Researchers ready to broaden our knowledge of women's health THE MEDICAL GENDER GAP

THE BALTIMORE SUN

Lauri Vidil had her first episode of chest pain eight years ago, when she was at Penn State University. It was severe enough to send her to the local emergency room.

"The doctor told me, 'Honey, you need to relax and learn how to handle stress,' " Ms. Vidil recalls. A year later, her family physician diagnosed her condition as "mitral valve prolapse," which is not life-threatening but can indeed cause chest pain.

"I found, from personal experience, that some doctors had a tendency to make me feel insecure about my symptoms," says Ms. Vidil, 29, now a Baltimore resident.

Reports published just last week suggest that other women have had similar experiences. Studies in the New England Journal of Medicine showed that women who report chest pain are less likely to have high-tech diagnostic procedures than are men. Women are also less likely to have kidney transplants, or to have their lung cancers recognized, according to an article in the Journal of the American Medical Association.

"I doubt that there are doctors out there saying, 'Isn't this amazing?' " says Dr. Stephen S. Gottlieb, one of the authors of one of the New England Journal reports. "I think there will be a realization that it is true, and that they haven't been thinking about it."

The reason for the disparity is probably lack of knowledge rather than deliberate discrimination, some medical experts say.

"I've seen patients here in the coronary care unit for five years, and I have not seen gender bias," declares Dr. Rick Veltri, director of cardiology at Sinai Hospital. "If women have chest pain they get the same type of therapies.

"The problem may be not what's happening in the hospital, which tends to be clear-cut. Perhaps the heightened awareness should be at the level of the doctors in private offices; perhaps that needs to be re-assessed."

And Dr. Gottlieb, director of the cardiac care unit at the University of Maryland Medical Center, suggested another contributing factor. Perhaps some women in the study did not think their chest pain or other symptoms were important enough to require care, he says: "I hope women will realize they do get heart disease and that they should take chest pain seriously."

Whatever the reason, the roots of the disparity could lie in another area in which women seem to have been left behind: Health studies tend to focus on men, not women.

"We have misperceptions, based on lack of data and incomplete data," says Dr. Linda P. Fried, assistant professor of medicine and epidemiology at the Johns Hopkins Medical Institutions.

For example, studies of younger people did indeed show that women were less likely to have heart attacks than men. That information has been erroneously generalized to older women, who have heart attacks at a rate approaching that of men but have not been as well studied.

The same sort of presumption might have kept doctors from looking for lung cancer in women. Until recently, women were less likely to smoke than men and so were less likely to have lung cancer, notes Dr. Ruth Kirschstein, acting associate director for research on women's health at the National Institutes of Health.

"Certainly no one should think that way now. Lung cancer is the leading cancer killer of women today," she says.

Even before last week's studies, attitudes toward women's health seemed to be changing.

"There are things that women have complained about -- palpitations and dizzy spells -- to which, in the olden days, there would be an instant reflex to say, 'Are you unhappy at home?' and Valium would be passed out," says Dr. Ruth Kantor, an internist and oncologist at Greater Baltimore Medical Center.

"That is not the present trend," she adds. "We have to be very, very careful, when an anxious, nervous woman comes in with multiple complaints, that we take her seriously. These people deserve a reasonable workup before we say they have a non-medical reason for their malaise."

In research, too, the lack of female participation is being redressed -- although, according to Kim Gandy, national secretary of the National Organization for Women, there's still a long way to go.

"All women have menopause, but there's virtually no research -- it's a woman's thing and doesn't get any attention," she says. "As many women die of osteoporosis as die of breast cancer, but there's no attention to osteoporosis, and the number of studies of breast cancer is small. Breast cancer gets only a fraction of the funds allocated to AIDS studies, and AIDS research has been done almost exclusively on male subjects, whether mice or men."

Still, research on women is expanding. At Hopkins and other centers around the country, there's a project aimed at finding out whether hormone replacement really does protect post-menopausal women from heart attacks. The East Baltimore medical institutions are also involved in a national study of cardiovascular disease in men and women past 65. And in May, Dr. Fried will begin recruiting women past 65 for a study of the causes and possible preventions of disabilities.

Women's health studies also have received a boost from the Office of Research on Women's Health, created at NIH a year ago. "We have reissued a series of guidelines on the inclusion of women in clinical studies supported by NIH grants and contracts, and we are saying, 'It must be done now,' " says Dr. Kirschstein, acting head of the office.

In addition, Dr. Bernadine Healy, director of NIH, has announced that a massive new study, known as the "Women's Health Initiative," will look at cancer, heart disease, stroke and osteoporosis in women. Hundreds of thousands of women will be enrolled, some of them in programs that evaluate the effects of weight loss, dietary supplements, exercise, smoking cessation and hormone replacement.

The flurry of activity may well have a snowball effect, as one study after another raises consciousness about women's health in the general public as well as the medical community. In the aftermath of the journals' articles, that may already have happened.

The articles suggest that "practicing physicians are not that keen on thinking of heart disease in women," says Dr. Arthur Serpick, head of the department of medicine at St. Joseph Hospital. "I think they've heightened our awareness about coronary artery disease in women."

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