When it comes to health care, men really could be from Mars and women from Venus. Women are more likely to seek medical care and use health care regularly than men are. They have unique and very different needs regarding their anatomical and hormonal makeup. Women also have unique psychological issues; they experience twice the rate of depression as men, regardless of race or ethnic background. Over the past year, the pharma-cotherapy landscape has undergone much change in the fi eld of women’s health. Here are overviews of those changes and insights into the contributions pharmacists can make to the health of their women patients. Problem not just as a weight issue but as overall well-being. [Randi clinic] has a team-model approach to taking care of our patients, which includes dietitian, pharmacist, and other providers [who] can send a message to the patient from multiple angles.”
Deaths from non-communicable diseases, communicable diseases and injuries among women in 2012, by the World Bank income category and the WHO region. Data were obtained from the Global Health Estimates 2014 Summary Tables.2 List of World Bank income categories and WHO regions: high-income countries: Andorra, Antigua and Barbuda, Australia, Austria, Bahamas, Bahrain, Barbados, Belgium, Brunei Darussalam, Canada, Chile, Croatia, Cyprus, the Czech Republic, Denmark, Estonia, Equatorial Guinea, Finland, France, Germany, Greece, Iceland, Ireland, Israel, Italy, Japan, Kuwait, Latvia, Lithuania, Luxembourg, Malta, Monaco, the Netherlands, New Zealand, Norway, Oman, Poland, Portugal, Qatar, Russian Federation, Saint Kitts and Nevis, San Marino, Saudi Arabia, Singapore, Slovakia, Slovenia, South Korea, Spain, Sweden, Switzerland, Trinidad and Tobago, the United Arab Emirates, the UK, the USA , Uruguay; African region: Algeria, Angola, Benin, Botswana, Burkina Faso, Burundi, Cabo Verde, Cameroon, Central African Republic, Chad, Comoros, Congo, Côte d’Ivoire, Democratic Republic of the Congo, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mauritius, Mozambique, Namibia, Niger, Nigeria, Rwanda, Sao Tome and Principe, Senegal, Seychelles, Sierra Leone, South Africa, Swaziland, Tanzania, Togo, Uganda, Zambia, Zimbabwe; region of the Americas: Argentina, Belize, Bolivia, Brazil, Colombia, Costa Rica, Cuba, Dominica, Dominican Republic, Ecuador, El Salvador, Grenada, Guatemala, Guyana, Haiti, Honduras, Jamaica, Mexico, Nicaragua, Panama, Paraguay, Peru, Saint Lucia, Saint Vincent and the Grenadines, Suriname, Venezuela; South-East Asia region:
Bangladesh, Bhutan, India, Indonesia, Maldives, Myanmar, Nepal, North Korea, Sri Lanka, Thailand, Timor-Leste; European region: Albania, Armenia, Azerbaijan, Belarus, Bosnia and Herzegovina, Bulgaria, Georgia, Hungary, Kazakhstan, Kyrgyzstan, Montenegro, Moldova, Romania, Serbia, Tajikistan, Macedonia, Turkey, Turkmenistan, Ukraine, Uzbekistan; Eastern Mediterranean region: Afghanistan, Djibouti, Egypt, Iran, Iraq, Jordan, Lebanon, Libya, Morocco, Pakistan, Somalia, South Sudan, Sudan, Syria, Tunisia, Yemen; Western Pacific region: Cambodia, China, Cook Islands, Fiji, Kiribati, Lao, Malaysia, Marshall Islands, Micronesia, Mongolia, Nauru, Niue, Palau, Papua New Guinea, Philippines, Samoa, Solomon Islands, Tonga, Tuvalu, Vanuatu, Viet Nam.
Despite the importance of NCDs to women’s health, medical research on NCDs has generally only involved men. This has occurred in part because of the widely held assumption that the occurrence and outcomes of NCDs, as well as the efficacy of preventative measures, are the same for men and women, and that the findings of studies into disease processes involving only men apply equally to women. There is an increasing notion that this is not the case and our knowledge about disease occurrence and disease outcomes—for men and women—can be improved by undertaking analyses of health data disaggregated by sex and informed by a gender perspective, as well as by including sufficient numbers of women in scientific studies. Hence, to optimise the health of women globally, the women’s health agenda must have a broader definition and prioritise a sex-specific and gender-specific approach to the collection and usage of health data.
These are addressed by the policy paper entitled “Women’s Health: A New Global Agenda”, published in the recent edition, detailing present practice and policy, and calling for a redefined and expanded women’s health agenda. The paper calls for prioritizing NCDs and for sex-specific and gender-specific approaches to health data collection, analysis, and reporting. A full version of the paper is found in the online supplementary appendix. Box 1 explains the terms “sex” and “gender”. A box also outlines the main findings and recommendations of the paper.
Rethink about Women’s Health
Current approaches to improving the health of women do not address those health conditions that are responsible for the greatest burden of ill health, namely NCDs. It also does not fully address the importance of certain reproductive health factors such as gestational diabetes and pregnancy-induced hypertension—for the health of women in later life. This limits the opportunities to improve the health of the maximum number of women in the most effective ways possible. Moreover, a women’s health agenda that focuses almost exclusively on women of childbearing age is discriminatory as it excludes those women who do not have children (either voluntarily or involuntarily) and women who are no longer of reproductive age. A broadened definition of women’s health that incorporates a greater focus on NCDs as well as a life-course approach to sexual and reproductive health (SRH) and NCDs has the potential to lead to greater health benefits for women and in effect the health of their communities globally.
Since 1990, maternal and infant deaths have decreased sharply and neither is ranked in the top 10 causes of death globally. Instead, ischaemic heart disease (IHD) and stroke were the number 1 and 2 leading causes of death for women, followed by chronic obstructive pulmonary disease (COPD), Alzheimer’s disease, diabetes, hypertensive heart disease and lung cancer.
4 Lower respiratory infections, diarrhoeal diseases and HIV/AIDS were the communicable diseases that completed the top 10 and were ranked at places 3, 7 and 8, respectively. Even in LMIC in Africa, NCDs account for an increasing burden of death among women. While infectious diseases, maternal and child conditions, and malnutrition remain a leading cause, NCDs caused a third of all deaths in 2012, compared with a quarter of all deaths in 2000 .2 Similarly, five of the leading causes of disability-adjusted life years for women across the world in 2013 were NCDs, namely IHD, low back and neck pain, stroke, major depressive disorder, and COPD. Complications arising from preterm birth continue to be included in the top 10 leading causes of disability, ranked at the ninth position.4 Lower respiratory infections, diarrhoeal diseases, HIV/AIDS and malaria completed the list of the top 10 leading causes of disability and were ranked at the third, sixth, seventh and eighth positions, respectively.
Sex-Specific and Gender-Focused Health Research
Sex differences and gender disparities in the occurrence, management and outcomes of chronic health conditions have long been under-recognised. Health research in CVD, for instance, was once predominantly conducted in men and it was assumed that medical practices based on research findings involving men only were equally relevant for women.13 This approach limits the generalisability of research findings and their applicability to clinical practice, in particular for women but also for men.
A growing body of evidence from studies including both men and women suggests that such research is prejudiced, as well as potentially harmful for women. For example, between 1997 and 2000, 8 of 10 drugs withdrawn from the US market because of side effects were withdrawn because of greater health risks for women than for men.14 Moreover, research on cardiovascular conditions increasingly demonstrates that there are clinically meaningful sex differences and gender disparities in the occurrence, management and outcomes of CVD.
Sex Differences in Cardiovascular Disease
CVD is still widely considered as a male disease, an assumption that stems largely from observations that CVD in women develops later in life than in men, and the historical misperception that CVD among women may not be as serious as it is in men. This is despite the fact that CVD causes more deaths in women than any other disease in almost all countries in the world. Awareness of the importance of CVD in women has increased substantially in HICs. However, there remains a substantial gap between the perceived and actual risk of CVD in women, and few women see it as a threat to their health.
Recent evidence has demonstrated that are clinically relevant differences between men and women in the occurrence of the various manifestations of CVD.Men tend to develop CVD at a younger age and, as such, have higher rates of IHD than women. In contrast, women are at a higher risk of having a stroke, which occurs more often at an older age. Healthcare services for the management of established CVD are also delivered differently between sexes.
This is despite evidence that, generally speaking, preventative therapies are equally effective in women as in men. For example, women are less likely to receive pharmacological treatment for CVD risk factors than men and are also less likely to be referred for diagnostic and therapeutic procedures.Suboptimal access to healthcare services could delay the diagnosis and treatment of CVD and may lead to worse prognosis and outcomes for women with CVD.
Apart from the disparities in the secondary prevention of cardiovascular disease, there is already strong evidence that certain risk factors—smoking and diabetes, for example—increase CVD risk disproportionately more in women than in men. The effects of excess weight, high blood pressure, and elevated lipid levels on CVD outcomes appear to be similar for both sexes.
The Need to Redefine and Expand the Women’s Health Agenda
Firstly and most importantly, we believe that current practice limits the opportunities to improve the health of the maximum number of women in the most effective ways possible, and by extension the health of the communities in which they live. Secondly, we believe that an agenda with an almost exclusive focus on women of childbearing age effectively discriminates against and excludes those women who do not have children and women who are no longer of reproductive age.
To optimise the health of women globally, a women’s health agenda should address those health conditions that are responsible for the greatest burden of ill health. As the next section of the paper will demonstrate, in most countries in the world, the leading causes of mortality and disability for women are NCDs.
However, to improve the health status and outcomes for mothers as well as newborns, the management of NCD risk behaviours and conditions in adolescent girls and women in their childbearing years is essential to ensuring the best birth outcomes.
Top Causes of Death and Disability in Women
The leading causes globally In 2013, data from the Global Burden of Disease study showed that ischaemic heart disease (IHD) and stroke were the leading causes of death for women worldwide (Table One).Furthermore, seven of the ten leading causes of death were NCDs, including chronic obstructive pulmonary disease (COPD), Alzheimer’s disease, diabetes, hypertensive heart disease, and lung cancer. By comparison, in 1990, NCDs accounted for only four of the leading causes of death.
Since 1990, maternal and infant deaths (as a result of preterm birth or low birth weight) have decreased, such that neither is now ranked in the top ten causes of death. Similarly, five of the leading causes of disability for women across the world in 2013 were NCDs, namely IHD, low back and neck pain, stroke, major depressive disorder and COPD (Table Two).Preterm birth complications continue to be ranked in the ten leading causes of disability, at number nine.
The leading causes in HICs
In HICs, all but one of the leading causes of death (lower respiratory infections) amongst women were NCDs, with Alzheimer’s disease listed as number three (following IHD and stroke) and three cancers (breast, lung and colorectal) also listed in the top ten (Table One). In the UK, similarly, all but one of the leading causes of death were NCDs, including Alzheimer’s disease, with four cancers (lung, breast, colorectal and ovarian) listed in the top ten. NCDs were responsible for all ten leading causes of disability in women in HICs, dominated by cardiometabolic conditions, musculoskeletal conditions, and neurological and mental health disorders (Table Two).
In the UK, similarly, NCDs were responsible for the ten leading causes of disability among women, led by low back and neck pain and including both breast and lung cancers.
The leading causes in LMICs In LMICs, stroke, IHD and COPD accounted for three of the four leading causes of death for women in 2013, and NCDs for five of the top ten causes, with diabetes ranked seventh and hypertensive heart disease ranked ninth (Table One). Unlike in 2010, preterm birth complications were no longer ranked in the top ten causes of death, with lower respiratory infections, diarrhoeal diseases, HIV/AIDS, tuberculosis and malaria accounting for the other leading causes of death. For women in India, seven of the leading causes of death were NCDs, led by IHD and stroke.
Three of the leading causes of death were chronic respiratory-related conditions, namely COPD, asthma and pneumoconiosis. Diarrhoeal diseases, lower respiratory infections and tuberculosis were the other leading causes of death. Unlike in 2010, preterm birth complications were no longer ranked amongst the leading causes of death.In China, NCDs and injuries accounted for nine of the ten leading causes of death for women, led by stroke, IHD and COPD. Lung, stomach and liver cancers ranked in the top ten causes of death, and Alzheimer’s disease was ranked at number six. Lower respiratory infections were the leading cause of disability amongst women in LMICs (Table Two).
However, NCDs, comprising IHD and stroke, low back and neck pain, major depressive disorders and COPD were responsible for five of the ten leading causes. Preterm birth complications were ranked number eight. In India, while IHD now ranks as the leading cause of disability for women, three of the leading causes of disability are still associated with pregnancy and birth outcomes, namely preterm birth complications, neonatal encephalopathy and iron-deficiency anaemia. In China, the leading causes of disability were low back and neck pain, stroke, IHD, COPD and major depressive disorders. Neither birth complications nor any of the major communicable diseases were ranked in the top ten leading causes of disability.
