Chapter 205: Women’s Health

The most common causes of death in both men and women are heart disease and cancer, with lung cancer the top cause of cancer death, despite common misperceptions that breast cancer is the most common cause of death in women. These misconceptions perpetuate inadequate attention to modifiable risk factors in women, such as dyslipidemia, hypertension, and cigarette smoking. Furthermore, since women in the Unites States live on average 5.1 years longer than men, the majority of the disease burden for many age-related disorders (e.g., hypertension, Alzheimer’s disease) rests in women.

ALZHEIMER’S DISEASE

Alzheimer’s disease (AD) affects approximately twice as many women as men, due to larger numbers of women surviving to older ages and to sex differences in brain size, structure, and functional organization (See also Chap. 182). The impact of postmenopausal hormone therapy on cognitive function and the development of AD is inconclusive, though some studies suggest increased risk.

CORONARY HEART DISEASE

Coronary heart disease (CHD) presents differently in women, who are usually 10–15 years older than men with CHD and are more likely to have comorbidities, such as hypertension, congestive heart failure, and diabetes (See also Chaps. 119, 120 and 121). Women more often have atypical symptoms, such as nausea, vomiting, indigestion, and upper back pain, and are less likely to recognize these and call 9-1-1. Physicians are less likely to suspect heart disease in women with chest pain and are less likely to perform diagnostic and therapeutic cardiac procedures in women. The conventional risk factors for CHD are the same in both men and women, though women receive fewer interventions for modifiable risk factors than do men. The prevalence of CHD is increasing in middle-aged women, at a time when the prevalence in men is unchanged or declining. The marked increase in CHD occurring after menopause or oophorectomy suggests that endogenous estrogens are cardioprotective. However, hormone replacement therapy in postmenopausal women was not shown to be cardioprotective in controlled trials such as the Women’s Health Initiative and other randomized trials. Therapy with estrogen plus progestin therapy was associated with increased cardiovascular events. The discrepancy between endogenous and exogenous estrogen effects is poorly understood but may be related to deleterious effects of late re-exposure to estrogen after a period of estrogen deficiency.

DIABETES MELLITUS

The prevalence of type 2 diabetes mellitus (DM) is similar between men and women (See also Chap. 173). Polycystic ovary syndrome and gestational diabetes mellitus are both common conditions in premenopausal women that carry an increased risk for type 2 DM. Premenopausal women with DM have identical rates of CHD to those of males.

HYPERTENSION

Hypertension, as an age-related disorder, is more common in women than in men after age 60 (See also Chap. 117). Antihypertensive drugs appear to be equally effective in women and men; however, women may experience more side effects.

AUTOIMMUNE DISORDERS

Most autoimmune disorders occur more commonly in women than in men; these include autoimmune thyroid and liver diseases, lupus, rheumatoid arthritis, scleroderma, multiple sclerosis, and idiopathic thrombocytopenic purpura (See also Chap. 158). The mechanism for these sex differences remains obscure.

HIV INFECTION

Heterosexual contact with an at-risk partner is the fastest-growing transmission category of HIV, and women are more susceptible to HIV infection than men (See also Chap. 105). Women account for about 50% of the 34 million persons infected with HIV-1 worldwide. Women with HIV have more rapid decreases in their CD4 cell counts than men do. Other sexually transmitted diseases, such as chlamydial infection and gonorrhea, are important causes of infertility in women, and papilloma virus infection predisposes to cervical cancer.

OBESITY

The prevalence of obesity is higher in women than in men, in part due to the unique risk factors of pregnancy and menopause (See also Chap. 172). More than 80% of patients who undergo bariatric surgery are women. The distribution of body fat differs by sex, with a gluteal and femoral (gynoid) pattern in women and a central and upper body (android) pattern in men. The android distribution of fat carries a higher risk for metabolic syndrome, diabetes mellitus, and cardiovascular disease. Obesity increases a woman’s risk for postmenopausal breast and endometrial cancer, in part because of adipose tissue aromatization of androgens to estrone.

OSTEOPOROSIS

Osteoporosis is much more prevalent in postmenopausal women than in age-matched men, since men accumulate more bone mass in their youth and lose bone more slowly than do women, in particular after age 50, when accelerated postmenopausal bone loss occurs in women (See also Chap. 177). In addition, differences in calcium intake, vitamin D, and estrogen levels contribute to sex differences in bone formation and bone loss. Vitamin D insufficiency is present in a large proportion of elderly women living in Northern latitudes. Osteoporotic hip fracture is a major cause of morbidity and an important cause of mortality in elderly women.

PHARMACOLOGY

On average, women have lower body weights, smaller organs, higher percent body fat, and lower total-body water than men do. Gonadal steroids, menstrual cycle phase, and pregnancy can all affect drug metabolism and action. Women also take more medications than men do, including over-the-counter formulations and supplements. The greater use of medications, combined with biologic differences, may account for the reported higher frequency of adverse drug reactions in women.

PSYCHOLOGICAL DISORDERS

Depression, anxiety, and eating disorders (bulimia and anorexia nervosa) are more common in women than in men (See also Chaps. 196 and 198). Depression occurs in 10% of women during pregnancy and 10–15% of women during the postpartum period.

SLEEP DISORDERS

During sleep, women have an increased amount of slow-wave activity, differences in timing of delta activity, and an increase in the number of sleep spindles (See also Chap. 56). They have a decreased prevalence of sleep apnea compared to men, a feature that may be related to lower androgen levels.

SUBSTANCE ABUSE AND TOBACCO

Substance abuse is more common in men than women (See also Chaps. 199 and 204). However, women alcoholics are less likely to be diagnosed than men and are less likely to seek help. When they do seek help, it is more likely to be from a physician than from a treatment facility. Alcoholic women drink less than alcoholic men but exhibit the same degree of impairment. Alcohol abuse poses special risks to a woman, adversely affecting fertility and the health of the baby (fetal alcohol syndrome). Even moderate alcohol use increases the risk of breast cancer, hypertension, and stroke in women. More men than women smoke tobacco, but the prevalence of smoking is declining faster in men than women. The effects of smoking on pulmonary disease (COPD and cancer) and osteoporosis are more pronounced in women than in men.

VIOLENCE AGAINST WOMEN

Domestic violence is the most common cause of physical injury in women. More than one in three women in the United States have experienced rape, physical violence, and/or stalking by an intimate partner. Women may present with symptoms of chronic abdominal pain, headaches, substance abuse, and eating disorders, in addition to obvious manifestations such as trauma. Sexual assault is one of the most common crimes against women (reported by one in five women in the United States) and is more likely committed by a spouse, ex-spouse, or acquaintance than by a stranger.