National Women Physicians Day: Insights From Aleksandra Pikula, MD, DipABPN, DipABLM, FELMO

In honor of National Women Physician’s Day, held February 3rd, NeurologyLive^® is spotlighting multiple women across neurology for their contribution to the field. Among them is Aleksandra Pikula, MD, DipABPN, DipABLM, FELMO, director of the JS Sonshine Center at the Toronto Western Hospital in Canada. With more than 20 years of experience in vascular neurology, Pikula also serves as the co-director of the Women’s Neurology Program at the University of Toronto alongside Esther Bui, MD.

To gain further insight, NeurologyLive spoke with Pikula about the meaning of National Women Physicians Day. She reflected on navigating academic medicine as an immigrant woman, the importance of mentorship and sponsorship, and honoring those who paved the way. Pikula also discussed the disproportionate burden of stroke and neurologic disease in women, gaps in trial representation and leadership advancement, and the impact of midcareer attrition, emphasizing how her work in vascular neurology and women’s brain health underscores the need for life-course prevention strategies and systems that support women physicians while advancing equitable, evidence-based care.

NeurologyLive: What does National Women Physician's Day mean to you personally and how would you describe its importance for other women in the field?

Pikula: After 20 years in vascular neurology — building a career focused on stroke prevention and women's brain health — this day makes me pause. Not just to celebrate, but to reflect on what it took to get here. The early mornings and late evenings, the years of training, the moments of self-doubt, the juggling of professional ambition with everything else life asks of us as women, mothers, daughters, partners. For me personally, navigating all of this as an immigrant woman who came to North America only 23 years ago added another layer of complexity — reintegrating, building networks from scratch, proving myself in unfamiliar environments while carrying the weight of starting over.

Personally, this day is an opportunity to honor the women who mentored me, the colleagues who supported me, and the patients who trusted me. It reminds me why I chose this path — not simply to practice medicine, but to transform how we understand and protect women's brain health across the lifespan.

This national day honors Dr. Elizabeth Blackwell, who became the first woman to receive a medical degree in 1849. Her courage opened doors that generations of women physicians have walked through since.

In neurovascular medicine, we also honor our own pioneer — Dr. Paola De Rango, an Italian vascular and endovascular surgeon who dedicated her life's work to understanding stroke management in women. Her focus on sex disparities was ahead of its time. When she passed prematurely in 2016, she left an extraordinary legacy. Since 2018, the Paola De Rango Invited Symposium at the International Stroke Conference has continued her mission every February. This year, I have the privilege of chairing the Paola De Rango Symposium in New Orleans, focused on sex differences in poststroke cognitive decline and prevention strategies across the lifespan — a full-circle moment.

Why does this matter? Because the problem we deal on daily basis is real. The global burden of neurological disease disproportionately impacts women, with women representing more than half of those affected worldwide.¹ Stroke kills more women than men.² Women also experience worse outcomes, higher rates of poststroke depression, cognitive decline, and disability.^2,3 In Canada, a woman suffers a stroke every 10 minutes. Yet systematic reviews confirm women account for only 37% of stroke trial participants, with no substantial improvement over 3 decades.³

Also, it has been women physicians and researchers who pushed to change this by asking different questions, demanding inclusion, and building the evidence for sex-specific risk factors and treatments. Many of our male colleagues have been essential partners — as mentors, collaborators, and advocates who recognized that improving care for women benefits everyone – patients and providers.

That brings me to the pipeline that equally matters. Women now comprise 57% of medical school applicants and 48% of neurology residents. But representation drops as we advance — to only 34% of vascular neurology fellows, 25% of full professors, and high rates of workforce attrition among women during midlife.⁴ Emerging work on physician wellness identifies burnout as a critical concern for women at certain career stages — the very stages that coincide with hormonal transitions and increased caregiving demands.⁵ When we lose mid-career women, we lose the momentum that has begun to close the gap in care for women patients as well.

Through all this, my work deepened at the intersection of brain health and women's health, I came to understand that brain health isn't static. It's particularly vulnerable for women during critical transitions — puberty, pregnancy, perimenopause, menopause. Each representing a neurobiological window where resilience can be built or depleted.

What gives me hope is that resilience is modifiable. We can intervene. We can prevent. We can build brain health across the lifespan — for our patients and for ourselves with emerging evidence in preventive neurology that directly affects most common neurological conditions.

This National Women’s Physician Day tasks us to create systems where women physicians can thrive — not despite our biology, but with full recognition of it.

We must admit that the next generation is watching. I want them to see what Dr. Blackwell made possible, what Dr. De Rango advanced, and what all of us modeling, that it's possible to build a meaningful career, protect your own brain health, and transform outcomes for the women we serve.

What motivated you to take a leadership role in advancing education surrounding women's stroke care? Why is it important to you?

Well, it started with my patients. Early in my career, I noticed things that made me pay attention. Women coming in with symptoms that didn't match the textbook — fatigue, confusion, generalized weakness, pain — and being sent home reassured that her mild weakness is ‘nothing to worry about’. Women having a stroke during pregnancy or postpartum or women in midlife who display symptoms attributed to stress or menopause when in reality, there was real vascular risk underneath that needed attention.

I kept seeing this, and as the field emerged, I kept asking — what are we missing?

Over past several decades, the research has confirmed what we observe in clinical settings. Large epidemiological studies show women under 35 have 44% higher stroke incidence than men the same age. Meta-analyses demonstrate women have higher lifetime stroke risk, greater mortality, and worse functional and cognitive poststroke outcomes.² Longitudinal cohort data reveal postmenopausal women have double the stroke risk of premenopausal women, and they account for over 60% of dementia cases — most of vascular origin.

When our team conducted a scoping review examining sex differences across neurology, we found striking gaps. Even when sex differences were documented in research, translation into clinical guidelines lagged behind. Sex-specific risk factors were treated as special topics, not core knowledge. Reproductive history wasn't routinely part of vascular risk assessment. Managing stroke in pregnancy felt unfamiliar to trainees. The connections between hormonal transitions and cerebrovascular risk weren't being taught systematically.^6,7

That's when I realized: the gap wasn't just in research; it was in how we were preparing the next generation. We needed to shift the narrative of women's neurology from niche medicine to mandatory knowledge.⁸

None of this would have been possible without genuine support — from women mentors who supported my career, from male allies who opened doors and amplified our work, and from institutional leaders who believed in this vision. Mentorship and sponsorship matter enormously, especially for women navigating academic medicine. I've been fortunate to have both, and I try to pay that forward with every trainee I work with.

But it was not until 2019, when my colleague Dr. Esther Bui — an epilepsy specialist — and I launched Canada's first accredited Women's Neurology Fellowship at the University of Toronto. At the time, only 2 such programs existed in North America: Harvard and ours. We built it from the ground up. I'm proud that the University of Toronto has emerged as a leader in establishing Women's Neurology — not only in North America, but globally. What we built here is now shaping how the field trains the next generation worldwide.

What started as one fellowship has grown into something much larger. We've trained over 20 residents and graduated 5 fellows from national and international backgrounds. The program has funding secured through 2033, with fellows committed through 2028.

In 2024, the American Academy of Neurology officially endorsed the Women's Neurology curriculum⁹ — a roadmap that any program worldwide can now use. In 2025, with Dr. Bui’s leadership, we established the INSIGHT network — Integrating Neurological Sex and Gender Issues in Global Health Training. I lead the cerebrovascular module, with many other experts involved, and we are focusing on stroke in pregnancy and menopause, now extending to fertility and contraception, and building through extended networks.

What we’ve learned is that change in medicine happens through infrastructure. One fellowship trains a handful of specialists and leads to a curriculum endorsed by a major professional organization that reaches thousands of programs. A global network creates sustainable momentum that has impact on societies.

But what really keeps me going is that stroke isn't an isolated event. It's connected to a woman's vascular and brain health across her entire life. When we train clinicians to see that continuity, we catch risk earlier and prevent strokes in time.

Our moto is that every resident who learns this, every fellow who graduates — it ripples outward. One clinician who understands sex-specific stroke care will take care of thousands of women over a career. That's the multiplier effect and that's what motivates me. We are translating the knowledge to where the knowledge belongs.

From your perspective, what factors have driven the growth of women's brain health and stroke care and research?

It's been a convergence of forces — and honestly, the timing finally aligned.

For years, the evidence was accumulating. Study after study — large prospective cohorts, registry analyses, neuroimaging research — showing that women have different stroke risk profiles, different presentations, and different outcomes. Research documenting that conditions predominantly affecting women — cerebral venous sinus thrombosis, reversible cerebral vasoconstriction syndrome, pregnancy-associated stroke — were understudied. Systematic reviews revealing that even when sex differences were documented, they weren't making it into guidelines or clinical practice.^2,3

At some point, and mostly in recent years, the weight of evidence became impossible to ignore, but evidence alone doesn't drive change, policy does. The 2016 NIH mandate requiring sex as a biological variable was a turning point — it created accountability among scientists. The Canadian Institutes of Health Research endorsed similar policies in 2021.¹⁰

We are once again navigating a shifting landscape. There's been uncertainty surrounding DEI initiatives and sex/gender-based research mandates in some jurisdictions, but the scientific case for this work has become strong enough to stand on its own merits. This isn't about ideology — it's about rigorous science, better patient outcomes, and better societies. We're seeing renewed government commitments to women's health through the US White House Initiative and continued CIHR support in Canada. The momentum we've built is resilient — grounded in evidence, driven by patient needs, and supported by a global community.

Yet we must be honest: despite progress, only a small fraction of research funding goes toward women's brain health. In Canada, less then 10% of research fundings goes toward women’s brain health. The gap between policy commitments and actual investment remains wide.

As more women enter neurology and leadership positions, the research agenda has shifted. Women researchers bring their own clinical observations and curiosities. They push for inclusion in trials and sex-stratified analysis. Our male colleagues who recognized the importance of this work have become essential partners, amplifying the message and supporting the infrastructure.

Patients have also been a driving force for us. In my dry lab, we have a strong Patient Advocacy Group. Women are asking — ‘why don't we know more about stroke during pregnancy? Why are perimenopausal symptoms and burden of vascular risks being dismissed?’ This builds momentum and true accountability on our end - academic medicine must respond to this.

Another factor that deserves attention that I am very passionate about, is the growing recognition of lifestyle medicine in preventive neurology. Large cohort studies, including the Nurses' Health Study and UK Biobank analyses, demonstrate that lifestyle interventions are not wellness extras. Instead, they are evidence-based tools for stroke prevention, particularly relevant for women navigating hormonal transitions. Integrating lifestyle medicine as a more holistic approach to care into neurology curricula is essential if we want trainees to approach prevention with the same rigor we bring to acute care, and this will also look different for women and men.¹¹

In addition, guideline development has matured as well. I currently serve as senior chair on the Stroke in Pregnancy Canadian Best Practice Guidelines, expected mid-2026. Having dedicated guidelines signals that the field recognizes this as essential knowledge that needs to be reinforced and implemented.

Global collaboration has accelerated everything. The World Stroke Organization's GENESIS Committee, that I chair, is an international research networks that focuses on gender and equity in stroke care, and initiatives like the Global Brain Health Coalition are equally invested in advancing holistic care and implementation science.

We must mention that there's a cultural shift as well. Women's health is no longer seen as niche. There's growing recognition that understanding sex differences isn't just about women — it's about precision medicine for everyone.

What gives me hope is that these factors reinforce each other. Better evidence leads to better policy, policy creates funding, funding builds infrastructure, and infrastructure trains the next generation. The question now isn't whether this field will grow — it's whether we can match our investment to the burden of disease that we are seeing among women.

What are some key breakthroughs or areas of progress in women's brain health and stroke care that have stood out to you over the last few years?

There's been meaningful progress — and what excites me most is that we're finally answering questions that were overlooked for decades.

On the scientific side, our understanding of pregnancy-related stroke risk has fundamentally shifted. We now recognize that pregnancy complications — preeclampsia, gestational hypertension, gestational diabetes — aren't just immediate concerns. They signal elevated cerebrovascular and cardiovascular risk that persists for decades. Large epidemiological studies, including registry data from millions of women, have demonstrated this convincingly. This means a woman's obstetric history is part of her vascular risk profile. It should be asked routinely in every stroke prevention conversation — and the 2024 AHA/ASA Guidelines now formally recommend this as a Class I recommendation, the strongest level of endorsement.^12,13

We've also made progress understanding how traditional risk factors operate differently by sex. Research consistently shows that diabetes confers greater stroke risk in mid-age women than in men with equivalent risk profiles and that this elevated risk appears at lower fasting glucose levels in women. This has real clinical implications for how aggressively we should be managing metabolic risk in women, yet it's not consistently reflected in practice.¹⁴

I think is also important to recognize that we don't necessarily need to discover new risk factors. We need better implementation of what we already know and that’s where we are failing currently. The knowledge around sex-specific stroke risk exists; the challenge is getting it into clinical practice consistently. The good news is that public awareness is also growing. Women are asking questions about their risk, about pregnancy history, and about hormonal transitions. That demand from patients is pushing clinicians and health systems to respond.⁶

Our understanding of the menopausal transition and brain health has also deepened considerably. We're moving beyond thinking of menopause as just a reproductive milestone. The hormonal changes affect vascular function, cognition, and mood. Major scientific statements from leading cardiovascular organizations now recognize menopause as a biological cardiometabolic and neuroendocrine transition that warrants clinical attention. Research is also clarifying which women might benefit from menopausal hormone therapy, what timing matters, and how to individualize these decisions based on a woman's risk profile, while more studies are emerging on brain health around MHT.^15,16,17

I'd also highlight the growing attention to poststroke cognitive decline in women. We know that 50% of stroke survivors develop cognitive impairment, and women experience this at higher rates than men. Understanding why, and what we can do about it, has important implications for prevention and recovery.^18,19

The shift toward patient-reported outcomes has been significant in past 4-5 years. We're getting better at measuring what matters to women after stroke, not just survival or disability scales, but fatigue, cognitive changes, mood, return to meaningful roles, life satisfaction, and self-agency.²⁰ The formal recognition of this field has been a breakthrough. The AAN's endorsement of the Women's Neurology curriculum⁹, the establishment of dedicated fellowships, and the INSIGHT network globalizing education create infrastructure for sustained progress.

What I find most encouraging is that these scientific advances are connected to clinical change. Better evidence is informing guidelines, shaping education which produces clinicians who recognize what was previously missed. We're not done — the gaps remain significant, particularly around implementation. When I compare where we were 10 years ago to now, the progress is real. It's accelerating and its exciting.

What roles do clinicians and patient voices play in shaping women-focused neurovascular research?

They're essential — and I'd argue the field wouldn't be where it is today without both.

Clinicians are often the first to notice what research hasn't yet captured. What they observe at the bedside generates hypotheses that drive research. Some of the most important questions in women's neurovascular health did not come from labs, but from clinicians paying attention to what wasn't adding up.

Clinicians also serve as the bridge between evidence and practice. We can generate all the research in the world, but if it doesn't reach the bedside, it doesn't help patients. When clinicians are involved in research design, we build in feasibility from the start. That alone isn't enough. Clinicians see disease, but patients live it. Those are different perspectives that need each other. I have patients who made poetry or musicals from their experience with stroke.

My entire program is grounded in patient-oriented research and co-design. This isn't just consultation or check mark — it's about patients as integral members of the research team from the beginning. Since 2019, I've formally integrated patient partners into our work. They contribute at every stage: idea generation, study design, outcome selection, interpretation of findings, and dissemination. We've built this approach through collaborations and funding from the Ontario SPOR and UHN Patient Engagement in Research Practice in Toronto.

Our lab's numerous mixed methodology studies on patient’s needs, care preferences, recovery, and stroke prevention have been foundational. Through co-design, we uncovered findings we would have missed otherwise. Women reported significantly worse outcomes — greater fatigue, sleep disturbance, depression, stigma, and cognitive concerns compared to men. Women had over 6 times greater odds of feeling stigmatized after stroke. They struggled more with social participation and rebuilding their sense of self. They told us what they needed: non-pharmacological approaches, support with identity, in-person care, longitudinal support around self-care for brain health – all that we are now testing though new models of care funding by Ministry of Health.²⁰

What’s Important to mention is that our intersectionality work revealed something equally significant: women's stroke symptoms are more likely to be dismissed, and this is shaped by more than gender alone. How gender intersects with age, race, ethnicity, language, socioeconomic status, and disability affects access to care. Research shows that Black, Indigenous, and socioeconomically disadvantaged women experience higher rates of adverse pregnancy outcomes, delayed diagnosis, and reduced access to preventive interventions. We can't address women's neurovascular health without addressing these realities.²¹

Those co-designed studies and the subsequent findings directly shaped the Women in Midlife Brain Health and Stroke Prevention Program at the Sonshine Centre at U of T/UHN. It's both a clinical program and a research and QI platform. We serve women in perimenopause and menopause — those with stroke history, high vascular risk, and neurological concerns during hormonal transition, while measuring various brain health outcomes.

The program spans the full continuum: access, primary and secondary prevention, and recovery. We integrate comprehensive vascular risk assessment, including screening for adverse pregnancy outcomes per the 2024 AHA/ASA Class I recommendation. We include cognitive screening, lifestyle counseling, and peer support. We work with obstetrics-gynecology and endocrinology colleagues on menopausal hormone therapy decisions — following current guidelines, taking a personalized approach.¹⁵

Critically, we're committed to developing culturally tailored, co-designed models of care through community-based research and education. One size does not fit all. Women from different backgrounds have different needs, barriers, and strengths. Effective programs must be designed with communities, not just for them. That's essential if we want to reach women who have historically been underserved.

What patients bring is irreplaceable. When women share their stories — their vulnerability, healthcare journeys, or dismissals and delays — it keeps us grounded. It reminds us why we entered medicine at the first place.

Looking forward, what areas of women's health in stroke neurology and brain health need to be further studied or explored more in the future?

Looking forward, several critical areas require deeper investigation. As our world faces unprecedented challenges, pandemics, climate change, social upheaval, the burden of neuropsychiatric and neurodegenerative disorders is growing. We have advanced remarkably, yet significant knowledge gaps remain. The Intersection between psychiatry and neurology may be one of the important link – mind and brain health.

Let me talk about something more fundamental: before we chase new discoveries, I have to say again, we must get better at implementing what we already know. We have decades of evidence on sex-specific stroke risk factors, on pregnancy complications signaling long-term vascular risk, on the impact of hormonal transitions on brain health. Yet this knowledge inconsistently reaches clinical practice. Implementation science, understanding how to translate evidence into real-world care while working with policy makers to help them see the priories, deserves far greater investment. Moving forward requires closing this gap first.²

Central to future research must be recognition that brain health is not static. It is a dynamic balance of neural, cognitive, and emotional processes, particularly vulnerable during life's critical transitions. For women, these transitions — puberty, pregnancy, perimenopause, menopause — represent neurobiological windows where brain health trajectories are shaped. We need research that embraces a whole person, life course approach for all.

I believe we also need to reframe brain health as brain capital — recognizing that neurovascular, cognitive and emotional wellbeing are assets that can be built, protected, or depleted across the lifespan. This framing applies equally to women patients, women trainees, and women physicians. We cannot separate the brain health of those we serve from those who provide the care.

Here's something I feel strongly about: not everything will be fixed by pharmacotherapy. Our job as neurologists is to embrace the science around lifestyle and behaviors that impact brain health. This isn't soft medicine, it's rigorous science. We must investigate lifestyle interventions as precision tools for stroke prevention and dementia prevention, not only in general population, but in neurological patients. Women with MS are at higher risk for stroke as it is a woman with Parkinson’s Disease, but we do not embrace these preventive opportunities either.

Validated tools like the Brain Care Score — integrating 12 modifiable factors across physical, lifestyle, and social-emotional domains — show remarkable promise as a motivational tool for self-care. UK Biobank data demonstrated that among adults under 50, each 5-point increase was associated with 59% lower dementia risk and 48% lower stroke risk, and in women too.^22,23 We're currently conducting a study evaluating how healthy lifestyle — using the Brain Care Score framework — impacts female-specific risk factors like adverse pregnancy outcomes and early menopause, and how these interact to influence long-term outcomes such as stroke and dementia. Can healthy behaviors modify the trajectory set by reproductive risk factors? Can lifestyle interventions during midlife attenuate the vascular vulnerability that pregnancy complications caries? The answers could reshape how we counsel women across the lifespan, not replacing pharmacotherapy but working alongside it as an equally evidence-based pillar of prevention.

And lastly, something that matters to me and all of us is that we need to better understand clinician brain health. Women in medicine navigate unique demands: professional pressures, leadership responsibilities, and their own personal and health transitions. When we empower the healer, everyone benefits. This isn't about deficit, it's recognizing that investing in women physicians is investing in all.²⁰

This brings me back to where we started — the pipeline. Women comprise 57% of medical school applicants, with significant midlife attrition (up to 40%). If we want to sustain momentum in women's neurovascular health, we must protect this pipeline as well. Women trainees are building their brain capital while learning to protect others'. Losing them means losing the next generation of leaders who will ask questions we haven't yet imagined.⁴

The future of women's health in stroke neurology is rich with possibilities — if we commit to translating what we know, asking bold new questions, and recognizing that every woman's brain deserves protection at every stage of life. That includes the women we treat, the women we train, and the women who dedicate their careers to this work.

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