HIS Why we need & HERS medicine
From heart disease to pain, men and women are being treated as if we’re all the same. But, as this expert reveals, it could be the death of us
Men and women have different needs when it comes to medical treatment. I am not talking about the obvious sexual and reproductive differences, such as the fact that it’s men who get prostate cancer and women who develop endometriosis. But there are a multitude of other, less apparent gender differences between the bodies of women and men that scientists are increasingly aware of, and which are enormously significant when it comes to their diagnosis and treatment.
For instance, studies regularly show that women’s symptoms — for example, when experiencing a heart attack — may be quite different from those of men, and that ignorance of such differences has resulted in poor treatment.
This leaves millions of men and women in peril of receiving treatments inappropriate for their sex — treatments that are ineffective, inappropriate and even potentially lethal.
While both sexes are affected, a particular concern for women’s health is the fact that most diseases and medications have been — and still are — researched and tested predominantly on men and male animals. This is because men are much more convenient research subjects: they do not have periods or get pregnant, which can complicate the results of drug trials.
But drawing diagnostic conclusions about one sex based on clinical experiments on the other is like designing evening gowns for women using a mannequin of an average male body.
meanwhile, for a select few ‘female’ diseases, such as osteoporosis and male breast cancer, men often receive inappropriate treatments because medics use data from trials on women in order to make deductions about men.
many of the reasons why modern men and women’s physiology are so different comes down to human evolution. As hunters and warriors, men developed a higher tolerance to pain than women. The biological basis for this higher pain tolerance among men is the male hormone testosterone. Yet this ‘powerful’ hormone also lowers men’s immune defences and makes them more prone to death and injury through recklessness.
The task of raising children, meanwhile, was historically delegated to women. The close physical contact necessitated by this role placed women at greater risk of contracting infectious diseases from their children. As a form of protection, they developed more robust immune systems.
Yet this is a mixed blessing. Women are also more susceptible to crippling auto-immune diseases such as rheumatoid arthritis, in which the immune system goes rogue and attacks the body it’s meant to protect.
For the sake of men and women across the world, it’s time to bring medicine into the 21st century and to employ our new understanding of gender and sex differences to create an era of gender-specific testing and treatment.
Here are some of the ways gender differences can affect diagnosis and treatment...
WOMEN’S DIGESTION MOVES MORE SLOWLY
Women’s digestive systems move more slowly than men’s — it takes twice as long for food to pass through their small intestine.
Their gallbladders also contract more slowly, and bile (which helps break down food) passes more slowly and its composition is different from the bile of men.
All this puts women at greater risk of gallstones, which are four times more prevalent in women.
The slower speed of digestion is linked to the female hormone oestrogen, among other things.
During pregnancy, when oestrogen levels rise, the speed decreases, helping to explain why gallstones are more common at this time. After the menopause, when oestrogen drops, food passes more quickly.
And because their bodies are much slower than men’s at emptying out their stomachs, women are also more prone to the effects of alcohol; the drink stays there for longer.
Furthermore, the make-up of their digestive juices is different.
In men the enzyme responsible for breaking down alcohol is five times more concentrated than in women. As a result, the female digestive system breaks down alcohol less efficiently. Thus, women become inebriated more quickly than men from the same amount.
According to research published in 2014 in the Journal of Women’s Health, mortality due to heavy consumption of alcohol is significantly higher among women.
The fact that their digestive systems are slower may also possibly explain why the most commonly used diagnostic screening tool for bowel (colon) cancer appears to be less sensitive in women. Faecal occult blood testing looks for subtle traces of red blood cells in the stools.
Because the contents of the colon move more slowly in women than in men, any small amounts of blood that would be indicative of disease in the colon, including cancer, also remain longer in the large intestine before being expelled.
The longer the blood remains in the digestive system, the more time the red blood cells have to become degraded, and are, therefore, liable not to be detected by the standard test.
This may lead to a delay in diagnosis, which is worrying as the time period between spotting the disease and treatment is crucial for success.
OUR HEARTS REALLY ARE DIFFERENT
IT Is a common belief that heart disease predominantly affects men. But this holds true only until the fifth decade of life when women reach menopause and they no longer have the protection provided by female hormones such as oestrogen.
There are a number of significant ways that heart disease in men and women differs, not least how their arteries are affected.
Among men, atherosclerosis — where the arteries become narrower and stiffen — is characterised by fatty sediments at different points on the inner wall of the blood vessels.
medical images typically reveal a blood vessel with a normal opening along its length, but with various degrees of narrowing or blockage at one or more sites.
By contrast, in a considerable number of women with heart disease the wall of the blood vessel is thickened along its entire length. In men, heart attacks are usually due to a tear in the fatty sediments; in women, it’s more common to see a crumbling of the sediments. The tearing effect in men is referred to as ‘explosion’, while the crumbling process in women is known as ‘erosion’.
These processes may happen anywhere in the body’s arteries, from where particles of clots can then be carried to major organs such as the heart, causing heart attacks, or the brain, causing strokes.
In women, erosion of the fatty sediments more frequently leads to the formation of smaller particles that pose a risk to the small blood vessels, including in the brain.
This is perhaps why strokes are more common among women, while heart attacks are more common among men.
THE GREAT HEART ATTACK DIVIDE
THe textbooks usually describe heart attacks as a man with sudden left-sided chest pain that radiates to his left arm.
But among 20 per cent of women, symptoms may instead develop slowly over hours or days, involving shortness of breath and pain radiating to the back of the neck or jaw (this may reflect the different effects of an ‘explosion’ versus ‘erosion’).
A woman having a heart attack, but without its classic symptoms, will go to A&e much later than a man will. The chances that she will be sent home without being diagnosed are two to four times higher than those of a man with chest pain.
Because immediate medical intervention is critical, a delay in diagnosis can be fatal.
When it comes to treatment itself, the gender differences are also significant.
For the women whose heart attacks are not caused by a blocked artery but clots in the very small blood vessels (around 30 per cent of cases), obviously conventional treatments — trying to open a blockage with a balloon or a stent (small tube), or open-heart surgery to bypass the blocked region — are less effective.
Another issue is that medications given to treat cardiovascular diseases may operate differently in some women compared with men.
some of these drugs are less effective, some have more side-effects and some endanger women’s lives.
For example, ACe inhibitors (that block an enzyme that narrows blood vessels) are less effective in women and cause more side-effects.
Women need new treatments, another important reason why the need for gender medicine — and studying the path of coronary heart disease among female patients — is so urgent.
CHILDBIRTH IS A RISK, TOO
THe main risk factors for heart disease vary. For men, it’s smoking, while in women they include high blood pressure and diabetes.
Certain diseases during pregnancy, such as gestational hypertension (high blood pressure) and gestational diabetes, are also risk factors.
In fact, childbirth remains a significant but inadequately understood risk for heart problems. A series of
studies found the future rate of cardiovascular illness among 5,000 women with gestational diabetes was almost three times greater than among those with uncomplicated pregnancies.
The researchers, writing in the American Journal of Obstetrics & Gynecology in 2013, also reported that women who gave birth prematurely had a 50 per cent higher risk of later developing cardiovascular disease.
Gestational hypertension also raises the risk of this disease. Therefore, it’s hard to understand why an in-depth obstetric case history is still not part of cardiologists’ guidelines in diagnosing and treating heart disease in women.
WHEN MEN GET A WOMAN’S DISEASE
SO fAr we’ve focused on the idea that research on diseases and medications has primarily been carried out on men to women’s disadvantage, yet there are a number of areas where the opposite is the case. One in two women is likely to develop the bone-thinning disease osteoporosis during her lifetime.
This is also the fate of one in five men, yet most people are unaware that men can suffer from it.
And even though it is more prevalent among women, illness and mortality from hip fractures caused by osteoporosis is more frequent among men.
This could be because men are less likely to be diagnosed or referred for treatment, suggests a 2012 review in the journal Annals of Oncology. The prevalence of osteoporosis among men is 12 per cent and in women it is 29 per cent. However, the real difference may be smaller, with relatively more men actually suffering from osteoporosis.
Doctors measure for osteoporosis by comparing the bone density of patients of either sex (aged 50 or over) with the average bone density of a twentysomething woman. The thinner the patient’s bone by comparison, the more osteoporosis is likely to be diagnosed and treated.
However, men start off in their 20s with much denser hip bones than young women. So the doctors’ benchmark is wrong for older men: the danger sign of their bonethinning is far more likely to go unnoticed — as an older man’s thinning hip bone may resemble the healthy hip density of a young woman.
Moreover, men are more likely to grow ill or die from fractures.
A Canadian study of around 4,000 hip fracture patients, reported in the Journal of Bone & Mineral research in 2005, found that the death rate among the women was around 5 per cent, while among the men it was 10 per cent.
BEST PAIN RELIEF FOR YOUR SEX
TESTOSTERONE endows men with a higher tolerance of pain. However, their levels gradually drop after they reach their 30s — and so does their tolerance to pain.
Older men do not simply complain more about pain than younger men — they’re actually more sensitive to it than they were when they were young.
Women, meanwhile are more sensitive than men to pain from heat. In 2013, brain scan experiments indicated that women, more than men, interpret heat