There is a perception among physicians and the public that stroke and heart disease are disorders affecting men, usually elderly men (NE J Med, 1991, 325:274-6). Although in middle age the death rate from coronary heart disease is five times higher for men than women, in old age the rates become similar when heart disease is the leading cause of death for women as well as men.

Women live longer than men and comprise 64 per cent of the population over the age of 75 (JAMA, 1992; 268:1417-22). Yet women and those over 65 are often excluded from research into heart disease and stroke. Several of the most well known research projects into cardiovascular disease have not included women (Women and Health Research, National Academy Press, 1994). Older people and women are often passed over by researchers because they complicate things: older people may have other health problems and may be taking other medicines which would interfere with the "purity" of a study's findings; women have a different chemical make up from the male "gold standard").Women, in particular are at risk of stroke from an increased number of medical causes. For instance, it has long been known that the contraceptive pill increases the likelihood of stroke. A low dose pill (50 micrograms of estrogen) can treble a woman's risk of thromboembolism (BMJ, 1996; 312:83-8; Lancet, 1995; 346:1375-82; see also WDDTY, vol 4 no 7). HRT carries a similar risk. According to US research, women taking drugs for heart conditions run a greater risk of developing torsades de pointes a sudden quickening of the heart beat rate (JAMA, Dec 1, 1993). There may also be a gender bias in the way women are treated for heart disease (NE J Med, 1991; 325:129-35; NE J Med, 325:221-5). Women are less likely to be offered surgery and more likely to be offered drugs (thrombolytics, diuretics, anti platelets) for treatment of heart disease, and these have been shown to increase the likelihood of a fatal stroke (see box, p 2).