“Women are more likely to be misdiagnosed than men” What, How, and Why?
-Written by Dr. Aakriti Chopra, Intern, Medical College Baroda, Vadodara
Every individual is different, we have our own likings-dislikings, thought process, habits, life-style etc. then how can diagnosis and treatment be the same for all genders ? I agree that in medical science we talk about common symptoms, adverse effects etc. But here I am referring to a different gender which has a different hormonal and emotional structure besides a common anatomy and physiology of body. As a matter of fact delayed and missed diagnosis is very common in women e.g (1) a girl visited a physician with really heavy pain during periods. But the ER doctor concluded that it was normal to have more pain with ovulation. However after a period of more than five years the GI doctors told her that she probably had irritable bowel syndrome which caused these symptoms [1]. Eg (2) Ankylosing spondylitis is a form of arthritis that affects spine and joints, causing pain and limiting range of motion. Firstly the symptoms in men and women are different. Secondly failure to do an MRI scan of the area of the spine where changes due to AS tend to be most visible, is a major reason ankylosing spondylitis is missed in women. Changes on an MRI scan are often subtler in women. Women may not present with the definitive radiographic [X-ray] changes seen in men that show signs of inflammation of the sacroiliac joints [2].
Hence many studies suggest women are more likely than men to be on the receiving end of medical misdiagnosis and the repercussions could be debilitating.
What is the root cause of this problem ?Why do so many women struggle to walk out of doctors’ chambers without knowing what’s really wrong with them?
Here are a few points which I feel are the reason behind this :
• Women are generally under-represented in medical research and health care system e.g. Twice as many women suffer from depression, but female animals make up less than half of preclinical studies, and a report showed that women make up only 38 percent of cancer trials [3]. Diagnosis in women gets even more complicated due to their under representation in clinical studies along with unspoken biases.
• Biological differences between men and women that may lead to differences in, say, how drugs are metabolized. Clinical studies are conducted largely or exclusively in men to make treatment recommendations for women ,which can be inappropriate—and downright dangerous”
• Other differences seen between the sexes (e.g., weight, muscle mass, body fat, metabolic enzymes, and plasma proteins) may also impact the pharmacokinetic parameters of a particular drug [4,5]
• Differences in pharmacokinetics of drugs between the sexes can be related to body composition and size [6]. Women typically have a lower body weight than men, so taking the same dose of a drug, results in a higher level of drug [7]. Lipophilic agents may have a larger distribution in females because of their higher body fat content [8]. Other variations between the sexes include protein binding, biotransformation, and even pharmacodynamic characteristics related to receptor and enzyme levels [6].
• According to a study entitled” Human Resource of health in India” published in Lancet only 17% of allopathic doctors and 6% of those in rural areas are women. In addition in India at MBBS level 51% of seats are earned by women (In Pakistan & Bangladesh this no. is 70% & 60% respectively) however this number decreases to one third at PG/doctoral level [9].
• Emotional factor: Women are considered to be more emotionally driven and are often referred to therapist rather being referred to a specialist.
• Lack of Awareness and Sensitivity among HCPs -A problem well stated is a problem half solved .Unfortunately this issue of misdiagnosis among women is not even known by many.This lack of awareness is a giant stone in the
• Lack of Awareness among Patients – Because of socio – economic, geographical, cultural & ethnic diversity, it has been observed that patients are ignorant & hesitate to share the entire disease pattern and history.
WAYS AND MEANS TO BRIDGE THE GAP
1) One of the ways to combat this menace is more inclusion of women in Clinical Trials – Non clinical & clinical trials are conducted to evaluate the efficacy and tolerability of drugs in animals and human beings but under representation of female subjects & women greatly impacts the credibility and outcomes of these trials as women have different hormonal structures and ratios and thus their metabolism is different. Women should be prospectively included and evaluated through all phases of drug development. Organizations should take a broader approach & make cautious decision to include at least 50% of women as subjects in clinical trials. Regulatory authorities should mandate it. After all it’s a matter of human safety. US FDA took a big step for inclusion of more women in trials by issuing new guidelines in 1993. But we all know that there is a long way to go [10].
There’s growing awareness of the importance of including adequate numbers of women in clinical studies. But turning future research into in-office action will still be a slow process.
2) More Women in Health Care System – Why does the women student number reduce to 1/3rd in PGs from 1/2 in MBBS? Reasons should be looked into .Our goal should be to improve the ratio of women in health care to at least 50% from current 17% [11].
3) Improving awareness among HCPs.- A chapter on special/ different healthcare need of women should be included in curriculum at graduation level. Workshops should be conducted for better alignment on the subject and to erase the known and unknown biases.
4) Patients should be encouraged to speak their hearts out and we as healthcare professionals should listen to them patiently, we all understand the importance and impact of a patient’s disease history on the diagnosis, treatment and therefore the final course of treatment . William Osler rightly said “Listen to your patient he/she is telling you the diagnosis”.
I conclude here with a humble submission that lets create a more inclusive society with at par representation of women, always have broader perspectives to reduce biases against women, be more aware of their needs and practice medicine as rationally as humanly possible.
About the Author: Aakriti is an intern doctor in SSG hospital , Vadodara. She is fond of sharing her views about topics concerning medicine and beyond.She aspires to be a dermatologist and has keen interest in research as well. Although medicine is challenging , she manages to take out time for travel and adventure sports ⛷️.
References
1. Shaw G. Why Women Struggle to Get The Right Diagnosis. https://www.webmd.com/women/news/20180607/why-women-are-getting-misdiagnosed, assessed on 21/5/22
2. Phillips Q. Why Ankylosing Spondylitis Is Often Misdiagnosed in Women. https://www.everydayhealth.com/ankylosing-spondylitis/diagnosing-ankylosing-spondylitis-in-women.aspx assessed on 21/5/22
3. Lee E. and Wen P. Gender and sex disparity in cancer trials. ESMO Open. 2020; 5(Suppl 4): e000773.
4. Miller M. Gender differences in the toxicity of pharmaceuticals- the Food and Drug Administration’s perspective. Int J Toxicol. 2001; 20(3):149–152.
5. Beierle I, Meibohm B, Derendorf H. Gender differences in pharmacokinetics and pharmacodynamics. Int J Clin Pharmacol Ther. 1999;37(11):529–547
6. Wizemann T. and Pardue M. Exploring the biological contributions to human health: does sex matter? Washington DC: National Academies Press; 2001
7. Parekh A, Fadiran E, Uhl K, Throckmorton D. Adverse effects in women: implications for drug development and regulatory policies. Expert Rev Clin Pharmacol. 2011; 4(4):453–466.
8. Pinn V. Sex and gender factors in medical studies: implications for health and clinical practice. JAMA. 2003;289(4):397–400.
9. Patel V., Parikh R., Nandraj S., Balasubramaniam P., Narayan K., Paul V. K., Reddy K. S. Assuring health coverage for all in India. The Lancet. 2015; 386(10011), 2422–2435.
10. Ogletree K. Women were left out of clinical trials until the ’90s,.https://www.wellandgood.com/women-clinical-trials/ assessed on 22/5/22.
11. Dar Y. A. The Glaring Case of Indian Medical Ecosystem: More Female Medical Graduates, but Less Female Doctors. https://m.siliconindia.com/news/career/The-Glaring-Case-of-Indian-Medical-Ecosystem-More-Female-Medical-Graduates-but-Less-Female-Doctors-nid-205422.html assessed on 22/5/22.
