Epidemiologic studies indicate that elderly women are at higher risk for Alzheimer disease compared to men. In order to pathologically verify this result, the extent of AD brain lesions (NFT and SP) was compared for men and women at each age, that is, at each decade from 25 years to 95 years, in a large sample of > 5000 routine autopsy cases. Women had more affected brain regions beginning in late middle age. They also had more extensive SP depositions throughout the brain compared to men at each early NFT stage I, II, and III. At later NFT stages IV, V, and VI both men and women had extensive SP deposits. The gender gap in SPs at early NFT stages was large and specific to women who carried the APOE4 allele (P <.001) and in addition to the acceleration in NFT stage also found for APOE4+ women.