Sex-specific risk factors for stroke in women: Focus on the 2024 AHA/ASA guideline

Paru S. David; Hannah Nordhues; Suneela Vegunta

doi:10.3949/ccjm.93a.25049

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TABLE 1

Sex-specific risk factors for stroke and recommendations for mitigating them

Risk factor	Risk for any stroke (95% confidence interval)	Recommendations to mitigate risk
Adverse pregnancy outcomes		Detailed obstetric history for all individuals
Hypertensive disorders of pregnancy	RR 1.74 (1.45–2.10)²
Gestational diabetes	RR 1.45 (1.29–1.63)²	Regular screening for hypertension, weight, smoking status, diabetes, and hyperlipidemia
Preterm birth	RR 1.65 (1.51–1.79)²
Stillbirth	HR 1.38 (1.11–1.71)²
Placental abruption	RR 1.70 (1.19–2.42)²	Comprehensive lifestyle modification^a
Recurrent pregnancy loss	HR 1.42 (1.05–1.90)²
Small-for-gestational-age	HR 1.30 (1.0–1.70)²
Preeclampsia	RR 1.81 (1.29–2.55)¹²

Premature menopause	RR 1.25 (1.04–1.51)²⁰	Estrogen replacement therapy until age of natural menopause
	HR 1.69 (1.37–2.08)²³
	HR 1.23 (1.12–1.36)²⁴
		Lipid and diabetes screen at time of premature menopause diagnosis
Early menopause	HR 1.57 (1.43–1.71)²³
		Annual screening for hypertension, weight, smoking status, and hyperlipidemia
		Comprehensive lifestyle modification^a

Endometriosis	HR 1.34 (1.10–1.62)³³ HR 1.20 (1.11–1.30)³⁴ HR 1.17 (1.07–1.29)³⁵ HR 1.18 (1.12–1.23)³⁶^b HR 1.13 (1.03–1.24)³⁸^b	Avoid treatments that induce premature and early menopause when possible
		Consider combined hormonal contraceptive with ethinyl estradiol ≤ 30 μg or progestin-only option
		Regular screening for hypertension, weight, smoking status, and hyperlipidemia
		Comprehensive lifestyle modification^a

Hormonal contraceptives		Consider combined hormonal contraceptive with ethinyl estradiol ≤ 35 μg or progestin-only option or nonhormonal contraceptive in patients with elevated baseline risk for stroke⁴⁵
Progestin-only contraceptives	Odds ratio 0.96 (0.70–1.31)⁴⁷
Combined hormonal contraceptive with ethinyl estradiol ≥ 50 μg	No longer in use due to unacceptable risk⁴⁸
Combined hormonal contraceptive with ethinyl estradiol ≤ 20 μg, 30–40 μg	Incidence rate ratio 1.77 (1.62–1.93)⁴⁸	Regular screening for hypertension, weight, smoking status, and hyperlipidemia Comprehensive lifestyle modification^a

↵^aComprehensive lifestyle modification includes heart-healthy diet, regular physical activity, smoking cessation, and maintaining a healthy weight.
↵^bRisk refers specifically to ischemic stroke.
HR = hazard ratio; RR = relative risk