We often think of health as a gender-neutral subject, but in reality, the difference between the sexes in medicine is almost as stark as in athletics. Feminism in health today is a basic need, and not a privilege; it is about questioning systems that disadvantage women.
For decades, medical research has largely been conducted on man (and even male animals), treating male bodies as the ‘default’ model. As a result, the clinical presentation of many diseases, drug dosages as well as side effects and even adverse reactions of surgical implants in women at times vary from the listed ones or the established norms after a study/ trial.
Avoiding the female body in studies has its own reasons—makes the work easier since the hormonal fluctuations in women in various stages of life and a month are complex and any trial taking these variables into consideration is a time- and effort-intensive process.
It is necessary to bridge the gender gaps in the current or past trials, as medicines from past trials are in use today. The studies that were done with remarkable gender imbalance should be identified and re-examined in order to rectify the potential variations in women.
The US Food and Drug Administration did not mandate the inclusion of women in drug trials/ clinical research until the 1990s. The repercussions of that are evident even today. Also, there is no regulatory body mandate for equal participation of both genders, and sex disaggregated data submission is still not an acceptance criterion for a clinical study/trial.
A meta-analysis of data from thousands of medical journals, published in Journal of Clinical Medicine in 2022, found that women are likely to experience adverse drug reactions twice as often as men. They develop higher blood concentration levels and longer drug elimination times, leading to higher degree of side effects.
Here are a few examples to help understand cases of misapplied medicine in women:
The most burning instance is the insomnia drug Zolpidem, which has slow pharmacokinetics (how the body reacts with a drug over time) in women, leading to complications. This drug concentration was higher (three-fold) in women and stayed in blood beyond the morning after its use, leading to drowsy office hours and worse, vehicular accidents. It was only in 2013, after 30 years of its availability in the market, that the FDA halved the recommended dose for women.
So is the case with antidepressants and antipsychotics. As any human anatomy book will reveal, women have higher body fat percentage, so the fat-soluble drugs (like SSRIs, antipsychotics) are stored and released differently, leading to varied or increased side effects.
When it comes to cardiovascular disease, a ‘classic’ symptom documented is chest pain radiating down the arm. But in women, the common symptoms are jaw pain, fatigue, nausea or even back pain. Moreover, aspirin—recommended for heart attack prevention—was found to reduce risk of stroke but not heart attack.
Also, more often clinicians treat chronic pain and even chest pain in women as psychological issues rather than investigating a physical source of the pain.
The story is similar, if not worse, in medical device usage. Since women have different hip angles, bone density and joint sizes, the hip implants tested on men presented with more adversities in women.
In cardiac pacemakers and defibrillators, women have been receiving fewer benefits. Women mostly have smaller heart, and the metabolism of electrical signals generated in these devices often differ in women. A JAMA (2009) meta-analysis reported women being less likely to benefit from intra-cardiac devices (ICDs), and face more complications during or post ICD implantation.
The size and design of artificial heart valves put women more at risk of mismatch between valve size and cardiac anatomy. As per research studies in Circulation (2014), women were at higher risk while undergoing transcatheter aortic valve replacement. Also, women’s smaller coronary arteries make stent placement riskier, with higher chances of restenosis (narrowing of artery) and complications. A study in European Heart Journal (2016) confirmed that women had worse outcomes post stenting.
Also, the clinical system today reflects a poor understanding of menopause—a landmark phase in a woman, with about 40 per cent of her life ahead. Menstruation and mental health around hormonal fluctuations are areas lagging in mainstream care-giving.
Now is the time to revisit stereotypes and ensure prudent policies for both genders. The solution approach to gender discrepancy in health care is enforcing inclusive clinical studies or trials and mandating sex-disaggregated data in every study. Those funding studies and journals publishing them should make this a mandatory requirement. The other best practice would be to include hormonal and life-stage variables in studies, tracking menstrual cycle, stages of pregnancy and menopause and influence of hormone therapy, which alter pharmacokinetics.
Most important, medical education needs reforms to sensitise budding doctors to such gender-related differences in physiology, pathology and in treatment protocols.
Gender equality and equity in health is a matter of scientific accuracy and also justice. Modern medicine has always presented itself as neutral, objective and universal, but it is time to add a female perspective in every research/ trial. This will address historical disparities and ensure well-being of half the world’s population.
The writer is a pathologist and an author.