New Guidelines for Stroke Prevention

One in five women in the US ages 55 to 75 will have a stroke. Learn about the risk factors specific to women.

New guidelines for preventing a first stroke are out from the American Heart Association and American Stroke Association. The guidance for health care professionals was recently published in Stroke and it contains specific strategies for assessing a woman’s risk for stroke, which is a cardiovascular condition.

What is Stroke?

A stroke happens when a blood flow to the brain is blocked due to a clot in a blood vessel or when a blood vessel bursts. Stroke deprives brain cells of oxygen-rich blood, damaging brain cells and often resulting in difficulty thinking, walking, talking, and other significant disability.

More than 600,000 people in the US have a first stroke every year. Stroke occurs more often in women, and age and menopause increase stroke risk.

If that all sounds grim, there is good news. About 80% of strokes are preventable. My father had his first stroke at age 56 and I’m doing everything possible to lower my chances, especially because I have a health condition that increases my risk. More on that later.

First, let’s get into how the new guidelines address the link between a woman’s health history and her chances for a first stroke.

Adverse Pregnancy Outcomes and Risk for Stroke

The guidelines advise health care professionals to pay particular attention to women who have experienced adverse pregnancy outcomes (APOs).  “Adverse pregnancy outcomes” is a term used to collectively describe conditions that occur during pregnancy. They can continue to affect a woman’s health after delivery, including decades later in midlife. 

Adverse pregnancy outcomes include multiple miscarriages, gestational diabetes, preterm birth, having a small-for-gestational age infant, placental abruption, preeclampsia, and high blood pressure. They are associated with an increased risk for stroke and stroke at a younger age.  

Elevated blood pressure during pregnancy is particularly concerning. The guidelines cite research that women with high blood pressure during pregnancy had a 20-30% higher risk for stroke in the long term. Managing blood pressure is especially critical for stroke prevention, in males and females, and with or without a history of an APO.  Though there are no definitive studies linking lower blood pressure with a reduction in long term stroke risk in women with APOs, there’s enough evidence from studies of the general population to make it a priority.

Experts estimate that up to 20% of pregnancies in the US are affected by an APO. The effects of APOs on a woman’s future health is cumulative. If you had one or more APO, tell your doctor or nurse practitioner (NP).

Endometriosis and Risk for Stroke

I knew that APOs influenced cardiovascular disease risk, but I had no idea about endometriosis.

According to the guidelines, research supports endometriosis as a specific risk factor for stroke. Endometriosis is when tissue from the uterus grows outside of the uterus and on other areas in the body where it doesn't belong, including the ovaries, fallopian tubes, and tissues that hold the uterus in place.

Endometriosis is linked to chronic inflammation, immune activation, and hormonal disruption. Endometriosis has been associated with cardiovascular risk factors, and people with endometriosis have a greater chance for high blood pressure, elevated cholesterol levels, and inflammation, all of which contribute to clogged blood vessels that can rob the brain of oxygen-rich blood.

For some, the painful symptoms of endometriosis improve after menopause. As the body stops producing as much estrogen, the growths shrink slowly, but the health risks linger. Make sure your doctor or NP knows that you have a history of endometriosis.

Menopause and Stroke Risk

As estrogen decreases during the transition to menopause (perimenopause), artery-clogging LDL-cholesterol (low-density lipoprotein) levels tend to rise while protective HDL (high-density lipoprotein) cholesterol decline. Estrogen loss also make arteries stiffer which can result in higher blood pressure. Many women gain weight around the midsection during the menopause transition, which contributes to a greater stroke risk by increasing inflammation and possibly raising blood pressure and blood glucose levels.

Learn more about midlife weight gain here.

Premature menopause (before age 40) and early menopause (before age 45 years of age) boost the chances for stroke.  The type of menopause, natural or surgical, doesn’t seem to affect the association with stroke, according to the guidelines.  It’s unclear if hormone therapy from the time of premature, early, or sudden menopause until at least the average age of menopause (about 51 years old) would change the association of menopause with stroke risk.

Severe and frequent hot flashes are linked to an increased chance for cardiovascular disease, but it’s uncertain whether hot flashes are associated with a greater chance for stroke. That said, what’s good for the heart is usually good for the brain, so there may be an association between hot flashes and brain health.

Read more about hot flashes and health here.

Migraine and Stroke Risk

Though migraine is not a female-specific factor for stroke, about 75% of people with migraine headaches are women. I’m one of them.

Migraines tend to peak during your 30s and decline after menopause. Yet, fewer migraines doesn’t negate the risk to your brain according to a 2018 study published in the British Medical Journal that followed people with migraine for 19 years.  People who had migraine with aura and more women than men had a greater risk for stroke. The link held even when researchers accounted for their body mass index and smoking.

The risk from migraine is cumulative. A 2020 study published in Headache found that migraine patients with risk factors for cardiovascular disease, including diabetes, high blood pressure, and elevated blood cholesterol levels, had higher rates for ischemic stroke (the kind caused by a blood clot) as compared to people with migraine and no risk factors for CVD.

The guidelines say health care providers should be mindful of people with this type of headache, and it’s something I discuss remind my doctor of at my yearly physical. Migraines are not to be ignored.

How to Reduce Your Risk for Stroke

It’s important to take charge of your wellbeing at midlife. Discuss your health history with your doctor or NP, and don’t assume that they know about the new stroke prevention guidelines specific to women.  Your provider should measure risks for stroke that are controllable, including blood pressure, body weight, blood cholesterol levels, and blood glucose concentrations, on a regular basis.

Here’s what you can do to limit stroke risk.

Mind you blood pressure: High blood pressure is the main risk factor for stroke. Levels less than 120/80 mm Hg are optimal. High blood pressure is defined as 130-139 mm Hg systolic pressure (the top number in a reading) or 80-89 mm Hg diastolic pressure (bottom number).

Manage your cholesterol: High levels of LDL cholesterol contribute to stroke risk. Diet and exercise can help you keep LDL levels within a healthy range, but medication may be necessary, too.

Eat nutritious foods.  Follow a plant-forward eating pattern with adequate protein and fiber that’s low in added sugars, sodium, and saturated fat and that provides the right number of calories to achieve and maintain a healthy weight. A healthy weight can support normal blood pressure as well as better blood glucose levels.

Control blood glucose levels. Menopause is associated with higher blood glucose concentrations.  Elevated blood glucose can damage blood vessels that carry oxygen-rich blood to brain cells and other parts of the body.  If you’ve had gestational diabetes, you’re prone to type 2 diabetes.  According to the American Diabetes Association, everyone over age 35 should be screened for type 2 diabetes every year.

Stay active: Get 150 minutes of moderate-intensity (such as brisk walking) or 75 minutes of vigorous-intensity (such as running) exercise every week.  Include at least two sessions of strength training weekly, too. The guidelines note that prolonged sedentary behavior is linked to a higher chance for stroke, which is why they suggest that health care professionals ask their patients about how much they sit during the day.   

Learn how to sit less and why moving throughout the day matters in this post.

Don’t smoke or use any type of tobacco. In any form. Period. According to the Centers for Disease Control and Prevention, secondhand smoke bumps up the risk of stroke in nonsmokers by 20−30%. Secondhand smoke exposure results in more than 8,000 deaths from stroke annually in the U.S.

Get adequate sleep: I know that midlife women often struggle with getting enough sleep, but it must be said: A good night’s sleep every night is central to cardiovascular health, which includes stroke risk. Do your best to get seven to nine hours nightly.

Let me know if you have any questions or comments!