1) Stroke is the third leading cause of death for women after heart disease and cancer, with rates varying by race and age. 2) Hormone therapy can increase a woman's risk of stroke by 40-50% and also increase risks of dementia and cognitive impairment. 3) The strongest risk factors for stroke in women are hypertension and atrial fibrillation, while female hormones may also play a role in women's stroke risk.

1. STROKE IN WOMEN
Ade Wijaya, MD – August 2018

2. Introduction
• Stroke is a devastating condition with high morbidity and mortality
• 3rd leading cause of death after heart disease and cancer
• M:F = 1:1
• Age adjusted rate of death in women is 45.6 / 100.000
• Black women > white women
Statistics NCfH. Health, United States. Hyattsville, MD: National Center for Health Statistics; 2007. Available at: http://www.cdc.gov/nchs/hus.htm.

3. Epidemiology
• Women have similar rates to men at ages 60–79 (7.6% and 7.8% respectively), and lower
prevalence than men at ages 80 and over (13.5% and 17.1% respectively
• Hispanic women have lower stroke mortality rates (33.5/100,000)
Statistics NCfH. Health, United States. Hyattsville, MD: National Center for Health Statistics; 2007. Available at: http://www.cdc.gov/nchs/hus.htm.
Lloyd-Jones D, Adams R, Carnethon M, De Simone G, Ferguson TB, Flegal K, et al. Heart disease and stroke statistics – 2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics
Subcommittee. Circulation. 2009;119(3):480–6.

4. Hormone Therapy
• Estrogen therapy with or without progestin, increases the risk of stroke by 40–50%
• Hazard ratio: 1,44 (for ischaemic stroke) & 0,82 (for hemorrhagic stroke)
• In addition, hormone therapy increased the risk of dementia and mild cognitive impairment
• hormone therapy should be given in the lowest dose and for the shortest time to relieve
menopausal symptoms
• However, it is not known how short or long that time may be. In WHI the increased risk of stroke
became apparent by one year of therapy
Hendrix SL, Wassertheil-Smoller S, Johnson KC, Howard BV, Kooperberg C, Rossouw JE, et al. Effects of conjugated equine estrogen on stroke in the Women's Health Initiative. Circulation.2006;113(20):2425–34.
Wassertheil-Smoller S, Hendrix S, Limacher M, Heiss G, Kooperberg C, Baird A, et al. Effect of estrogen plus progestin on stroke in postmenopausal women: the women's health initiative: a randomized trial. JAMA. 2003;289(20):2673–84.
Shumaker SA, Legault C, Kuller L, Rapp SR, Thal L, Lane DS, et al. Conjugated equine estrogens and incidence of probable dementia and mild cognitive impairment in postmenopausal women: Women's Health Initiative Memory Study. JAMA. 2004;291(24):2947–58.
Shumaker SA, Legault C, Rapp SR, Thal L, Wallace RB, Ockene JK, et al. Estrogen plus progestin and the incidence of dementia and mild cognitive impairment in postmenopausal women: the Women's Health Initiative Memory Study: a randomized controlled
trial. JAMA. 2003;289(20):2651–62.

5. Hendrix SL, Wassertheil-Smoller S, Johnson KC, Howard BV, Kooperberg C, Rossouw JE, et al. Effects of conjugated equine estrogen on stroke in the Women's Health Initiative. Circulation.2006;113(20):2425–34.
Wassertheil-Smoller S, Hendrix S, Limacher M, Heiss G, Kooperberg C, Baird A, et al. Effect of estrogen plus progestin on stroke in postmenopausal women: the women's health initiative: a randomized trial. JAMA. 2003;289(20):2673–84.
Shumaker SA, Legault C, Kuller L, Rapp SR, Thal L, Lane DS, et al. Conjugated equine estrogens and incidence of probable dementia and mild cognitive impairment in postmenopausal women: Women's Health Initiative Memory Study. JAMA. 2004;291(24):2947–58.
Shumaker SA, Legault C, Rapp SR, Thal L, Wallace RB, Ockene JK, et al. Estrogen plus progestin and the incidence of dementia and mild cognitive impairment in postmenopausal women: the Women's Health Initiative Memory Study: a randomized controlled
trial. JAMA. 2003;289(20):2651–62.

6. Pathophysiology

7. D'Agostino RB, Wolf PA, Belanger AJ, Kannel WB. Stroke risk profile: adjustment for antihypertensive medication. The Framingham Study. Stroke. 1994;25(1):40–3.

8. Summary
• Stroke risk is multifactorial but the strongest risk factors are hypertension and atrial fibrillation
• Female hormones might play a role in women stroke.