Midlife as the Critical Window for Women’s Stroke and Dementia Prevention: Pivotal Advances and Implementation Priorities

Women face a higher lifetime risk of stroke and dementia than men, yet prevention strategies are not optimally implemented for women. Midlife (ages 40-65) represents a critical yet underused life stage window for prevention. This period encompasses the menopausal transition, when hormonal, metabolic, vascular, and neurological changes converge. Despite this, women remain underrepresented in stroke trials, and sex-specific risk factors are poorly integrated into routine prevention. This review synthesizes the transformative advances in midlife women's stroke and vascular dementia prevention from 2015 to 2025, drawing on evidence from clinical guidelines, cohort studies, neuroimaging studies, randomized trials, and implementation research. It highlights research priorities and an implementation framework for the future. Six major advances were identified: first, the 2024 American Heart Association/American Stroke Association guidelines introduced a class I recommendation to screen for adverse pregnancy outcomes. Second, neuroimaging now demonstrates that adverse pregnancy outcomes are linked to vascular brain injury decades after they occur. Third, the 2020 American Heart Association statement established menopausal transition as a distinct cardiometabolic and neurobiological transition affecting vascular brain health. Fourth, menopause hormone therapy controversies have resolved through evidence supporting personalized, timing-based approaches. Fifth, inflammatory and lipid biomarkers measured in midlife can predict stroke risk years out. Sixth, postmenopausal women show greater vascular benefits from physical activity. Despite these advances, women do not routinely receive appropriate screening or prevention recommendations. These findings support a comprehensive midlife assessment that incorporates reproductive history, menopausal transition status, and novel biomarkers alongside traditional risk factors, and should be offered streamlined recommendations for lifestyle strategies and menopause hormone therapy when indicated. Closing the implementation gap will require health system adaptation, provider education, and embedded pragmatic trials to incorporate these advances into routine care.