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Harvard Commentaries
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Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School


Medical Myths Medical Myths
 

Gender Matters in Health


October 18, 2012

By Robert H. Shmerling M.D.

Beth Israel Deaconess Medical Center


Just the other day, I saw a newspaper ad urging women to get their care at a nearby women's health clinic.

That got me wondering about the growing field of gender-based medical care.

Perhaps you've seen similar ads or doctors touting their expertise in "men's issues." Health care professionals in these settings may have bedside manners or practice styles that appeal more to one gender than the other. For example, a female physician may be able to sympathize with a patient's menopausal symptoms if she, the doctor, has gone through menopause herself, while a male physician does not have that experience to draw on.

But how does the actual medical care provided in gender-based practices differ from that provided by "regular" doctors?

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The Obvious Differences

You won't get an argument from me about the profound differences between men and women. The obvious anatomic differences translate into different health needs.

    • Women can get uterine and cervical cancer and may develop pregnancy-related problems (such as pre-eclampsia) while men cannot.
    • Menstrual symptoms and menopause have no obvious analogy among men — although some people believe there is a male menopause. (But that's a topic for another time).
    • Men can get prostate cancer, a disease with no direct counterpart in women.

 

    • Anemia due to iron deficiency is much more common among women, due to menstrual blood loss.

But for the parts of the body that men and women share, how are health issues different?

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The Not-So-Obvious Differences

Heart and blood vessel disease is probably the best example of an important medical condition where gender matters, despite similar anatomy.

Angina, for example, is a serious condition that occurs when too little blood flows to the heart through arteries. The classic symptom is chest pain or pressure when you exert yourself that travels to the left arm, jaw or neck, and stops when you rest. You may also have nausea or severe sweating.

Studies show that men are much more likely than women to have these typical symptoms. Women, meanwhile, tend to have the classic chest pain less often than men. They are more likely to have shortness of breath, abdominal pain and fatigue. Doctors may not consider that these less typical symptoms are due to a heart problem.

In addition, confusing or misleading test results for heart disease are more common for women.

    • Stress tests results are more likely to be uncertain among women than men.
    • Coronary angiograms, the "gold standard" for checking for blockages in the coronary arteries, may miss important narrowings in women, according to a 2006 study. Women are more likely than men to have a smooth narrowing of small arteries. These narrowings could cause angina or cause a heart attack, but might not stand out on the angiogram.

Here are other examples of how men and women respond differently to a disease or its treatment.

  • Recovery from stroke – Studies suggest that women tend to recover better from strokes than men. This may be because men and women use their brains in different ways while healthy. A 1995 study found that when men and women sound out words, women use both sides of the brain while men tend to use a small area on only one side. It's possible that this difference makes women better able to compensate for lost brain tissue after a stroke.
  • Pain treatment – Women tend to wake up from anesthesia sooner than men. And when doses are adjusted for weight, women tend to have less pain relief from morphine. A 2008 study in mice may have found the reason for this: Female mice have fewer "mu-opioid" receptors in key areas of the brain involved in pain signaling. These receptors bind morphine, which tells the brain to stop sending pain signals. Fewer receptors may mean less benefit from morphine treatment. It's possible these findings also apply to humans.
  • Medication side effects – Due to body size and hormones, the same dose of a medication may cause more or different side effects in women than men. This effect is usually small. One example of this is the HIV medication, ritonavir (Norvir). Compared with men, women taking this medicine tend to have more nausea and vomiting, and less diarrhea. The reason for these differences isn't clear, but they don't seem to affect how well the medication works.
  • Alcohol tolerance – Women tend to have higher blood alcohol levels than men when they drink the same amount of alcohol. Most of the differences relate to body composition and size. Men tend to be larger and have higher total body water content. So, alcohol is "diluted" more in men than women. This leads to lower blood-alcohol levels in men. In addition, women have less of the enzyme (called alcohol dehydrogenase) that helps break down alcohol in the body. As a result, they tend to have a higher blood-alcohol level than men even if they drink the same amount.

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Consider the Source

It's important to mention that differences in how men and women respond to illness or medications could be greater than we think. That's because, until recently, large research studies tended to include more men than women. That's changing, but it's important to consider the research sources of any knowledge about health and disease. Given gender-based differences mentioned above, a study of medications for angina or a study assessing pain could reach different conclusions if it includes only men or only women.

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Some Differences Are Due to Behavior

Some of the differences in health between the genders are not related so much to differences in the ways diseases affect them, but rather from differences in how men and women behave.

For example, men tend to smoke and drink more than women, so health problems related to these habits are often more common in men. And it's well-documented that men tend to ignore symptoms and delay getting medical care.

One 2006 study makes this point dramatically. Researchers found that men who became sick or got hurt while watching a major sporting event, such as the Super Bowl, tended to wait to get medical attention. The effect was so pronounced that 30% fewer men came to emergency rooms during major televised sporting events and 40% more came in for medical care soon after the game ended.

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A Matter of Frequency

There are many conditions that are more common in one gender than the other. Often, we don't know why. For example:

    • Depression and certain autoimmune diseases, such as lupus and rheumatoid arthritis, are more common among women.

    • Sleep apnea is more common among men.

 

    • Heart attacks may be more common among men because more men have risk factors like smoking.

Urinary tract infections (UTIs), on the other hand, are much more common in women because of anatomy. Compared to men, bacteria have a much easier time reaching the bladder and causing an infection. When men have a UTI, it's usually due to some other problem such as an enlarged prostate (which blocks urine flow) or recent urinary surgery.

Whether we know the reason for these differences or not, people and their doctors may dismiss the possibility of a disease when it occurs in the gender that gets it less often.

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The Bottom Line

Despite the differences, it seems to me that the health needs of men and women are much more alike than different. In my view, the notions that a woman can only get good care by seeing a specialist in women's health and that a man should only see a doctor who limits his practice to male patients are often more about marketing than improving health.

In fact, differences in the practice styles of individual male and female doctors are probably more important to health outcomes and patient satisfaction than differences in the medical needs of their male and female patients.

Rather than focusing on different health needs among men and women, I think it's more important to find a responsive doctor you trust and you can talk to easily. That's the challenge for each person, regardless of their gender or their doctor's.

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Robert H. Shmerling, M.D. is associate physician at Beth Israel Deaconess Medical Center and associate professor at Harvard Medical School. He has been a practicing rheumatologist for over 20 years at Beth Israel Deaconess Medical Center. He is an active teacher in the Internal Medicine Residency Program, serving as the Robinson Firm Chief. He is also a teacher in the Rheumatology Fellowship Program.

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