Gender Medicine

Gender medicine is becoming increasingly important. At the annual meeting of the German Society of Internal Medicine (DGIM) in Mannheim in April 2017, gender differences in selected diseases were among the key topics.

Women with CHD, a heart attack or heart failure are known to receive worse care on average than men – possibly because the diseases are still considered “men’s diseases.” Disadvantages in medical care exist just as much for men when they suffer from a classic “women’s disease” such as osteoporosis.

The prevalence of osteoporosis is significantly higher in women than in men, but men also develop the disease not so rarely. “The prevalence is in the order of %–10%in men,” reported Prof. Susanne Kaser, MD, of Innsbruck University Hospital. Based on 2010 figures, about 21 million women and 5.5 million men are affected in the 27 EU countries.

Just as with heart disease, there are significant differences between the sexes in osteoporosis. Secondary forms of osteoporosis are much more common in men than in women, e.g., due to excessive alcohol consumption, systemic glucocorticoid therapy, or hypogonadism, whereas in women the focus is on the postmenopausal form. The mortality of men with osteoporotic fractures is higher than that of women, Kaser said. In men aged 50 and older, the same T-score ≤-2.5 is used to diagnose osteoporosis as in women (Table 1) . However, the reference value refers to the average bone density of a 20-29-year-old woman in bone density measurement by DXA at the femoral neck, the endocrinologist pointed out. Men would have a higher fracture risk than women for the same T-score. This risk increases with age.

Screening for osteoporosis is recommended by the German Osteology Association (DVO) – the association of all scientific societies in Germany, Austria and Switzerland that deal with diseases of the bone – in each case 10 years later in men than in women – a kind of analogy to the thesis that heart attacks affect women about 10 years later than men. General screening is recommended in men from 80 years of age (women from 70), in men with risk factors from 70 years of age (women from 60), and in those with previous fractures or systemic glucocorticoid therapy from 60 years of age (women from menopause) [1].

“Much less often than in women, men receive osteoporosis therapy, although the indications for therapy are the same,” Kaser said. The proportion is less than 10% compared to around 50% for women. One possible reason is that studies in men with osteoporosis are limited. In principle, the same standard medications are recommended for osteoporosis therapy in men as in women. Testosterone has no place in therapy for men because a benefit in terms of fracture rates has not yet been demonstrated, Kaser explained.

Returning to gender differences in cardiovascular disease and, in particular, the poorer prognosis of female patients. According to a Europe-wide analysis of WHO data, age-adjusted CHD mortality has decreased by an average of 49% in men but only 39% in women over the past 25 years. One reason for this is that female infarct patients are less often treated with the full arsenal of cardiological options due to more nonspecific symptoms, i.e., they receive cardiac catheterization, balloon dilatation, bypass surgery, or guideline-based drug therapy less often than men.

However, a new analysis shows that women with myocardial infarction are more likely to suffer complications down the road, even if they initially received the same treatment as men. A total of approximately 33,000 records of patients with ST-elevation myocardial infarction from the Coronary Angiography and PCI Registry of the German Society of Cardiology (DGK)[2] were evaluated. 28% of the data were from female patients, who were on average 7 years older than the male patients but were less likely to have had previous PCI (percutaneous catheter intervention) or bypass surgery.

Technically, the intervention was successful equally often in both sexes (93.5% in women and 94.7% in men). However, later in life, only 3.9% of men had a serious cardiovascular complication (nonfatal myocardial infarction, stroke, or TIA) compared with 6.8% of female patients. Clinic mortality was also significantly higher in women than in men (6.3% vs. 3.6%). The higher average age of the women could not explain these differences, according to the Munich authors led by Dr. Tobias Heer of the Klinikum München Schwabing. The reasons for the gender differences would need further investigation.
There is another explanation for the poorer prognosis of women with heart failure that has received less attention to date: women are significantly more likely than men to have diastolic heart failure with preserved pump function, for which there is as yet no established therapy. About 70% of all patients with diastolic heart failure are women, reported Dr. Elpiniki Katsari, cardiac surgeon at Karlsburg Hospital. Men would be more likely to have ischemic cardiomyopathy, but this also correlates with a less favorable prognosis. NYHA stage was a more important predictor of mortality in men than in women, he said.

Heart failure risk is particularly high in women with diabetes and with hypertension compared with corresponding men. On average, women are 2.7 years older than men when first diagnosed with heart failure.

Rheumatic diseases, especially collagenoses, frequently affect women. As one explanation, Dr. Gabriele Kehl of the Darmstadt Hospital cited the special role of the X chromosome in the inheritance of autoimmune diseases. Hormonal influences must also be taken into account. The risk of systemic lupus erythematosus (SLE) is increased in women with early menarche, he said.

SLE is a classic female disease, with a sex ratio of about 9:1, and usually manifests in the potentially reproductive phase between the ages of 15 and 50. Pregnancy can be a trigger for both initial manifestation and recurrences, Kehl reported. The female dominance is somewhat less clear in systemic sclerosis (3-4:1) and rheumatoid arthritis (2-3:1). Spondyloarthritis is an exception, with a balanced sex ratio. In the past, ankylosing spondylitis was considered a man’s disease. Women often develop the disease later than men and the diagnosis is also often delayed, Kehl reported.

Differences in care between the sexes are poorly documented for rheumatic diseases. What is striking, however, is that male and female patients often deal with their disease in very different ways, according to the internist. Self-perception, symptom appraisal, and coping mechanisms differed. Men usually dealt with the disease in a fact-oriented way, women in an emotional-holistic way.

Another important aspect in gender medicine, for which there is evidence both in heart disease and in transplantation medicine: How well guideline-based therapy is implemented also seems to depend on the gender of the treating physician. Outcomes are best when male patients are treated by male physicians and female patients are treated by female physicians, Katsari said.

Source: 123. Congress of the German Society of Internal Medicine (DGIM), D-Mannheim, Symposium “…und es gibt doch, den kleinen Unterschied – im Fokus Niere, Herz und Knochen”, April 29, 2017.

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