New dimensions in women’s health

The unique biology of women requires different research practices and medical treatments

By Morgan Mercer

Lying on the exam table, Donna Block didn’t know anything about intrauterine devices (IUD). But she didn’t have time to ask. Her gynecologist walked in, grabbed a speculum and jammed the piece of t-shaped plastic inside her. Donna sat up and fainted from the pain.

“There was no warning. You felt like you got hit by a truck,” says Dr. Block about her first gynecological appointment nearly four decades ago. “I was absolutely traumatized. It made such an impression on me that I didn’t want anyone else to have that experience.”

So, in her early thirties, Dr. Block headed off to medical school. She graduated in 1987 and eventually opened her own gynecology and obstetrics practice in Edina for women in 2004. Clinic Sofia became a way for her to keep patients informed and healthy in a system that many women said didn’t seem to listen to them.

That’s not a new feeling though. For decades, the medical community let the female experience go largely unexplored outside of areas like childbirth and the reproductive system. Research, drug trials and standards in clinical practice developed from information skewed toward the male experience. The rise of a new kind of clinic, however, puts women’s needs first, and sets a fresh precedent in the medical field.

“You’re not applying a one-size-fits-all treatment plan. You’re taking some basic information and tweaking it to fit the particular person’s needs, whether they’re male or female,” says Dr. Block. “[Women] are just different. When they come to our clinic they have one moment to pay attention to themselves.”

“Bikini” medicine and beyond

A stressed-out and pregnant Melisa Franzen walked up to the next house on the block and knocked on the door. Despite her high-risk pregnancy, Franzen couldn’t sit at home with a campaign to be reelected as one of Minnesota’s senators. Despite the hours spent canvassing, Clinic Sofia made sure the mom-to-be stayed healthy.

“They take care of your mind and soul, not just your physical health,” says Franzen, who won her second term in office when she was seven months pregnant. “You don’t feel like you only have ten minutes to talk with them. The extra time creates an environment where you can be more straightforward and actually feel like your provider cares about you. Health care is complex. You don’t know what you don’t know unless someone guides you to it.”

For Franzen, that meant health care advice that went beyond her pregnancy and accounted for all the roles she took on in her life: working professional, wife, new mom and senator. Although for some providers, consideration of how those factors affect health are just the beginning when it comes to personalizing care for women in the future.

When Dr. Stephanie Faubion graduated from her residency program, working at a women’s health care clinic held no allure for her. She wanted to treat women outside of gynecology and obstetrics. Her interest in women’s health shifted, though, when she discovered the field is actually much broader. While the medical community treated women for a range of conditions unique to them or that occurred more frequently in women, it often failed to account for conditions that showed up or needed to be treated differently in women than in men.

“We’re moving beyond what we call bikini medicine. It’s not just about the breasts and the reproductive tract,” says Dr. Faubion, the director of the Office of Women’s Health at Mayo Clinic. “We’re not giving appropriate care for anyone, men or women, if we don’t take sex and gender factors into account.”

At the cellular level, men and women are different. Women have different hormones and chromosomes; they metabolize drugs at different rates; even their stem cells don’t behave the same way in a Petri dish. These biological or sex-based differences affect how men and women respond to and experience nearly every health condition.

Take cardiovascular disease, the leading cause of death in men and women in the United States. With coronary heart disease (CHD), men typically report feeling crushing chest pain or pressure. About 50% of women experience similar symptoms, but the other half report feelings of indigestion, nausea, dizziness and shortness of breath — signs that could easily be dismissed or mistaken for something other than CHD. A woman’s risk for cardiovascular disease also exponentially increases after menopause.

Beyond that, health care gets even more complicated when you start considering gender-based differences, or the cultural ways we define men and women and the roles people take on in their lives. Yet until the early 1990s, basic sex- and gender-based differences like these went mostly ignored in research laboratories and doctors’ offices.

A new era in women’s health

For decades, researchers often excluded women from clinical trials out of fear of jeopardizing the health of babies. This patriarchal stance left women’s health experiences unexplored and uncharted.

“Most of the evidence for our medical practice is based on men. We have this huge hole that still needs to be filled regarding what happens to women,” says Dr. Virginia Miller, the director of Mayo Clinic’s Women’s Health Research Center. “It’s a win-win for everybody when we start paying attention to these kinds of details. The scientific community really missed the beat here, and the medical community just ignored it.”

However, that began to change when the National Institute of Health (NIH) issued the Revitalization Act of 1993, requiring the scientific community to include women and minorities in testing. With Bernadine Healy standing at the head of the NIH, centers of excellence in women’s health developed around the country. Around the same time, national groups like the Society for Women’s Health Research formed. Over the next ten years these organizations and others started to publish research and landmark studies arguing for the importance of sex-based differences in health care.

“We aren’t using all the information we need to understand women’s risks, women’s needs and the appropriate assessment and treatment of disease,” says Dr. Faubion. “We’re missing out.”

When researchers don’t account for sex-based differences in clinical trials, conflicting results in men and women can make drugs appear ineffective or lead to harmful side effects. When researchers separate results by sex though, they reveal previously hidden insights. Take Ambien, a drug approved by the FDA in 1992 to treat insomnia. After women started falling asleep at the wheel, researchers discovered that females metabolize the drug more slowly than men. Nearly 20 years after it was released, the FDA cut the recommended dose of Ambien in half for women, making it one of the few drugs with dosing recommendations based on sex differences.

Faced with a lack of information, the medical community had to confront a new reality: it didn’t know nearly as much about its female patients as it did its male ones. To remedy that, women’s health clinics began to pop up around the country, including Mayo Clinic’s first in 2005. Research policies also continued to change, including a 2016 NIH policy finally requiring scientists to list the sex of the animal or cell used in trials.

“This is people-specific medicine. If we figure out something that is different in women, that also helps men because it helps us understand what the differences are,” says Dr. Faubion. “This is driving toward individualized medicine. It’s not just about women’s health. It’s more global than that.”

However, even as momentum for women-specific health care picked up, researchers were met with new challenges that threatened to slow progress toward better and more personalized care.

“As a field, we haven’t figured out a way to convince everybody that sex-differences research and sex-differences health care is vital to everyone’s health,” says Dr. Nancy Raymond, the director of the Deborah E. Powell Center for Women’s Health at the University of Minnesota. “We’ve got a significant way to go. For whatever reason, we haven’t found a language that engages everyone in being concerned about the topic.”

Clinicians like Dr. Raymond are starting to change the conversation in labs and schools throughout Minnesota. Of the twelve Specialized Centers of Research on Sex Differences in the nation, two are located in Minnesota — at the Mayo Clinic and at the University of Minnesota. These two sites are also where Dr. Raymond and Dr. Virginia Miller train the next generation of scholars, scientists and health care workers in the value of sex and gender-based medicine through an NIH-funded program called Building Interdisciplinary Research Careers in Women’s Health. BIRCH is one of several building blocks leading to a new tradition in health, one that makes sure the unique needs of women — and men — aren’t ignored anymore.

Did you know?

  • INJURY AND THE MENSTRUAL CYCLE Female athletes are two to 10 times more prone to ACL knee injuries than men playing the same sports. Women are at increased risk for the injury at different times in the menstrual cycle. Female athletes also more commonly suffer from concussions.
  • EARLY MENOPAUSE RISK FACTOR Women who experience premature menopause (before age 45) have an increased risk for developing dementia, Parkinsonism, osteoporosis, heart disease, mood disorders, sexual dysfunction and early death.
  • HYPERTENSION AND PREGNANCY Women who develop hypertension (high blood pressure) during pregnancy are likely to suffer from hypertension and cardiovascular disease later in life.
  • EARLY CANCER DETECTION At 50,000 cases a year, endometrial cancer is the most common gynecology malignancy. But Mayo Clinic researchers say early detection is possible by identifying tumor DNA from cells picked up by ordinary tampons. Such a test would be minimally invasive and cost-effective.
  • GREATER RISK OF ALZHEIMER’S Women make up nearly two-thirds of patients with Alzheimer’s disease and experience cognitive decline faster than men. At 65 years old, women have twice the chance of developing the illness compared to men. Researchers are exploring how estrogen affects the development of amyloid, the substance that forms sticky plaques that build up in the brain in Alzheimer’s disease.