by Carolyn Thomas ♥ @HeartSisters
In September, I mentioned here an important book written by Dr. Alyson McGregor, an Emergency physician and associate professor of medicine at Brown University. The book: “Sex Matters: How Male-Centric Medicine Endangers Women’s Health and What We Can Do About It“. Her first chapter opens with a story about Julie, a 32-year old woman she met in her Emergency department one day – a story that’s disturbingly familiar to women like me whose heart attack has been misdiagnosed: .
“Julie had visited her primary care doctor several times prior to coming to our Emergency department and had also seen at least two other physicians in the previous 48 hours. She was experiencing chest discomfort and shortness of breath that worsened markedly the more agitated she became. Immediately, I thought to myself, ‘This woman doesn’t look good.’ I had a gut feeling that something was really wrong. But like Julie’s previous doctors, the cardiologist I called in decided that Julie was just displaying symptoms of anxiety. Her EKG, however, was slightly abnormal, so he finally agreed to take her to the cath lab for an angiogram.”
What was identified in the cath lab that day was in fact a blocked main coronary artery. In a man, this cardiac event is often called a ‘widow maker heart attack’, as Dr. McGregor explains:
“We see it all the time in men over 50, and in a number of post-menopausal women. And yet, here was sweet 32–year-old Julie presenting with a condition that if left untreated was likely to kill her in weeks, if not days – and no one had thought to look for it because her symptoms and risk factors weren’t consistent with the classic male model of a heart attack.”
She adds that women’s cardiac symptoms often mimic other diseases and events that are considered more ‘female’ – such as the panic attacks cited by Julie’s previous doctors. She adds something that my regular Heart Sisters readers already know: misdiagnosis is unfortunately common among female heart patients – particularly in younger women.
This misdiagnosis reality continues to be confirmed in study after study. For example, researcher and professor of Cardiac Pharmacology Dr. Sian Harding recently wrote:
“As well as being misdiagnosed, women are less likely to be treated quickly, less likely to get the best surgical treatment and less likely to be discharged with the optimum set of drugs. None of this is excusable.”
Dr. McGregor suggests a possible reason to explain those realities:
“If a man comes into the Emergency Department with chest pain and shortness of breath, there’s no question that he may be having an MI (myocardial infarction).
“If a woman comes in with the same issues, and she has a history of anxiety listed in her chart, the consensus will likely be that she’s just suffering muscular or respiratory spasm related to anxiety. If her EKG comes back ‘normal’ or close to normal, she’ll be sent home.
“Women in cardiac distress don’t receive the diagnostic tests they need because our protocols don’t account for the way heart disease presents in women’s bodies.”
That’s a distressing statement for female heart patients to ponder. Because I apparently needed more distress in my life, I took a break from reading Dr. McGregor’s book to watch her compelling 2015 TED talk called “Medicine Often Has Dangerous Side Effects for Women“ – filled with astonishing illustrations of how male-centric medicine can hurt women, starting with her example of the medications that are prescribed for us:
“We know that 80% of the drugs that are withdrawn from the market are due to side effects in women.
“It takes years for a drug to go from an idea to being tested on cells in a laboratory, to animal studies, to clinical studies in humans, finally to a regulatory approval process to be available for your doctor to prescribe – not to mention the millions of dollars in funding this takes.
“Why are we discovering drug side effects in women only AFTER the drug is already approved and introduced in the market?
“In every aspect, our current medical model is based on, tailored to, and evaluated according to male models and standards. We give aspirin to healthy men to help prevent a heart attack. But if we give aspirin to healthy women, it’s actually harmful. (See also: “Should women take daily aspirin to prevent heart attack?“)
“It turns out that those cells used in those research laboratories were male cells. And the animals used in the animal studies were male animals. And the clinical studies have been performed almost exclusively on men.
“How is it that the male model has become our framework for medical research?”
She calls our attention to a drug called Ambien (Zolpidem) – first prescribed over 25 years ago to help people sleep at night:
“Since then hundreds of millions of prescriptions have been written for Ambien, primarily to women because women suffer more sleep disorders than men.
“But the FDA has now recommended cutting the dosage in half for women only – because they realized that women metabolize this drug at a slower rate then men, which causes them to wake up in the morning with more of the active drug in their system. Drug monitoring reports found 1,000 cases of women who, the morning after taking Ambien, were injured in motor vehicle crashes related to being impaired.”
By the way, here’s how Sanofi-Aventis (the drug company that manufactures Ambien) describes that dangerous side effect in an oddly milque-toast way on their own patient information site: “Getting out of bed while not being fully awake and doing an activity that you do not know you are doing.” (I’m guessing that covers activities like driving while asleep).
Dr. McGregor says she now wonders: how many of the car accident-related injuries in women she has treated in Emergency over the years could have been prevented if drug side effect analysis that included women had been performed long before the Ambien they were taking was approved?
She adds that drug companies prefer to do their drug research on men instead of women because “men’s bodies are pretty homogenous”. Men, after all, don’t have the constantly fluctuating levels of hormones that women do. So for decades, medical research has been performed on men, and their results were then automatically applied to women.
And despite current funding requirements for equitable representation of women in new research studies, female participation numbers in research still lag far behind male participants, especially in heart research. See also: Cardiac research and the mystery of the missing facts
Researchers must actively recruit women for their studies, but women too must agree to participate. We know, for example, that women will volunteer for “bikini area“ research (breast and reproductive organs) – but far less often for cardiac studies – likely because many women still consider heart disease to be a man’s problem, as revealed in the discouraging results of the American Heart Association’s latest national survey.
And as Dr. McGregor reminds us:
“Women are NOT just men with boobs and tubes.
“We have our own anatomy and physiology that deserves to be studied. One of the biggest and most flawed assumptions in medicine is: if it makes sense in a male body, it must make sense in a female one, too. But in every aspect, our current medical model is based on, tailored to, and evaluated according to male models and standards.”
“Women are different from men in every way, from their DNA on up. Women’s blood vessels surrounding the heart are smaller in women than men. The way those blood vessels develop disease is different than in men. And the diagnostic tests we use to determine a heart attack were designed and tested and perfected in men – and aren’t as good as determining that in women.”
She lobbies for improved medical education as a key to improving both awareness and skills of future physicians and healthcare professionals – which I see as an extremely important step.
I often say that current students in medical school may well be our next best hope in addressing pervasive disparities in women’s cardiac research, diagnostic tools, treatment and outcomes.
Dr. McGregor believes that we’re now in the midst of what she calls a second women’s revolution.
“The first revolution in women’s health began in the 1970s with the publication of the groundbreaking book Our Bodies, Ourselves. This was the first time women were invited to understand themselves as biologically different from men. Women demanded access to things like birth control and pain relief. . . They demanded autonomy, and when the
establishment resisted, they claimed it anyway.
“There’s no going back now.”
“We need to re-invent modern medicine from the ground up to include the half of the human population it has, until now, marginalized and left behind. We know just enough to know that we weren’t doing it right. This is not only about improving care for women, but about the power to transform medicine for everybody.”
♥
Photo of Dr. Alyson McGregor at Rhode Island Hospital: Benedict Evans/©The Observer
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Q: Have you ever encountered a problem with diagnosis or treatment based on male-centric medicine?
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NOTE from CAROLYN: I wrote much more about cardiology’s gender bias in Chapter 3 of my book, “A Woman’s Guide to Living with Heart Disease”. You can ask for it at your local library or bookshop, or order it online (paperback, hardcover or e-book) at Amazon – or order it directly from my publisher, Johns Hopkins University Press (use their code HTWN to save 30% off the list price).
See also:
-Dr. McGregor’s 15-minute TED talk called “Why Medicine Often Has Dangerous Side Effects for Women”
–Must women bring an advocate along to help doctors believe us? (more on Dr. McGregor’s book – plus two other must-read books on the gender gap in women’s health care)
-Links to many more Heart Sisters articles on cardiology’s gender bias
Heart Sisters 
I was told a month ago by my male cardiologist that the research on heart medication was all done on males, females and different ages, and ethnicities.
From what you’re saying, that is not true, but I don’t have the research to reply. My male cardiologist was abrupt and difficult to communicate with over the phone, so I insisted on in-person appointments. I tried to request a change to one of the two female cardiologists in the same office. That was refused, because I think that all the cardiologists are full.
I felt that if I had a female, they would be more likely to treat me more compassionately and also as a female patient.
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Hi Sharon – I can’t guess which medical journals that cardiologist was quoting. Not the same ones Dr. McGregor is reading, I’d guess.
Even the recommendation to take aspirin for the primary prevention of heart disease, for example, was widely published in 2007 – just a year before my own heart attack. But newer published research (including three clinical trials in 2019) found that, for healthy adults with low risk of heart disease, taking aspirin reduced the relative risk of a serious cardiovascular event by 17%, BUT also increased the risk of major gastrointestinal bleeding (47%) and brain bleeds(34%) – in both men AND women. Yet healthy adults can still buy aspirin over the counter believing it will prevent heart disease.
That’s just one drug – I too would like to believe that all cardiac meds have been carefully tested in men, women and minorities of different ages – but that’s simply not true (especially for women, minorities and seniors). I’m guessing that your cardiologist is not alone in refusing to elaborate on statements that do not seem accurate.
I happen to have a male cardiologist and a male pain specialist who are both fantastic. Many male cardiologists are, too! but I sure understand the appeal of preferring a female doctor. See my response to Jill’s comment (below). I cringe at the the thought of you with an “abrupt and difficult” doctor. Is there a way you could seek another cardiologist in a different office?
Take care, stay safe. . . ♥
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Each of your weekly articles brings up so many issues besides the main theme. For me, Dr McGregor’s statement: “I had a gut feeling that something was really wrong.” was very important. That, along with her valuing that feeling and defending it until she got what her patient needed.
Doctors are trained in so many protocols of how to diagnose and treat in both medical school and continuing education that their innate ability to connect with a patient and feel what their patient is feeling is blunted or totally unavailable.
When a doctor does not connect and put himself in the patient’s shoes, he cannot easily access that gut feeling or intuition that can save a life.
I remember once my cardiologist was listening to my symptoms and first suggested the usual protocol, a nuclear medicine scan. I said “Do you really think that will be helpful? I have never felt that my past scans were at all helpful.”
At which time we both agreed that I needed a cardiac Catheterization. He mentioned that was what he REALLY FELT from the beginning. The Cath led to a stent in a 90% occluded circumflex artery.
Not to be gender-biased but female doctors seem to be more in touch with their intuition or at least more comfortable in relying on it and defending it.
My cardiologist was male but was very open to connecting to his patients and learning from them.
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Hi Jill – love your nuclear medicine scan story! I too was instantly taken by that “I had a gut feeling” statement from Dr. McGregor. But how many gut feelings are dismissed by physicians after seeing our “normal” diagnostic tests?
In my own Emergency department experience, for example, my cardiac enzyme (troponin) blood tests came back “normal”. How is that even possible in mid-heart attack? It’s possible because all cardiac diagnostic tests have been, as Dr. McGregor reminds us, “designed and tested and perfected in men.”
That’s why I love what Dr. Karin Humphries in Vancouver has been working on: troponin testing in women. If this cardiac enzyme is detected in blood tests, it’s typically a pretty reliable marker for heart muscle damage caused by a heart attack. But the commonly used troponin threshold in this test is based on a level that’s considered appropriate for men, but may be set too high for women – whose blood tests would be incorrectly interpreted as “normal”. Dr. Humphries and her colleagues suggest we need to set a lower female-specific troponin threshold. Hallelujah! Great example of taking women’s physiology into account in diagnostics.
Think of how many women could be diagnosed correctly if we had those improved troponin thresholds!
You’re not being gender-biased – there are in fact several studies suggesting that patients with female physicians do have better outcomes compared to male docs (unless the male docs work alongside female docs!) Here’s just one example.
Thanks Jill for weighing in here as a retired nurse AND a heart patient – your perspective is always interesting to me! ♥
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Blessings Carolyn….I have spent the majority of my life advocating for patients and that is what you do also. . . Kindred Spirits!
I am happy to hear about the Troponin research for women.
However, always looking for the subtle and philosophical. . . If troponins are a marker for damaged heart muscle, why are we not looking at what can indicate impending danger to heart muscle BEFORE it happens?
Yes, managing risk factors is important but what about that grey area between risk of heart attack and damaged heart muscle? I know there are risks involved with cardiac cath but it would be interesting to know the risk of not doing a cardiac cath when your gut tells you that is what the patient needs?
If there was not that slight alteration in the EKG would Dr McGregor have been able to convince the cardiologist to do a cath based on her intuition?
My ex-husband’s life was saved by a female ER doc. He looked like a classic Acute MI but every test was negative. She knew he should not be sent home and decided to do a chest CT and she found he had a deadly saddle pulmonary embolism.
Sorry for dragging you down my rabbit hole.
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Hi Jill – you seem to have some of the same rabbit holes I have!“Why are we not . ..?” is one of my favourite ways to start ruminating on yet another mystery in how women are diagnosed and treated.
I suspect we all know the answer to your question on whether Dr. McGregor would have been able to convince that cardiologist to see her patient based on her intuition WITHOUT that slight alteration in the patient’s EKG? Depending on the intuitive powers of the cardiologist involved, my guess: NO WAY!
I’ve often told my Heart-Smart Women audiences that if their cardiac diagnostic tests come back “normal”, the reality is that they can pretty well kiss a cardiac diagnosis goodbye.
Unless you’re a man.
Many studies have confirmed this (men/women with identical cardiac symptoms + “normal” tests are often assessed very differently in Emergency). Your ex was remarkably fortunate that for some reason, his Emerg doc trusted her gut feeling based not on his “normal” diagnostics, but on his textbook symptoms.
Re your rabbit hole question of “not doing a cardiac cath when your gut tells you that is what the patient needs?” Since not referring an Emerg patient to cardiology despite what your gut tells you could end up being a misdiagnosis, and since no jurisdictions that I’m aware of require mandatory reporting of diagnostic error, we will never know what happens – since technically, those misdiagnoses never happened. . .
Another rabbit hole. . . !!
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I am very happy to see more young women in Cardiac Medicine.
Women present differently than men during cardiac events. I was diagnosed accidentally with hypertrophic cardiomyopathy six years ago. Then, it was discovered that I needed a quadruple bypass which was done three years ago.
Still waiting for an alcohol ablation. Cardiac care in women is more than “anxiety “! Please listen!
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Hello Darlene – Excellent advice: LISTEN! You were likely very lucky to be “accidentally diagnosed” six years ago. What if that hadn’t been noticed?
I sure hope your wait will end soon so you can finally have your procedure done.
Good luck – take care and stay safe. . . ♥
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Hello Darlene,
As a retired nurse and an HCM patient, I could list multiple instances where being knowledgeable about my disease and its treatment options have improved or saved my life.
I was finally diagnosed with Obstructive Hypertrophic Cardiomyopathy in 2006 after 2 decades of symptoms that went unexplained or misdiagnosed. I had septal reduction surgery at Mayo Clinic in 2014 with dramatic improvement.
I am happy to say that since my diagnosis, HCM education has become much more available to both patients and doctors. You may want to visit: http://www.4HCM.org for general info or http://www.HCMbeat.com for all the latest research including new medications that are reducing the need for surgery or ablation in some patients!
Blessings on your journey!
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Thanks Jill for recommending those two HCM sites for Darlene! ♥
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Hi, Carolyn!
Two stories:
1) Saw a male cardiologist for chest pain, shortness of breath. Have long cardiac history, including MI (myocardial infarction) and 7 stents (5 in “Widowmaker” artery). His diagnosis? “Patients who come with pain and nothing organically wrong (?!?) are always women. We don’t know why.”
2) Have had multiple stress tests, been told I passed “with flying colors.” Due to symptoms, fought for caths. Every single time, there was at least 1 major blockage (1 was 95% in my main artery).
Now I have abnormally low heartbeat. “Not sure if you need a pacemaker.” Would there be uncertainty if I was a male?!?!?
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Hello Fran – I’m yelling at my laptop screen on your behalf as I read your stories. WTF?!?
I can just picture that male doctor pondering “we don’t know why”. Seems like his own sense of unwarranted certainty made it impossible for him to even consider that women in pain can actually have SOMETHING ORGANICALLY WRONG. Arrrrrgh!
I believe you are 100% correct: men do NOT have to fight to be believed. Women do.
It has to stop.
Thanks for this – take care and stay safe. . . ♥
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