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Taking a second look at stroke in women


Once considered primarily a man’s disease, stroke is now emerging as a major health risk for women. In the United States, roughly 795,000 people have a stroke each year- about 60,000 more women than men. But 70% of women aren’t aware that they’re more likely than men to have a stroke.

From age 55 to 75, men have a higher annual incidence and short-term risk of stroke than women. But women generally live about 10 years longer than men, so their lifetime stroke risk is higher and they account for a larger fraction (about 61%) of stroke deaths each year. (See Stroke facts by clicking the PDF icon above.)

Stroke management is similar in both sexes. The latest guidelines from the American Heart Association (AHA) and American Stroke Association (ASA) recommend that patients with a suspected ischemic stroke receive clot-busting drugs, such as tissue plasminogen activator (tPA), and other treatments within 1 hour of arrival in the emergency department (ED) to minimize brain damage and speed recovery. For optimal effectiveness, tPA should be given within 4.5 hours after symptom onset.

Risk factors

Stroke risk factors differ somewhat between the sexes. Women have unique risks linked to pregnancy and menopause. Pregnancy increases the stroke risk threefold. (See Comparing stroke risk factors in women and men.)

For both sexes, unmodifiable risk factors include gender, age, race, ethnicity, and family history. The most important modifiable risk factors are hypertension, diabetes mellitus, hyperlipidemia, cigarette smoking, atrial fibrillation, obesity, and physical inactivity. Other modifiable risk factors include heavy alcohol consumption, sleep apnea, and illicit drug abuse.

AHA and ASA have identified metabolic syndrome as a secondary risk factor for stroke. Metabolic syndrome is a constellation of interrelated risk factors—high blood pressure, increased blood glucose level, elevated serum triglyceride and low high-density lipoprotein levels, and increased waist circumference. To help reduce stroke risk, primary care providers should treat each individual syndrome component.

Recognizing stroke

Stroke must be recognized as quickly as possible to prevent disability and death. Unfortunately, many people don’t know the signs and symptoms of stroke. Delayed recognition delays effective, time-sensitive treatment, including specific pharmacologic and endovascular treatments.

Because stroke injures the brain, victims may be unable to verbalize symptoms-or even recognize them. So the burden of quick, efficient action shifts to alert bystanders (such as family members, friends, neighbors, and coworkers) and healthcare providers. That’s why education about stroke symptoms is so important.

It’s also important to realize that stroke symptoms may differ somewhat in women and men. Symptoms common to both sexes include sudden onset of:

  • numbness or weakness of the face, arm, or leg (especially on one side of the body)
  • difficulty speaking or understanding
  • confusion
  • difficulty seeing in one or both eyes
  • difficulty walking
  • dizziness
  • loss of balance or coordination
  • severe headache with no known cause.

Symptoms that seem to be unique to women include sudden onset of:

  • facial and limb pain
  • nausea
  • general weakness
  • chest pain
  • shortness of breath
  • palpitations
  • hiccups.

A transient ischemic attack (TIA) starts like a stroke but resolves within 24 hours, usually leaving no noticeable symptoms or deficits. With both TIA and stroke, symptoms arise suddenly. In many cases, multiple symptoms arise at the same time.

Women-specific issues

Several stroke-related issues are specific to women:

  • increasing stroke burden in women
  • role of postmenopausal hormone replacement therapy (HRT)
  • pregnancy and stroke
  • stroke in young women.

Increasing stroke burden in women

Misperceptions persist that stroke and other forms of cardiovascular disease aren’t serious health problems for women. And many women are more fearful of breast or ovarian cancer than of stroke or myocardial infarction. Yet from 1999 to 2004, women ages 45 to 54 were more than twice as likely as men to suffer a stroke. Women have both an increased residual disability burden from stroke (including dementia) and a higher incidence of depression after stroke.

To reduce stroke incidence in women, healthcare providers must focus on identifying and treating risk factors in women and on using antiplatelet and antithrombotic drugs as appropriate. Hypertension is the leading stroke risk factor for both women and men; treating hypertension aids primary stroke prevention. Diabetes mellitus puts women at a slightly increased stroke risk than men, while atrial fibrillation doubles the stroke risk in women. For women with metabolic syndrome, the most important risk-factor combination is an enlarged waist and high triglyceride levels, which increases stroke risk fivefold.

Role of HRT

Most strokes in women occur after menopause, leading clinicians to wonder if aging and hormone status play a role. The Women’s Health Initiative, which studied more than 16,000 women, found that taking estrogen plus progestin increased a woman’s ischemic stroke risk by 44%. This excess risk occurred in all age groups and across all categories of stroke risk in women with and without hypertension.

Pregnancy and stroke

Fewer than 5% of strokes in women occur before age 50. The risk of ischemic stroke or intracerebral hemorrhage during pregnancy and the first 6 weeks postpartum is 2.4 times greater than in nonpregnant women of the same age and race. In women younger than age 50, the total stroke rate is 34.2 per 100,000 for the combined pregnancy and postpartal period.

Stroke in young women

Long-term disability is greater in young women who’ve had strokes, but so is the opportunity to modify stroke risk factors. Three ischemic stroke risk factors are more common in younger women, migraine, cigarette smoking, and oral contraceptive use. Hypertension combined with any of these factors further raises a young woman’s stroke risk.

Worse outcomes in women

Researchers have found worse stroke outcomes in women than men, even after accounting for differences in age and other potential risks. This disparity may be linked to a lower quality of acute stroke care for women; for instance, women are less likely to receive tPA for acute stroke.

Also, women generally are less likely to recognize stroke symptoms and thus more likely to delay seeking care. Several studies have found women with stroke symptoms experience longer delays between ED arrival and brain imaging and longer delays in first contact with a physician both of which delay treatment. Women whose stroke symptoms differ from those typically seen in men may experience treatment delays long enough to make them ineligible for time-sensitive treatments.

After a stroke, women tend to have greater physical and cognitive impairment, more depression, and more limitations in activities of daily living—all of which can lower their quality of life. Largely because of their poorer functional outcomes, strokes typically have a greater social impact in women.

Nurses’ role

Nurses play a key role in helping patients survive and recover from acute stroke. Although progress has been made in stroke care, most survivors have long-term disabilities related to physical, cognitive, communicative, and emotional deficits. Nurses need to recognize their important role in the chronic phase of rehabilitative stroke care with both patients and their families. The AHA Council on Cardiovascular Nursing promotes recommendations to help nurses and the interdisciplinary care team manage stroke victims‚continuing rehabilitation in later recovery phases.

Nurses learn early in their education about the need to talk with patients about healthy living and disease prevention. We know it’s easier to prevent a stroke than to help victims and their families recover from one. Given the constraints on nurses’ time and the need to minimize healthcare costs, what can nurses do to help prevent stroke?

First, take a moment to think about how your typical week unfolds. Where do you work? Exercise? Worship? Do your children go to child care? School? What organizations or clubs are you active in each month? Where do you live‚ house, apartment complex, condominium, gated community? In the country? A small town? A city? Do you use social media? In all of these settings, you have opportunities to educate the women you encounter. You can provide formal educational programs, or you can share your knowledge in less formal ways for instance, by putting together a message note to send to social contacts, hang on a bulletin board, place in a newsletter or church bulletin, or share at the book club meeting. In this note, you can address how altering personal behavior, making healthy lifestyle choices, and getting regular checkups can help reduce stroke risk. (See How to help prevent stroke by clicking the PDF icon above.)

Also consider attending government meetings to help local elected officials understand the importance of creating and funding healthy legislation or policies, such as increasing safe walking or bicycling pathways and supporting more senior centers with access to public transportation.

If all 3.1 – 3.6 million registered nurses in the United States use their day-to-day resources and contacts to share their knowledge of stroke prevention and symptoms, we can help decrease stroke incidence in those who’ve put their trust in us.

Selected references

Furie KL, Kasner SE, Adams RJ, et al. Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42(1):227-76.

Gargano JW, Wehner S, Reeves MJ. Do presenting symptoms explain sex differences in emergency department delays among patients with acute stroke? Stroke. 2009;40(4):1114-20.

Goldstein LB, Bushnell CD, Adams RJ, et al. Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42(2):517-84.

Jauch EC, Saver JL, Adams HP Jr., et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44(3):870-947.

Lisabeth LD, Brown DL, Hughes R, et al. Acute stroke symptoms: comparing women and men. Stroke. 2009;40(6):2031-6.

Miller EL, Murray L, Richards L, et al. Comprehensive overview of nursing and interdisciplinary rehabilitation care of the stroke patient: a scientific statement from the American Heart Association. Stroke. 2010;41(10):2402-48.

National Stroke Association. Women and stroke. Last updated May 2010. www.stroke.org/site/PageServer?pagename=WOMEN. Accessed March 3, 2013.

National Stroke Association. Women’s stroke risk. www.stroke.org/site/PageServer?page
. Accessed March 3, 2013.

Kathleen A. Ennen is an assistant professor of nursing at the University of North Carolina Wilmington School of Nursing.

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