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- Cardiac and stroke diagnosis and treatment in women
- Prescription and dosing of pharmaceuticals;
- Subjective evaluation of women’s symptoms;
- Pain and pain management;
- Hormones and female biochemistry (including prescribed hormones);
- How economic status, race, and gender identity are additional critical factors.
AS AN UNDERGRADUATE in the University of New Hampshire’s premed program, I took only one elective that wasn’t directly related to my major (or, at least, I thought at the time that it wasn’t related). That course was women’s studies. I loved circling up with other women to talk about the history of women in society and the gender-related issues we faced both individually and collectively. It was illuminating and truly inspiring. When the class ended, and our spirited discussions were replaced in my schedule by yet another biology lab, I felt like a bit of the spark had gone out of my collegiate life.
I didn’t know it at the time, but that course—and the questions about sex, gender, and the female experience it sparked in me—would have a profound influence on the trajectory of my career.
When I finished medical school at the Boston University School of Medicine, I applied for a residency at Brown University in my hometown of Providence, Rhode Island. When my residency ended, I wanted to stay on and work there. Because Brown is an academic institution, I needed to choose a research focus in order to apply for a long-term position. When I sat down and thought about it, the only path I wanted to take was one that would improve the lives and health of women. I wanted to know about women’s bodies and how those bodies affected (and were affected by) modern medicine—in particular, emergency medicine.
At the time, sex and gender research didn’t even exist. My choice to pursue a specialty in women’s health felt like a nod to my feminist beliefs and personal philosophy, a way to keep feeding my passion for women’s issues.
I had no idea just how deep an ocean I was diving into or how many challenges I would face in bringing women’s unique health concerns into the medical mainstream.
When I mentioned to my advisors that I’d like to explore fields related to women’s health, the immediate reaction was, “Oh. You want to do OB/GYN.”
“No,” I’d reply. “I want to study women’s health holistically. As in, the overall health of women.”
No one seemed to know what I meant. That was my first clue about what was really happening in our medical establishment.
As I discovered, and as I’ll share in this book, there is far more to “women’s health” than pelvic exams and mammography. Women are different from men in every way, from their DNA on up. The medical practice of differentiating women from men according to their reproductive organs alone is both reductionist and, as it turns out, hugely problematic—but the male-centric model of medicine is so pervasive in our healthcare systems, procedures, and philosophy that many don’t even realize it exists. Most people simply assume that women’s differences are already being taken into account—yet nothing could be further from the truth.
My research on and passion for this issue has placed me at the forefront of a medical revolution. As a researcher, educator, speaker, and physician, I—and my colleagues in this cutting-edge field—are tasked with integrating emerging information about women’s health into the mainstream medical culture. We are advocates for women and their unique bodies in a system that has largely ignored them, marginalized them, and minimized them. We are women (and a few good men) taking a stand for women in a way that has never been done before.
Awareness Is the First Step to Change
As a nationally recognized expert on sex and gender medicine, I have made researching and bringing awareness to health disparities between men and women across all areas of medicine my life’s work. In addition to my “day job” seeing patients in the emergency department of an urban trauma center—and dealing with everything from colds to car accidents, headaches to heart attacks, and broken bones to overdoses—I wear a few other hats: I’m the division director for the first program in sex and gender emergency medicine at the Alpert Medical School of Brown University and a cofounder of the Sex and Gender Women’s Health Collaborative. I am also a sought-after visiting professor and Grand Rounds speaker at medical institutions across the country, and I’m a keynote speaker for community advocacy groups, including the Laura Bush Institute for Women’s Health, the Barbra Streisand Women’s Heart Center, the National Aeronautics and Space Administration, the Society for Women’s Health Research, the Organization for the Study of Sex Differences, and the Office of Women in Medicine and Science at Brown University, among others. I’ve written or cowritten over seventy peer-reviewed publications in scientific journals on the topic of sex and gender, and I’m the lead editor for the medical textbook Sex and Gender in Acute Care Medicine.
While much of my work is accomplished within the medical community itself—through educating medical students and professionals, advocating for changes in research guidelines and pharmaceutical prescribing standards, and conducting research on sex and gender issues—changing the system from within is only half the battle. The other half is educating the women whose lives and health are being impacted by that system every single day. My TEDx talk, “Why Medicine Often Has Dangerous Side Effects for Women,” was intended to open the eyes of women around the world to the issues discussed in this book.
Every time I talk about sex and gender issues in medicine, I hear stories from women about how the system has ignored, minimized, or outright failed them. This failure of care may not be intentional on the part of women’s doctors and providers—but neither is it acceptable.
How to Use This Book
While this book contains facts and observations that you may find revelatory or even shocking, my intention is for it to serve as far more than an exposé.
Ultimately, information is more useful when it’s actionable. It’s not enough for us to merely observe the scope of the problems women face in our modern medical system or even to voice our feelings of anger and betrayal at what we see; we need to always be asking, “What can we do about this?”
This book is intended to be both informative and prescriptive. By the time you turn the last page, I hope that you will understand not only how male-centric medicine affects women in both broad and specific terms but also exactly what steps you, personally, can take right now to begin to reduce your personal risk factors and make grassroots changes in your local medical community.
In Part I of this book, we will look at the broad picture of male-centric medicine: how it came to be, how it works in practice, and how its lack of recognition of women’s physiological differences is jeopardizing the health of women across America and the world.
In Part II, we will look at specific disease patterns and areas of health that impact millions of women across the country—including heart attacks, strokes, pain disorders, pain management, and pharmaceuticals. We’ll also look at the role of women’s hormones and biochemistry in various areas of health, as well as at how issues and biases related to gender, race, ethnicity, and religion affect medical treatment and outcomes both subtly and explicitly.
In Part III, I’ll write you a prescription for action! We will look at how the landscape of medicine is changing for the better and how you can tap into existing resources to take a more active role in your own health care. In Chapter 10, I’ll share specific questions you can ask your providers to help you get the answers you need, as well as resources to assist you in your own research.
By picking up this book, you have become part of a movement for change. You have chosen to educate yourself about the realities of how modern medicine treats women and their bodies. Throughout this book, I will give you tools to translate your new awareness into advocacy—for yourself and for other women like you.
As a patient and as a woman, you have a voice—and your voice matters. This book will equip you to use your voice effectively in a medical setting. You’ll learn what questions to ask, what pitfalls to look out for, what tests to request or avoid, and what resources to employ so that you can receive the quality of care you need and deserve. Effectively, you will become a more equal partner in your own health care.
ON THE NEXT PAGE, you will begin your journey into the discovery of women’s health as it stands in our current medical system. You will learn things that will surprise you and many that may distress you. But in the end, I hope that you will find in these pages a feeling of empowerment and the knowledge you need to become a voice for your own health and the health of women everywhere.
Are you ready to get started?
MODERN MEDICINE IS MALE-CENTRIC MEDICINE
I’LL NEVER FORGET THE DAY that a thirty-two-year-old woman almost walked out of my emergency department while having a heart attack.
In emergency medicine, there are many algorithms by which we evaluate risk factors and stratify incoming patients. Not everyone who walks through the doors of the emergency department is on death’s door, so we treat the most urgent cases first. For example, someone who’s asphyxiating or suffering from a stab wound will be regarded as a higher priority than someone suffering from nonspecific pain or who “just doesn’t feel quite right.”
This risk assessment makes sense theoretically and works fairly well in practice too. But once the obvious cases have been dealt with, we’re navigating a large gray area. Unfortunately, the subtle (and often subjective) strata by which we prioritize patients who don’t appear to be at immediate risk are far from perfect—particularly when those patients are women.
Women are different from men in more ways than merely the obvious—and nowhere is this more apparent than in the halls of the hospital where I work and teach every day.
For example, the research upon which our stratification procedures are based cites things like the “estrogen-protective effect” (meaning, the way in which blood estrogen levels appear to reduce or modify traditional risk factors like oxidative stress, arrhythmia, and fibrosis in premenopausal women) and the supposedly low statistical likelihood of premenopausal women presenting with acute heart conditions. In other words, even if a young woman were to come into the ED and say, “I think I’m having a heart attack,” unless she displayed blatant and very specific symptoms, most doctors would immediately look for another explanation.
Julie, the young woman I met that day, had visited her primary care doctor several times prior to coming to the emergency department and had also seen at least two other physicians in the previous forty-eight hours. She was experiencing discomfort in the region of her chest and shortness of breath that worsened markedly the more agitated she became.
I was working in the critical care area when she came in. Immediately, I thought to myself, This woman doesn’t look good. I had a gut feeling that something was really wrong.
Her other doctors had attributed Julie’s symptoms to a combination of anxiety and stress to her heart due to her obesity. The vagueness of her descriptions when she talked about her symptoms, combined with her age and the fact that she had been clinically diagnosed with anxiety several years before, made her current discomfort seem like a no-brainer for her doctors. She was having panic attacks, and her weight was compounding the issue. End of story.
However, as a specialist in sex and gender medicine, I knew that during myocardial infarction (MI)—aka, a heart attack—and other cardiovascular events, women often present much differently than men. In fact, women’s cardiac symptoms are often described as “atypical” and “unusual” in medical literature. While men might experience pain radiating down the left arm, chest heaviness, or other stereotypical signs of a heart attack, women often present with only mild pain and discomfort, possibly combined with fatigue, shortness of breath, and a strong feeling that “something isn’t right.”
Julie was very pleasant, but I could tell she was scared. I calmly explained that, while her current issue might be exactly as other doctors had described, I would be more comfortable if we ordered an electrocardiogram (EKG) and blood work to make sure things looked normal.
When we got the results, I caught my breath. There was something very wrong here. This could actually be a myocardial infarction, I thought.
I immediately called our attending cardiologist. “I believe this woman is having an MI and needs to go to the cath lab,” I told him. The cath lab is the medical suite where a procedure to fix blocked arteries is performed.
“A thirty-two-year-old woman?” There was a slight pause, then a sigh. “Oh, all right. I’ll send someone down to take a look.”
Like Julie’s previous doctors, the cardiologist’s assessment was that she was displaying symptoms of anxiety. But her EKG was slightly abnormal, so he finally agreed to take her to the cath lab.
About an hour later, I got a call from the cardiologist. “Dr. McGregor,” the attending cardiologist began, sounding a bit astounded, “I wanted to let you know that your patient, Julie, had a 95-percent occlusion of her main coronary artery. We placed a stent to restore blood flow to her heart.”
An occlusion of the main coronary artery, in a man, is often called a “widow maker.” We see it all the time in men over fifty and in a number of postmenopausal women. And yet, here was sweet, thirty-two-year-old Julie presenting with a condition that was likely to kill her in weeks, if not days, if left untreated—and no one had thought to look for it because her symptoms and risk factors weren’t consistent with the classic male model of a heart attack.
Thankfully, Julie pulled through the procedure and recovered. I didn’t see her in the ED again, but her story has stayed with me. Sometimes, I wonder how many other women like her walk out the doors of other emergency departments every day without receiving the lifesaving treatment they need and deserve. Even one is too many—but I have a feeling the number is much, much higher than that.
Our Modern Medical System Is Failing Women
The human mind built the automobile. It built televisions and computers and smartphones. When these things break, we understand how to fix them; we have an inventory of all the relevant components, diagrams of all the working parts.
But we didn’t create our bodies. In some sense—whether you believe in evolution, natural selection, or intelligent design—our bodies are mystical. We are not developing them; we are merely trying to reveal how they work. And, in many ways, they are still beyond our ability to fully comprehend.
When we approach our bodies from a scientific perspective, we are therefore limited in our ability to hypothesize, study, test, and evolve our understanding. We have made massive strides in the last several decades, but in a sense, we still enter into every observation from a place of not having the full picture. We begin with a set of assumptions built on our prior research, but—as my work and that of others is beginning to prove—many of those assumptions may be erroneous.
One of the biggest and most flawed assumptions in medicine is this: if it makes sense in a male body, it must make sense in a female one.
In every aspect, our current medical model is based on, tailored to, and evaluated according to male models and standards. This is not an abstract statement or even an observation. It’s a fact. All our methods for evaluating, diagnosing, and treating disease for both men and women are based on previous research performed on male cells, male animals, and male bodies. There are reasons our system has evolved this way, many of them scientifically reasonable. However, recent research is revealing that female bodies are physiologically different from men’s on every level—from our chromosomes to our hormones to our bodily systems and structures. Therefore, the medicine that works for men doesn’t always work for, or even apply to, women.
In the ED, I am on the front lines of medicine, and this gives me a unique perspective. I see a broad view of all aspects of health care and the conditions that many women live with every day. From infections to heart conditions, sprained ankles to strokes, head trauma to back pain, I see them all at play, in real time, across thousands of patients per year. More, I see how the current male-centric model of medicine is causing women to receive potentially inappropriate, ineffective, or even substandard care, every single day.
Women in cardiac distress don’t receive the diagnostic tests they need because our protocols don’t account for the way heart disease presents in women’s bodies. Women are prescribed inappropriate doses of common medications because the initial drug trials didn’t take into account the differences in female metabolism and hormonal cycles. All these issues, and more, contribute to poorer overall outcomes and higher mortality for women of all ages and backgrounds.
TO ME, Julie’s case was significant because she actually presented with male-pattern heart disease, but in a distinctly female way. Women’s symptoms are simply different from men’s. They don’t always have the classic male symptoms and pain profiles. Their symptoms often mimic other diseases and events that are considered more “female”—such as the panic attacks cited by Julie’s previous doctors. Unfortunately, the difficulty she had in obtaining a diagnosis is all too common for women with cardiac issues, particularly younger women.
If a man comes into the ED with chest pain and shortness of breath, there’s no question that he may be having an MI. If a woman comes in with the same issue, and she has a history of anxiety listed in her chart, the consensus will likely be that she’s just suffering muscular and respiratory spasm related to anxiety. If her EKG comes back normal or close to normal, she’ll be sent home. Although the symptoms she’s exhibiting are strong potential indicators of female cardiac distress, our tests and protocols simply aren’t designed to diagnose female patterns of disease, which tend to be more diffuse and uncharacterized than their male counterparts.
Discrepancies like these are what led me to specialize in sex and gender medicine in the first place. As a fresh-faced attending physician with a passion for women’s issues and a strong calling to distinguish myself as a researcher in my chosen field, I found it fascinating that researchers and specialists alike acknowledged both vast and subtle differences in symptomology, disease progression, and outcomes between men and women across the spectrum of physical and mental health—and yet no one was asking why such differences were present or how they might be affecting the way women were being cared for every day in both inpatient and outpatient settings and across all specialties. Sex and gender differences in medicine weren’t even being explored beyond the traditional scope of “women’s health”—meaning, obstetrics and gynecology (OB/GYN) and breast health—let alone incorporated into the research and dialogue that ultimately shapes our medical procedures and policies in the ED and elsewhere.
Although I know that there are researchers like me working diligently to explore the difference in male and female physiology, the procedural and practical support necessary to put that knowledge into action isn’t available to most emergency physicians when they show up to work. As a system, we simply aren’t set up to give women the specialized care and treatment they need and deserve.
There are many reasons for this, which we will explore together in detail throughout this book. The core issue, however, is that, despite decades of research and accumulated information, we are only just beginning to understand the scope of the differences between men and women and how those differences might impact everything from how drugs are prescribed, to how routine tests are performed, to how pain is assessed and treated, to how systemic disease is diagnosed.
In other words, we need to reinvent modern medicine from the ground up to include the half of the human population it has, until now, marginalized and left behind.
The New Women’s Health Revolution?
We are in the midst of a second women’s revolution.
The first was the movement that gained women the right to operate in the world alongside men as legally equal human beings. We claimed the right to own and govern our bodies, our minds, and our property. We demanded the opportunity to pursue our educations, our passions, and our dreams. My mother’s generation tore down the walls that, a mere fifty years ago, would have made my career in medicine and medical leadership challenging, if not impossible, to pursue.
The first revolution in women’s health began in the 1970s with the publication of the groundbreaking book Our Bodies, Ourselves. This was the first time women were invited to understand themselves as biologically different from men. Women demanded access to things like birth control and pain relief. They realized that their bodies were not somehow flawed or “less than” simply because they were female. They demanded autonomy, and when the establishment resisted, they claimed it anyway.
Now, though, we need to call in another wave of change—a change based on the irrefutable facts available to us around women’s health and women’s bodies in all areas, not just in sexual and reproductive health.
Although we women have spent the last several decades fighting for equality, we are also becoming aware, sometimes painfully, that there are significant differences between men and women—differences for which our egalitarian vision did not account. These differences are at the heart of this new women’s revolution, which is now coming to prominence.
Physiologically, neurologically, cognitively, socially, and experientially, women are unique. Every system in our bodies operates according to a biological imperative fine-tuned to our womanhood and the daily functions that womanhood necessitates. We are not simply men with breasts and ovaries—or, conversely, men who lack penises and testicles. We are not a genetic offshoot of men, as literal interpretations of scripture might imply. We are unique in every single cell of our bodies.
WHEN I FIRST STARTED my research on sex and gender differences in emergency medicine, I classified my work as “women’s health.” That made perfect sense to me, since I was literally researching the ways in which women’s bodies operate and how their unique physiology influences diagnosis, disease progression, morbidity, pharmacological response, and other factors in health care. However, the outdated thinking around women’s bodies is unbelievably pervasive; I wasn’t prepared for how often others in my field would miscategorize and even misrepresent my work.
For most people—including the majority of medical professionals—“women’s health” is synonymous with “reproductive health.” OB/GYN and breast health immediately come to mind as areas of medical practice directly related to the health of women. (In fact, I spent much of my residency being called all over the ED to perform pelvic exams—not because no other doctor in the ED could do them, but because everyone thought that, as a women’s health specialist, that would be my first priority. It still makes me laugh when I think about it!)
The truth is, women’s health deals with exactly what the words, removed from their vernacular context, imply: the overall health and well-being of women. It is not simply about female reproductive organs, or pregnancy, or breast health, although those are all vital components. When I talk about women’s health, I’m referring to the health of the whole woman, body and mind, with all the complexities inherent to a physiologically female body.
Every cell in a human body contains sex chromosomes. These chromosomes in turn influence every biological, chemical, sensory, and psychological function performed by that body. Most cells both produce and respond to sex hormones such as estrogen, progestins, testosterone, and androgens, and the functionality of each cell is affected in both subtle and overt ways by its relationship to these hormones.
Although these genomic differences have not been widely researched in all organs and systems, in areas where they have been studied, the implications are clear: women’s bodies deal with everything from internal communication (neurotransmission) to external influences such as pharmaceuticals according to a different set of genetic and hormonal criteria. This means that what is considered medically “normal” for men may not be normal for—or even applicable to—women.
Here are a few common examples of how male-centric medicine impacts women’s health every day:
• Coronary artery disease is the leading cause of death in both men and women, but women have statistically poorer outcomes and higher mortality in otherwise equivalent situations. A 2010 study found that “the under-recognition of heart disease and differences in clinical presentation in women lead to less aggressive treatment strategies and a lower representation of women in clinical trials.”1
• Women are more likely to receive a psychiatric diagnosis for a multitude of conditions—including stroke, cardiac events, irritable bowel syndrome, autoimmune disorders, and various neurological disorders—while men are more likely to be referred for tests.
• Men and women have markedly different responses and reactions to pain. Women have both a lower threshold for pain and a lower pain tolerance—meaning, they are more likely to perceive and report a lower level of discomfort as “pain” than men despite an equal degree of stimulation—however, the more vocal women become about their pain, the more likely their providers are to “tune them out” and prescribe either inadequate or inappropriate pain relief medication.
- "Enraging and clearly written, this book is a must-read for all women, who have to deal with our biased medical system. A call to arms for those who always suspected that women's pain and symptoms were dismissed and minimized, it also provides practical suggestions for getting better care."—Maia Szalavitz, New York Times bestselling author of Unbroken Brain
- "Well-researched, riveting, and insightful, Sex Matters is a triumph for women's health. Dr. McGregor exposes the gender, racial, and economic biases in medicine and puts the spotlight back where it belongs--on the needs of individual patients."—Wendy S. Klein, MD, MACP, Medical Director, Health Brigade and co-founder, VCU Institute for Women's Health
- "Artfully relayed through storytelling, Dr. McGregor brings several familiar stories from the emergency department to your living room, showcasing the many ways men and women are different and why each requires tailored medical care. Her personal experiences of a tortuous path of advocacy are the foundation of action steps to help readers to take charge of their own health and change the future of medicine."—Basmah Safdar, MD, FACEP, Associate Professor, Yale University, Sex and Gender Medicine Expert
- "From the frontlines of the medical establishment, McGregor offers a bold indictment of a status quo that's failing women. Ultimately hopeful, Sex Matters combines actionable advice for individual patients navigating a health care system built for men with an urgent call for revolutionary collective change."—Maya Dusenbery, author of Doing Harm: The Truth About How Bad Medicine and Lazy Science Leave Women Dismissed, Misdiagnosed, and Sick
- "I learned so much from this new book. I am grateful to Dr. McGregor for her insight and wisdom. We need to spread the word: sex differences are about much more than ovaries and testicles!"—Leonard Sax, MD, PhD, New York Times bestselling author of Why Gender Matters: What Parents and Teachers Need to Know About the Emerging Science of Sex Differences
- "Sex Matters is highly learned, readable, and inspiring. A call to action--we learn exactly how women are understudied and misdiagnosed. We must all insist that medical schools and funding agencies do better. We must all support research in sex and gender medicine so that ultimately your doctor can do right by you!"—Londa Schiebinger, PhD, professor, Stanford University, and Director of Gendered Innovations
- "McGregor is to be commended for showing how medicine has long skewed male and harmed women. Especially spot-in are the chapters on implicit bias, treatment of women of color, and issues affecting trans individuals. The author concludes with to-do lists, questions women can ask their providers, and suggestions for advocacy roles to raise awareness of the issues. Good ammunition for mandating sex- and gender-based differences in health professional education, research, and practice."—Kirkus Reviews
- "This book is addictive! You will not be able to put it down until you have read it from cover to cover and then want start all over again. The sheer wealth of information is an eye opener for the intelligent lay person and a great source of up to date information for health care workers."—Marek Glezerman, MD, Immediate Past -President, International Society for Gender Medicine
- "Alyson McGregor is a persuasive and intelligent advocate for the unique health care needs of women. The two sexes are significantly different in all the tissues of the body--even to the way the same genes are expressed. An expert in emergency medical care, her deep and informed knowledge of the way disease presents itself in women ensures their prompt and accurate diagnosis and treatment. She is a powerful force in gender-specific health care."—Marianne J. Legato, MD, PhD (hon. c.), FACP, Emerita Professor of Clinical Medicine, Columbia University
- "Dr. Alyson McGregor sounds the alarm for the state of women's health in this country. Her excellent, evidence-based book reveals that women's health is still in its infancy and needs significant research to ensure that women are receiving the best possible medical care. The fact that most drugs that were approved in this country did not even have enough women included in the studies that got them approved to know if the effects in women were the same as in men is just one of many concerning findings. Her book shows that there is much work to do in this area (much more even more than we thought) and that we can count on this call to action to spur us onward! This book will be appreciated by medical and lay people alike given its excellent readability. I am thrilled that this book is out there to provide benchmarks and goals so that we can ultimately transform women's health."—Judy Regensteiner, MD, Director of the Center for Women's Health Research at the University of Colorado
- "Dr. McGregor makes a clear and compelling case that women, particularly women of color, in the United States time after time receive inadequate or even harmful medical care. Dr. McGregor also explains how cultural stereotypes about women are frequently used by physicians to justify a dismissive approach to women's symptoms even when these symptoms herald conditions with potentially dire outcomes. Taking it one step further, Dr. McGregor provides the reader with suggestions on how to cut through a physician's ability to dismiss her symptoms, encouraging her to find another provider if necessary."—Molly Carnes, MD, MS, Virginia Valian Professor, Departments of Medicine, Psychiatry, and Industrial & Systems Engineering, Director, Center for Women's Health Research, Co-director, Women in Science and Engineering Leadership Institute (WISELI), University of Wisconsin-Madison
- "I have worked with Dr. Alyson McGregor as a national leader in the area of sex and gender in medicine and healthcare--I commend her on this book."—C. Noel Bairey Merz, MD, Director, Barbara Streisand Women's Heart Center, Cedars-Sinai
- On Sale
- May 19, 2020
- Page Count
- 272 pages
- Hachette Go