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Interviewer: We all know that a stroke is a serious and potentially life-threatening situation, but it might surprise you that it impacts women more than men. According to the CDC, stroke is the fifth leading cause of death for women in the U.S., and as many as one in five women between the ages of 55 and 75 will have a stroke.

To help us better understand why women face an increased risk of stroke, were joined by Dr. Jana Wold, an associate professor of neurology and a stroke specialist at University of Utah Health.

Dr. Wold, let's start out with why are women at more risk of stroke than men?

Dr. Wold: So the best way to understand it is because women live longer than men and because stroke risk increases with age. So because we have a larger proportion of the population in this older age group, the greater-than-85-years-old age group that are women, and also that's when your stroke risk really ramps up, overall more women have strokes than men.

Interviewer: So I'm hearing that more older women might have strokes than men. What about younger women?

Dr. Wold: Unfortunately, there is a risk of stroke in pregnancy. So, at a younger age, there also is a brief period of time when women are of childbearing age that their stroke risk could be higher than some men.

Interviewer: Yeah. And that is very unique, childbearing, to women obviously. What are some other risk factors that are very unique to women versus men?

Dr. Wold: Yeah. So women take oral contraceptives. Not all women, but some women do. And those medications, unfortunately, do carry a small risk of stroke. So in the wide scheme of things, it's a very small risk.

And women who take oral contraceptives tend to be women younger than the age of 50, so their overall risk of stroke is low, but if you are taking oral contraceptives, that can double your stroke risk. And if you are smoking while you are taking your oral contraceptives, that can dramatically increase your stroke risk.

Also, in speaking of oral contraceptives, oral contraceptives should not be given to women who have migraine with aura because that also increases your stroke risk, because migraine with aura independently increases your stroke risk.

Hormone replacement therapy. So if you are taking hormone replacement therapy for a long period of time, this also can increase your risk of stroke. There was a time many years ago when we thought maybe taking hormone replacement could actually decrease your risk of stroke, and that is not true.

The other important thing that I haven't mentioned yet — atrial fibrillation. So atrial fibrillation carries a high risk of stroke. It is uncommon in the younger population, but as you age, your risk for atrial fibrillation increases. And it's actually riskier for women to have atrial fibrillation than it is for men when you consider their stroke risk. So atrial fibrillation, you can be screened for this in your doctor's office when you are above the age of 75.

Interviewer: So if a woman's listening and she recognized some of these increased risk factors, does that mean that perhaps hormone therapy is not a great idea, birth control is not a great idea? How can a woman weigh the risk versus the benefits of those things?

Dr. Wold: Yes, absolutely. So this is where your primary care doctor comes into play. Everyone should have a primary care doctor whether or not you're a woman or a man, and you need to discuss this with your primary care doctor.

So, for example, if you are a young woman and you're considering going on oral contraceptives, you need to make sure that your physician is aware if you suffer from migraine with aura or if you are a current smoker or if you have high blood pressure. So you need to be in good communication with your primary care physician to make sure that they are also considering your overall risk of stroke.

When it comes to hormone replacement therapy, again, I would have a conversation with your primary care physician or whichever physician would be prescribing this treatment for you. And you would just need to understand the risks and the benefits, because it's going to be different for different women.

Interviewer: And I understand that women sometimes don't experience the standard stroke symptoms. What are those standard symptoms?

Dr. Wold: Yeah. So the standard stroke symptoms, the way we like to remember them is an acronym known as FAST. This stands for face, arm, speech, time.

Face is for that facial asymmetry that you were speaking of before. So if your face is droopy on one side, that can be a symptom of stroke.

Also, if you have one arm that is weak, that can be a symptom of stroke.

And then if you have a change in your speech, that can be a symptom of stroke as well.

The T is for time, because if you notice any of those symptoms, you need to immediately call 911 and go to the emergency room to be evaluated.

Interviewer: And those standard symptoms, those aren't necessarily always the way women experience stroke symptoms. Can you expand on that?

Dr. Wold: Not necessarily. There are some studies showing that women are more likely to have atypical symptoms of stroke, but it's not clearly defined what those would be. So, overall, I would say when you experience any sort of acute change in your vision or your speech or your strength or your walking, that's when you need to consider stroke.

Interviewer: And are there other risk factors that women would want to keep in mind?

Dr. Wold: I would just consider changes in those areas. And a lot of women, also men, like to call their neighbor, call their son, call their daughter. I would encourage you to call 911 when you notice those symptoms.

Interviewer: Right. Because the tricky thing about stroke is it can kind of trick you, can't it?

Dr. Wold: It can. And the medications that we can provide in the emergency room, there's one medication and it's time sensitive, so you need to get to the emergency room very quickly.

Interviewer: Dr. Wold, in your experience, what are some of the misconceptions that you find that people have when it comes to women and stroke?

Dr. Wold: I think a misconception can be that there's nothing that you can do about your risk for stroke, and because the risk of stroke increases as you age, that it sort of is just inevitable, and that once you have a stroke, then you need to try to prevent the second one. But we as stroke physicians would certainly like people to be interested in preventing that first stroke, which you certainly can do.

Interviewer: If there's a woman listening and she might be worried now about her risk of stroke, what takeaway message would you give to them?

Dr. Wold: The takeaway message would be to know what your independent risk is for stroke, and so to consider if you have high blood pressure. If you have high blood pressure, you need to be under the care of a physician. You need to have it properly treated. And if you are a smoker, you should consider stopping smoking.

The other thing that you can do as far as lifestyle measures are concerned is to exercise regularly, and we mean cardiovascular exercise, and also keep a healthy diet that is high in fruits and vegetables.

If you are considering having breast implants, for whatever reason, how do the new FDA guidelines on breast implants affect you and your decision?

Breast augmentation is near the top of the most cosmetic surgical procedures. Although the number of women who had breast implants fell by one-third in 2020, probably related to COVID-19 pandemic, still 200,000 people had breast implants in the U.S. in 2020, down from the usual 300,000 implants per year. About 75% of the implants are for cosmetic reasons, and the rest are part of reconstruction after breast cancer surgery.

Recently, the FDA took some new steps to improve and strengthen the information guidelines about implants and short- and long-term consequences.

It's hard to know how women want to receive information about the risks of breast implants. They believe that they know the benefits, at least for the persons they believe themselves to be right now. They can't really assess the benefits to the woman they will be at, let's say, 60. However, the assessment of benefits is a completely personal process and will be different from woman to woman. And this includes trans women making the decision to have breast implants.

The risks are harder to communicate. Language is often very medical, numbers are hard to process, and some people don't even want to know the risks.

There are data from a randomized trial of information giving that women who received more information were happier with their decision, were less likely to experience preoperative anxiety, and were less likely to experience postoperative regret. So in the information era, I think more is better.

So what are the new components of these new FDA guidelines? First of all, they aren't exactly new. They've been worked on for several years now, and they went out for public comment and were published back in 2020. However, they became more official in the fall of 2021.

Firstly, the boxed warning, the ominous black box that comes on some package inserts of medications and devices that actually nobody really reads unless you stick it on their nose.

I'm going to quote here the example from the FDA with my own asides put in. "Warning," and this is in a big black box, "breast implants are not considered lifetime devices. The longer people have them, the greater the chances are they will develop complications, some of which will require more surgery.

"Breast implants have been associated with the development of a cancer of the immune system called breast-implant-associated anaplastic large cell lymphoma. This cancer occurs more commonly in patients with textured breast implants than smooth implants. Although the rates are not well defined, some patients have died from this." Okay, that's number two.

Three, "Patients receiving breast implants have reported a variety of systemic symptoms, such as joint pain, muscle aches, confusion, chronic fatigue, autoimmune diseases, and others. Individual patients' risk for developing the symptoms has not been well-established. Some patients report complete resolution of the symptoms when the implants are removed without replacement." Okay, that's the black box.

Well, I would want to know more about the phrase that the implants are not considered lifetime devices. There are no recommendations that breast implants be removed after some certain years, not like IUDs that have a finite effectiveness with recommendations for removal at a certain time.

Eighty percent of women who've had an implant placed still have it at 10 years. Of course, the woman that you are at 25 will not be the woman that you are at 55, and neither are your breasts, as all of us know.

"The chance of complication increases over time." What does that mean? Your surgeon should explain those complications, what they are, how often they happen, and what can be done about them.

The common ones are hard fibrous walls around the implant that can be unnatural-looking and feeling, or rupture of the implant capsule.

The uncommon one is the cancer that's associated with the certain kind of implant with a textured, not a smooth, outer covering. That cancer, which is mentioned in the black box, is called breast-implant-associated anaplastic large cell lymphoma. This is a mouthful, but is lymph cancer that arises over time, rarely.

The incidence in women who have these textured implants is 1 in 3,000 to 1 in 30,000. So it's not common. We have a great interview with Dr. Jay Agarwal on this kind of cancer and breast implants. You can find this interview at The Scope if you want to know more.

"Breast implants have been associated with these systemic symptoms." What does that mean? Some women have experienced symptoms such as pain, autoimmune symptoms, chronic fatigue. In the past, this has been somewhat ignored. But there are some women who've had fewer symptoms after their breast implants are removed. This isn't very well understood, but here it is in the black box.

To help understand the black box warning about breast implants, the FDA has created a model patient decision checklist. I think this is really great if it's given to the woman well in advance so she has time to read it or have someone read it to her and explain it to her. This isn't something to be handed out in the pre-op visit just to sign, the way you sign your permissions to your software like Google or your phone. This should actually be read word for word.

The FDA created this checklist to add to that surgeon's counseling. It is meant to be a springboard for discussion, and the patient will read and check off that they've read it and understood it.

It is long, multiple pages, with places for the patients to sign at the bottom of each topic. It includes who shouldn't have implants, at least at the moment: women who have an infection, women who are pregnant or breastfeeding, women who are having chemotherapy or have a suppressed immune system. It includes more information about the rare lymph cancer and about long-term systemic symptoms.

Actually, the example in the FDA guidelines is a really, really good one. If you're an information junkie like me and you read at, at least, the 12th-grade level, it's great.

The long-term risks of complications are spelled out. The frequency at which these things happen are attached, such as painful scar tissue around the implant reported in 51% of patients, rupture or leaking of the implant 30%, need for reoperation 60%. But those are just the biggies.

It's a really great document. It's what your surgeon should have been telling you anyway, but in the heat of the moment in the office, they might not take the 30 minutes to talk to you about this. And you might not remember. This is a great chance to take it home and read it carefully and bring it back with your questions.

And with the FDA guidelines, there's an updated suggestion about management of breast implant rupture or leakage, that 30% of the time it happens.

And last but not least, there's a card for the patient to keep forever in her wallet or personal records about what kind of implant she has, what it's made from, and when it was placed.

Now, you think you'll remember all this stuff, but you won't. And maybe you'll have them still at 80 and your memory is fading. Your surgeon may have retired or gone on to surgeon heaven. Your medical records may be lost. But at least you have a document about what is existing in your body.

If I had implants, I would laminate mine and put it next to my driver's license or my organ donation card.

I think these are really good steps in the right direction in patient information and decision-making. I know you just want what you want and you wanted it yesterday, but it's a long-term decision with long-term consequences, some good, some not so good. You should take your time and try to get it as right as you can.

Thanks for joining us on the "7 Domains of Women's Health" at The Scope.

Interviewer: Were you aware that lack of knowledge about colorectal cancer causes a significant percentage of adult deaths from colon cancer every single year? So that means just by listening to this podcast today you are going to reduce your risk of colorectal cancer.

Dr. Priyanka Kanth is from Huntsman Cancer Institute and here are the bullet points that we're going to talk about today to help inform you so you are less likely to get colorectal cancer.

So, first of all, it's one of the most common cancers, and it causes a significant percentage of adult cancer deaths. Colorectal cancer impacts men and women equally. You need to have screening even if you don't have a family history and by the time you have symptoms it can often be too late, that's why screening is so important. So let's start with the first one Dr. Kanth, colorectal cancer I didn't realize this, one of the most common cancers and causes a lot of deaths.

Dr. Kanth: That's correct. So colon cancer is the third most common cancer in the U.S. And so number one being lungs and number two being breast and prostate in the respective gender. And then third is colon cancer, and that's pretty high. And it is also the second most common cancer to cause death in the U.S. So the first is lung cancer, leading the highest deaths from a cancer, and the second is colon cancer. So it is surely that the burden of disease is very high.

Interviewer: Yeah. I think that surprises a lot of people. A lot of people don't realize that and, as a result, maybe don't take screening as seriously. Another misperception is that men . . . It's a man's disease, but it actually impacts men and women equally. Tell me more about that.

Dr. Kanth: Absolutely. So there is no separate recommendation for men and women. Both genders can get this cancer, and both genders should start at the same age. So there is no difference in recommendation. It is a disease for anyone. So anyone should get screened and now at age 45, yes.

Interviewer: And another perception is, well, my family, nobody in my family had colorectal cancer. So I'm probably going to be okay. Maybe I don't need to get screened at 45, which is the new recommendation. Maybe I can wait till I'm 60. But that's false too.

Dr. Kanth: Absolutely, you're very correct about it. A lot of time we don't think that it is a problem for us because we don't have anyone in our family, but that's not correct. It can happen to anyone. In fact, 70% of all colorectal cancer patients don't have a family history. So that's a big number. And that's why it's so important to have this screened because screening is the best prevention.

Interviewer: I also understand that there's a misperception that colorectal cancer just happens to older people, like in their 60s, 70s, and 80s, so I can put off my screening.

Dr. Kanth: Again, a very, very good point. It can happen to anyone. So age is a number. It surely can happen more in older age, but even young people can get it. And we have seen a rise in incidents in less than age 50. So it is not a disease of only old age. It is a disease for anyone to be worried about.

Interviewer: And then the other misperception that I've heard is, oh, I'll go in and get my screening when I start to show symptoms. But that's very dangerous and inaccurate.

Dr. Kanth: It is. It is very dangerous because colon cancer, especially early stages will not have any symptoms. Even sometimes late stages you'll have symptoms, very minimal symptoms. This is a disease where you don't produce symptoms, you don't think about it and it is inside you. So you have to be very, very aware of this. That don't wait for symptoms. Go ahead and get your screening.

Interviewer: And how difficult is it for treatment if a patient comes to you is at the point where they have symptoms?

Dr. Kanth: Absolutely. So if the symptoms are already there, we are worried it is a late-stage disease. And treating a late-stage disease when it has spread beyond colon is much more difficult compared to treating a stage one or two disease, when it is just in the colon. If it's just in the colon, we take your colon out. We all can live without our colon believe it or not. We can have some change in quality of life, but we can have same life expectancy. So treating an early-stage colon cancer is way easier compared to treating a stage four, late-stage colorectal cancer, yes.

Interviewer: And the two options you've got the stool test, or you've got a colonoscopy. Tell me the advantages and disadvantages of each one of those, because, you know, we know that 45 is the number we should be screened at, but some of us don't necessarily want to take, you know, the day off before and after to get a colonoscopy, so talk me through that.

Dr. Kanth: That's correct. So colonoscopy is gold standard. The reason we call it gold standard is this is the only preventive tool where we can go in, we can see a precancerous lesion, which is a polyp, and we can take it out.

Interviewer: And so it's a diagnostic tool.

Dr. Kanth: It's a diagnostic.

Interviewer: In addition too, if there's a problem at the same time, you can take care of it.

Dr. Kanth: You've taken care of it. It will never turn into cancer. Stool test are very, very, very good tests to detect colon cancer. They may not detect polyps, but they will detect colon cancer at a very high sensitivity. So it is a very good option for patients who are worried about colonoscopy. Now, colonoscopies are not without risk. It's an invasive procedure. We give you sedation. You have to go through a prep as well. You have to take time off, like you mentioned, and yes, some risks associated with the procedure itself, like bleeding or perforation. Those risks are very small, very, very small, but can happen. Stool tests on the other hand, are very safe, can detect colon cancer readily, may not be polyps, but it's a very good tool, once we find that you have blood in stool. Now remember this, if your stool test is positive, you have to get a colonoscopy. That is the next step. So just to keep in mind, any screening test result like we said, best screening test is the one that gets done. So we should consider screening whatever option works for you.

Interviewer: And the advantage of a colonoscopy too, is once you have that done, if no polyps are discovered, you're good for another 10 years.

Dr. Kanth: Absolutely. If your prep was good, if you did a good exam and no polyps were found, you have no family history, you don't have to repeat it for 10 years. So even with small polyps now we don't have to repeat it for 7 to 10 years. So the recent recommendation has changed and become more relaxed for even if you had one or two small polyps, you're okay.

Interviewer: And the stool test is yearly.

Dr. Kanth: So stool test, there're a couple of stool tests. One stool test, where you have to do pretty much yearly is called fecal immunochemical testing. The other stool test is called FIT-DNA, which is commercially called Cologuard which you may consider doing it every three years. But it is surely more frequent to do it than getting a colonoscopy done.

Interviewer: And let's talk briefly about barriers that keep people from getting either one of the two screenings. So maybe we can help talk them through and encourage them, you know, if they have average risk to get screened at 45, because that is really the best way of preventing death from colorectal cancer. So what are some of the barriers and how can people overcome those?

Dr. Kanth: Absolutely. So the biggest barrier, I think, is the knowledge. They should know that they have to get screened. So there is a provider and patient education involved either away. So if no one told them, or if they did not hear it on the radio, say they don't know. So that's the biggest barrier. So education is very important from both aspects. The other barriers are, I would say another very big barrier is, of course, insurance coverage, if you don't have insurance. But there are other tools, there are other ways, like I said, stool tests, they are very cheap. So things can still be done even if you don't have insurance. Apart from that, other barriers are just being worried about getting a procedure. A lot of people think colonoscopy is painful. I have to go through this. It's not true. Colonoscopy is a very smooth, painless procedure, honestly. So those kinds of things that this is going to hurt me, that's not correct. So those are the main things. I would say if I have to pick any, I would say education. If you're aware you're going to do it, you will do it.

Interviewer: And sometimes it's just getting it on the calendar, right?

Dr. Kanth: Absolutely.

Interviewer: Whether it's the colonoscopy or whether it's the stool test, just talk to your primary care provider. Have that discussion find out where it works out for you.

Dr. Kanth: Absolutely. Yes. And that's for average risk screening, you can choose anything, colonoscopy or stool test. There are other tests, other modalities too, but these two are the most common. If you've family history, we recommend colonoscopy, that's the usual tool is recommended. So the best way is to contact your primary care provider, talk to them what's best for you.