Yentl Syndrome: cardiology’s gender gap is alive and well

17 Apr

by Carolyn Thomas  @HeartSisters

There’s a big fat yawning gap between cardiovascular diagnostic tests and resulting medical treatments – depending on whether doctors are looking at a male or a female patient lying there on the gurney. I’ve been saying this out loud ever since I came home from Mayo Clinic, where I first learned about the gender gap from Mayo cardiologists following my own heart attack misdiagnosis.

When asked if we might need to develop a new set of diagnostic/treatment protocol guidelines to specifically address this gap, Dr. Sharonne Hayes (founder of the Mayo Women’s Heart Clinic) responded:

“Part of the problem now is that the clinical practice guidelines are less likely to be applied to women compared to men.

“We know that when hospitals have systems in place to ensure they do provide care according to the guidelines, women’s outcomes improve.”

You may be wondering what it will take to put into place systems and guidelines (already used in male patients) for all patients, including women – in order to finally close that gender gap for good. 

Or must we merely resign ourselves to yet another cardiac study that reports, as my Mayo Clinic heart sister and Spontaneous Coronary Artery Dissection survivor Laura Haywood-Cory describes it in her comment to this 2011 Heart Sisters post called The Sad Reality of Women’s Heart Disease Hits Home:

“Sucks to be female – better luck next life!”

Recent research published in the journal Clinical Chemistry and Laboratory Medicine showed that women heart patients may have to wait longer than we had first hoped for the same quality of care that our male counterparts both expect and get.

Lead researchers Dr. Giovannella Baggio starts off this important Italian study called Gender Medicine: a Task for the Third Millennium(1) by telling us about what doctors now call the Yentl syndrome.

It was the late physician, cardiologist and academic Dr. Bernadine Healy who coined this phrase in 1991, writing in The New England Journal of Medicine:

“Yentl, the 19th-century heroine of Isaac Bashevis Singer’s short story, had to disguise herself as a man to attend school and study the Talmud. Being ‘just like a man’ has historically been a price women have had to pay for equality.

“Being different from men has meant being second-class and less than equal for most of recorded time and throughout most of the world. It may therefore be sad, but not surprising, that women have all too often been treated less than equally in social relations, political endeavors, business, education, research, and in health care.”

This health care inequality includes cardiology. A New England Journal of Medicine editorial in the same issue highlighted this discrimination against women in cardiology, including the reality that women hospitalized for coronary heart diseases underwent both fewer major diagnostic and therapeutic procedures than men did.(2)

But that NEJM editorial was written back in 1991. Surely things have improved for women heart patients since then?  Not so fast . . .

Twenty years after Dr. Healy had first written about the Yentl Syndrome, cardiologist Dr. Noel Bairey Merz of Cedars-Sinai Heart Institute in Los Angeles wrote her own editorial for the European Heart Journal, observing that:

“The Yentl syndrome is alive and well!” 

She cited disturbing results of two cardiac studies:(3)

“Both studies demonstrate medical undertreatment of women, including lower rates of aspirin and ACE inhibitor use in stable women compared with men, and lower rates of ACE inhibitor, beta blocker and statin medication in women with Acute Coronary Syndrome (ACS) compared with men.

“Both studies also show gender differences in use of procedures, where interestingly stable women undergo more repeat angiography, while women with ACS undergo fewer angiograms, revascularization, cardiac catheterizations,  and coronary artery bypass grafts compared with their male counterparts, and with higher death rates than men.

“The adverse outcomes described in these new works are consistent with earlier literature – both studies demonstrate adverse gender differences for women.”

The Italian study confirms this reality once more. Dr. Baggio et al compiled a distressingly long list of  areas in which the cardiac gender gap is still alive and well, observing for example that:

  • coronary heart disease (CHD) is widely perceived to be less of a public health problem for women than for men even though CHD is the leading killer of women by 65 years of age;
  • mortality for cardiovascular diseases and in particular for CHD has not decreased in the last 30 years in women as it has in men;
  • the in-hospital mortality of an acute myocardial infarction (heart attack) is higher in women than in men up to 70 years of age;
  • survival after six months of acute myocardial infarction is lower in women;
  • clinical trials on prevention and treatment of cardiovascular diseases have been conducted either exclusively in males or in populations with very low numbers of females;
  • women are less likely than men to have typical angina and are more likely to have atypical or non-anginal symptoms;
  • CHD in women is ever often under-recognized particularly at younger ages or in patients with diabetes, and the disease is more severe and complicated (MI, hearth failure, sudden death);
  • compared to men, women are less likely to undergo cardiac monitoring, enzyme measurement, recovery in coronary care unit, coronary angiography, and revascularization;
  • coronary angiography in women may show no evidence of atherosclerotic coronary artery disease because of the frequent involvement of microvascular circulation;
  • women with atrial fibrillation are at higher risk of stroke, and they are less like to receive anti-coagulation and ablation procedures compared to men;
  • stroke of any origin is more frequent in women than in men;
  • smoking is associated with a 70% increase in CHD mortality, but smoking rates are declining more slowly for women than for men;
  • hypertension (high blood pressure) has an age-related increase and is more prominent in women; only systolic blood pressure predicts cardiovascular outcomes in women and isolated systolic hypertension (a marker of loss of large-artery elasticity) is more common in women than in men;
  • much of the seminal research on dyslipidemia (high cholesterol) and CHD has involved middle-aged men and none or very few women;
  • Type 2 diabetes is a potent coronary risk factor in women, increasing their risk of developing or dying from CHD by 3-7 fold, as compared with a 2-3 fold risk increase in men; adverse cardiovascular profiles are more common among diabetic women than among men;
  • psychosocial factors such as depression, anxiety, and chronic psychosocial stress have greater adverse effects on women’s heart rate, blood pressure, visceral obesity, endothelial dysfunction, inflammatory activation and likely raise CHD risk;
  • side effects of statin drugs to treat cholesterol are frequently associated with a variety of skeletal muscle complaints in women including myalgia, cramps and weakness;
  • side effects of ACE inhibitor drugs (such as severe coughing) are reported significantly more frequently in women than in men;
  • Beta blocker drugs like propranolol and metoprolol reach higher plasma concentrations in women than in men that could lead to frequent reports of greater drug toxicity in women;
  • several studies on men have found that daily low-dose aspirin therapy was associated with a significant 32% reduction in the risk of heart attack in men;  but studies on women have found that among women under age 65 years, there was no heart attack prevention benefit, and only a small benefit in the reduction of stroke risk

IMPORTANT UPDATE:

January 31, 2016:   The American Heart Association released its first ever scientific statement on women’s heart attacks, confirming that “compared to men, women tend to be undertreated, and including this finding: “While the most common heart attack symptom is chest pain or discomfort for both sexes, women are more likely to have atypical symptoms such as shortness of breath, nausea or vomiting, and back or jaw pain.”

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Thanks to my Astute Reader, Suze, for sending a link to the Italian study.


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1.  Clinical Chemistry and Laboratory Medicine. Volume 51, Issue 4, Pages 713–727, ISSN (Online) 1437-4331, ISSN (Print) 1434-6621, DOI: 10.1515/cclm-2012-0849,  March 2013

2.  Ayanian JZ, Epstein AM. Differences in the use of procedures between women and men hospitalized for coronary heart disease. N Engl J Med 1991;325:2221–5.

3. European Heart Journal. doi:10.1093/eurheartj/ehr083

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13 Responses to “Yentl Syndrome: cardiology’s gender gap is alive and well”

  1. Stella A November 24, 2014 at 2:39 am #

    I just say it is really true that women are not treated the same as men for heart disease. Even GRACE risk score and other calculations are based on the gender difference and they reduce the possibility immediately if you chose female gender. Although you may already have a cardiac event – no matter how serious – your score is low just because of your gender. It is a trap both for us and for doctors. I have noticed wide difference in standards between women and men towards this condition.

    A woman under 50 probably is not menopausal, so it is quite difficult to take aspirin everyday. It causes bleeding during menstruation. We also cant take nitrates just before menstruation because it causes serious headaches. Personally I avoid it. I have to deal with chest pains just before menstruation or during it, only by resting. I take b-blockers and I avoid cases that can trigger the problem.

    It is probably more difficult for doctors to treat coronary disease in women. It is more difficult to put stents as the arteries are narrower than mens and the immune system of women reacts in different way to them.

    Like

    • Carolyn Thomas November 24, 2014 at 5:55 am #

      Thanks for this, Stella. When coronary stents were first introduced, they were too large to fit women’s smaller arteries. This has changed however, and should no longer be an excuse for not treating heart disease in women as doctors would treat men’s.

      Like

  2. Marlon April 19, 2013 at 6:55 am #

    Thanks for an informative article, I really can’t believe that there’s still a gender gap in having a heart related disease. My wife and I never experienced it. Good thing. This is really helpful and I will share it with my wife.

    Like

  3. helensamia April 17, 2013 at 5:37 pm #

    Yes gender issues.. It took a whole week in hospital to diagnose Pericarditis as I did not fit the profile.. Female, not diabetic, not overweight, looked fit, etc etc so no ECG done..

    I was in so much pain everywhere getting weaker and weaker. When I was eventually diagnosed the heart specialist said I had the “typical symptoms” if only someone had done an ECG in the emergency department. Four weeks later after 8grams of antibiotics IV per day and 250 mls fluid removed from around the heart, I lived to tell the tale!!!

    Like

    • Carolyn Thomas April 17, 2013 at 8:07 pm #

      Wow! Good thing they actually kept you in hospital and didn’t just send you home with a nice pat on the head (as they did when I presented with textbook MI symptoms).

      I’ve often heard that even a simple stethoscope is helpful in diagnosing pericarditis (listening for that characteristic “pericardial rub” sound) in the hands of experienced practitioners.

      But the question remains: a (female) patient presents in Emergency with chest pain and does NOT get an ECG ordered! – can you even imagine this happening if a male patient presented with identical symptoms?

      Like

      • helensamia April 17, 2013 at 8:25 pm #

        The only reason I stayed in hospital was I totally refused to leave!!! I think they thought I was there for some hard drugs!! Other than child birth I was in the most intense pain ever and running a very high temperature. When I look back it seems ridiculous….

        Like

        • Carolyn Thomas April 17, 2013 at 9:19 pm #

          It does, doesn’t it? (but do patients exhibiting drug-seeking behaviours run a very high fever?)

          Like

          • helensamia April 17, 2013 at 9:50 pm #

            I’m sure not but it was the way they made me feel… When I was eventually diagnosed it was such a relief…

            Like

            • Carolyn Thomas April 18, 2013 at 5:23 am #

              Of course! Because a correct diagnosis finally validates what you’ve been telling them all along!

              Like

  4. Kimberley April 17, 2013 at 7:42 am #

    Hello Carolyn!

    I went to see my new cardiologist in Chattanooga and she said without even taking her own scans/ekg’s, etc. for herself she has diagnosed: “Yes, from what you have told me and from what I have seen of your records so far, you have equal rights. IN other words, with your symptoms of going into v-tach so much, you can do just as much damage if not more to your heart if you do not get a proper diagnosis and from what I am seeing…..yes, you have had a heart attack! “

    From what she told me of her experience in 30 years, she has come to learn that if left untreated or constantly misdiagnosed even though you know yourself something is not right and it is in no way whatsoever indigestion when you know the difference between gas & pain at the heart…. especially when you have an implanted loop monitor for the electroactivity of my heart and it hurts around the monitor…yes, we can say that I DID HAVE a heart attack.

    For the first time in my life I found a cardiologist that agreed with me even though I am not a Dr. myself. Just by being a medical googler and having been a CNA in the past. I may not have a college degree in healthcare but I am not an idiot either.

    I have learned some street smarts along the way to survive this long!

    Like

    • Carolyn Thomas April 17, 2013 at 8:19 am #

      Hello Kimberley – so glad you have this new cardiologist on board now!

      Like

    • Stella A November 24, 2014 at 2:51 am #

      I found out about my heart attack 2 and a half months after it. I had an atrial septal infarction that caused paradoxical movement of that part. It was shown on an echo. I knew something was not right. I couldn’t swim without pain, I couldn’t walk more than 2 blocks without symptoms. I remember the day that I felt the most serious pain I have ever felt until now, but I didn’t go anywhere because I didn’t faint. I just had a strange pain that came and went away for a day.
      I had a constant ST depression of 2.8 mm. The doctor sent me for a treadmill stress test and it showed the problem. At first the doctor at the medical center told me the test was normal. But when I took the results 3 days after she signed it as positive. I was never advised what to do next. I am completely in the dark of what to do. I have no idea what to do next. I still have symptoms and I just take b-blockers to handle high heart rate.

      Like

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