Download 42 Gender Specific Issues

42 Gender Specific Issues
1. In the assessment of clinical problems that might present differently in men and women,
maintain an inclusive differential diagnosis that allows for these differences (e.g., women with
coronary artery disease, depression in males).
The patient's gender is an important factor in the consideration of nearly every clinical presentation. While some
concerns are anatomically sex-specific and present distinctly (ex. menopause vs andropause, testicular vs ovarian
torsion), others are more frequent in women (ex. breast cancer, eating disorders) and may be more easily
overlooked when they occur in men, and vice-versa.
Depression: Women are historically diagnosed with depression twice as often as men, however completed
suicide rates are higher in men than women. Men tend to present less frequently to medical attention and tend
not to disclose emotionally distress to their physicians. Physicians may require a higher index of suspicion in
screening for depression in men, and recognize that extreme conformity to masculine norms has been associated
with higher rates of depression 1⁠ . Depression in men may also be masked by substance use2⁠ .
CAD: Cardiovascular mortality is much greater in men than women, however the prevalence of angina is higher
in women worldwide 3⁠ . Cardiac chest pain is more likely to be atypical in women.
COPD: COPD tends to be under-diagnosed in women, however the impact on women in terms of associated
anxiety and quality of life is greater when COPD is diagnosed4.
Many other gender-specific issues should be covered in more detail within each topic review.
2. As part of caring for women with health concerns, assess the possible contribution of domestic
violence.
See section on domestic violence for details.
3. When men and women present with stress-related health concerns, assess the possible
contribution of role-balancing issues (e.g., work-life balance or between partners).
Sociologic studies have indicated that work-life imbalance in men is predicted by “longer work hours, wives
who work fewer hours, perceived unfairness in sharing housework, marital unhappiness, and tradeoffs made at
work for family and at home for work. For women, only marital unhappiness and sacrifices at home are
imbalancing, and for women who are employed full-time, young children are.” 5⁠ These factors should be
assessed in patients presenting with stress-related concerns.
4. Establish office policies and practices to ensure patient comfort and choice, especially with
sensitive examinations (e.g., positioning for Pap, chaperones for genital/rectal exams).
5. Interpret and apply research evidence for your patients in light of gender bias present in clinical
studies (e.g., ASA use in women).
See individual topic reviews for details. Clinical studies have traditionally used men as a prototype for all
humans, however research increasingly suggests significant differences in the presentation, epidemiology and
management of many illnesses. Caution must be applied when applying results from clinical trials in which
results are not stratified by gender, or in which one gender was under-represented. Clinical evidence is lacking
for most health conditions for people who are transgendered.
Particular attention has recently been paid to the use of statins and ASA in cardiovascular protection in women.
Whereas there is evidence that statins contribute to a reduction in all-cause mortality when use for primary
prevention in men, the same may not be true of women. Sex-specific data has shown reductions in CHD events
for women using statins, but not in decreasing all-cause mortality 6⁠ . While newer evidence has made ASA less
popular than it has been previously for primary prevention, its potential for cardiovascular benefit in men relates
to a reduction in the incidence of MI, whereas in women the cardiovascular benefit of ASA relates to reduction
of CVA 7⁠ .
Optional reading: Some interesting facts from the Partnership for Gender-Specific Medicine at Columbia University:
Brain/Nervous System
Males are more likely than females to identify binge eating as normal.
Women are more likely than men to recover their speech after a stroke.
Parts of the hypothalamus are larger in heterosexual males than in transgender and homosexual males.
Women experience more pain from pressure and electrical stimulation than men.
Men have larger brains; women have more brain cells.
Because of the later maturation in males of the part of the brain that weighs risks and moderates impulsive
behavior, adolescent boys are more likely than girls to take life-threatening risks, commit suicide and die violently
than girls of the same age.
Heart
Men who are diagnosed with heart disease are typically ten years younger than women.
When a woman reaches menopause, her risk for cardiovascular disease increases four-fold.
In general, coronary artery disease strikes men almost two decades earlier than it does women; most men with
coronary artery disease are dead by the time they are 65.
Sudden cardiac death is more common in males.
Men have larger hearts; women’s hearts beat faster.
Lungs
It is more dangerous for women to smoke than for men. For the same number of cigarettes smoked, women
are 20 to 70 percent more likely than men to develop lung cancer.
Women are less prone to hiccups than men.
IEven when corrected for body size, men’s lungs are bigger than women’s.
A man takes 12 breaths per minute while a woman takes only nine breaths per minute on average.
Immune System
Because they have more active immune systems, women have the ability to fight off viral infections better than
men.
Men are more susceptible to parasitic infestations than women because of their higher levels of testosterone,
which promotes parasite breeding rates.
Digestive System
Boys between 11 and 15 are more likely than their sisters to have iron deficiency anemias because girls
absorb iron more easily from their gastrointestinal tracts than boys at that age.
Women are more likely than men to feel overly full after eating and have more problems with bloating and gas
immediately following a meal.
The composition of bile is different between the sexes; some of the breakdown products of bile increase
women's risk for colon cancer and may also explain the twice-higher incidence of inflammatory bowel disease in
women.
Food takes twice as long to pass through the digestive system of women compared with that of men.
Food leaves a man's stomach a third faster than a woman's, and liquids twice as quickly.
Skeletal System
Eighty percent of hip fractures occur in women.
Medications
Women clear several medications faster than men, including erythromycin, prednisolone and diazepam.
There are sex-specific differences in the absorption and metabolism of pain killers and anesthetics.
Mortality
Life expectancy in men is six years shorter than in womenthan women when they die.
Cancer
Pancreatic cancer occurs three times more frequently in men than in women. Estrogen and progesterone
appear to protect women from pancreatic cancer.
Women develop melanoma on different areas of the body than men. Skin cancer occurs more frequently on the
ears and necks of men and on the legs of women probably due to the shorter hairstyles of men and the exposed
legs of women, since they are almost always caused by exposure to the sun.
A typical colon cancer is located 10 to 20 percent higher up in the colon in women than in men.
1. Mok H, Mckenna M, Ogrodniczuk JS. Effect of gender socialization on the presentation of depression among
men Recherche Effet de la socialisation spécifique à chaque sexe sur la façon dont se présente la dépression chez
les hommes. Canadian Family Physician. 2011;57:e74-78.
2. Addis ME. Gender and Depression in Men. Clinical Psychology: Science and Practice. 2008;15(3):153-168.
Available at: http://dx.doi.org/10.1111/j.1468-2850.2008.00125.x.
3. Hemingway H, Langenberg C, Damant J, et al. Prevalence of angina in women versus men: a systematic
review and meta-analysis of international variations across 31 countries. Circulation. 2008;117(12):1526-36.
Available at: http://www.ncbi.nlm.nih.gov/pubmed/18347213. Accessed October 31, 2011.
4. Chapman KR, Tashkin DP, Pye DJ. Gender bias in the diagnosis of COPD. Chest. 2001;119(6):1691-5.
Available at: http://www.ncbi.nlm.nih.gov/pubmed/11399692.
5. Council N, Relations F. Playing All the Roles : Gender and the Work-Family Balancing Act. Family Relations.
2012;61(2):476-490.
6. Bukkapatnam RN, Gabler NB, Lewis WR. Statins for primary prevention of cardiovascular mortality in
women: a systematic review and meta-analysis. Preventive cardiology. 2010;13(2):84-90. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/20377811. Accessed November 7, 2011.
7. Berger JS, Roncaglioni MC, Avanzini F, et al. Aspirin for the primary prevention of cardiovascular events in
women and men: a sex-specific meta-analysis of randomized controlled trials. JAMA : the journal of the
American Medical Association. 2006;295(3):306-13. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/16418466.