Different strokes? Varying stroke outcomes for men and women point elsewhere

Most Americans know someone who has died of a stroke—not surprising, considering that the Centers for Disease Control (CDC) cites it as the cause of 1 out of every 18 deaths in the United States. Most of us also recognize that responding quickly when a loved one experiences a stroke can significantly impact a stroke’s severity. What many Americans may not realize, says Dr. Farida Sohrabji, a professor at the Texas A&M Health Science Center College of Medicine, is that recognizing stroke in women has, historically, been far more complicated than identifying it in a man—and that women suffer far greater complications from stroke as a result.

“The motto for stroke is ‘Time is Brain,’ said Dr. Sohrabji. “The American Heart Association recommends that as soon as you see a person you think has had a stroke, which is commonly indicated by the acronym ‘FAST’—facial falling, arms unable to be raised, slurred speech, time to call—you must get them to the emergency room.”

Educational campaigns and faster treatment times, along with advances in treatment methods, have resulted in a decrease in stroke mortality of 35 percent or more for both men and women, according to the CDC.

However, the “stroke burden,” in terms of impairment caused by strokes, continues to be heavily borne by women. The question is, why?

“One of the things we are realizing is that the way men and women present for a stroke is different,” said Dr. Sohrabji. “The typical symptoms of slurred speech or the drooping face or not being able to move your arm occur in men and women, but there are going to be atypical symptoms that can occur, and they more often occur in women. A woman is more likely to report that she has neck and jaw pain, or a feeling of generalized anxiety or confusion, or a migraine, and describe that as her primary symptom.”

When a patient’s experience of a stroke does not correspond with the more predominant symptoms of slurred speech or drooping facial muscles, female patients can lose precious time waiting to see a doctor.

“If the physician in the ER does not diagnose you as a stroke patient, you will not be attended to right away. You will have to wait your turn,” Sohrabji said. “This person will now be sitting longer in the ER waiting to be attended to, while the person with the typical, hallmark stroke symptoms will be rushed in there, and treatment will be started right away. If you get treated in a delayed manner, then your stroke will end up being more severe, and you may end up with bad outcomes because you weren’t treated fast enough. So that may be the top of the pyramid, in terms of why the strokes are more severe in females: These atypical symptoms do not get recognized as stroke, and all of these small variations in what is to be expected and what is unexpected can delay treatment.”

The challenge is how to address these divergent outcomes. Major studies in the early 2000s probed a possible link between hormone replacement therapies and decreased stroke susceptibility, but later science undermined their initial findings, said Dr. Sohrabji, herself a laboratory researcher. “Larger, randomized, double-blind studies have shown that that is not the case,” she said.

One solution is ensuring that hospital ERs are prepared for the more subtle signs of stroke in women. “We need to have more education about these atypical symptoms,” Dr. Sohrabji said.

Current research in hormone replacement therapy and stroke also offer some guidance to women, Dr. Sohrabji says. “New studies suggest that anyone considering hormone replacement therapy can safely use such treatment for a few years, in perimenopause or early menopause. Use it to make the transition easier, and then taper off or stop its use.”

Women and men can also take protective measures to reduce their risk of stroke.

“Most risk factors are related to lifestyle, and all of the lifestyle factors that apply to cardiovascular disease also apply to stroke – exercise, diet, and controlling hypertension,” Dr. Sohrabji said. “Another factor of particular interest for women is diabetes. Diabetes may occur across the board in men and women, but a large number of women will start to show borderline diabetic type profiles, like the higher sugar, higher triglycerides and increased hypertension, generally around the perimenopause. It’s linked to the loss of hormones, but that type of diabetes can increase the risk of stroke.”