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The 1990s might well be characterized as the decade of women's health — a new, finally well-defined specialty in medicine. The women's health movement in many ways grew out of the women's movement in general in the 1970s.
Twenty years or so later, we are seeing medical, political and media incorporation of women's health issues into the public awareness.
My medical school training was in the early 1980s. At that time our freshman class was 25 percent female. Today, classes are approaching the 50-percent mark.
In my day, the seminar I remember from the women in medicine group on campus centered on domestic violence. This is one of many broader concerns that have emerged as the need for a comprehensive approach to women's health and is being incorporated into medical training, medical practices and community outreach.
Concerns that arose, especially over the past two decades, surrounded the notion that women and their needs were being left out of mainstream medicine.
Heart disease in women is a good example.
The focus on heart attacks naturally occurred earlier for men since the majority of attacks in women come at a later age. Eventually, we noticed that women with heart disease were less likely to get aggressive care for a heart attack and that their disease tended to be worse when it did appear. This was an example of when a gender difference in a disease — later onset — had a very negative effect on medical outcomes.
A more global concern surrounded the view of the typical patient as a 70-kilogram white male.
This was reflected in the subject populations chosen for large and important studies. But disease tends to follow different overall patterns in the sexes. Thus, conclusions drawn from studying men represented what we call a biased sample, and could not necessarily be applied to women's health.
As a result of this awareness, society has made great strides in research and funding for women's health since 1980. The National Institutes of Health (NIH), and a multitude of other government and private institutions have taken steps to ensure focus, funding and research.
The NIH Office of Research on Women's Health was formed in 1990 and mandated by Congress in 1993 to ensure that: · All aspects of women's health are defined and studied. · Women are included in appropriate studies. · Women are recruited and advanced in biomedical careers.
The NIH currently denies funding for studies that don't use their inclusion criteria for women.
Of course, this all has been the culmination of many movements — feminist, grass-roots and physician — throughout the years. In internal medicine, for example, we have been almost obsessed with slowing the progression of osteoporosis in women, and many studies examining treatments have been done and are in progress.
In fact, we have been acutely aware of more pronounced differences in certain diseases between men and women. The list includes alcoholism, heart disease, cancer, rheumatoid disease, migraine headaches, gall bladder disease and irritable bowel syndrome.
The University of Cincinnati's College of Medicine Women's Health Program newsletter adds urinary tract infections, osteoporosis, menopause and differences in pharmacokinetics, childbearing and aging. Other problems mentioned are related to assault, violence and substance abuse. Many sources also point out that the effects of socioeconomic factors, the doctor-patient relationship and subtleties of the physical examination need to be emphasized.
When I started looking to see where we stand in Cincinnati, I opened the Yellow Pages. No luck on a women's health category, so I turned to gynecology/women's diseases. One large ad started with "Woman's Health," then clarified this with the terms, "obstetrics, gynecology and gynecological surgery." Another advertisement adds incontinence to this list.
But the current women's health movement is focused on expanding the definition beyond this, although fertility and gynecological issues, especially prevention of gynecological cancers, are a strong foundation.
"Developing our women's health program over the next several years will be somewhat dependent on funding," says Marcia Swehla, director of The Health Alliance of Cincinnati Women's Health.
The services offered by the Alliance are multifaceted. A corps of vans, "mammovans," fully equipped for doing mammograms on site, travel throughout the Greater Cincinnati community.
Swehla says that "community outreach for women's health, both for education and for providing care, is a major goal and will remain so into the future."
Alliance women's health has special birthing centers in its area hospitals, one of the largest infertility services in the nation and specialized menopause/endocrinology services.
"Although similar services are offered by others," Swehla says, "there are services more unique to us."
For example, the Alliance provides nine clinics for women's health care out in the community, specifically geared to those who cannot afford care elsewhere. Physicians are sent to these locations.
Unique services also move rapidly into the area of community education. Among other seminars, Alliance Women's Health has sponsored "Speaking of Women's Health," a day-long seminar repeated for three days each year.
Partnerships also are emphasized such as those with Procter & Gamble Co. and Kroger for health and osteoporosis screening.
Research is an important area of women's health. The Alliance recently completed a large heart survey for identifying women at high risk for cardiovascular disease, obtaining 4,900 responses.
The initial screening identified 35 percent of the sample as being at high risk for cardiovascular disease. All women received a call from a registered nurse to explain the results and to offer outpatient follow-up.
"The Tristate area population presents a significant opportunity for intervention," Swehla says.
Patients in Ohio, Kentucky and Indiana rate fairly high on deaths from heart disease, stroke and cancer compared to the rest of the country. In addition, we rate poorly in terms of being overweight, having a lot of smokers and not exercising enough.
"In the next three years," Swehla says, "our goal will be to continue to bring women's health care and education to the community through our screening programs and partnerships."
Cincinnati also has one of 40 trial centers for the Women's Health Initiative, sponsored by the NIH, through the University of Cincinnati. The initiative will test the benefits of hormone replacement therapy, a dietary program and the effects of vitamin D intake with calcium.
Finally, the College of Medicine's women's health program is promoting education, research and funding opportunities for women's health and gender-specific medicine. The program will play a key role in developing training curricula in women's health.
"In fact," says Barb Rinto, administrative director, "in the future, the label gender-specific medicine may have more meaning than women's health in terms of education, research and an actual medical specialty."
This would be in line with other expert comments that point out the importance of understanding disease in both sexes because of gender-related differences. Men also get breast cancer, for example, but why exactly do women get so much more?
The parallels between all of this and the women's movement in general stand out:
Feminism as a study has become gender studies in colleges. As a political movement, feminism has contributed to advancing equal rights and opportunities for not only women, but minorities in general. The movement also has helped produce more egalitarian workplaces and higher educational systems in our country.
In a similar manner, women's health is placing medicine in the context of wider social issues, such as our gender roles and socioeconomic status at a time when the management of medicine threatens restriction.
As feminism wound up benefiting all of us politically, women's health, or gender-specific medicine, can only contribute to our entire populations' medical progress in the next century.
