Paula Johnson: When Does Medicine Leave Women Behind?

Feb 10, 2017
Originally published on February 24, 2017 2:00 pm

Part 4 of the TED Radio Hour episode Getting Better

About Paula Johnson's TED Talk

Men and women experience some diseases differently. Doctor Paula Johnson says this is alarming — because most treatments were designed for men, not women.

About Paula Johnson

Dr. Paula Johnson is a cardiologist and president of Wellesley College. Prior to that, she was executive director of the Connors Center for Women's Health and Gender Biology, and chief of the Division of Women's Health at Brigham and Women's Hospital. She was one of the first in her field to call attention to sex differences in medical treatment.

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GUY RAZ, HOST:

So if Dorothy Roberts argues that race is a bad proxy for trying to figure out how to diagnose a patient, what about sex?

PAULA JOHNSON: More and more, there is the realization that there are certain disorders that are expressed differently in women.

RAZ: This is Dr. Paula Johnson.

JOHNSON: I'm a cardiologist by training, and I'm president of Wellesley College.

RAZ: And Paula says there's a very simple reason why men and women don't always experience diseases the same way.

JOHNSON: We are different down to the cellular level. Because of that basic biologic difference, our cells and then our organs are different. So if you're not really thinking about the fact that these sex differences occur, you might miss the disease.

RAZ: And this problem actually starts with clinical studies because up until the 1990s, many of them didn't include women. And even today, a lot of studies that include both men and women don't look at the differences between them.

JOHNSON: And in a way, if you have women and men in the study, and then you give an average as the result, that's really not good for women or men, quite frankly, because it doesn't give the right answer for either of them.

RAZ: And the wrong answer or no answer at all can be devastating. Here's Paula Johnson on the TED stage.

(SOUNDBITE OF TED TALK)

JOHNSON: Some of my most wonderful memories of childhood are of spending time with my grandmother, Mamar. She loved life. And although she worked in a factory, she saved her pennies, and she traveled to Europe. And I remember poring over those pictures with her and then dancing with her to her favorite music. And then when I was 8 and she was 60, something changed. She no longer worked or traveled. She no longer danced. My mother missed work and took her to doctors who couldn't make a diagnosis. And my father would spend every afternoon with her just to make sure she ate. And by time a diagnosis was made, she was in a deep spiral.

Now, many of you will recognize her symptoms. My grandmother had depression. Today, we know that women are 70 percent more likely to experience depression over their lifetimes compared with men. And even with this high prevalence, women are misdiagnosed between 30 and 50 percent of the time. Now, we know that women are more likely to experience the symptoms of fatigue, sleep disturbance, pain and anxiety compared with men, and these symptoms are often overlooked as symptoms of depression. And it isn't only depression in which these sex differences occur, but they occur across so many diseases.

Today, we know that every cell has a sex. And what it means is that men and women are different down to the cellular and molecular levels, from our brains to our hearts, our lungs, our joints. And we've learned that there are major differences in the ways that women and men experience disease, but we're not making the investment in fully understanding the extent of these sex differences. We aren't taking what we have learned and routinely applying it in clinical care. So we have to ask ourselves the question. Why leave women's health to chance?

RAZ: Say you're a doctor who really, like, earnestly wants to fix this problem fast. Are the tools available today to properly diagnose women and men differently for what might appear to be the same diseases?

JOHNSON: It depends on the disease. Certain disorders, yes - there are tools that can be used. You just have to be thinking about them. There's plenty of opportunity to think about how we apply our knowledge differentially to women and men. Just think about the whole pharmaceutical area.

You know, it was about three or four years ago when the drug Ambien was found to have a very significant differential impact in women and men. And what it led to for the first time was the FDA changing the dose, the recommended dose for women. They cut it in half. There are other drugs that are metabolized quite differently in women leading to different effects.

RAZ: But, I mean, there are still a lots of diseases and treatments that do affect men and women the same way, right?

JOHNSON: Yes. And there are absolutely areas where women and men respond similarly. The question is does similarly mean the same? And you don't know the answer until you ask the question and look at the data. The issue is that the data are there, but they've not necessarily been used in practice.

RAZ: When we come back, Dr. Paula Johnson on how we can use the data to better diagnose and treat women. Today on the show, Getting Better, ideas on how medicine can work better for all of us. I'm Guy Raz, and you're listening to the TED Radio Hour from NPR.

(SOUNDBITE OF MUSIC)

RAZ: It's the TED Radio Hour from NPR. I'm Guy Raz. And on the show today, Getting Better - ideas about medicine, conventional wisdom and how so much of it is changing - and fast. And we were just hearing from Dr. Paula Johnson. A few years ago, she started looking at how men and women experience diseases differently. Here's Paula on the TED stage.

(SOUNDBITE OF TED TALK)

JOHNSON: Let's start with heart disease. Linda is a middle-aged woman who had a stent placed in one of the arteries going to her heart. When she had recurrent symptoms, she went back to her doctor. Her doctor did the gold standard test - a cardiac catheterization. It shows no blockages. Linda's symptoms continued. She had to stop working, and that's when she found us. When Linda came to us, we did another cardiac catheterization. And this time we found clues, but we needed another test to make the diagnosis.

So we did a test called an intra-coronary ultrasound. We used sound waves to look at the artery from the inside out. And what we found was that Linda's disease didn't look like the typical male disease. The plaque is laid down more evenly, more diffusely along the artery, and it's harder to see. So for Linda and for so many women, the gold standard test wasn't gold. Now, Linda was lucky - she found us. We found her disease. But for too many women, that's not the case. We have the tools. We have the technology to make the diagnosis, but it's all too often that these sex differences are overlooked.

(SOUNDBITE OF MUSIC)

RAZ: I mean, would it be a stretch to say that a man experiencing heart disease and a woman experiencing heart disease might very well be experiencing different diseases entirely?

JOHNSON: Oh, I think that that's a very good question. So another fact that we know today is if you look at the arteries of women and men who have had heart attacks, there are ways in which the blockage actually occurs. One is through plaque erupting - right? - so there's plaque in the artery, that's the buildup of fat and everything. And it, you know, a crack occurs. And all the sticky white cells kind of go near it. And it causes an immediate blockage. OK.

Then there's another way that it can happen which is called plaque erosion. And that's almost like if you have the plaque in the artery, and you rub sandpaper over it and it becomes rough. Well, it's the same sticky surface, and you can get a blockage. Now, what you see more often is in women, women are more likely to have plaque erosion than eruption. And the question is why? So are these the same disease when this happens? And we don't know today. And if we don't know, it means are we treating the right thing?

RAZ: Yeah. So we've been talking about sex difference in humans, but what about in, you know, with animals. I mean, am I right that most animal research is done generally using male animals or where they don't specify the sex at all?

JOHNSON: Oh, absolutely. Now, why does that happen? Well, it's easier, right? If you don't have to include both sexes it's easier because, well, you don't have to think about the differences between the two groups. It is - and it's more expensive. Is that really the reason not to do it? Because those are the studies on which we base human science, human research. So if we get it wrong from the cellular level and from the animal level, then we are already behind by the time we get to the human level. That is a very significant problem.

RAZ: Yeah.

JOHNSON: How often in stem cell research are we paying attention to the sex of the cells? And then the next question becomes is that potentially why we've not seen some of the benefits that we thought we should have seen by this point in time in this area of stem cell research?

(SOUNDBITE OF TED TALK)

JOHNSON: Now, let me share with you an example of when we do consider sex differences it can drive the science. Several years ago, a new lung cancer drug was being evaluated. And when the authors looked at whose tumors shrank, they found that 82 percent were women. This led them to ask the question, well, why? And what they found was that the genetic mutations that the drug targeted were far more common in women. And what this has led to is a more personalized approach to the treatment of lung cancer that also includes sex. This is what we can accomplish when we don't leave women's health to chance.

Imagine the momentum we could achieve in advancing the health of women if we considered whether these sex differences were present at the very beginning of designing research. Women's health is an equal rights issue as important as equal pay. And this is so important, not only for ourselves, but for all of those whom we love. Our legacy can be to improve the health of women for this generation and for generations to come. Thank you.

(APPLAUSE) Transcript provided by NPR, Copyright NPR.