The Promise of Gender-Specific Care
Dr. Paula Johnson is a women's health specialist and a pioneer in the treatment and prevention of cardiovascular disease. She conceived of and developed one of the first facilities in the country to focus on heart disease in women. At Boston's Brigham and Women's Hospital (BWH), Dr. Johnson was made chief medical resident in 1990--the first woman to hold that position in the history of the hospital. Dr. Johnson is serves as head of the Mary Horrigan Connors Center for Women's Health and Gender Biology and is chief of the Division of Women's Health at Brigham and Women's Hospital in Boston. She also directs the Center for Cardiovascular Disease in Women.
Question: Why is gender specific care important?
Paula Johnson: Gender-specific care is very important because if we reflect on where we are today scientifically—it’s the era of the potential of the genome, it’s the era of “the emergence of personalized medicine”—and if we think about sex-specific or gender-specific care (and I just want to be clear, sex is who we are genetically women have two X chromosomes. Men have an X and a Y. And gender is how we are responded to in society because of our sex). If we think about this era of the potential of science, and we think about the fact that men and women are different biologically—you know every cell has a sex, and that’s the phrase that the institute of medicine coined. The potential for the development of science, as we think about sex differences is just enormous.
What it means when we think about sex differences in health and diseases [is] that men and women differ in every aspect of health and disease. The potential for discovery here is tremendous. Today we only are at the very early stages of understanding what some of differences are, from a clinical standpoint, and we really have a long way to go before we fully understand the scientific basis for some of those differences.
Just to give you an example, if you look at a woman who has heart disease, where there are symptoms that make one think that she might blockages in her arteries, we know that those symptoms differ between men and women. Now that’s a clinical observation, what we don’t know is why we see those differences and symptoms. Then, if you do testing in a man or a woman, the qualities of the test, the sensitivity and the specificity the characteristic of the test differ, between man and women—certain tests are better in women that they are in men. And then, very interestingly when you actually look at the type of disease women have, so their arteries actually look like, the arteries can look different, and what we begin to understand is that some of the standard tests that we’ve been using for many years, that are based on the typical disease that man have, may not function as well in women.
We’ve had many years of women undergoing this test and being told that they are actually fine. So today we are on a different place, we understand that there are some of these differences, some of that knowledge is not as generalized as widely understood as we need it. What we don’t understand is, biologically, why we do we see those differences? So, as you can see, there is this cycle between clinical observation, science getting the word out, translations of that science to clinical care, and observation, once again feeding more science
Question: Are there health issues specific to women?
Paula Johnson: I wouldn’t say that there are specific issues that are unique to women, what I would say that there are issues that are either more prevalent in women: those need to be focused on. And [there are] some risks that impact women differently. So for example, if you look at diabetes—for reasons that we don’t fully understand, the impact of diabetes on women’s heart health seems to be more profound than it is in men. And so diabetes will wipe away some of the early protection woman have against heart disease. But women will be more likely to die of cardiovascular disease. And then, when you layer over that some differences in, for example, cross-racial ethnic groups, you’ll see some very stark differences, for example in African-American women, compared with white women—with African-American women having much higher rates of diabetes, and also having much higher rates at the very early age of cardiovascular disease. Another major health problem is depression: depression is more common in women, and also [it] seems as though depression may be more linked in to development of further events, further coronary events, when women already have heart disease. So once again—differences on the prevalence of disease, and then differences, potentially, in the impact on outcomes in women.
Question: Are there medical technologies being developed specifically for women?
Paula Johnson: There are some newer technologies in the area of cardiology that I think are very exciting for women. So for example if we look at the fact that women are more likely to lay down plaque in their arteries in a way that is diffusely laid down, as opposed to there being a very discreet blockage in the artery that can be opened up, for example, with a stent. If women will have that more diffused disease more frequently, then it’s hard to see with our traditional test which is the cardiac catheterization.
Newer innovations with things like intro-vascular ultrasound, which allow us to put a tiny ultrasound probe into the artery and look at the artery almost from the inside out—that is a very important development for women in particular. Not that every women should have it, but for certain women for example, who might have [a] positive stress test—they get in the catheterization lab, the traditional test is done and there is no answer—this might be the appropriate next step.
Another exciting advancement is the use of small wires that measure flow throughout the artery if women are more likely to have what we call a micro vascular disease, disease in the tiny arteries. The small arteries are coming off the big one, once again that you can’t see with our goal standard tests. Then, once again, for certain women for whom the answer is not totally clear with the traditional test, this [is] maybe an option, and this is very important because it allows us to make a diagnosis in an important subpopulation of women.
By thinking about women in how they differ, it will help us look at all patients differently. And it’s always my belief that by looking at women, I’m looking at science and translating that science into clinical care. We actually improved the health of everybody, because we begin really thinking about what each and every individual needs appropriate to the evidence.
Recorded on: June 6, 2009
Connors Center for Women's Health Executive Director Paula Johnson defends the importance of healthcare designed for women and describes the latest advances in the field.
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