What is the appropriate acute management for a 63‑year‑old postmenopausal obese woman on oral hormone replacement therapy (Femoston (estradiol/dydrogesterone)) presenting with acute left upper‑extremity weakness suggestive of a right middle cerebral artery ischemic stroke?

Acute Management of Right MCA Ischemic Stroke in a Woman on Oral HRT

Immediate Stroke Management

Proceed with standard acute ischemic stroke protocols including thrombolysis or thrombectomy if indicated by time window and imaging criteria; the presence of oral HRT does not contraindicate acute reperfusion therapy. 1

Acute Reperfusion Therapy

• Administer IV alteplase if patient presents within 4.5 hours of symptom onset and meets eligibility criteria (no contraindications such as recent surgery, active bleeding, or coagulopathy). 1
• Evaluate for mechanical thrombectomy if large vessel occlusion is confirmed on vascular imaging and patient presents within 24 hours of last known well, depending on perfusion imaging criteria. 1
• The fact that she is taking oral HRT (Femoston) does not alter acute stroke treatment decisions—proceed with standard protocols. 1

Immediate HRT Discontinuation

Discontinue Femoston (estradiol/dydrogesterone) immediately upon diagnosis of acute ischemic stroke. 1, 2, 3

• Women who develop acute stroke while on HRT have a 2.9-fold increased risk of fatal stroke if they continue estrogen therapy, as demonstrated in the Women's Estrogen for Stroke Trial. 3, 4
• The American Heart Association/American Stroke Association explicitly recommends against postmenopausal hormone therapy for secondary prevention in women with ischemic stroke or TIA (Class III recommendation, Level of Evidence A). 1, 3
• Immediate discontinuation minimizes the risk of venous thromboembolism associated with both stroke-related immobilization and residual prothrombotic HRT effects. 3

Acute Hospitalization Management

VTE Prophylaxis

• Initiate pharmacologic VTE prophylaxis with subcutaneous heparin or low-molecular-weight heparin unless contraindicated by hemorrhagic transformation risk. 1
• The combination of acute stroke immobilization plus residual HRT effects creates a multiplicative hypercoagulable state, making aggressive VTE prophylaxis essential. 3
• Use sequential compression devices in all patients with lower extremity weakness. 1

Blood Pressure Management

• Monitor blood pressure closely, as hypertension markedly amplifies stroke risk in HRT users. 2
• In the acute phase (first 24 hours), permit permissive hypertension unless BP exceeds 220/120 mmHg or patient received thrombolysis (then maintain BP <180/105 mmHg). 1
• After the acute phase, target BP <140/90 mmHg for secondary prevention. 1

Antiplatelet Therapy

• Initiate aspirin 325 mg within 24-48 hours of stroke onset if thrombolysis was not given, or after 24 hours if thrombolysis was administered. 1
• Consider dual antiplatelet therapy (aspirin plus clopidogrel) for 21 days if high-risk TIA or minor stroke, based on contemporary stroke guidelines. 1

Secondary Prevention Strategy

Long-Term Anticoagulation Assessment

• Perform comprehensive stroke workup including transthoracic echocardiogram, telemetry monitoring, and carotid imaging to identify cardioembolic or large-vessel atherosclerotic sources. 1
• If atrial fibrillation is detected, initiate oral anticoagulation for secondary prevention. 1
• Screen for hypercoagulable states (antiphospholipid antibodies, factor V Leiden, prothrombin 20210 mutation) given her prothrombotic risk profile (obesity, prolonged estrogen exposure). 1

Cardiovascular Risk Factor Modification

• Aggressively manage all modifiable stroke risk factors: hypertension, diabetes screening (given obesity), lipid management with high-intensity statin, and weight reduction counseling. 1, 2
• Obesity itself is a stroke risk factor that is compounded by HRT use. 2

HRT Management After Stroke

Permanent Discontinuation

Do not reinitiate systemic HRT after stroke recovery under any circumstances. 1, 3

• The Women's Estrogen for Stroke Trial demonstrated that estrogen therapy in women with prior cerebrovascular disease resulted in more severe neurological deficits with recurrent strokes and increased fatal stroke risk (RR 2.9). 3, 4
• Both estrogen-alone and combined estrogen-progestin formulations increase stroke recurrence risk by 36-41%. 1, 2, 3
• Even low-dose transdermal estradiol, which shows lower stroke risk in primary prevention, is contraindicated after established cerebrovascular disease. 2

Management of Menopausal Symptoms

• For vasomotor symptoms (hot flashes), prescribe non-hormonal alternatives: selective serotonin reuptake inhibitors (low-dose paroxetine or venlafaxine), gabapentin, or clonidine. 3
• For genitourinary symptoms only, low-dose vaginal estrogen (0.01% estradiol cream) may be considered with extreme caution and informed consent, as it provides local effect with minimal systemic absorption and does not increase stroke or VTE risk. 2, 3
• First-line therapy for genitourinary symptoms should be non-hormonal vaginal moisturizers and lubricants. 3

Critical Pitfalls to Avoid

Common Errors

• Do not delay acute stroke treatment to obtain detailed HRT history—proceed immediately with time-sensitive reperfusion protocols. 1
• Do not restart HRT "at a lower dose" or switch to transdermal formulations after stroke—all systemic HRT is contraindicated. 2, 3
• Do not assume vaginal estrogen is completely safe—while systemic absorption is minimal, theoretical risk remains and requires informed consent in stroke survivors. 3
• Do not overlook the need for aggressive VTE prophylaxis—the combination of immobilization and residual HRT effects creates multiplicative thrombotic risk. 3

Patient Counseling

• Explain that continuing HRT after stroke nearly triples the risk of fatal stroke and worsens neurological outcomes if recurrent stroke occurs. 3, 4
• Discuss that her 6-year HRT exposure likely contributed to this stroke event, as meta-analyses show 12-32% increased stroke incidence with HRT use. 2, 3
• Emphasize that non-hormonal alternatives exist for menopausal symptom management. 3