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Try out PMC Labs and tell us what you think. Learn More. The new concept of evidence-based sex and gender medicine—which includes the fundamental differences of biology and behaviour between women and men—should improve health care for both sexes. Men and women are alike in many ways.
However, there are important biological and behavioural differences between the two genders. They affect manifestation, epidemiology and pathophysiology of many widespread diseases and the approach to health care. Despite our knowledge of these crucial differences, there is little gender-specific health care; the prevention, management and therapeutic treatment of many common diseases does not reflect the most obvious and most important risk factors for the patient: sex and gender. Addressing gender in health and health care therefore requires new approaches at many levels, from training medical personal to clinical medicine, epidemiology and drug development.
To discuss and address properly the differences in health and health care between men and women, it is necessary to distinguish between sex and gender and their respective effects on health. Sex differences are based on biological factors.
These include reproductive function, concentrations of sexual hormones, the expression of genes on X and Y chromosomes and their effects and the higher percentage of body fat in women. By contrast, gender is associated with behaviour, lifestyle and life experience. It determines access to health care, use of the health care system and the behavioural attitudes of medical personnel.
Typical gender differences in health care include differences in the use of preventive measures, the prescription of drugs, health insurance reimbursement and referral for or acceptance of particular surgical therapies such as pacemaker implantation or heart transplantation. In practice, however, it is often not easy to separate the influence of sex and gender.
On the one hand, sex influences health by modifying behaviour: testosterone, for instance, causes aggressive behaviour associated with risk-seeking and neglecting personal health. On the other hand, gender-behaviour can modify biological factors and thereby health: exposure to stress, environmental toxins, poor nutrition or lifestyle choices can induce genomic and epigenetic modifications in adults, children and even the developing fetus. These modifications and their physiological effects are different in women and men, as DNA repair and epigenetic mechanisms are modified by sex hormones Fig 1.
Thus, medical hypotheses need to take into the effects of both sex and gender. Gender medicine therefore aims to include biological and socio-cultural dimensions, and their effects on women and men, to improve health and health care. As such, gender-sensitive medicine is not the same as considering the specific needs of women in health care—such as during pregnancy or during menopause—and might even be contradictory.
Gender medicine must consider the needs of both sexes. This might require giving greater attention to women where specific data on women are lacking, and greater attention to men where specific data on men are lacking. For example, more data on men are needed in regard to osteoporosis and depression, whilst more data on women are urgently needed in the cardiovascular area. Indeed, because sex and gender affect a wide range of physiological functions, they have an impact on a wide range of diseases including those of the cardiovascular, pulmonary and autoimmune systems, as well as diseases involving gastroenterology, hepatology, nephrology, endocrinology, haematology and neurology; they also influence pharmacokinetics and pharmacodynamics [ 1 ].
These differences are reflected in the scientific literature: more than 10, articles deal with sex and gender differences in clinical medicine, epidemiology, pathophysiology, clinical manifestations, outcomes and management Sidebar ATable 1. Women with myocardial infarction receive less guideline-based diagnosis and less-invasive treatment than men [ 3 ].
Women with heart failure receive fewer guideline-based diagnostic procedures and treatments, and fewer implantations and heart transplantations. Nevertheless women have a better outcome than men [ 54 ]. Women with atrial fibrillation receive less anticoagulation treatment with warfarin. Even so, they have a greater risk for stroke than men [ 51 ]. Women obtain dialysis later than men, and undergo fewer kidney transplants, both from living and deceased donors [ 5253 ]. There is a ificant delay in referral of female patients with rheumatoid arthritis to an early arthritis clinic in comparison with male patients [ 15 ].
Osteoporosis and depression are considered female diseases. Both might be under-diagnosed in men [ 16 ]. Sex is the greatest invention of all time: not only has sexual reproduction facilitated the evolution of higher life forms, it has had a profound influence on human history, culture and society. This series explores our attempts to understand the influence of sex in the natural world, and the biological, medical and cultural aspects of sexual reproduction, gender and sexual pleasure.
Sex and gender differences in cardiovascular diseases are particularly well-investigated because there is strong epidemiological evidence that men and women face different risks and have different outcomes. As such, it is useful to explore some of the differences between men and women and how they experience cardiovascular disease.
The overall incidence of myocardial infarction is in decline worldwide in all population groups except young women [ 2 ]. This group has probably not been reached by prevention programmes, and also faces increased cardiovascular risk owing to lifestyle changes—such as smoking or experiencing increasing job stress. In addition, young women have a higher rate of mortality after the first myocardial infarction and coronary bypass graft surgery than do men in the same age group.
Conversely, men in all age groups have a higher risk of ischaemic sudden death. Women and men also differ in regard to the causes of myocardial infarction: psychological factors are more important in women; heavy exercise is a more common cause in men. Social stress is another main determinant of re-infarction after a first myocardial infarction in women [ 3 ].
In terms of diagnosis and treatment, women receive less guideline-based diagnosis and less-invasive treatment for myocardial infarction than men, not as a result of evidence-based strategies, but simply owing to the habits of physicians. For coronary artery disease, the average age of female sufferers is about ten years older than that of male sufferers. Women also present more frequently with single vessel disease and disturbances of the microcirculation. Although exercise echocardiography is frequently misleading in women for reasons not fully understood, exercise echocardiography, scintigraphy or magnetic resonance imaging are generally of greater diagnostic value for women.
Women more frequently experience heart failure with normal systolic function or diastolic heart failure, whereas men present more often with heart failure with reduced ejection fraction. The main causes for these differences include calcium alling, nitric oxide synthesis and profibrotic mechanisms, which depend partly on the action of oestrogens and androgens. Survival is comparably poor for both sexes, but women have a better outcome than men [ 5 ]. Hypertension is more frequent in young men than in young women, but the incidence among women increases steeply after the menopause.
Hypertension and myocardial hypertrophy are also relatively greater risk factors for heart failure in women than in men [ 3 ]. Cardiomyopathies occur slightly more frequently in men than in women with a ratio of 1.
It is associated with psychological stress and mimics the features of acute myocardial infarction with open coronary arteries, accompanied by severe left ventricular dysfunction. Similar to heart failure, women with cardiomyopathies and systolic failure receive less-invasive treatment devices or organ transplants than men. Women have more bleeding complications when undergoing invasive therapies in the coronary arteries, receive less anticoagulation with warfarin and have a higher risk of bleeding with different forms of anticoagulant.
Women also experience more strokes than men, yet this is mostly owing to greater incidence of stroke with increasing age. In addition, an increasing of younger women are affected by stroke each year. Atrial fibrillation is a greater risk for stroke in women than in men [ 67 ].
Of course, cardiovascular diseases are by no means the only area in which men and women differ in their susceptibility to and survival of disease. Generally, women are more frequently affected by all forms of anaemia; iron deficiency is a frequent cause of anaemia among women [ 8 ].
There are also clear gender differences in regard to pulmonary diseases. There is a higher incidence of asthma among young boys, but this reverses over time such that, in young adulthood, women seem predominantly affected [ 910 ] and experience more severe symptoms.
Lung cancer and chronic obstructive pulmonary artery disease remain a serious problem for both women and men. Owing to increased smoking prevalence among women and a greater sensitivity of women to tobacco toxicity [ 11 ], their prevalence in women is rising and will soon reach the same level as in men [ 12 ]. Another clear sex difference is the fact that women have a lower of nephrons in their kidney and less capacity to concentrate urine than men. In terms of disease, more women have stage 3 chronic kidney diseases [ 13 ] and they experience more complications of kidney failure.
Conversely, lupus nephritis is more common in men and displays a more aggressive progression. Polycystic kidney disease is also more prevalent in men and has a worse outcome than in women [ 14 ]. Most autoimmune diseases are more frequent in women than in men [ 15 ]. Systemic lupus erythematosus is more frequent in women of reproductive age, as its severity is affected by serum oestrogen concentration.
Fibromyalgia, a poorly understood disease, is more frequent in women than in men, as is rheumatoid arthritis. In addition, there is a ificant diagnostic delay for rheumatic diseases in women in comparison to men. Sex and gender differences in the incidence and prevalence of diabetes mellitus are small and in part controversial [ 16 ]. However, diabetes increases the risk for coronary artery disease to a higher degree in women than in men and is associated with a greater risk of death after myocardial infarction in women.
Thyroid diseases and anti-thyroid antibodies are more common in women, whilst male sex is a risk factor for thyroid cancer. Osteoporosis is more frequent in women, but it is frequently under-diagnosed in men and is a hidden cause of hip fracture. Alzheimer disease is more frequent in women and more frequently associated with depression.
Despite the wealth of data on differences, medical practice does not sufficiently take gender into in diagnosis, treatment or disease management. In summary, there is a ificant of sex and gender differences for many common diseases and disorders that need to be considered in health care, public health strategies, regulations and training of medical personnel.
Unfortunately, they are largely neglected.
In Europe, and in particular in Germany, relatively few public health organizations or health politics promote gender-sensitive health care. This is further compounded by the fact that there are almost no systematic analyses of treatment differences between women and men, at least in German public health. Studies that have analysed the use of drugs in heart failure in Germany [ 17 ] or coronary artery disease [ 1819 ] have found that women are less frequently treated with evidence-based therapies.
This is most pronounced when the physician is male and is dealing with cardiovascular diseases [ 1720 ] and diabetes [ 21 ]. In Europe, women receive less echocardiography, less angiography to diagnose coronary artery disease and less percutaneous coronary intervention or bypass surgery if needed [ 22 ].
Usually, the lack of treatment of women is justified by their higher age, but this argument neglects the ificant fact that women on average live longer than men, and that elderly women and men 6—8 years younger are similar in regard to biological age and life expectancy. Similarly, rehabilitation and disease management programmes are not always adjusted to the specific needs of each gender.Live sexing Butte Montana women and men
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