Estrogens and Stroke: Use of Oral Contraceptives and Postmenopausal Use of Estrogen: Current Recommendations.

Stroke in women is a major medical problem. More than half of all strokes occur in women and women account for nearly 60% of stroke-related deaths. The current generation of oral contraceptives may be associated with an increased risk for stroke. However, the absolute risk is small (less than the mortality associated with pregnancy). Women older than 35 years who use oral contraceptives, especially women with hypertension, smoking, or migraines, seem to be the group at greatest risk for stroke. Some guidelines advise against the use of oral contraceptives in these groups. Postmenopausal hormone therapy is not effective for reducing the risk of a first stroke. It also is not effective for reducing the risk of a recurrent myocardial infarction, death, and/or stroke among women with myocardial infarction. Postmenopausal hormone therapy is not effective for reducing the risk of a recurrent stroke or death among women with a recent TIA or stroke. Among women who have had a stroke and are taking hormone replacement therapy, there may be an increased risk of fatal (recurrent) stroke. There also may be a more severe impairment after a recurrent stroke among women using hormone replacement therapy. Results similar to those for cerebrovascular disease have been found with cardiovascular disease for primary and secondary prevention (no evidence for efficacy). Physician judgment is required with nonvascular indications for postmenopausal hormone therapy. The reported absolute reported rates of stroke, myocardial infarction, and vascular death although low can help inform physicians to make a more realistic assessment of the risks and benefits of hormone therapy among postmenopausal women.