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Evolving Paradigms in Women’s Health

Evolving Paradigms in Women’s Health. Eileen Hoffman, MD, FACP Clinical Associate Professor of Medicine NYU School of Medicine DGIM Grand Rounds April 24, 2007. Evolving Paradigms in Women’s Health. Review the recent history of the field

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Evolving Paradigms in Women’s Health

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  1. Evolving Paradigms in Women’s Health Eileen Hoffman, MD, FACP Clinical Associate Professor of Medicine NYU School of Medicine DGIM Grand Rounds April 24, 2007

  2. Evolving Paradigms in Women’s Health • Review the recent history of the field • Describe the developmental stages & their contributions to improving care • Describe the newest paradigm - plasticity • Provides a lens for looking at the whole woman across the life cycle that is not just the sum of her parts • Use the new paradigm showing how it contributes to the health of women & men

  3. INITIAL (OLD) PARADIGM women’s health = reproductive health

  4. Hoffman. The Women-Centered Health Care Team –Implications for Multiprofessonal Interdisciplinary Education. J Women’s Health. 1998.

  5. TRANSITIONAL PARADIGM Women’s health • Diseases, disorders and conditions that are unique to, more prevalent among, or far more serious in women, or for which there are different risk factors or interventions for women than men (ORWH…and expanded by NAWHME) Goldman & Hatch. Women & Health. Academic Press, 2000.

  6. TRANSITIONAL PARADIGM • Limited to differences • Reductionist and organ-based • Old model of science • Old model of medicine • At best is “multidisciplinary” Johnson & Dawson. Women’s health as a multidisciplinary specialty: An exploratory proposal. JAMWA 1990.

  7. Traditional Collaborative Care Integrated Collaborative Care   Medical Practitioner  Relational Field Mental Health Specialist Medical Practitioner Mental Health Specialist • Co-location • Separate services offered • Facilitates “screen and refer” • Quality of collaboration depends on quantity of interaction between clinicians • Integration • Interaction blurring boundaries between mind & body • Facilitates immediate assessment • Quality of collaborative relationship is a part of the therapeutic process A x B = C A + B = A' + B' Women-centered Collaborative Care: Beyond Co-Location. APA Proceedings.2002

  8. NEWEST PARADIGM Women’s Health is • A sex- and gender-informed practice centered on the whole woman in the diverse contexts of her life, grounded in an interdisciplinary sex- and gender-informed biospychosocial science (ACWHP) Hoffman, Magrane, Donoghue. Changing Perspectives on Sex and Gender in Medical Education. Acad Med 2000.

  9. ACWHP Menstrual Cycle Concept Map Concept Mapping – A Tool for Knowledge-Management. Workshop on Theoretical Foundations of Medicine. Santa Fe Institute. 2006.

  10. NEWEST PARADIGM • Uses “difference” differently • Not as sex- and gender-based variations from a “gender-neutral” norm • A norm based on “plasticity” • Distinguishes living from non-living systems • Ability to customize genome to environment • Pediatrics-- discipline based on “developmental plasticity”

  11. NEWEST PARADIGM • Women’s Health – A Norm of Her Own • Maximal plasticity • “developmental” & “reproductive” plasticity • Interaction between the 2 types of plasticity • Consistent with new trend in medicine “systems biology” • Systems are comprised of parts that interact • Emergent phenomena are properties of the whole • Not reducible to sum of parts • Must be studied as a whole

  12. Plasticity in the Female • Anticipation of pregnant state • Menstrual cycle • Luteal phase transformation to accommodate conception • Adaptation to pregnant state • Flexible physiology and anatomy • Transformation by pregnant state • Microchimerism – link between generations • Enhancement of health for survival • Mosaicism – buffers sex-linked disease • Gatekeeper to developmental plasticity Migeon. The Role of X Inactivation and Cellular Mosaicism in Women’s Health and Sex-Specific Diseases. JAMA 2006

  13. Failures of Plasticity • PCOS • Pre-menstrual Asthma • Gestational Diabetes • Pre-eclampsia • Low birth weight • Pre-term labor • Autoimmunity/Organ regeneration Williams D. Pregnancy: A Stress Test for Life. Current Opin Obst Gyn 2003. Khosrotehrani et al. Transfer of Fetal Cells with Multilineage Potential to Maternal Tissue. JAMA. 2004. .

  14. Applying the New Paradigm Failures in Plasticity & Risk for CVD • Chronic disease -- a fixed state • Prior states have some plasticity • Which prior state has maximal plasticity for preventive intervention? • Early warning signs • Failures in reproductive plasticity Sattar & Greer. Pregnancy complications and maternal cardiovascular risk: Opportunities for intervention and screening. BMJ USA. 2002.

  15. Applying the New Paradigm Failures in Plasticity & Risk for CVD • Earliest stage for intervention • in utero – fetal environment • “Low birth weight” • Proxy for fetal nutrition • Potent predictor of CVD risk/mortality • Sets the stage for future life style risk factors Godfrey & Barker. Fetal Programming and Adult Health. Public Health Nutrition 2001.

  16. Failures in Plasticity and the Epidemic of Chronic Disease • In hypercaloric environment what environmental factor contributes to LBW? • Epidemic of chronic disease began with shift from agrarian to industrialized society • Industrialization led to low sun exposure • Low sun exposure causes Vitamin D deficiency • Vitamin D deficiency leads to LBW & programs the fetus for a trajectory toward chronic disease McGrath J. Does”imprinting” with low prenatal vitamin D contribute to the risk of various adult disorders? Medical Hypothesis 2001. Barker D. The developmental origins of insulin resistance. Horm Res 2005.

  17. Populations with Vitamin D Deficiency • Healthy adults, children, adolescents • Sunscreen users • African Americans • Obese • Elderly/limited sun • Living at northern latitude • Immigrants from southern to northern latitude • Veiled women • Medical inpatients including nursing homes • Osteoporotics on bisphosphonates • HIV positive on PI • Smokers

  18. Calcemic and Non-Calcemic Actions of Vitamin D

  19. Rickets/Osteomalacia Diabetes Hypertension CVD PCOS Cancer Mental health Osteoporosis Falls in the elderly Periodontal disease Infection Immune regulation Autoimmune disease Chronic liver disease Fat Malabsorption Parkinson’s disease Primary HyperPTH Psoriasis Vitamin D and Chronic Disease Holick M. High Prevalence of Vitamin D Inadequacy and Implications for Health. NEJM.2006

  20. Maximizing the fetal environment improves the health of both women and men!

  21. Old Paradigm › Reproduction Reproduction + › › › New Paradigm Interdisciplinary Field Reproductive & Developmental Plasticity

  22. Summary • Women’s Health, as a field, is evolving & is going through developmental stages • Reproductive health • Sex differences based on male norm • Interdisciplinary field based on plasticity • Systems biology model provides for new understandings of health & disease in both women & men • Application of this model provides insights such as the role of vitamin D in the epidemic of chronic disease

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