Gender Medicine is a young science and a cross-cutting subject.
Gender differences in the diagnosis and therapy of coronary heart diseases and heart attack were, in addition to drug testing also for women, the first topics investigated in Women’s Health and Gender Medicine research. Since the 1990s countless scientific articles have been written on this topic. After all, heart death is the main cause of death in women and men worldwide. One of the most important publications from the early days of Gender Medicine research is the editorial “The Yentl Syndrome” by Bernadine Healy. It was published in the New England Journal of Medicine in 1991, the then and still now highest-ranking medical journal. “Women must first prove that they have the same heart disease as men in order to receive the same treatment”: women have a smaller chance of receiving top-class medicine, such as a cardiac catheter, intensive care unit, bypass operation, valve operation, heart transplant. Women also need longer to access these diagnostics and therapy. The trend of these findings was confirmed in all studies. The question raised was what are the reasons for this situation. The reasons are certainly multifactorial, with the main reason undoubtedly being that coronary heart disease, heart attacks are presumed to be a male medical problem and thus the diagnostics and therapy were focused on men.
For us, the question is naturally: Yentl Syndrome – 25 Years Later, whereby a lot has happened in 25 years. Not only were countless scientific studies conducted on this subject, but there were also awareness campaigns such as “Go Red” and many similar ones, as well as a lot of information and support provided by the media. In addition, there were naturally also attempts to explain the situation away, for example women have “atypical heart symptoms” or are older or have more comorbidities. To sum it all up, right down to today the scientific studies continue to show a gender difference in accessing heart diagnostics and therapy to the disadvantage of women, albeit only slightly.
In addition to these gender differences in cardiology, that are largely problems women experience in accessing medical care, in the meantime the main question raised is: are there gender differences in coronary heart disease, in heart attacks between women and men and what do we really know about these differences? And: do we put this knowledge to use in diagnostics and therapy? The prime question here is: is this disease the same in women and in men? Differences have been proven here in several respects. For example, the classical picture of coronary heart disease, i.e. calcification of the large coronary arteries, considerably more often affects men that women. In women, it is the microvessels that are more often involved. Moreover, spasms of the coronary vessels are more often seen. This fact alone, namely that women and men have different calcification patterns of the coronary vessels, leads to big gender differences in diagnosis for women and men. For decades an ergometric exam was performed as the best screening method for suspected coronary heart disease, and if there were clearly defined ECG changes a cardiac catheter exam was recommended. This was and still is the method of choice for men, but not for women. Countless false-positive ergometry results lead to a recommendation for a cardiac catheter exam, which often does not show the expected serious degree of calcification of the large coronary vessels. The subsequent problem is that clearly fewer ergometries were and still are performed in women and, despite this, numerous cardiac catheter investigations turn out to be unremarkable. Nevertheless, such findings do not protect women from a heart attack, nor do the false-negative findings. In this case there are indeed separate screening methods for women and men, namely the SPECT methods or stress echocardiography for women. Also relatively popular meanwhile is the coronary CT angiogram, which, however, should be avoided in young women because of the high radiation exposure.
These gender differences for coronary heart diseases and heart attacks should be anchored in the guidelines. Separate guidelines for diagnosis and therapy of heart diseases in women and men are indispensable, and there is still a lot of catching up to be done here. There are only very few gender-specific guidelines, such as from the American Heart Association (AHA) on the topic of prevention of coronary heart disease for women and the guidelines for pregnant women put out by the European Society of Cardiology (ESC). I feel it is essential that all the guidelines for heart disease emphasize the gender differences between women and men and address these with focused recommendations.
Heart death is the main cause of death for women and men. As a general rule women are easier to motivate for preventive medicine than are men. For coronary heart disease and heart attack prevention this is not so clear-cut, because heart attacks and heart death are still considered to be a male thing. There is still very much awareness work to be done to make sure that women know they have a heart risk.
The main risk factors for heart attack and coronary heart disease are the same for women and men, namely high blood pressure, diabetes, dyslipidemia, smoking, stress, abdominal fat, lack of exercise and alcoholism. Science has shown that each of these points involves gender differences, such as the fact that diabetes considerably increases the heart risk for women more than for men, that smoking is a greater risk at least for young women and that it is harder for women to quit smoking, and many other differences. Emotional stress as a recognized risk factor is certainly also associated with the fact that depression is twice as common in women as in men and that women more often have multiple stress factors, such as family, raising children, caring for older family members and job. However, these differences have no influence on the preventive medicine recommendations, so that no major gender differences have to be made here.
Gender Differences in Coronary Heart Disease, Heart Attack
The fact that hormones play a role is known from numerous scientific publications. For example, it is known that cardiomyopathy can occur during pregnancy, and it has been seen that the estrogens can have a beneficial effect on coronary heart diseases. The estrogens are certainly one of the main reasons for the occurrence of coronary heart disease and heart attacks in the later years of a woman’s life. Many studies also show that fluctuations, changes in the sex hormone status increase the heart risk. This is true of pregnancy, menopause, hormone treatments.
Medication plays a major role in the prevention and also the diagnosis and especially the therapy of coronary heart diseases and heart attack. In addition to heart disease, the untested gender differences in the effects and side-effects of medication were a leading topic in the early days of Gender Medicine research. Here, too, a discussion surrounded heart medication, namely with the Physicians’ Study on Aspirin. This was a study that excluded women from participating as a matter of principle. Aspirin was tested in men and found to have an advantageous effect. It was sold to women without being tested in them. The result was a long discussion that ended by not recommending aspirin as preventive medication for women younger than 65. Such a clear-cut recommendation does not exist for most of the other medications prescribed in cardiology. Consequently, medication intolerance and side-effects demotivate women to such an extent that they do not take their prescribed medication.
The recall campaigns undertaken by the US Food and Drug Authority, that are usually due to complications recognized too late in women, show that things could be better. An additional point is that separate testing and test evaluation for women and men is the rule for clinical tests, but not for basic research, where medication development begins. This is obviously the next step to be taken, namely drug development should look at gender differences right from the beginning in basic research, i.e. with female and male mice.
In conclusion, the decades of Gender Medicine research in the field of coronary heart disease and heart attack have revealed many gender differences. In the beginning the studies focused on differences in obtaining access to diagnostics and therapy, with the same possibilities being demanded for women and men alike. In the meantime, research has been focusing on the differences in coronary heart disease between women and men and the findings have shown that women and men should not have the same diagnostic and therapy possibilities, but they should each have the best possibilities for their gender. Guidelines are needed here. A first step is the Fact Sheet from the GENCAD Project that was commissioned by the EU and that is expected to be published this autumn. It will present scientific, evidence-based findings to show the special needs of women in preventive medicine, diagnostics, therapy and rehabilitation of coronary heart diseases and heart attack. This will be one more step in the direction of custom-tailored medical offerings for women and men, thus personalized medicine.
Research Fields, Research Possibilities
Women’s Health/Men’s Health
Discrimination and Power Constructions
Diploma Thesis and Dissertation Topics
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