Improving stroke care for women
Paola De Rango session delves into expanded areas of study.
Peering into the health gap between the sexes, physicians and researchers see numerous questions that, when answered, could provide vital insights into stroke risk, prevention and outcomes in women. Exploring such questions, across women’s lives and through the course of their care, is the focus of the International Stroke Conference’s annual Paola De Rango Session, which takes place on Wednesday. The goal is to increase awareness of sex and gender differences in stroke and to improve prevention and treatment in women.
“One area of need to address (in women’s) health equity includes an improved understanding of how risk, resilience and recovery are modified by changes in women’s physiology throughout the lifespan,” said Thalia Field, MD, FRCPC, MHSc, an associate professor of neurology at the University of British Columbia in Vancouver. “This includes puberty and menstruation, pregnancy, menopause and its late effects on frailty.”
“We also need to take a gender-focused lens to understand how sociocultural and other intersectional identity considerations interface with biological factors to impact wellness, illness and recovery,” said Field, who will discuss women’s health and cerebral venous thrombosis (CVT) on Wednesday.
During the first half of the session, speakers will present data on four areas of study pertinent to stroke risk in women: management of carotid stenosis, sleep disorders and disruptions, gender-affirming hormone therapies and CVT. Critical sex differences exist in these areas but largely have been understudied, Field said. For example, both stroke risk associated with carotid disease and the efficacy of surgery for carotid stenosis differ by sex, yet women continue to be underenrolled in relevant clinical trials.
Similarly, sleep disturbances are a stroke risk factor that disproportionately affects women during peri- and postmenopause, but more research is needed to design effective interventions.
It’s also critical to understand more about treatment using hormone therapies. Evolving data indicate elevated risk of stroke and cardiovascular disease associated with gender-affirming hormone therapies.
For cerebral venous thrombosis, a condition more prevalent in women, specific risk factors include iron deficiency anemia from menorrhagia, exogenous hormones, pregnancy and autoimmune disease.
From 66% to 75% of people with CVT are women, usually younger, Field said, but this is because CVT is commonly seen in association with oral contraceptives, pregnancy and the postpartum period. Also, as with other types of stroke, women are more likely to have delays in correct diagnosis, she said.
“However, risk profiles and incidence in men and women are similar outside of reproductive years, and reported incidence of CVT is growing in men,” Field said, possibly due in part to factors including improved detection with routine vascular neuroimaging and recognition of CVT as a complication in medically complex patients.
In addition, she said, gender-specific risk context is critical in forming CVT treatment and prevention strategies. Women of reproductive potential, for example, need to be treated with anticoagulant prophylaxis for future pregnancies if they do not remain on long-term anticoagulation.
“We don’t often think about heavy menstrual bleeding as neurologists, but because this may be a complication in women with CVT who are treated with anticoagulation, we need to counsel around this issue and have strategies to mitigate this issue if it arises,” Field said.
CVT is a rare condition, accounting for fewer than 1% of all stroke patients — and is considered a disease with a “good” prognosis. About 85% to 90% of survivors will be functionally independent, Field said. But this overlooks the important and under-studied impact of “invisible” deficits, such headache, mood, fatigue and cognitive issues, as well as other serious complications not well-captured by traditional functional outcomes scales, including epilepsy and visual impairment.
Wednesday’s session also will feature Seemant Chaturvedi, MD, FAHA, professor of neurology at the University of Maryland School of Medicine in Baltimore. His presentation, “New Insights Regarding Carotid Stenosis Evaluation and Treatment in Women,” will review the reduced benefit of carotid surgery in women and the physiologic basis for this finding. He will also discuss the underrepresentation of women in previous carotid trials.
“Carotid stenosis is more common in men, so this may explain why men account for 60% to 70% of patients in trials. Some research indicates that women are less accepting of invasive therapies,” Chaturvedi said. “Nevertheless, it is important to understand the pros and cons of carotid surgery in women, since if there is reduced benefit with surgery, then intensive medical therapy will be preferred.”
Women respond differently to treatments such as thrombolysis, carotid surgery and blood pressure-lowering medicines, he said.
Another important issue is how to address undertreatment of risk factors in women, such as lower statin use and lower rates of anticoagulation for atrial fibrillation.
Chaturvedi also reminds clinicians that it’s important to address why stroke outcomes are worse in women. “Is it due to age, social isolation, frailty, or a combination of these factors?” he asked. “Poststroke outcomes such as depression, loneliness and cognitive dysfunction appear to be more common in women. Rehab strategies should be cognizant of these disparities.”
Field said Wednesday’s session aligns with De Rango’s body of work and legacy. De Rango died in 2016, shortening an illustrious career dedicated to advancing knowledge of gender differences in stroke and improving stroke treatment for all.
“I did not have the opportunity to meet De Rango, but reading about her legacy, I have learned that she was a vascular surgeon who was a leader in her field, an outstanding clinician, a rigorous and ethical researcher, and a dedicated team player,” Field said.
“In her roles as a vascular surgeon and frequent research collaborator, I think De Rango’s legacy is recognized by the efforts that are increasingly taken in our work to build bridges internationally to study rare diseases and between specialties to improve communication and accelerate the sharing of ideas and discovery.”
