanic white women, notes the U.S. Department of Health and Human Services’ Office of Minority Health.
Bushnell said black women also have higher rates of pregnancy complications related to hypertension, compared to Hispanic and non-Hispanic white women.
This, Madsen points out, is a reflection of problems with access to medical care and other social factors that influence health.
What happens after a stroke
According to the most recent data from the National Center for Health Statistics, stroke was the fourth leading cause of death for women in 2021. Among men, it was the fifth leading cause.
Because women live longer than men, they are more likely to have a stroke during their lives. “Women tend to be about six years older at the time they have their first stroke, compared to men,” Madsen said. “That could partly explain why stroke appears 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 fully recover their abilities.
How women can protect themselves
Women need to know their blood pressure and, if it is high, make sure they are working with a doctor to control it, Madsen said.
Both Madsen and Bushnell said the best way to prevent a stroke is to follow Life’s Essential 8, an AHA guide that encourages the public to not smoke, maintain a healthy weight, stay physically active, eat a healthy diet, get enough sleep, and keep blood pressure, blood glucose, and cholesterol levels within normal ranges.
Pregnant women should be especially aware of the risks of high blood pressure, Bushnell said, and should work with their OB-GYN to monitor it and, if necessary, treat it.
“Some women may be reluctant to take medication because they fear for their baby, which I completely understand,” she said. “But there are safe medications.” Additionally, Bushnell emphasized, the risks of high blood pressure related to pregnancy do not end when the pregnancy ends.
‘There is a lot we don’t know’
Women have been underrepresented in stroke studies, Bushnell said, but researchers are working to remedy that.
“There is a lot of work going on to understand the reasons for some of these differences between the sexes,” Madsen said, such as the role of hormones in stroke risk. “There is a lot we don’t know. But the stroke research community is working very hard.”
American Heart Association News reports on heart and brain news. The opinions expressed in this article do not necessarily reflect the official position of the American Heart Association. American Heart Association, Inc. is the owner or copyright holder, and all rights are reserved.