Five things to know about how stroke is different in women

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

The American Heart Association (AHA) turned to experts to explain some of the most significant differences and what women can do to protect themselves.

Women with hypertension have higher risk of stroke

Dr. Tracy Madsen, an associate professor of emergency medicine and epidemiology at Brown University in Providence, Rhode Island, noted that women and men share many risk factors for stroke, such as high blood pressure, diabetes and atrial fibrillation.

Of all the risk factors, high blood pressure has the greatest impact on stroke risk. And “at a certain level of high blood pressure, the risk of stroke may be higher in women than in men,” Madsen said.

According to guidelines from the American Heart Association and the American College of Cardiology, high blood pressure is defined as a systolic (top number) of 130 or higher or a diastolic (bottom number) of 80 or higher. A reading below 120/80 is considered normal.

Research has shown that a woman with a systolic pressure of 120 to 129 - the 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, professor of neurology and vice chair for research at Wake Forest University School of Medicine in Winston-Salem, North Carolina.

"I think it raises a lot of questions about whether men and women should be treated differently for high blood pressure," she said.

Complications during pregnancy can pose a lifelong risk

Some risk factors are specific to women. "Probably one of the most important is pregnancy," Bushnell said.

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

Complications during pregnancy can increase the risk of stroke. Preeclampsia, a condition that causes high blood pressure and organ dysfunction, can lead to immediate stroke. It also increases a woman’s lifetime risk of stroke.

About one in five pregnant women will have problems like preterm labor, gestational diabetes, and other conditions that are considered adverse pregnancy outcomes. All of these conditions can increase the risk of stroke in the future. This includes ischemic stroke, in which a blood clot blocks blood flow to the brain, or hemorrhagic stroke, in which a blood 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 45, and especially before age 40, has a higher risk of stroke than a woman who goes through menopause at the typical age of 50 to 54.

A 2020 study published in the journal Stroke suggests that the risk of stroke is higher in young women aged 25 to 44 compared to their male peers. “It’s certainly not lower,” said Madsen, a co-author of the study. The main takeaway, she said, is that “strokes do happen in this age group, and people need to be aware of their risk factors and warning signs.”

Stroke can manifest differently in women

Classic stroke symptoms are the same for women and men and can be remembered using the acronym FAST: "F" - drooping face; "A" - weakness in the arm; "S" - speech impairment; "T" - time to call an ambulance.

But women are more likely to experience additional symptoms, including nausea, loss of consciousness, or confusion.

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

These migraine aura symptoms, along with numbness or weakness, can overlap with stroke symptoms, Madsen said, which "can complicate diagnosis and lead to possible delays in diagnosis."

What happens after a stroke?

Stroke was the fourth leading cause of death for women in 2021, according to the National Center for Health Statistics. It was fifth among men.

Because women live longer than men, they are more likely to experience a stroke during their lifetime. “Women tend to be six years older at the time of their first stroke compared to men,” Madsen said. “This may be part of the reason why stroke has a more devastating impact on women.”

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

How can women protect themselves?

Women need to know their blood pressure and, if it's high, be sure to work with their doctor to get it under control, Madsen said.

She and Bushnell both emphasized that the best way to prevent stroke is to follow the AHA's "Life's Essential 8," which includes not smoking, maintaining a healthy weight, being physically active, eating a healthy diet, getting enough sleep, and maintaining normal blood pressure, glucose, and cholesterol levels.

Pregnant women should be especially careful about their risk of high blood pressure, Bushnell said, and work with their gynecologist for monitoring and, if necessary, treatment.

“Some women may not want to take medications because they are concerned about the baby, which I completely understand,” she said. “But there are safe medications.” And, Bushnell emphasized, the risks associated with high blood pressure during pregnancy do not go away after delivery.

"There is a lot we don't know"

Women have been underrepresented in stroke research, Bushnell said, but scientists are working to correct that.

“There’s a lot of active work going on right now to understand the reasons for these sex differences,” Madsen said, such as the role of hormones in stroke risk. “There’s a lot we don’t know. But the stroke research community is working hard to figure that out.”