Woman’s body, man’s medicine

More cases of depression and anxiety

Worse living and working conditions for women, double working days (particularly for less qualified workers), domestic and care work, guilt and perfectionism can all have an impact on women’s health. Women are more likely to experience mental health problems such as anxiety and depression, which affect almost double the number of women (13.7%) than men (7.4%). Further to this, one in three women say they feel emotional distress, while in men this figure is one in five.

More anxiolytics

Women are more likely to be sent away with a diagnosis of mental illness at an initial visit than men, in whom an organic cause is immediately suspected and additional tests are requested. This gender bias leads to overmedication in women: 85% of psychotropic medications are administered to women. This overdiagnosis can also invisibilise physical diseases that are hidden behind an incorrect diagnosis of mental illness or psychosomatic symptoms, because they might not fit the “normal pattern” that is the male model.

The taboo of motherhood

Another area ignored by science is mental health and motherhood. One in four women experience some kind of mental health problem, some more severe than others, during pregnancy or in the postpartum period, and most of them are not treated. This is not helped by the fact that the postpartum and nurturing period is a lonely time for many women. Traumatic childbirth, a difficult pregnancy, childhood trauma or stressful situations can trigger postpartum depression and the most common symptoms are sadness, hopelessness, emotional changes, insomnia or difficulty bonding with the infant.

Leading cause of death

Cardiovascular disease is the leading cause of death in women in Spain, ahead of breast cancer. While men experience more heart attacks and women more strokes and heart failure, women are twice as likely to die in the event of a heart attack. The mortality rate of myocardial infarction is 9% in men and 18% in women. There are various reasons for this. It takes women longer to go to hospital and their symptoms are often mistaken for anxiety.

Delayed diagnosis

Women seek care later, playing down the symptoms or putting the care of others before their own, and this leads to delayed diagnosis. The symptoms are also confusing at times. Chest pain is a symptom in 90% of women, but they also have other additional symptoms, which are more intense than in men, including nausea, vomiting, dizziness and headache. “They also have chest pain and shortness of breath, like men, but by the time women go to the doctor the chest pain has already passed because they are already in heart failure”, adds Sambola.

More research

Practitioners are calling for an emphasis on cardiovascular disease prevention as there are risk factors in women that are largely unaddressed and that are closely related to pregnancy and childbirth, such as preeclampsia, gestational diabetes and premature birth. “The menopause also increases cardiovascular risk. Has that been explained? There isn’t enough information. We’re completely lost”, acknowledges Elisa Llurba, Head of the Gynaecology Department at Sant Pau Hospital. They also call for campaigns to promote self-care.

Aesthetic pressure

Breasts have been used to sell everything from cars to perfumes, but we have rarely seen what they look like on the inside. The breast has not been studied from an anatomical or physiological perspective. “It has become trivialised as something which is aesthetic rather than functional, and we have gone from not knowing anything about breasts to knowing only their pathology, breast cancer”, says surgeon Maria Jesús Pla. Furthermore, the depiction of a perfect breast has failed to take into account the fact that they come in all shapes and sizes. “The mammary gland is neither seen nor explained. We don’t know how it works, but they do teach us how the liver and kidneys work. Most women don’t know what the raised bumps on the areola of the nipple are called”, adds breastfeeding expert Alba Padró.

Breastfeeding

Over 90% of women who give birth breastfeed their children in the first few days, but this percentage decreases as months go on. There are multiple reasons for this, ranging from insufficient leave from work to a lack of breastfeeding support.

Breast cancer

Approximately one in every eight women will develop breast cancer in their lifetime. It is the most common tumour in women worldwide and in Catalonia it accounts for about 30% of the tumours affecting women. Most cases are diagnosed between the ages of 35 and 80, with the highest number of cases between the ages of 45 and 65. The disease also has an emotional impact that other cancers might not have, as it is a more visible organ and has sexual and aesthetic implications. The challenge for these patients is to return to their work and sexual life.

Controversial mammograms

Survival rates have increased with the improvement in treatments, as this is a tumour that is subject to a lot of research, and early detection through population screening. In Catalonia, mammograms are recommended between the ages of 50 and 69 every two years, not annually. Routine mammograms are not recommended in women under the age of 50 with no risk factors. The effectiveness of screening in women between the ages of 40 and 49 is a controversial debate. “The disease is less prevalent and mammograms are less effective. If population screening were to be extended, it has been said that it would be better to do so in those between the ages of 70 and 75”, explains Maria Jesús Pla.

Lung diseases

Respiratory diseases that were considered to be predominantly male conditions have risen among women due to the increase in smoking. This is the case for chronic obstructive pulmonary disease (COPD), which, according to a study by the Hospital del Mar, shows more symptoms in women: increased breathlessness, increased muscle involvement and more lesions than in men with an equally severe disease.  COPD is a disease that is underdiagnosed in women.  According to Carme Valls, there is a tendency to diagnose women with asthma when in actual fact it is COPD. Practitioners believe it progresses differently not only because of the biological characteristics of sex, but also because of the sociocultural characteristics of gender. Women with this disease have a worse quality of life.

Lung cancer

Lung cancer, which is the leading cause of cancer death, is also on the rise among women due to the increase in smoking. It has gone from being the fourth most common tumour among women in 2015 to the third, and it is expected to continue increasing in the coming years, overtaking breast cancer. Meanwhile, it is expected to become less common among men due to the decline in smoking.

Long COVID

There are people, mostly women, who have already had an acute coronavirus infection but continue to have symptoms six months later. These are generally young women, between the ages of 35 and 50, who have a wide range of fluctuating symptoms including headache, extreme fatigue, tachycardia, muscle and joint pain, breathing difficulty and memory loss. This even occurs after having had a mild form of COVID. The symptoms are similar to those of chronic fatigue, a condition with which they also share preconceptions and a lack of understanding. Long COVID is thought to affect between 10% and 20% of patients. There has been a lack of information on this condition for months, which has led to underdetection and those affected have at times felt questioned by the healthcare system.

Silenced disease

There are diseases that only affect women, such as endometriosis, for which there is a lack of investment and research because, as scientist Maria Montoya from the Spanish National Research Council (CSIC) ironically puts it, “they only affect 50% of the population”. Endometriosis is the gynaecological disease with the highest incidence: it affects at least 10% of women of reproductive age, but this figure could be higher as the condition is underdiagnosed. It is a chronic disease, and its best known symptoms are pain during menstruation, pelvic pain and infertility. However, the pain has become socially normalised among women to the point that a diagnosis can take up to eight years.

Obstetric violence

The healthcare system has medicalised normal physiological processes in women, such as pregnancy, childbirth and the menopause, by imposing a paternalistic approach: seven out of ten women say they have felt belittled during pregnancy or childbirth. However, women are becoming increasingly informed and empowered and are pushing for a change in the care model, demanding a more humanised and less medicalised care. “Depending on how we deal with childbirth, we can leave a young, healthy woman with a chronic condition, and the healthcare system and practitioners must be held accountable for this”, says Maria Llavoré, midwife at Sant Pau Hospital.

The caesarean section rate in Catalonia (27.4%) is still double the WHO’s recommended rate (15%) and is, together with inductions, an indicator of obstetric quality. Episiotomies, the Kristeller manoeuvre and overmedication are just some of the practices that have been criticised. But infantilising a woman or disregarding her consent is also considered to be obstetric violence. This respect applies not only to childbirth, but also to miscarriages, abortions and infertility or assisted reproduction procedures. The Ministry of Equality, like the Catalan law on gender-based violence before it, plans to include obstetric violence as a form of violence against women in the reform of the abortion law. The Catalan Society of Obstetrics and Gynaecology and the four Catalan medical associations have recently acknowledged that obstetric violence exists and are calling for a debate, even though they have admitted that the term makes them uncomfortable.

Sexuality

Female sexuality has been invisibilised or is full of taboos and stereotypes, and pleasure and the female body have long been an unknown reality, even to women themselves. We have not received sex education, and the education we have received has perpetuated sexist models. However, more and more women are reclaiming their pleasure while making sexual and gender diversity visible beyond binarism. Further to this, consultations related to sexuality are increasing because issues such as pain during sex and anorgasmia are no longer normalised.

Pelvic floor

Almost half of women (46%) have one or more pelvic floor disorders, such as urinary or bowel incontinence or pelvic organ prolapse. This has a major impact on their quality of life. Pregnancy and childbirth are key factors, but there are also other causes such as high-impact sport, constipation, ageing and the menopause. Until recently, it was considered that, since no one died, it was simply accepted, but practitioners are calling for check-ups and treatment of the pelvic floor to be routine practice in the healthcare system and for there to be a prevention strategy: the pelvic floor should be discussed from an early age, and training should be provided in schools. Teaching how to do Kegel exercises should be like teaching to brush your teeth.

Gynaecological cancers

These cancers begin in the female reproductive system. They can affect the cervix (the neck of the uterus), ovaries, uterus, vagina and vulva. The risk increases with age and some gynaecological cancers are caused by the human papillomavirus (HPV). Girls and women between the ages of 9 and 26 can be vaccinated against HPV, and vaccination is recommended before becoming sexually active. If the vaccine were less expensive, practitioners believe that it would also be advisable to administer it to boys.

Chronic pain

One in three women report having pain or discomfort, while in men this figure is one in five. Women are more likely to experience chronic pain as most diseases that cause muscle or joint pain are more common in women. “Chronic pain is one of medicine’s unresolved issues”, says endocrinologist Carme Valls. Experts are calling for it to be addressed as a public health problem.

Physical and mental overload

Rheumatic and musculoskeletal diseases such as arthritis, osteoarthritis, back pain, osteoporosis and fibromyalgia are a common cause for consultation in primary care. It is estimated that these conditions take up around 30% of primary care physicians’ time. Valls states in her text that the pain of many women is often silenced or invisibilised with psychotropic medications and that studies do not take into account the physical and mental overload experienced by women in their lives and workplaces.

Fibromyalgia

Fibromyalgia is characterised by chronic pain throughout the body, particularly in the muscles and joints of the back and limbs, and hypersensitivity to pain, noise, smells and light. It can also be accompanied by cognitive and sleep disorders, gastrointestinal disorders and fatigue. It is a disease that occurs more frequently among women (4.2% of women and 0.2% of men in Spain), its origin is unknown and, in many cases, it is debilitating. Those affected can spend years going from one consultation to the next until eventually reaching the diagnosis of a highly stigmatised disease.

It is not without controversy. Carme Valls wrote in her text that “all kinds of muscle pain for which no explanation could be found have been attributed to this disease, with no objective evidence”. She questions the fact that it is treated with psychotropic medications and believes that more research studies are needed for women diagnosed with fibromyalgia.

Attacked by our own defences

Autoimmune diseases are those in which the immune system attacks the body's own organs. It is estimated that one in ten people in Catalonia has an autoimmune disease. Some only attack specific organs, such as autoimmune thyroiditis, the most common form, which affects the thyroid gland, while other systemic forms involve a generalised attack. Sjögren’s syndrome is the most prevalent of these, but lupus is the most paradigmatic.

More women affected

Two-thirds of those affected are women and in some specific conditions this proportion is even larger: for every man with lupus there are nine women, and for every man with Sjögren’s syndrome there are six women. There are multiple reasons for this, but female sex hormones are a major factor, and “periods in which they are more active, from puberty until menopause” is when the most disease onsets and the most flare-ups occur.

Pregnancy

It also affects women of childbearing age, which has special implications. Forty years ago it was said that women with lupus would not be able to have children as they would miscarry and the disease would flare up. Nowadays they have similar fertility to the general population, although pregnancies are more closely monitored.

The other bias

In this case, it is men who may experience a delay in diagnosis because, ‘in theory’, doctors find it hard to believe that a man might have lupus, for example. But when they do have it, it is more severe.

Clinical trials

For decades there has been gender bias in clinical research. Due to hormonal changes and for safety reasons, women were not included in clinical trials and this exclusion has led to gaps in knowledge. This is also the case for studies with animals, in which two-thirds are male. When women have been included in trials, the results have not been segregated, meaning that the results are applied equally to both men and women, even though the participation of women is lower. “When you don’t segregate by sex, you don’t know the situation for either men or women, or the specific characteristics of each of them, and that’s bad science”, notes Lucía Artazcoz. But this is changing, partly thanks to COVID.

Adverse reactions

Excluding women from clinical trials means that adverse drug reactions are either unknown or take years to be noticed and for measures to be taken. Eight out of ten drugs withdrawn from the market in the USA between 1997 and 2000 had greater health risks for women than for men. As an example, statins, a widely used drug, have been shown to have more adverse effects on women.

The way in which the drug is metabolised or how we benefit from the drug is different due to metabolic and genetic history as well as hormonal issues. Again, there is little information available, or incomplete information, regarding the adverse effects of drugs on pregnant and breastfeeding women, and the coronavirus vaccine is an example of this. The information on COVID in pregnant women has been contradictory since the start of the pandemic.

Doses

It has been assumed that if a dose is appropriate for a man, it is also appropriate for a woman, but men and women are different in many respects, one of which is body mass. For example, men have 80% fat-free body mass and women have 65%, and this affects the way in which we metabolise a drug.

In oncology, “the same drug may be less effective or ineffective in one sex compared to the other, and we might have to use different drugs depending on whether the patient is a man or a woman”, Wagner adds. But this also poses a challenge because sex is not the only factor involved in the variability of responses to a drug. To this end, practitioners are calling for more clinical trials and the inclusion of non-binary genders too.

Contraceptive pills

To downplay the risks of thrombosis of the AstraZeneca vaccine, these were compared to those of contraceptive pills, which are more common, and no one was surprised. Without criminalising contraceptives, which were a liberation for women, women are demanding that they be provided with full information about side effects. The risk of thrombosis is estimated to be 1 to 10 in every 10,000 women, making it a rare adverse effect, but we must be aware of the factors that may favour it, such as family history, being over 35, smoking, excess weight and hypertension. The other most common side effects include mood disorders, reduced libido, migraines, nausea and fluid retention. They are also prescribed for other conditions such as polycystic ovaries and endometriosis, and this may lead to other possible solutions not being investigated.

The pills are said to “regulate the cycle”, but in actual fact they inhibit it. With contraceptives there is no real bleeding because there is no ovulation. It is a fictitious bleeding because during the break there is a sudden hormonal change. This is meant to mimic the female cycle, because it is a way of reassuring women, but it is not really menstruation, although many women do not know this. “Why the male contraceptive pill has never been marketed is a matter for further reflection”, writes Valls. As for the relationship between contraceptives and breast cancer, there is much controversy and there are no conclusive studies, although Pla assures that “it has not been proven to be a risk factor”.

Menopause

On the other hand, hormone replacement therapy (HRT) with oestrogens and progestin, which is used to alleviate some of the effects of the menopause, such as vaginal dryness and hot flushes, has been linked to an increased risk of breast cancer and women are advised against receiving it for over five years. According to a 2004 study, 43% of women who were prescribed this were unaware of the risks involved in its use.