Sex Matters

CHAPTER ONE

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: