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Medical research has always been done with men as the default, and the ‘one-size-fits-all’ approach does not work well in diagnosis and treatment of illness in women.
Jayanti is a 56 year old house-wife, who was suffering from a burning sensation in her chest. After trying some home-remedies, she approached her family physician. Knowing that she was stressed due to some family problems, initially she was dismissed as attention-seeking and treated her for ‘acidity’. However, when her “heart-burn” persisted, a complete check-up was ordered (more as a tongue-in-cheek indulgence than any belief in her symptoms). The changes in her ECG alarmed the physician and prompted an immediate angiography, where it was determined that she had had a heart attack and needed a bypass surgery at the earliest.
The American Heart Association estimates that women more often ignore symptoms and postpone seeking treatment. They also have symptoms that are different from the typical and are consequently more likely to be dismissed as non-cardiac complaints. In percentage terms, this kind of illness in women received less of guideline-directed medical therapy or aggressive, invasive treatments.
Renuka works in a bar and is the sole bread-earner of her family. She had cough and shortness of breath for a few weeks. A physician treated her for ‘cough-and-cold’, and later for ‘lung infection’. When persistent symptoms led to further tests being done, she was found to have lung cancer. Second-hand smoke can be a reason for lung-cancer in young women and many treating doctors simply fail to consider this.
In the US of A, annually over 11 million prescriptions are given for the drug Zolpidem (Ambien) which is a sleep medication. The prescribed adult dose was 10mg (and has been the same for nearly 20 years). However, in 2011, a study found that women had a higher level of the drug in their blood stream the next day (eight hours later) as compared to men. This was a great risk as it results in impaired decision making, slower response time thereby affecting skills such as driving, etc. As a result of this research, the FDA cut down the dosage of the drug to HALF (5 mg.) for women. It was also recommended that prescribing doctors take into account the individual needs of patients rather than prescribe the same dose for all patients.
The incident involving Zolpidem (Ambien) overdosage in women created a storm of public interest. It exposed a little researched and hitherto neglected area of medical science – that of sex/gender differences in disease and the way illness in women might not be handled right. If a sleep medication, widely used and over a long period of time could behave so differently in women and escape detection, the mind boggles at the scope of the problem.
Medical science broadly categorises patients into adult and paediatric. Even among adults, pregnant women are recognised as a different category (physiologically, biochemically, etc.) for treatment and clinical trials.
Thus adults, pregnant and paediatric were the three broad categories of patients for treating physicians.
Non-pregnant adult female and adult males are, however, lumped together.
Interestingly, if we exclude sex-specific diseases like prostate enlargement or uterine fibroids, etc., statistics show that many other conditions occur more often in one sex or the other.
Autoimmune diseases (such as Lupus) are commoner in women as is clinical depression. Thyroid diseases and anti-thyroid antibodies are more common in women, whilst male sex is a risk factor for thyroid cancer. Women are more likely to develop Alzheimer’s and COPD. Alcohol enters the blood stream more rapidly in women and they are affected by it faster. Women are more susceptible to the effects of alcohol induced liver disease as well and secondhand smoke. Post menopause, women are more likely to have ischemic heart disease. And so forth.
Not only are the numbers distributed unequally, the symptoms and risk factors also frequently vary in the two sexes. In Jayanti’s case, the classic triad of symptoms – chest pain, shoulder or neck discomfort, and sweating were missing. Women often have ‘atypical’ symptoms like heartburn, fatigue, discomfort, etc. which could delay diagnosis by physicians who are used to male patients and their ‘classic’ symptoms. Younger women like Renuka are susceptible to lung cancer due to second hand smoke.
What about the drugs that are used to treat such conditions? Are they tailored, adapted, tuned for treating women differently from men? Obviously not! The Ambien case in 2011 is a striking case where women received double the required dose for YEARS.
Logic dictates that women and men ARE different. Women have different fat content, kidney blood flow, liver function, water content, surface area, hormonal levels, and so on. They differ in their physical activity, quality and quantity of food intake, stress levels, etc. Not only do women neglect their health, they often delay getting medical attention, and once it is sought, the emphasis is on ‘budgeting’ the expenditure, especially if the woman is not an earning member of the family.
Research is expected to be egalitarian, equal, logical and non-partisan in its approach to “evidence-based” results. But it is sadly not so.
In a 2014 report, researchers at the Brigham and Women’s Hospital in Boston chronicled the exclusion of women from health research and its impact on women’s health:
The science that informs medicine – including the prevention, diagnosis, and treatment of disease – routinely fails to consider the crucial impact of sex and gender. This happens in the earliest stages of research, when females are excluded from animal and human studies or the sex of the animals isn’t stated in the published results. Once clinical trials begin, researchers frequently do not enroll adequate numbers of women or, when they do, fail to analyze or report data separately by sex. This hampers our ability to identify important differences that could benefit the health of all.
Drugs that are mainly tested on male subjects are also used by female patients. Doses for men and women can differ. Side effects and complications can be more severe in females as the hormonal levels, fat content and liver and kidney functions that metabolize these drugs are different.
An analysis of hundreds of studies on common cancers published in the journal Cancer, involving millions of patients, suggests women are underrepresented in three out of every four cancer studies.
The FDA in USA has now laid down guidelines for clinical trials where adequate number of women should be represented and the response to the drugs should be recorded differently for women and men.
Illness in women in India gets the short stick every time.
Indian women neglect their own health and seek medical treatment much later than their male counterparts.
Less money is spent on the vaccination of girls than boys, as also medical treatment of women.
Treating physicians are also less aware of the difference in symptoms or risk factors that female patients are likely to have.
Women are also expected to have more ‘hysterical/psychological’ problems than men and not taken seriously.
Research into medical problems affecting women is also lacking.
This is a fundamentally flawed approach as it ignores nearly half the patient population. Often this leads to late diagnosis of the illness in women, wrong treatment or the wrong dosage of the right treatment. Ignorance of socio-economic factors leads to limited reach of the therapeutic treatment. While gender specific medicine is a twenty-first century phenomenon and is a welcome one, in India sadly, we still follow the ‘one-size-fits-all’ approach so far.
Image source: FreeStockPhotos
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I am Ujwala Shenoy Karmarkar. I love reading, meeting people, listening to music, watching plays,
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