Biological sex as a risk factor for stroke

Research shows that biological sex (and perhaps also gender) can impact stroke risk.

Generally, males tend to have a higher risk of stroke at younger ages. But females have a higher lifetime risk of stroke because they tend to live longer1.

Note that most of the published data on stroke have not explicitly separated sex and gender and likely incorporate both influences2. Sex refers to biological characteristics such as genetics including features that define our appearance (for example height or colour of our skin). Gender refers to identity, expression, roles and stereotypes for female, male and gender diverse people.

Stroke risk in females

Females are more likely to have a subarachnoid haemorrhage (a bleed in the space between the brain and the surrounding membrane)1.

Research also shows that in females, the risk of an ischaemic stroke (caused by a blockage to the blood supply in the brain) begins rising at lower blood sugar levels3. There may also be a stronger link between high blood pressure and stroke in females.

Some factors may specifically affect females’ stroke risk1:

  • Preeclampsia and gestational diabetes during pregnancy can increase stroke risk both during pregnancy and later in life4
  • Oral contraceptives, especially those containing oestrogen, may slightly increase stroke risk. This is particularly true in people who smoke or have other risk factors
  • Some studies suggest that hormone replacement therapy, and particularly oestrogen-only therapy, may increase stroke risk in post-menopausal females, especially those who start treatment later in life
  • Females who experience migraines with aura may have a slightly higher stroke risk.

Stroke risk in males1

On average men have a higher risk of strokes than women although they tend to have strokes at a younger age and have higher rates of haemorrhagic stroke (which is caused by brain bleeds).

Men are more likely to be smokers; they have a higher incidence of atrial fibrillation and an increased risk for stroke related to hyperlipidaemia (high fats including cholesterol). Some men have sex-specific risks related to low testosterone levels.

Biological sex and stroke: Key points

Stroke is a leading cause of death for males and more likely to occur at younger ages.

However, females have an array of specific risk factors, from longer lifespans to pregnancy complications, that mean they carry a bigger burden of disability related to stroke.

Research with gender diverse people who do and do not take hormones is still in its infancy. There is some evidence that taking oestrogen raises stroke risk in this population5.

No matter what our sex or gender is, it is critical to be aware of our stroke risk and take steps to lower your risk. Physical activity, drinking less alcohol and managing certain medical conditions can help prevent strokes.

References

  1. Kathryn M. Rexrode, Tracy E. Madsen, Amy Y.X. Yu, Cheryl Carcel, Judith H. Lichtman and Eliza C. Miller. The Impact of Sex and Gender on Stroke. Circulation Research. 2022. 130:512–528 https://doi.org/10.1161/CIRCRESAHA.121.319915
  2. Hanna Mckay, Ashley Wabnitz, Parneet Grewal. J Stroke Cerebrovasc Dis. 2024. Apr;33(4):107624. Sex and stroke risk factors: A review of differences and impact. https://doi.org/101016/j.jstrokecerebrovasdis.2024.107624
  3. F Mauvais-Jarvis, N Bairey Merz, PJ Barnes, RD Brinton, JJ Carrero, DL DeMeo, GJ De Vries, CN Epperson, R Govindan, SL Klein, et al. Sex and gender: modifiers of health, disease, and medicine. Lancet. 2020. 396:565–582. https://doi.org/10.1016/S0140-6736(20)31561-0
  4. TE Madsen, DL Long, AP Carson, G Howard, DO Kleindorfer, KL Furie, JE Manson, S Liu, VJ Howard. Sex and race differences in the risk of ischemic stroke associated with fasting blood glucose in regards. Neurology. 2021. 97:e684–e94. https://doi.org/10.1212/WNL.0000000000012296  
  5. KW Davidson, MJ Barry, CM Mangione, M Cabana, AB Caughey, EM Davis, KE Donahue, CA Doubeni, AH Krist, M Kubik, et al. Screening for prediabetes and type 2 diabetes: US preventive services task force recommendation statement. JAMA. 2021. 326:736–743. https://doi.org/10.1001/jama.2021.12531
  6. M Goodman, Q Zhang. Stroke and Blood Clot Risk in Transgender Women Taking Hormones. Patient-Centered Outcomes Research Institute, 2021. https://doi.org/10.25302/05.2021.AD.SS4532

STROKE RISKS

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