HRT: Estrogen

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Health Care 101 Women's Health
Paula A. Johnson, MD, MPH Executive Director,
Connors Center for Womens Health and Gender
Biology Chief, Division of Womens Health Brigham
and Womens Hospital
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Womens Health What is it?

• Health issues specific to women
• Health problems more common among women
• Health problems experienced differently by women
• Different social contexts of women

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Womens Health Facts

• Leading causes of death among U.S. women
• Heart disease
• Lung cancer
• Breast cancer
• Chronic Conditions among U.S. women
• High blood pressure (25)
• Arthritis (22)
• Osteoporosis (20)
• Diabetes (6)
• Source Making the Grade on Womens Health,
  National Women s Law Center, 2001

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Health Issues Specific to Women

• Diseases of the reproductive tract
  (endometriosis, fibroids)
• Pregnancy (health prior to pregnancy, prenatal
  care, labor and delivery, postpartum)
• Female-specific cancers (breast, cervical,
  uterine)
• Sexual health (family planning, protection
  against sexually transmitted diseases, abortion)
• Menopause (hormone replacement therapy)

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Health Issues Specific to Women-Examples

• Health of women prior to pregnancy
• Tomorrows older women
• Vulnerable population who can fall through the
  cracks given focus on pregnancy and children
• No clear measures
• Disparities in low birth weight is indicator of
  disparities in health prior to becoming pregnant

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Health Issues Specific to Women-Examples

• Breast Cancer
• Leading cause of death for American women ages 34
  to 54 second leading cause of cancer death for
  all American women
• Massachusetts is among the top 3 states for the
  highest incidence of breast cancer, and the top
  10 states for the highest mortality (American
  Cancer Society)
• Mammography remains the standard for routine
  screening and early diagnosis (significant
  progress in MA)
• New technologies for diagnosis and treatment are
  emerging

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Source NCHS public use data file. Rates are
age-adjusted to the 2000 US standard million
population by 5-year age groups. Regression lines
are calculated using the Joinpoint Regression
Program.
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Health Issues Specific to Women-Examples

• Breast Cancer -- Issues
• Potential relationship between environment and
  increased incidence
• MassHealth Breast and Cervical Treatment Program
  expected to be implemented in 1/04
• Crisis in mammography
• long waiting times
• relatively low reimbursement
• litigation directed at radiologists
• difficulty in recruitment of breast imaging
  faculty to academic medical centers

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Health Problems More Common Among Women Than Men

• Autoimmune diseases (multiple sclerosis, lupus,
  fibromyalgia, etc.)
• Arthritis
• Osteoporosis
• Urinary incontinence
• Depression
• Alzheimers disease
• Domestic violence

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Health Problems More Common Among Women Than Men-
Examples

• Autoimmune Diseases/Lupus
• Immune system attacks healthy cells in the body
  can effect the joints, skin, kidneys, brain,
  heart, lungs and blood
• 9 out of 10 people who have lupus are women
• Lupus is 3 times more common in black women than
  in white women
• Afflicts almost 2 million Americans death rates
  are on the rise
• Onset usually occurs between the ages of 15 and
  40 a leading cause of kidney disease, stroke
  and premature cardiovascular disease in women of
  childbearing age

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Health Problems More Common Among Women Than Men-
Examples

• Autoimmune Diseases/Lupus -- Issues
• Biologic basis of disease and female/racial
  predominance not understood-- may involve the
  action of estrogens on immune system
• Possible link between environmental toxins and
  increased incidence of disease
• Early diagnosis is critical and often not
  achieved

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Health Problems More Common Among Women Than Men-
Examples

• Depression
• Women experience depression at about twice the
  rate of men
• Most frequently occurs in women aged 25 to 44
• Suspected contributing factors in women include
• biological differences (reproductive, hormonal,
  genetic)
• psychosocial factors (stress from work/family
  responsibilities and societal roles/expectations
  increased rates of poverty and sexual abuse
  chronic illness)
• Women attempt suicide twice as often as men men
  are more likely than women to die by suicide

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Health Problems More Common Among Women Than Men-
Examples

• Depression (continued)
• Equal rates of depression pre-adolescence, but
  precipitous increase in depression in girls ages
  11-13 with girls twice as likely to experience a
  major depressive episode by age 15
• Research shows a strong relationship between
  eating disorders (anorexia and bulimia nervosa)
  and depression in women (90-95 of cases of
  anorexia occur in young females)
• Second leading cause for hospitalization of
  younger women in 2000

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Health Problems More Common Among Women Than Men-
Examples

• Depression -- Issues
• Depression in women is misdiagnosed approximately
  30 to 50 of the time.
• Less than 50 of women who experience clinical
  depression will ever seek care.
• Link between depression and other illnesses
  (heart disease, obesity) and economic well-being

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Health Problems More Common Among Women Than Men-
Examples

• Domestic Violence
• One out of twenty women aged 18-59 report
  experiencing physical violence, fear, or control
  by an intimate partner in the past year
• One in five female high school students report
  being physically or sexually abused by a dating
  partner, potentially leading to health risk
  behaviors (substance abuse, eating disorders,
  risky sexual behavior, suicide)
• 37 of all women who sought emergency room
  treatment for violence-related injuries were
  injured by a current or former spouse, boyfriend,
  or girlfriend
• Each year, medical expenses from domestic
  violence total at least 3 to 5 billion

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Health Problems Experienced Differently by Women

• Heart disease
• Lung cancer
• Diabetes

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Health Problems Experienced Differently by Women
- Examples

• Heart Disease
• Heart disease is the leading killer of women in
  the U.S.
• Women have their first heart attack on average 10
  years later than men, but are more likely to die
  from their first one
• Women experience different symptoms than men
• Some risk factors have different prevalence and
  different impact in women, for example-- diabetes
  and obesity
• Women tend to be underdiagnosed and undertreated
  (both medications and procedures)
• Underlying physiology is probably different in
  women

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Ratio of IHD Mortality for Blacks vs. Whites,
United States 1996
Ratio of Death Rates for Blacks Whites
Age (yrs)
National Center for Health Statistics Vital
Statistics of the United States, 1996.
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Health Problems Experienced Differently by Women
- Examples

• Heart Disease -- Issues
• Origins of sex-based differences
• Earlier identification and treatment of risk
  factors-- especially those that impact women
  (diabetes, obesity)
• Improve awareness among women who are still not
  aware of their risk
• Ensure ability of those with few resources to
  adopt healthy eating behaviors
• Develop strategies directed towards women for
  rehabilitation and make rehabilitation more
  available to women

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Health Problems Experienced Differently by Women
- Examples

• Lung Cancer
• Second leading cause of death of women in the
  U.S.
• Leading cause of death from cancer in women
• Women smokers may be more susceptible to lung
  cancer than male smokers
• Type of lung cancer differs
• adenocarcinoma more common in women and
  nonsmokers
• more women nonsmokers have lung cancer then men
• differences not explained by smoking patterns

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Health Problems Experienced Differently by Women
- Examples

• Lung Cancer (continued)
• Increased risk of smoking-related deaths and
  smoking-related morbidities (heart attack,
  stroke, hip fractures, and decreased fertility)
• High risk populations with gender-specific
  increase in lung cancer
• long-term or heavy smokers
• poverty and Medicaid recipients
• late menopause or estrogen replacement in smokers
  
• breast cancer survivors

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Lung Cancer Death Rates per 100,000 women,
1930-1990
From   Baldini Chest, Volume 112(4) Supplement
4.October 1997.229S-234S
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Health Problems Experienced Differently by Women
- Examples

• Lung Cancer -- Issues
• Origins of sex-based differences
• Improve awareness of risk among women and health
  care providers
• Maintenance of smoke free environments
• Gender-specific strategies in smoking cessation
• Improved coverage of smoking cessation (programs
  and pharmaceuticals)

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Health Problems Experienced Differently by Women
- Examples

• Diabetes
• Half of people with diabetes are women (8.1
  million) prevalence is 2-4 times higher among
  black, Hispanic, American Indian and Asian
  Pacific Islander women than white women
• From 1990 to 1998, diabetes rates increased 70
  among women ages 30-39
• For those with diabetes
• risk of heart disease is greater for women than
  men
• women have lower survival rates and poorer
  quality of life following a heart attack than men
• women are at greater risk of blindness than men

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Health Problems Experienced Differently by Women
- Examples

• Diabetes (continued)
• Pregnant women with diabetes are at greater risk
  for complications such as preeclampsia, Cesarian
  section, and infections
• Children exposed to diabetes in-utero have a
  greater likelihood of becoming obese during
  childhood and adolescence and of developing Type
  2 diabetes

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Health Problems Experienced Differently by Women
- Examples

• Diabetes -- Issues
• Promote early diagnosis and reward improved
  control of diabetes
• Improve education that diabetes is to a large
  part preventable
• Enhance prevention, especially in the young
• Improved physical education programs in schools
• Healthy eating in schools and at home
• Target those at risk

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Why do these differences exist?

• Incomplete understanding of how biologic
  differences between women and men relate to
  disease and health
• Lack of women participating in clinical trials
  and analysis of health studies by gender
• Potential provider and healthcare system biases
  (i.e. lower provider referrals for women to
  services compared with than men and programs that
  do not address womens needs)

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Why do these differences exist?

• Lack of integrated and comprehensive models of
  care for women
• Disparities in access to care (more women than
  men rely on Medicaid and Medicare for their
  health coverage)
• Societal factors
• Poverty, transportation, child care, stress,
  competing priorities (i.e. care-taking of
  children, parents, others)

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Why do these differences exist?

• Insufficient reimbursement funding for
  obstetrics, mammography, preventive and
  comprehensive services for women
• Financial pressures including funding and
  reimbursement may affect women disproportionately
  (decreased profitability of obstetrics for
  hospitals, mammography, etc.)

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Womens Health Report Card 2001

• Developed by the National Womens Law Center
• 33 health status indicators
• 32 policy indicators
• 4 categories addressed
• Access to health care services
• Wellness and prevention
• Diseases and causes of death
• Living in a healthy community

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Womens Health Report Card 2001

• Massachusetts ranks second best in nation
• BUT
• Overall grade was U (unsatisfactory plus)
• (Received a grade of Satisfactory on 12 of 33
  indicators)

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Womens Health in Massachusetts

• Patterns in use of preventive services and health
  practices vary by race, income, education, and
  age (BRFSS 2000-2001).

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Innovations in Womens Health

• Science
• Understanding the sex differences in the biology
  of disease
• Need to develop the cross-disciplinary structures
  to make advances in science
• Role of environment in potentiating disease in
  women
• Role of stress in mental and physical health

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Innovations in Womens Health

• Technology
• Video-assisted surgery through small incisions
  (thoracics and cardiac)
• Radiology -- MRI assisted surgery for breast
  cancer
• Focused ultrasound to treat uterine fibroids as
  alternative to hysterectomy
• Testing to improve risk stratification-- Ca125,
  hs-CRP

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Innovations in Womens Health

• Delivery of Care
• Provide comprehensive, integrated care for women
• Provide care that reflects the specific needs of
  women across the lifespan
• Ensure care is accessible and reflects the
  cultural needs of the patient
• Address the care of women more proactively, with
  a focus on prevention
• Measure outcomes for women

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Innovations in Womens Health

• Policy/Advocacy
• Health and economic policy will be critical to
  continued innovation
• Increasing awareness and support of issues
  affecting the health of women
• Focusing on comprehensive care for women at all
  stages of life
• Create synergy between womens health and
  addressing health disparities

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What else needs to be done?

• Increase the number of women participating in
  health related research
• Increase funding for womens health research and
  reward interdisciplinary research
• Create policy that enhances comprehensive care of
  women of all ages
• Promote adequate reimbursement for obstetric,
  mammography and preventive services
• Evaluate provider practices and understanding of
  critical womens health issues
• Reduce disparities in access to care and outcomes

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Contact Information

• Paula A. Johnson, MD, MPH
• Executive Director, Connors Center for Womens
  Health and Gender Biology
• Chief, Division of Womens Health
• Brigham and Womens Hospital
• 75 Francis Street, Boston, MA 02115
• Phone [phone]
• Rachel A. Wilson, MPH
• Director of Womens Health Policy and Advocacy
• Phone [phone] Email rwilson1_at_partners.or
  g