Health Care 101: Women's Health

1. 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

2. Women’s 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

3. Women’s 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 Women’s Health, National Women ‘s Law Center, 2001

4. 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)

5. 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

6. 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

7. 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.

8. 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

9. Health Problems More Common Among Women Than Men • Autoimmune diseases (multiple sclerosis, lupus, fibromyalgia, etc.) • Arthritis • Osteoporosis • Urinary incontinence • Depression • Alzheimer’s disease • Domestic violence

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. Health Problems Experienced Differently by Women • Heart disease • Lung cancer • Diabetes

17. 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

18. 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.

19. 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

20. 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

21. 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

22. Lung Cancer Death Rates per 100,000 women, 1930-1990 From:   Baldini: Chest, Volume 112(4) Supplement 4.October 1997.229S-234S

23. 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)

24. 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

25. 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

26. 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

27. 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 women’s needs)

28. 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)

29. 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.)

30. Women’s Health Report Card: 2001 Developed by the National Women’s 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

31. 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)

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

33. 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

34. 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

35. 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

36. Innovations in Women’s 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 women’s health and addressing health disparities

37. What else needs to be done? • 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

38. 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: rwilson1@partners.org