Stroke in women: anticoagulation in a complicated puzzle

Stroke is the third leading cause of death and the most important reason for disability. It is worth noting that 60% of all stroke deaths involve women. This review aims to revise the prothrombotic hemostatic alterations in hypertension along with the often-overlooked role of depression and the job strain of the homemakers’ condition proven to be risk factors for stroke. Moreover, the impact of atrial fibrillation and the related oral anticoagulation with either vitamin K antagonists (VKA) or direct oral anticoagulants (DOAC) in women will be discussed. Another point is that women are treated less with anticoagulants than men. Underdosing is also frequent. In our opinion, defensive medicine represents the basic bias, which plays a major role in this contest. The main reasons are the overlooking of the increased cardioembolic risk in women, the fear of an increased bleeding risk, and the wrong concept regarding a hypothetical higher frailty. In conclusion, from a practical point of view, thrombosis centers should consider all these factors when a woman shows a bad quality of anticoagulation with VKA or a poor adherence to DOAC treatment. Underdosing should also be carefully avoided. We hope that the sex gap in terms of inadequate treatment and inclusion in clinical trials will be covered in the future. Lastly, defensive medicine should be strongly discouraged.