Transcript HRT: Estrogen

Health Care 101: Women's Health
Paula A. Johnson, MD, MPH
Executive Director, Connors Center for Women’s Health and Gender Biology
Chief, Division of Women’s Health
Brigham and Women’s Hospital
Women’s Health: What is it?
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Health issues specific to women
Health problems more common among
women
Health problems experienced differently by
women
Different social contexts of women
Women’s Health Facts
Leading causes of death among U.S. women
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Heart disease
Lung cancer
Breast cancer
Chronic Conditions among U.S. women
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High blood pressure (25%)
Arthritis (22%)
Osteoporosis (20%)
Diabetes (6%)
Source: Making the Grade on Women’s Health, National Women ‘s Law Center, 2001
Health Issues Specific to Women
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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)
Health Issues Specific to Women-Examples
Health of women prior to pregnancy
 Tomorrow’s 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
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
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.
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:
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long waiting times
relatively low reimbursement
litigation directed at radiologists
difficulty in recruitment of breast imaging faculty to
academic medical centers
Health Problems More Common Among
Women Than Men
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Autoimmune diseases (multiple sclerosis, lupus,
fibromyalgia, etc.)
Arthritis
Osteoporosis
Urinary incontinence
Depression
Alzheimer’s disease
Domestic violence
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
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
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)
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Women attempt suicide twice as often as men; men are
more likely than women to die by suicide
Health Problems More Common Among
Women Than Men- Examples
Depression (continued)
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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
Health Problems More Common Among
Women Than Men- Examples
Depression -- Issues
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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
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
Health Problems Experienced Differently
by Women
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Heart disease
Lung cancer
Diabetes
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
Ratio of Death Rates for Blacks : Whites
Ratio of IHD Mortality for Blacks
vs. Whites, United States 1996
Males
Females
Boston Female 1998
4
3
2
1
0
35-44
45-54
55-64
65-74
75-84
85
Age (yrs)
National Center for Health Statistics: Vital Statistics of the United States, 1996.
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
Health Problems Experienced Differently
by Women - Examples
Lung Cancer
 Second leading cause of death of women in the U.S.
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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
Health Problems Experienced Differently
by Women - Examples
Lung Cancer (continued)
 Increased risk of smoking-related deaths and smokingrelated morbidities (heart attack, stroke, hip fractures,
and decreased fertility)
 High risk populations with gender-specific increase in
lung cancer:
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long-term or heavy smokers
poverty and Medicaid recipients
late menopause or estrogen replacement in smokers
breast cancer survivors
Lung Cancer Death Rates per 100,000 women,
1930-1990
From: Baldini: Chest, Volume 112(4) Supplement 4.October 1997.229S-234S
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)
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
Health Problems Experienced Differently
by Women - Examples
Diabetes (continued)
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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
Health Problems Experienced Differently
by Women - Examples
Diabetes -- Issues
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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
Why do these differences exist?
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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
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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 women’s needs)
Why do these differences exist?
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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)
Why do these differences exist?
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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.)
Women’s Health Report Card: 2001
Developed by the National Women’s Law Center
 33 health status indicators
 32 policy indicators
 4 categories addressed:
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Access to health care services
Wellness and prevention
Diseases and causes of death
Living in a healthy community
Women’s 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)
Women’s Health in Massachusetts
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Patterns in use of preventive services and
health practices vary by race, income,
education, and age (BRFSS 2000-2001).
Innovations in Women’s 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
Innovations in Women’s 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
Innovations in Women’s 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
Innovations in Women’s Health
Policy/Advocacy
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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 women’s health and
addressing health disparities
What else needs to be done?
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Increase the number of women participating in health
related research
Increase funding for women’s 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 women’s health issues
Reduce disparities in access to care and outcomes
Contact Information
Paula A. Johnson, MD, MPH
Executive Director, Connors Center for Women’s Health
and Gender Biology
Chief, Division of Women’s Health
Brigham and Women’s Hospital
75 Francis Street, Boston, MA 02115
Phone: (617) 732-8985
Rachel A. Wilson, MPH
Director of Women’s Health Policy and Advocacy
Phone: (617) 525-7512; Email: [email protected]