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Try out PMC Labs and tell us what you think. Learn More. Stroke has a greater effect on women than men because women Woman want sex Vass more events and are less likely to recover. Age-specific stroke rates are higher in men, but, because of their longer life expectancy and much higher incidence at older ages, women have more stroke events than men.

With the exception of subarachnoid haemorrhage, there is little evidence of sex differences in stroke subtype or severity. Although several reports found that women are less likely to receive some in-hospital interventions, most differences disappear after age and comorbidities are ed for. However, sex disparities persist in the use of thrombolytic treatment with alteplase and lipid testing.

Functional outcomes and quality of life after stroke are consistently poorer in women, despite adjustment for baseline differences in age, prestroke function, and comorbidities. Here, we comprehensively review the epidemiology, clinical presentation, medical care, and outcomes of stroke in women. There is growing recognition of the clinical and public health importance of stroke in women. Moreover, stroke-related outcomes, including disability and quality of life QOLare consistently poorer in women than in men, yet the reasons for this are not well understood.

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The societal impact of poor stroke outcomes in women is compounded by the fact that elderly women are much more likely to live alone and to be socially isolated. The importance of the differential effect of stroke on women will continue to grow over subsequent decades as an increasingly older population in an ever greater of stroke events in women. Because of this oncoming epidemic, the stroke community needs Woman want sex Vass address the underlying biological, epidemiological, and clinical causes and manifestations of stroke in women.

Our aim is to provide a comprehensive review of the published literature on sex differences in stroke, with specific emphasis on the epidemiology, clinical presentation, medical care, and outcomes. In turn, we hope to raise awareness of the important sex differences in stroke, and to identify priority areas for further research.

However, these sex differences are strongly modified by age figure 1. Age-adjusted data therefore obscure the complex relation of sex differences at specific ages, and mask the higher stroke mortality for elderly women. The focus on age-adjusted and age-specific stroke mortality rates also conceals the greater total of stroke deaths in women. The excess of deaths in women from the higher mortality in older women and their disproportionate representation in the population. At the age of 50 years, the female:male population ratio is 1.

Inin the USA there were marginally fewer stroke deaths among white women than men below the age of 65 years 13 vs 14 However, there were approximately more stroke deaths in women aged 75—84 years, and nearly 26 more stroke deaths in women aged over 85 years.

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The greater burden of stroke deaths in women is predicted to be even higher in the future. Figure 2 applies the current US stroke mortality data to the US Census Woman want sex Vass population projections, 2 and projects sex-specific stroke deaths among whites through to again, other race groups have similar patterns. The 32 excess stroke deaths in women in steadily increases to nearly 68 by Similar to age-adjusted mortality, women have an overall lower age-adjusted stroke incidence than men.

The projections describing sex differences in the of incident strokes are similar to the mortality data. Applying the current GCNKSS stroke incidence to the US population estimates gives an estimated 82 incident stroke events in white women and 49 events in white men, and inan estimated events in white women compared with events in white men.

Reports assessing sex differences in stroke case fatality are surprisingly variable, with many providing little evidence of a substantial difference, 6 — 10 some showing higher case fatality, 1112 and some reporting lower case fatality in women. Higher case fatality in women was shown in the International Stroke Trial, 12 which randomly ased women and men to aspirin or heparin, or both; day case fatality in women was However, adjustment for baseline differences in age, stroke severity, atrial fibrillation, and blood pressure resulted in ificantly lower 6-month mortality in women odds ratio [OR] 0.

Little information exists on sex differences in stroke prevalence. A study based on the Behavioral Risk Factor Surveillance System, a nationwide telephone survey of over US residents, found a similar stroke prevalence in women 2. However, because of the preponderance of women at older ages, the estimated total of stroke survivors was higher for women 3. The most common biological explanation for sex differences in stroke is related to sex steroid hormones, particularly oestrogen. This hypothesis is supported by robust sex differences in animal models of ischaemic stroke.

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For example, after middle cerebral artery occlusion in rodents, females have smaller stroke volumes than have males. However, ovariectomised females have similar stroke volumes to males, whereas volumes in ovariectomised females given oestrogen replacement are similar to intact females. Post-menopausal women receiving oestrogen replacement therapy have reactivity Woman want sex Vass similar to pre-menopausal women.

As a putative neuroprotective agent, oestradiol might be the most widely studied molecule, and yet it has never been tested in patients with acute stroke. Human studies of hormone therapy have focused on disease prevention rather than acute treatment. Two randomised trials in women with established cardiovascular disease found no benefit of hormone therapy.

The Heart and Estrogen-progestin Replacement Study found that, in postmenopausal women with coronary heart disease, exogenous oestrogen and progesterone did not reduce the risk of coronary events. These also conflict with epidemiological studies that have shown consistent protective effects against risk for cardiovascular disease, 28 although most of these studies have not shown protective effects against stroke. One explanation for the negative of these trials is that most of the participants were well past menopause at the time of enrolment eg, mean age of WHI participants was 64 years.

A follow-up secondary analysis of the WHI trial showed that, within 5 years of menopause, oestrogen protected against heart disease but not stroke. Sex differences in the response to injury and cell death have been shown without the direct influence of sex steroid hormones. For instance, marked sex differences have been observed in cultures of XX ie, female and XY ie, male cells tested in steroid-free media in vitro.

XY cultures seem to be more susceptible to excitotoxic cell death, whereas XX cells are more sensitive to pro-apoptotic programmed cell death. Future research should consider the importance of the neurovascular unit and the alling processes that occur among the glia, neurons, and endothelium components.

studies have shown greater effectiveness of intravenous therapy in women, 3132 although interestingly, similar differences have not been found for intra-arterial alteplase. At least two studies have shown that women have worse prestroke disability than men. Women with stroke are older at onset by an average of about 4 yearsand are more likely to have atrial fibrillation and hypertension, whereas men with stroke are more likely to have a history of heart disease, myocardial infarction, peripheral arterial disease, diabetes, and alcohol and tobacco use.

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Although both diabetes and metabolic syndrome are recognised to increase the risk of ischaemic stroke in men and women, 36 studies point to both risk factors having a greater effect in women. A recent study found that metabolic syndrome doubled the risk of ischaemic stroke in women but had no effect in men. Migraine is an independent risk factor for stroke. In a recent meta-analysis of 14 observational studies, stroke risk in people with migraine was more than doubled RR 2.

Some stroke risk factors are specific to women of reproductive age. A recent meta-analysis concluded that oral contraceptive use increases ischaemic stroke risk by almost three times RR 2. Ischaemic stroke tends to aggregate in families, with a positive family history conferring a relative risk of stroke of roughly 1. More research is needed to understand whether sex-specific genetic mechanisms exist for ischaemic stroke. Overall, women do not seem to have more severe strokes than men, especially after taking into stroke subtype and age, although the evidence is somewhat contradictory.

In two studies that measured stroke severity with the Canadian neurological scale, one found that women had greater severity on presentation, 9 whereas the other found no sex difference. In terms of stroke type, several studies have shown an increase in the risk of subarachnoid haemorrhage in women. For example, by use of the Oxford Community Stroke Project classification, women were shown to have a higher frequency of total anterior circulation stroke than had men, 12 and a lower frequency of posterior circulation strokes.

Many studies have been undertaken in several countries to identify factors that are associated with the Woman want sex Vass from stroke onset to arrival in the emergency department ie, prehospital delay. Nearly all of these studies have found no evidence of clinically important differences in prehospital delay between women and men.

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Two studies have shown that prehospital times are shorter for witnessed stroke events. One can surmise that if a person lives alone, the onset of symptoms is less likely to be witnessed by another person. Women are more likely than men to live alone; 1011 according to the US census, approximately 8 million women and 2. Although in-hospital delays have not been studied as extensively as prehospital delays, there is evidence that after arriving in the emergency department, women experience greater delays than do men. Although a few studies have not found ificant sex differences in assessment times, 636786 four studies found that women have somewhat longer door-to-scan times.

Relatively few studies have examined whether sex differences exist in the care of patients with acute stroke. Although some studies have found evidence of differences in the use of specific diagnostic and treatment-related procedures, 116092 — 95 overall the and magnitude of these differences has been relatively small, indicating that there are not major sex differences in the quality of in-hospital care. However, a European study found that women were less likely to receive brain imaging, carotid ultrasound, and echocardiograms than were men, after adjusting for age.

However, apart from lipid investigation, these differences disappeared after adjustment for age. Studies in the USA, 92 — 94 Europe, 11 and Canada 97 have found that women are less likely to undergo carotid endarterectomy than are men. The lower use of carotid endarterectomy in Canadian women was not attributable to differences in age or comorbidity, and therefore seems to represent a true disparity.

Regardless of any disparities in the use of carotid endarterectomy, women who do receive the surgery seem to gain similar benefits to men. Some evidence of sex differences exists in the use of stroke-related medications in both inpatient and outpatient settings, although the findings are variable. Several studies in the USA, Canada, and Germany have reported on sex differences in intravenous alteplase use. A recent report from a single academic hospital in Nova Scotia, Canada, examined data from over stroke patients and found ificant sex differences in alteplase use.

Finally, a recent analysis of over ischaemic stroke admissions in the US Woman want sex Vass Inpatient Sample found that alteplase treatment was given to only 1. There are several sex differences relevant to antiplatelet treatment that are of potential clinical importance. Sex hormones have a differential effect on platelet function, with testosterone promoting platelet activity and oestrogen inhibiting it. However, sex-related differences in the efficacy of aspirin have been seen only in primary-prevention stroke trials.

Only two of the six trials included both men and women, and nearly all data specific to women came from the Women's Health Study, which did not include men. In contrast to primary prevention, aspirin seems to provide similar benefits in terms of secondary-stroke prevention in both men and women. Women with non-valvular atrial fibrillation have nearly double the risk of stroke than men with the same risk factor.

The seventh report of the t National Committee on high blood pressure found no sex-related differences in the effectiveness of any particular type or class of antihypertensive agent. Despite evidence that Woman want sex Vass admitted to hospital with stroke are less likely to receive lipid testing, 1096 the use of statins at discharge seems to be similar for men and women,although data from two studies in Scotland indicate lower statin use in women stroke survivors.

One study found that although women had ificantly greater carotid stenosis, men had greater plaque area. Surprisingly few studies have been done with the primary objective of examining sex differences in functional outcomes after stroke. Published studies table include those from Europe 791112and North America. Women have more physical impairments and limitations in activities of daily living ADLas measured by the Barthel index. Only a few reports have looked at sex differences in QOL by use of stroke-specific instruments, such as the stroke impact scale or stroke-specific QOL scale.

Almost all the studies show that women have lower overall QOL than do men after stroke. With respect to specific domains, several studies have found lower physical function scores among female stroke survivors. For example, in the Kansas City Stroke Study, women scored ificantly lower than men on the item short-form SF health survey physical Woman want sex Vass scale.

The causes of the sex differences in functional outcomes and QOL have yet to be fully elucidated. Differences are most often explained by the fact that, compared with men, women are older, have poorer prestroke function, have more comorbidities such as depression, less social support, and are more likely to be widowed.

However, adjustment for these factors does not adequately explain the observed differences in stroke outcomes between men and women. Clearly, more studies that assess stroke survivors in both subjective eg, health-related QOL and objective eg, cognitive functioning, depression measures are needed to determine the causes of these differences in outcomes. In the USA and elsewhere, women are less likely to be discharged home and are more likely to be discharged to nursing homes and long-term care after a stroke.

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These findings were hypothesised to be attributable to differences in muscular strength between men and women. The findings of sex differences in rehabilitation, post-acute care outcomes, and discharge disposition suggest a complex interplay of demographic factors, psychosocial functioning, pre-existing health state, and disease severity. Because of the sex disparities in recovery and outcomes after stroke, women need rehabilitation programmes to focus more on improving their physical functioning and to diagnose and treat depression. Given their greater social isolation, women are also in need of increased social support and counselling.

The sex differences in stroke can be summarised as follows: women have more stroke events due to their longer life expectancy and older age at the time of stroke onset.

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Sex differences in stroke: epidemiology, clinical presentation, medical care, and outcomes