If asked to define women’s health, what would you say? If you answered obstetrics/gynecology, you’d only be partially right. Sure, you’re not going to find too many male patients in an Ob/Gyn clinic, but the effect of sex upon health is not restricted to the reproductive organs.
“Every cell has a sex,” said Paula Johnson, chief of the Division of Women’s Health at Brigham and Women’s Hospital in her talk at the University of Chicago Medical Center this week. “There are sex differences influencing disease and we are only at the very tip of the iceberg of understanding the extent of those differences.”
Johnson spoke to the Department of Medicine Grand Rounds Tuesday about the growing field of women’s health and how it can be better integrated into academic medical centers. Trained as a cardiologist, Johnson used predominantly examples from her own discipline, where female deaths due to cardiovascular disease have outnumbered male deaths for the last 25 years. But her message applied to nearly any branch of medicine and science, as research shows again and again that the same diseases can often differ in many significant respects between men and women.
However, much of that research was only recently done, Johnson said, pointing out that it wasn’t until 1993 that the National Institutes of Health formally required clinical trials to include women among the subject pool. Even with that requirement, only a minority of studies break down trial results by sex to reveal whether there are differences in how men and women respond to a new drug treatment or therapy.
Such omissions are looking increasingly ridiculous as more physiological differences between men and women are found. Returning to the example of heart disease, Johnson acknowledged that some of the difference between cardiac deaths in men and women can be attributed to the longer lifespan of females. But women are more likely to die of previously-undetected heart disease than men, suggesting that the course of the disease – and, potentially, its origins – are different in the female population. One study even found that the most common mechanism of arterial blockage differs between sexes, with plaque rupture seen traditionally in men and older women while younger women present with plaque erosion. The difference may sound subtle to the layperson, but it could mean that heart disease in younger women might be overlooked by diagnostic tests, Johnson said.
“The end result is myocardial infarction and you would not be able to tell the difference,” Johnson said. “What we don’t understand is why [plaque erosion] is more common in women, whether there are differences in biology of what incites either of these, and if potentially there are, do those differences have implications for treatment or prevention.”
Menopause has long been known as a risk factor for cardiovascular disease, but studies are finding additional factors that could predispose women to the disease at an earlier age. Some risk factors are seen as early as fetal development or obesity during childhood, while others appear to arise during a woman’s pregnancy, with gestational diabetes and preeclampsia increasing the chance of heart disease later in life. Johnson also suggested a more speculative link between recent research showing differences in male and female brain activity when stressed that could influence cardiovascular health.
But to prove such a link, academic centers must create room for women’s health research that spans all medical and scientific disciplines, Johnson argued. At her home in Brigham & Women’s Hospital in Boston, both a Division of Women’s Health and a Center for Women’s Health and Gender Biology have been established, to encompass both the clinic and laboratory. New doctors also need to be educated to recognize sex differences in commonly-seen diseases, Johnson emphasized, citing a classic New England Journal of Medicine study that found emergency rooms physicians less likely to refer women (particularly black women) for cardiac catheterization.
Johnson said that the future of women’s health would need to draw upon education in basic science research, health care delivery and public health to best equip tomorrow’s doctors to give both men and women the best possible care.
“If we in women’s health are going to create healthier populations of women, our next generation of trainees and future leaders have got to be versed in this full range,” Johnson said.