Women are not ‘small men’

I know, I know, wild idea huh!

An article in The Conversation prompted me to write a few words about this issue that gets my goat.  The article is by Deb Colville and it describes the apparent gender blindness in some areas of medicine.

In seriousness, over the years the majority of research on diseases as well as in the development of pharmaceuticals has been conducted exclusively or primarily on men.

There are some reasons for this that are understandable, to a point. For example, in research you need to remove as many variables as possible so you can be more sure that the effects you’re seeing are from the drug and not some other factor; women who are in their reproductive years obviously have varying levels of hormones during their menstrual cycle so it was easier to exclude them. Easier. Easier to exclude them, not correct to exclude them. It is apparent that women and men respond to pharmaceuticals differently, therefore research needs to be conducted on BOTH women and men.

An example of men-only research is the Coronary Drug Project which was the first major clinical trial funded in 1965 by the U.S. National Heart Institute, (now National Heart, Lung, and Blood Institute).  This trial was conducted between 1966 and 1975 to assess the long-term efficacy and safety of five lipid-influencing drugs in 8,341 men aged 30 to 64 years who had previously had a heart attack.  Zero women were included.  And yes, women do have heart attacks.

Another study based on the population in Framingham showed that there was a 10-year lag in female cardiovascular morbidity and mortality rates relative to those of men, a lag that was changed with menopause and this suggested that oestrogen had a protective effect (women’s heart disease risk goes up after menopause).   This information was one of the key reasons to introduce HRT, for if losing oestrogen made it more likely a woman had cardiovascular disease then it made sense to just give her some more.  The hypothesis is reasonable, however the treatment was given and it was not fully evaluated until 3 decades after the Coronary Drug Project.   The key study to do this (challenges and all in the interpretation of it) was the Women’s Health Initiative and this ultimately showed not only lack of significant benefit from oestrogen replacement therapy, but actual risk. It took 30 years.  As per Dougherty, “Thus, for 3 decades, futile and sometimes harmful hormonal therapy was widely prescribed to women, on the basis of flawed clinical-trial methodology.” (1)

There is a difference in the symptoms of disease experienced by men and women, with heart disease and heart attacks being a good example. A man is more likely to have symptoms that are regarded as ‘classic’ – clutching his chest, leaning forward, sweating, rapid heart rate, feels like an elephant is sitting on his chest, etc. A woman is somewhat less likely to have these symptoms or have them as strongly. She might feel really tired (and may therefore explain away her symptoms – “I’ve been busy, heavy periods, had the flu” etc), be sweaty and have a rapid heart rate (“stupid menopause”) and chest heaviness (“maybe I’m just anxious”). These differences mean women may not seek medical help or report them as being cardiac in nature. What’s more, and more than a bit disturbingly, women’s symptoms are more likely to be dismissed or not considered as significant. Argh.  Here are a few points relating to cardiovascular disease:

• Women and doctors (overall, clearly not everyone) have flawed knowledge of the difference in presentation of heart disease in general and heart attacks specifically, in women compared to men.
• Pharmaceutical research is predominately conducted with male research subjects – if you cannot include women in the trial because “they are different” then how in the hell can you rationalise treating them with the same drugs on the same regimes and expect the same results? Further, are there differences between pre- peri- and post-menopausal women?  This needs to be explored.
• Women, especially young women, with cardiovascular disease (including heart attacks) are inappropriately discharged from the Emergency Department more frequently than men (that is, with an inaccurate diagnosis and ineffective treatment). (2)
• Women who are 30-54 years of age and hospitalised due to a heart attack are more likely to die than men. (2)
• Women have higher bleeding rates during percutaneous coronary interventions (stents etc) performed through femoral arterial access. (3)
• Women are more susceptible to drug-induced cardiac arrhythmias (irregualr heartbeat, which can range from mild and manageable to fatal). (3)

Not acknowledging and responding appropriately to sex/gender differences in healthcare disadvantages both men and women.  When it comes to cardiovascular health it disadvantages women to a far greater extent, and this is critical given the level of cardiovascular disease.  In Australia for every woman who dies of breast cancer, three die of heart disease and in 2016, more than 3000 Australian women died of a heart attack before they got to hospital – so it is no small number of women we are discussing. (4)  Below are the causes of death for women in Australia, 2015 where you can see how many women die from heart disease (with cerebrovascular disease and dementias having similar features and causes).(5)

AD = Alzheimer’s Disease, IHD = Ischaemic heart disease (atherosclerosis, heart attack), cerebrovascular disease = primarily stroke.

Moral of the story

Men and women are different.  Each individual is different.  Not better, not worse. Different. And each individual deserves equal care.

We need to be mindful of this in decisions in one-on-one consultations and in deciding how to spend millions of dollars on research and service provision.

AND IMPORTANTLY

I haven't even begun to talk about differences between ethnicities, and factors like poverty, violence and other factors that play a huge factor in a woman's health and wellbeing.

1. Dougherty, A. H. (2011). Gender Balance in Cardiovascular Research: Importance to Women’s Health. Texas Heart Institute Journal, 38(2), 148–150.
2. A Gupta, Y Wang, J Spertus, et al. 2014. Trends in Acute Myocardial Infarction in Young Patients and Differences by Sex and Race, 2001 to 2010. Journal of the American College of Cardiology, 64(4): pp337-345.
3. https://www.fda.gov/ScienceResearch/SpecialTopics/WomensHealthResearch/ucm134670.htm
4. http://www.abc.net.au/radionational/programs/healthreport/the-number-one-killer-of-australian-women/8328194  
5. http://www.abs.gov.au/ausstats/[email protected]/Lookup/by%20Subject/3303.0~2015~Main%20Features~Australia’s%20leading%20causes%20of%20death,%202015~3