1. Health Care 101: Women's Health Brigham and Women’s Hospital
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. Higher incidence in white women, but higher mortality in black women at every age; five-year survival rate for women with invasive breast cancer is 87% for white women and 72% for black women
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
MassHealth Breast and Cervical Cancer Treatment Program will cover women who are screened in the program and who are eligible for MassHealth. There are women who will still fall through the cracks.

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 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 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 Death Rates for Blacks : Whites
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 S-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 ).

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)
Rachel A. Wilson, MPH
Director of Women’s Health Policy and Advocacy
Phone: (617) ;