The risk of ischemic stroke for women from 15 to 45 is about 5 per 100,000 women per year. Ischemic strikes are caused by an obstruction in a blood vessel in the brain that deprives adjacent neurons of oxygen (so they die and don't grow back, though with time other parts of the brain may take over the lost function).
Add birth control pills (OCPs for oral contraceptive pills) and that number doubles to 9, presumably due to the estrogen component of OCPs. Add migraines with aura, and now we're talking 50 to 60 strokes per 100,000 women per year. Add cigarette smoking and age over 35 and the number skyrockets.
Migraines are severe, disabling, usually but not always one-side headaches, usually associated with other neurologic symptoms. An aura is the presence of these symptoms (usually visual disturbances) just before the onset of the headache.
35 year old Bonnie has migraines, often (but not always) with aura. Her headaches increase just before and during menses, but decrease when she takes OCPs every day (not pausing for a week as most OCPs are taken in order to trigger a reassuring ("my period started--I'm not pregnant") menstrual flow. I provided a very low estrogen dose OCP to minimize stroke risk. But she developed acne. She asked for a pill which may reduce not increase acne. Such a pill exists but appears to increase strokes more than other OCPs.
So, fewer migraines on continuous OCPs, but great risk of stroke because of her aura migraines. But some experts say never ever OCPs for women with migraines with aura, but shouldn't the patient be the one making that decision, assuming she has been presented with and understands the risk data presented above?
Friday was Wear Red Friday. A couple of days before I met a patient whose story tells us why there is a Wear Red Friday. She is a PE teacher, and for many years has participated in several runs a year, from 5 to 20K. Ten years ago she dropped out of a half marathon because of a nose bleed. The nose bleed turned out inconsequential, but in the course of an interview with the race's volunteer doc, she explained how she had become slower in the past few years, even to the point of dropping out of one race because of fatigue.
She attributed this to age (47 at the time) but remembers him telling her that she should be getting faster with more races, or at least be holding her own. So re recommended follow-up with her primary care doctor. She did and was scheduled for a treadmill test (in which one undergoes continuous monitoring of the heart's electrical activity while running). A heart not receiving enough oxygen during exertion will show abnormal electrical activity. She "failed" the treadmill test and a week later underwent double coronary artery bypass.
Her weight is normal, she has never smoked, is not diabetic, and has no family history of cardiac disease. Were it not for a doctor's perceptive questioning, she might have had a fatal heart attack during one of her runs.
The theme for Wear Red Friday: Coronary Artery Disease is the #1 cause of death among women.
