What Women Need to Know About Preventing a First Stroke

Oral contraceptives, certain pregnancy complications, and early menopause can all increase stroke risk. But there are ways to minimize the threat.

Women who want to reduce their risk of a first stroke need to do more than adopt well-known prevention strategies like eating right, getting plenty of exercise, and not smoking. They also need to focus on gender- and sex-specific risk factors like oral contraceptive use, pregnancy complications, and menopause timing.

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This is a main prevention message in updated guidelines from the American Heart Association (AHA) that for the first time call out specific stroke risk factors that may apply only to people who take birth control pills, have a uterus, become pregnant, go through menopause, or receive certain gender-affirming medical treatments.

“The most effective way to reduce the occurrence of a stroke and stroke-related death is to prevent the first stroke, referred to as primary prevention,” said Cheryl Bushnell, MD, the lead author of the guidelines and a neurology professor at Wake Forest University School of Medicine in Winston-Salem, North Carolina, in a statement.

“Some populations have an elevated risk of stroke, whether it's due to genetics, lifestyle, biological factors, or social determinants of health, and in some cases people do not receive appropriate screening to identify their risk,” Dr. Bushnell said. 

Most importantly, many sex- and gender-specific risk factors for a first stroke can happen when people are young. 

“This is important because women have unique risk factors for stroke, with contraceptives and pregnancy being leading contributors to stroke in the young in particular,” says Joshua Willey, MD, an associate professor of neurology at the Columbia University Vagelos College of Physicians and Surgeons and the medical director of the NewYork-Presbyterian Columbia Comprehensive Stroke Center.

“Since a high proportion of young women will use contraceptives, or are planning or will plan a pregnancy, specific guidelines for a large segment of the population are important and had not been previously specifically addressed,” says Dr. Willey, who wasn’t involved in writing the guidelines. 

These are five specific risk factors women need to know about.

1. Oral Contraceptives

People who have used oral contraceptives with higher estrogen content are twice as likely to experience a stroke later in life as people who use birth control pills with little or no estrogen, according to the guidelines. 

People who have other risk factors for stroke — such as being older than 35, having high blood pressure, or smoking — should consider progestin-only birth control pills or nonhormonal contraceptives, the guidelines advise. 

2. Pregnancy Complications

People who become pregnant also face some unique stroke risk factors, according to the guidelines. High blood pressure during pregnancy, known as gestational hypertension, dangerously elevated pregnancy blood pressure known as preeclampsia, and postpartum high blood pressure can all increase stroke risk — not just while these conditions are occurring but also afterward, according to the guidelines. Screening and treatment for high blood pressure during pregnancy can reduce this risk. 

Beyond this, pregnancy complications such as gestational diabetes, placental abruption (in which the placenta separates from the uterus), preterm delivery, miscarriage, and stillbirth can all be associated with an increased risk of a first stroke, according to the guidelines. It's important to manage blood sugar during pregnancy and treat any underlying medical issues that may contribute to other complications.

3. Endometriosis

Endometriosis, in which endometrial tissue grows outside the uterus, is a chronic gynecological condition that’s associated with an up to 34 percent higher risk of stroke, the guidelines noted. 

4. Menopause

Menopause timing and symptom severity can also indicate stroke risk, according to the guidelines. Women who go through menopause before age 45 or experience severe and frequent vasomotor symptoms like hot flashes and night sweats all have an associated increased stroke risk. 

In addition, people who use hormone replacement therapy to manage menopause symptoms may have an increased risk for a first stroke if they’re older than 60 or use hormones for more than 10 years after menopause, according to the guidelines. 

5. Gender-Affirming Estrogen Therapy

Transgender women and gender-diverse individuals who take estrogens as part of gender-affirming medical treatment may have an increased risk of stroke, according to the guidelines. There isn’t much data yet to say for sure how much increased risk they may have, or how specific types or duration of estrogen treatment might impact their risk.

As a result, the guidelines recommend that these individuals follow well known stroke prevention strategies, such as not smoking and getting screened and treated if necessary for high blood pressure. 

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The guidelines advise people who are overweight or have obesity and type 2 diabetes to consider treatment with new GLP-1 drugs like Ozempic that can promote dramatic weight loss and lower blood sugar. Obesity and high blood sugar are both risk factors for a first stroke. 

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In addition, the guidelines call out a variety of social determinants of health that can impact stroke risk. These are nonmedical factors such as education, income, and the accessibility and affordability of care. They also include things like neighborhood walkability and access to healthy food close to home. 

Knowing that all these things can impact stroke risk, along with gender- and sex- specific risk factors, can help women make choices throughout their lives to manage their risk, says Michael Hill, MD, a neurology professor at the University of Calgary in Alberta who wasn’t involved in the guidelines. 

“Sex differences in stroke risk exist and are relevant throughout the phases of life,” says Dr. Hill. “These phases of life are different for men and for women and interact with choices taken in those phases. Emphasizing this is important.”