Legend has it that God, after creating the heavens and the earth, formed Adam out of dust from the earth and placed him in the Garden of Eden. Subsequently, He removed one of Adam’s ribs and created Eve from the bone.
Adam and Eve [and their progeny] are made from different kinds of matter. Every cell in our bodies has a sex – XX or XY, which means men and women are different at a cellular level. There are important physiological, hormonal, metabolic, genetic and behavioural differences between the two. Women are smaller in stature and have a different ratio of body fat to lean mass compared to man. Their hormones fluctuate on account of periods.
However, modern health care assumes that men and women are alike in every way, apart from their reproductive organs and sex hormones. Despite the wealth of data on differences, medical practice does not sufficiently take gender into account in diagnosis, treatment or disease management. Most of the medical research is done with the assumption that men and women are biologically the same. When doctors are looking for symptoms that are observed in male patients – but not necessarily in female ones – that may mean a poor diagnosis and wrong treatment. This kind of misdiagnosis is not rare. Thus women’s symptoms get overlooked, dismissed as anxiety or not acknowledged as problem in the first place, because diseases manifest differently in women than they do in men; and doctors do not discern these differences. For example, women with myocardial infarction and heart failure receive less guideline-based diagnosis and less-invasive treatment than men because there is tendency among doctors to think of cardiovascular disease as a problem that is particular to men. Women describe their symptoms in a way different from men.
Exclusion of women from research
Women are frequently excluded from drug trials as their hormone levels fluctuate throughout menstrual cycle and this can impact the research. Not only that, some women take birth control pills, which can also affect hormone regulation. Then, as they age, women go through menopause, which once again dramatically changes hormone production. Widespread concerns for pregnant women and women who might become pregnant result in women being left out of studies. In only one third of cardiovascular clinical trials subjects are female and only 31 per cent of cardiovascular clinical trials that include women report results by sex.
Women metabolize drugs differently
Women metabolize drugs differently than men; other parameters such as drug absorption, drug distribution, and excretion are also affected. However, gender-specific dosing recommendations are absent for most drugs. The United States Food and Drug Administration has suggested that women experience more adverse events than men, and those adverse events are more serious in women. A recent Government Accountability study revealed that 80 per cent of drugs withdrawn from the market are due to side effects on women only after a drug has been released to the market. These differences between genders can be critical in response to drug treatment. It is therefore essential to understand those differences to design safe and effective treatments.
Women’s symptoms get overlooked, dismissed as anxiety or not acknowledged as a problem in the first place, because diseases manifest differently in women than they do in men; and doctors do not discern these differences
McGregor pointed out an account of zolpidem, a drug used to treat insomnia, released on the market over 20 years ago. Last year the Food and Drug Administration recommended the dose in half for women only, because they just realised that women metabolise the drug at a slower rate than men, causing them to wake in the morning with more of the active drug in their system. They are less alert for activities like driving. So they become vulnerable to motor vehicle accidents. Similarly, doses of aspirin, opioids, and antibiotics need to be reduced when prescribing for women. In order to prevent strokes, women are advised to take 81 mg of aspirin; the recommended dose for men is 325 mg.
Gender differences in manifestation of diseases
Women over 50 years of age have a four times higher rate of osteoporosis and a two times higher rate of loss of bone. They tend to have fractures 5-10 years earlier compared with men. Bone loss is due to the direct skeletal consequences of estrogen (a female hormone) deficiency. Women start out with thinner, smaller bones and less bone tissue than men. Men usually have fractures of stronger bones, especially at the lumbar spine, and they tend to have a higher mortality risk after the hip fracture.
Lower incidence of stroke is observed in younger women. However, after menopause, they suffer more stroke events than men, coincident with lower levels of estrogen. The two sexes show differences in manifestation of the disease. While women suffering a stroke reveal loss of consciousness, fainting, general weakness, shortness of breath, disorientation, sudden behaviour changes, agitation, hallucination, nausea, pain, seizures, hiccup and fever, men suffer loss of senses, loss of control of body movements, double vision, and repetitive uncontrolled eye movements. Both sexes show face drooping, arm weakness, speech difficulty, sudden confusion, sudden trouble seeing, sudden dizziness, and sudden severe headache. Aspirin lowers the risk of stroke but not of myocardial infarction or cardiovascular death in females whereas in men aspirin reduced the risk of myocardial infarction but not the risk of stroke.
Cardiovascular disease is the number one killer of women, and it affects men and women differently at every level, including symptoms, risk factors and outcomes. During a heart attack, only about one in eight women report chest pain – a classical symptom; they describe it as pressure, aching, or tightness rather than pain. Some feel extremely tired or short of breath. Other atypical symptoms include nausea and abdominal, neck, and shoulder pain, nausea or vomiting and dizziness. Women’s symptoms may occur more often when women are resting, or even when they’re asleep. Mental stress also may trigger heart attack symptoms in women.
Although only 8 per cent of the population develops autoimmune diseases, 78 per cent are women. In autoimmune diseases such as rheumatoid arthritis and systemic lupus erythematosus, immune system is directed against one’s own body. Rheumatoid arthritis is an inflammatory arthritis associated with a variety of other manifestations. Women tend to develop RA at a younger age than men, with symptoms typically appearing between the ages of 30-50. It is three times more common in women than men. Dry eye syndrome is the most common ophthalmic manifestation; women are 9 times more commonly affected than men.
In case of SLE, gender plays a key role with women being nine times more commonly affected than men. It most commonly affects Asians and African women in their reproductive years. Significant hormonal alterations such as pregnancy and postpartum can cause worsening of disease activity because of increase in the levels of female hormones. Skin and joints manifestations seem to be more frequent in women whereas serious damage to kidneys and nervous system occurs in men.
Depression is more common in women than men. One in four women will require treatment for depression at some time, compared to one in 10 men. The reasons for this are unclear, but are thought to be due to both social and biological factors. Moreover, there are many significant differences in how the two sexes experience the disease. Women experience depression at a younger age and experience it more severely than men. It has also been suggested that depression in men may have been under diagnosed because they present to their general practitioner with different symptoms, for example a range of physical, stress related symptoms. Women are twice as likely to experience anxiety as men. Of people with phobias or obsessive-compulsive disorder, about 60 per cent are female.
While men and women have similar prevalence of schizophrenia, onset studies demonstrate that female onset is typically 3-5 years later than males. There are also sex differences in symptoms of schizophrenia. For example, men appear to have more negative symptoms and more severe clinical features than females, particularly in social withdrawal and substance abuse. Women with schizophrenia often present mood disturbance and depressive symptoms. Female patients show better treatment response than men and approximately 50 per cent less hospitalisations. On the other hand, men with psychosis often require higher doses of anti-psychotic drugs.
Women are also more at risk for migraine, urinary tract infections and multiple sclerosis.
The writer is a freelancer