Part 3 - What is Gender Medicine? - Cardiology, body weight, cancer, depression & medications

Gender-specific approaches in medicine

Since hormones have a significant impact on disease development and progression, endocrinology is the ideal basis for all areas of gender medicine; interdisciplinary approach and integration of scientific knowledge are also employed here.

The glucose and fat metabolism as well as the energy balance differ in healthy women and men, especially as far as various disorders such as obesity and diabetes are concerned.

Women's health centers and the women's health resort la pura (www.lapura.at), which offers innovative concepts for the prevention of specific conditions in women based on the latest findings in gender medicine, in cooperation with the Medical University of Vienna, provide a model for practical implementation in women.

Cardiology

Gender medicine started out by observing heart diseases. Young women's vessels are protected by estrogen. Cardiological diseases have different developments and different symptoms: In the case of a heart attack, female patients are on average 10 years older than males. Their pain is often of non-specific, vegetative nature. Chest pain is not that sharp, therefore, heart attack is often imperceptible.

In medicine, we speak of the "Yentl Syndrome"; the name comes from the movie with the same name featuring Barbra Streisand, in which a woman disguises herself as a man in order to be able to study. Dr. Bernadine Healy, cited a phenomenon she called the "Yentl Syndrome" (also known as the "Yentl Effect") back in 1991: Women have to fake symptoms of a male heart attack in order to be treated as well as a man.

Cardiovascular diseases in women are often symptom-free and fatal:

• women are running a 50% higher risk of dying in the first year after a heart attack
• twice as high a risk of having complications after bypass surgery
• mortality increases among women under 55 (has increased in recent years)
• women seldom display chest pain
• it is often the smallest vessels that are affected

Stroke risk factors are rarely detected in women. While in men, hemiplegia is the typical symptom, women more often display dizziness, confusion and speech disorders.

Women and body weight

Weight issues are not a women's thing. They affect both sexes alike, but men usually do not perceive them that way, they do not perceive them as a problem. Women are over-represented in obesity – partly because they visit a doctor more often because of the excess weight. In general, they care more about health issues, pay more attention to healthy eating, they (currently) smoke and drink less than men. 80% of patients seeing a doctor about a figure problem, are women. The studies on the subject show similar results: 80% of those who volunteer to participate in the study, are female. Overweight, underweight and eating disorders such as bulimia, anorexia or binge eating (stuffing with lots of food without vomiting) are also big issues for women.

The statistics clearly reflect this trend:

• Many women are dissatisfied with their weight or figure.
• They already become familiar with diets in teenage years.
• Women account for 80% of all patients undergoing gastric bypass surgery.
• Women have to struggle with increasing weight, in particular, starting from menopausal transition.
• Many women use cigarettes to suppress their appetite.
• Obesity rarely occurs in women alone. They also have to struggle with hormonal imbalances and mental health conditions.Gender medicine and diabetes
• Whether or not someone is overweight depends, among other things, on their social status and educational background. It is also largely dependent on a person's occupation.

1. Estrogen:
   Biologically, men run a significantly higher risk of getting diabetes mellitus, while women are protected, among other things, by an increased release of estrogen until a hormonal change in menopausal transition.
   
   
2. Fat distribution:
   Men are usually running a higher risk because they have more belly fat and more liver fat and lower insulin sensitivity, even if they are not overweight. In contrast, it has been shown that fat on thighs, which is more common in women for genetic and estrogen-related reasons, plays a protective role. On the other hand, the abdominal circumference in women has a better predictive value for diabetes as compared with men.
   
   
3. Testosterone:
   The male sex hormone testosterone also works differently in men and women: For men, testosterone deficiency is a risk factor, while in women, higher male sex hormones are associated with a higher risk.
   
   
4. Stress:
   Psychosocial or job stress, lack of freedom of choice in case of high work pressure and lack of sleep, often accompanied by a stress-related weight gain, are more common diabetes causes in women than in men.
   
   
5. Biomarkers:
   There are gender-specific differences in biomarkers that can help detect early diabetes risks: For example, the fetuin-A protein produced by liver and copeptin (a hypothalamic prohormone) and proneurotensin (a neurotransmitter) are the promising biomarkers in women, rather than in men. Leptin, which sends chemical messages to stop eating and to start producing energy from the stores, such as fat deposits, is a strong biomarker.

Gender and cancer

The most common type of cancer is prostate cancer in men and breast cancer in women. Even though a man's breast cells and tissues can still develop cancer, male breast cancer is a very rare disease. The latter is mainly attributed to a certain "reverse Yentl syndrome" (see above): it is hardly assumed in the investigations that men can develop breast cancer, therefore, this is often overlooked or diagnosed at a very late stage.

Lung cancer rate has reduced in men, while in women, it has recorded a significant increase. The reason for this is obvious: the number of female smokers is increasing.

In colorectal cancer, studies demonstrate that the incidence is approximately the same in both sexes (slightly more common in men), but on average women tend to develop it ten years later than men. Colorectal cancer screening is generally recommended from the age of 50 years. Gender-medical proof suggests that this is too late an age for men. It would be better practice to have screening performed from the age of 45 years in men and the age of 55 years in women.

Gender and depression

Depression (a major health issue according to the WHO) is diagnosed twice as often in women. This begins in puberty (from the age of 13) and extends well into old age. Gender-specific roles, stress (partly also gender-specific), additional physical conditions and negative life experiences, are considered major risk factors.

Nonetheless: Two to three times as many men commit suicide. This suggests that there are many undiagnosed depression cases in men. (Because 30-70% of suicides occur during a depressive period.)

Male depression involves symptoms that different from those commonly associated with depression. These often include:

• increased willingness to take on risks
• bursts or fits of anger
• low level of impulse control
• low level of stress tolerance
• irritability, restlessness, dissatisfaction
• acting out of behavior

For women, depression is particularly dangerous in the context of heart disease. Said combination leads to a nearly three-fold increase in mortality risk.

Gender and medications

Women and men often take the same medications in the same dosage. What is not taken into account here are the clear differences in metabolism and in the cell and hormone structure of the two sexes. This, however, requires further research.

The fact that a man is taken as a medical prototype in trials, has the following consequences:

• Most medications withdrawn from the market pose a greater health risk for women.
• Women are underrepresented in the early stages of clinical trials.
• There is no effective control of gender-specific mechanisms in the development of medications.

The reasons for different effects of medications on men and women require further research. These involve both biological and social factors: Do physicians prescribe different medications for men and women? Are there any interactions with the diet plans? (For example: grapefruit, which is known to interact with medications, is consumed much more often by women. What about the commitment to a prescribed therapy? Are there any interactions with other medications? In particular, elderly women often take many medicines, etc.

In general, men are prescribed medications for cardiovascular diseases and diabetes more frequently, and women are prescribed much more painkillers, psychotropic drugs and sleeping pills. Side effects are much more common in women of any age group.

Classic examples of the gender-specific influence on medications:

• aspirin tends to provide better protection from heart attacks for men, and from strokes for women
• antihypertensives: work better in women, but also display more severe side effects
• QT prolonging medications: higher risk for women whose QT interval is longer in the first place; dangerous arrhythmia can develop

So far, there is a single medication for which the US Food and Drug Administration (FDA) actually prescribes different intake routines: the sleeping pills Zolpidem should be prescribed to women only in half a dose (5mg instead of the previous 10mg).

Conclusion: Gender medicine is an important step towards individualized healthcare. Both sexes benefit equally from gender-sensitive care and therapy. Gender-specific aspects must therefore be promoted in research and education, as well as translated into medical applications!

The author Prof. Dr. med. Alexandra Kautzky-Willer, Medical University of Vienna (MedUni Vienna), is the scientific director of the Institute for Gender Medicine in Gars am Kamp, a healthcare facility of VAMED in cooperation with the MedUni Vienna.

These articles might also interest you:

+ "Part 1 - What is Gender Medicine? - The Genders" - from Univ. Prof. Dr. Alexandra Kautzky-Willer
+ "Part 2 - What is Gender Medicine? - physical differences, metabolism, energy balance, sex hormones, life expactancy & Smoking" - from Univ. Prof. Dr. Alexandra Kautzky-Willer
+ "Lose weight in a healthy and sustainable way" - from Dr. univ. med. Alex Witasek