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Stopping ‘The Yentl Syndrome’ - Medical Observer

Medical & health articles | Medical Observer 15 Apr 2019
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In this 'Women's Health' article for Medical Observer, general and interventional cardiologist Dr Fiona Foo looks at the issue of poorer cardiac care for women.

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Jean Hailes is proud to provide a monthly column in the medical newspaper, Medical Observer. Designed to give GPs and health professionals a short informative summary of important women's health topics and conditions, these articles provide practical information to inform and enhance clinical practice.

By Dr Fiona Foo
MBBS (HONS), FRACP
General and interventional cardiologist, Sydney Cardiology Group, MQ Health Cardiology: Macquarie University, NSW

GPs will be well aware of the gender gap in healthcare that means women receive poorer care than men. The disparity is especially true in the field of cardiology – the specialty of leading US physician Dr Bernadine Healy, who coined the term 'The Yentl Syndrome' to describe the phenomenon in 1991.

Dr Healy, the first female director of the US National Institutes of Health, was inspired by the 19th-century heroine of a short story who is forced to masquerade as a man in order to pursue a realm of study only available to males. The character was famously portrayed by Barbra Streisand in the 1983 film Yentl.

Writing in an academic paper more than 20 years ago, Dr Healy used the Yentl Syndrome to highlight the underdiagnosis and undertreatment of women and the adverse outcomes they experienced from ischaemic heart disease and myocardial infarction.

It was "sad, but not surprising" that this inequality affected so many areas of a woman's life, from her social relations and political endeavours to her healthcare, she wrote. Since Dr Healy first identified the issue, there has been a cascade of studies evidencing the gender gap in cardiac care.

For example, research has identified treatment disparities for acute coronary syndromes (ACS), which include women receiving fewer evidence-based pharmacotherapies, less intensive treatment, and both fewer investigations and invasive procedures such as angiography and stents.

Women are also more likely to have delays in treatment and reperfusion compared with men, and have higher periprocedural and bleeding complications.1,2

As a result, there is significant potential for gender gap differences in outcomes. A study of younger women with ACS shows they have a worse prognosis, higher mortality post-ACS in hospital and at one year, and more frequent serious complications of ACS, such as heart failure, than men aged 45 or younger.3

The Yentl Syndrome is evident in Australia, with a 2018 paper showing women admitted with ACS, particularly in ST-elevation MI, are less likely to receive invasive management, revascularisation and preventive medication such as beta blockers and statins on discharge than men.4

Their chance of having a major adverse cardiac event or mortality at six months after admission is also higher, and they are also less likely to be referred for cardiac rehabilitation.4

Much medical research has focused primarily on symptoms of male MIs and, as a result, many women die because of misdiagnosis as their symptoms present differently, or simply because treatment is not sought quickly or aggressively enough.

Some of these differences can be partly explained pathophysiologically. When women and men present with male-pattern disease (obstructive coronary artery disease) they receive treatment.

However, many women present with female-pattern disease (microvascular dysfunction and non-obstructive coronary arteries) and receive less treatment, leading to worse outcomes.

Fewer than 40% of women know that ischaemic heart disease is the biggest cause of female deaths in Australia, killing three times as many women as breast cancer. Every hour in Australia, a woman dies of ischaemic heart disease, while every two hours a woman dies of a MI.5

While women and heart disease is an area of special interest to me as a cardiologist, GPs are perfectly placed to address the modifiable risk factors in female patients and educate women about the atypical signs and symptoms of a MI.

Signs and symptoms of MI in women

Women are older at presentation, have more comorbidities, and longer delays to hospital presentation. While most women will present with chest pain, many present with other atypical symptoms such as:

  • pain in the jaw/neck/throat/shoulder/arm
  • shortness of breath
  • cold sweat
  • weakness/extreme fatigue
  • dizziness
  • nausea

It is the more atypical symptoms that women may not recognise as initial symptoms of heart disease that lead to delays in seeking and receiving aggressive medical care.

Doctors may also fail to evaluate these atypical symptoms of MI as early in women as they do in men, because of comorbidities and underestimating their risk factors.

Non-traditional risk factors for CVD that are unique to women include:

  • early menarche
  • early menopause/surgical menopause
  • breast cancer treatment such as radiotherapy (particularly if it's on the left side) and chemotherapy
  • autoimmune diseases such as rheumatoid arthritis and SLE
  • depression – an increasingly prevalent and recognised factor for the development of coronary artery disease and an unfavourable outcome after a cardiac event
  • polycystic ovary syndrome – associated with a number of CVD risk factors such as obesity, diabetes and dyslipidaemia
  • endometriosis
  • pregnancy complications such as hypertension, pre-eclampsia, eclampsia, gestational diabetes, preterm delivery and small-for-gestational-age babies

Management of risk factors

For a woman with risk factors, the main aim is to make sure BP, cholesterol and blood sugar levels are all under good control, and that patients maintain a normal weight. I encourage all my patients to do regular cardiovascular exercise (including moderate- to high-intensity exercise) and strength/ resistance training.

Provide advice on minimising alcohol and not smoking.

Discuss diet and recommend a Mediterranean diet, with more fruit and vegetables, wholegrains, oily fish, legumes and nuts, and less processed food, saturated and trans fats, sugar, salt and red meat.

Take a pregnancy history. For those women with a history of pregnancy-related complications, advise them of their increased cardiovascular risk. Measure BP, lipids and blood sugar levels regularly and discuss lifestyle modifications and medications as required.

Women with a history of polycystic ovary syndrome, endometriosis, early/ surgical menopause or autoimmune disease should have regular BP, blood sugar and lipid levels checked and aggressively treated. Encourage them to maintain a healthy weight, exercise regularly and have a healthy diet. Treat depression, anxiety and other mental health disorders.

Patients who have had chemotherapy for breast cancer should have echo surveillance of their left ventricular function and, 5-10 years after radiotherapy, a functional non-invasive stress test.

Practice points

Heart disease is the leading cause of death in women in Australia.

There is a significant gender gap with regards to treatment and outcomes of ischaemic heart disease. Women are treated less aggressively and have a worse prognosis.

Be aware that women may have atypical symptoms. Ensure your patient is aware of these symptoms and ask if they have experienced any of them.

Recognise ischaemic symptoms in women to avoid delay in diagnosis and management. After discharge with ACS, all patients should be on evidence-based medications such as statins, antiplatelets, ACE-I and beta blockers, and referred to cardiac rehabilitation when appropriate.

Recognise traditional and non-traditional risk factors in women that increase their risk of ischaemic heart disease. Measure BP, blood sugar and cholesterol levels in female patients over 55 (or earlier if they have any of the above risk factors), regularly follow them up and encourage lifestyle modifications.

References

  1. D'Onofrio G et al. Sex differences in reperfusion in young patients with ST-segment-elevation myocardial infarction: results from the VIRGO study. Circulation. 2015; 131:1324-1332.

  2. Anderson RD & Pepine CJ. Gender differences in the treatment for acute myocardial infarction: bias or biology? Circulation 2007; 115:823-6

  3. Bangalore S et al. Age and gender differences in quality of care and outcomes for patients with ST-segment elevation myocardial infarction. Am J Med 2012; 125:1000-9

  4. Khan E et al. Differences in management and outcomes for men and women with ST-elevation myocardial infarction. MJA 209 (3). 6 August 2018

  5. Australian Bureau of Statistics, 2016. National Health Survey: First results, 2014-15, ABS cat no. 4364.0.55.001, March.

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