Chapter 1
Unfair to the Fairer Sex
When we consider the miracles of modern medicine, itâs easy to think weâve arrived. The technological wonders of intensive care have all but brought people back from the dead and allowed some of us to survive even the most horrific injuries. We now have pharmaceuticals built on a molecular level and surgeons using the worldâs most precise tools to maneuver inside our veins, muscles, joints, and even brains. Despite these incredible capabilities, we have not arrived. Not by a long shot.
In medical school, a professor told my class, âFifty percent of what weâre about to teach you is wrong; itâs up to you to figure out which half.â Weâve made some huge gains in medicine since then, but much of the half we had wrong is still taught in medical schools, practiced in hospitals and clinics, and pervasive in mainstream culture. In my opinionâshaped through the lessons of four board certifications, a double masterâs degree, and the experience of treating thousands of women for chronic ailments in my clinic, where 80 percent of patients are femaleâno area of modern medicine is less understood than heart health in women.
Take this story for example. Sue was scheduled to have her gallbladder removed after three days of severe heartburn. I was the doctor on call at the time, and although the decision had already been made to do the surgery, I wanted to talk to her one last time to make sure the problem was her gallbladder before sending her under the knife. Because she was having abdominal pain and not the classic chest pain associated with heart attack, no one had checked her heart enzymes, the standard method for detecting a heart attack. Women sometimes present heart attacks differently than men: although most have pressure or pain in the chest, some women can instead experience vomiting and/or stomach, back, or jaw painâsymptoms easily confused with other, less lethal ailments.
I ordered an enzyme test for Sue, just to be sure. The result? She had been having a heart attack for three days. Because Sue did not present the usual symptoms, we almost sent her into the operating room for gallbladder surgery while she was having a heart attack!
Instead of removing Sueâs gallbladder, we sent a tiny balloon into one of her arteries and inflated it at the point where blood flow was compromised. Unfortunately for Sue, this procedure is best performed within hours of a heart attack, not after the heart has been starved for oxygen for three days. Afterwards, a cardiologist confirmed that Sueâs heart muscle was severely damaged and told her she was likely to be a âcardiac crippleâ for the rest of her life.
Sueâs story doesnât end there, and it even has a happy ending, but to understand the path that led her to the brink of being operated on for the wrong condition, we must look at the story of heart disease and the misunderstandings about womenâs heart health, which go far beyond the hospital and have become deeply ingrained in our mainstream culture. The institution of medicine has not treated womenâs heart health with the same care and investment as menâs for a number of reasons, but two are particularly important: the history of heart disease research, and the complex relationship between female hormones and female hearts.
A Manâs Disease
Men have historically been the focus of heart disease research and concern, both because it develops, on average, nearly a decade later in women than in men and because more men than women die in middle age of heart disease. These facts are partly responsible for why heart disease has seemed like less of an issue for women, going as far back as the late 1800s; indeed, at that time some physicians viewed heart disease as a âmachoâ way to die, a sign that the deceased had been a hardworking man. This perspective changed (somewhat) thanks to studies in the 1950s that linked heart disease with lacking fitness and nutritionâin men. For the next fifty years, that trend continued: the vast majority of heart disease research favored men. While the men were being monitored for heart health, the womenâs hearts were largely ignored. Even as recently as the 1980s and â90s, many landmark studies on heart disease were entirely focused on men. The Multiple Risk Factor Intervention Trial of 1982, recognized as one of the first studies to prove a link between cholesterol and heart disease, involved over 12,000 men and zero women. Appropriately perhaps, its acronym is MRFIT.
In 1991, the editor of the New England Journal of Medicine wrote, âHeart disease is also a womanâs disease, not just a manâs disease in disguise.â Yet the sample for the Physicians Health Study of 1995, which found that aspirin reduced the risk of heart attack, included over 20,000 men andâyou guessed itânot one single woman.
According to the American Heart Association (AHA), a total of 38 percent of heart disease research subjects have been women. Even this percentage doesnât tell the whole story, since most of the heart disease studies on women have been conducted only in recent years. Also, research attempts to treat men and women equally without actually giving both an equal shake in the lab have led to unintended consequences. A 2007 article in the Journal of the Royal Society of Medicine explains: âThe evidence bases of medicine may be fundamentally flawed because there is an ongoing failure of research tools to include sex differences in study design and analysis. The reporting bias by which this methodology maintains creates a situation where guidelines based on the study of one sex may be generalized and applied to both.â
Treating women and men equally? Good idea. Treating womenâs bodies the same as menâs in conclusions drawn from medical research? Not so much. It is now clear that we have done a huge disservice to women and their health. Thanks to all the research into menâs heart health, the rate of heart attack in men between the ages of thirty-five and fifty-four is declining. In women of the same age, however, heart attack rates are increasing, and researchers have noted a particularly alarming heart attack rate increase of more than 1 percent annually among thirty-five- to forty-four-year-old women.
The other main reason womenâs heart health has been overlooked for the last century is that, during the reproductive years, women have a heart health advantage over men. Womenâs hormones, and the more flexible physical structure of womenâs hearts, veins, and arteries, offer a layer of protection that reduces the occurrence of heart disease in women before menopause. Their hormones give women a little more time to heal wounds, correct imbalances, and work toward optimal function before heart disease takes hold. This advantage, however, is a double-edged sword: it also obscures the picture of a womanâs heart health during her younger years. Essentially, if you are premenopausal, you may have several high-risk factors for heart disease, but thanks to the protective quality of your hormones and feminine vascular system, you (and your doctor) donât even realize it.
The protective/deceptive role of womenâs hormones in their heart health is a tricky concept to grasp, but think of it this way: Imagine if your female hormones protected you from gaining weight for the first half of your life, but as soon as menopause hit, the weight you could have gained during those years because of your genetics and lifestyle choices suddenly appeared all at once. It would be truly shocking and terribly unfair to wake up one day with all that weight suddenly hanging from your body. This, of course, is not what happens with weight, but it does happen with heart health: younger women need to monitor and nurture their heart health in the absence of some of the feedback mechanisms available to men, or risk arriving at menopause with a dramatic, sudden, and unexpected uptick in heart disease riskâor even the seemingly sudden appearance of the disease itself.
The Big âDuh!â
The seriousness of heart disease in women is underappreciated from the living room to the examination room and all the way to the emergency room. Scenes of men having heart attacks in movies and TV shows have trained the entire world to assess men for heart disease, and yet even our most skilled health experts may dismiss the symptoms of heart distress in women. This cultural and professional misunderstanding of womenâs heart health has led to some terribly unfortunate trends. To this day, women with heart disease are less likely to be tested to determine its severity and less likely to undergo procedures to unclog blocked arteries, even when they and their physicians know that their arteries are compromised. And the prognosis for a woman who has a heart attack is much worse than is typical for a man. Women between the ages of forty and fifty-nine are up to four times more likely to die from heart bypass surgery than men of the same age, and all women are twice as likely as men to die within the first few weeks of suffering a heart attack.
It is my opinion that even in the emergency room, the venue for life-saving medicine, womenâs heart health is not treated with the same sense of urgency as menâs. Doctors are blindsided every day by the markedly different symptoms of heart disease that women present: different electrical signals, problems manifesting in different areas of the heart, and different surface symptoms of heart dysfunction. What this means for a woman experiencing a heart attack that is not accompanied by the typical symptoms is that by the time the problem is diagnosed correctly, her heart muscle has already been damaged and any procedures she undergoes will be riskier than if the problem had been detected earlier. âTime is myocardiumâ and âTime is the issue for the tissueâ are the mantras of the heart catheterization lab, where small balloons are inserted into arteries to open blockages. We say these mantras to remind ourselves that the more time passes before intervention, the more heart damage occurs. Too many times I have seen bad things happen to women whose symptoms were misdiagnosed or for whom intervention was delayed. This is especially disheartening (literally) when early suspicion, knowledge, and intervention could have saved the dayâand their heart muscle.
On Valentineâs Day, I was âcoercedâ into watching an episode of Greyâs Anatomy, a wildly popular TV medical drama. On this episode, Dr. Bailey, the female chief of surgery, drops off her fireman husband at work and takes herself to a different hospital ER to be evaluated for a heart attack. She goes up to the front nursing desk and blurts out, âI am having a heart attack.â This highly accomplished doctor knows that she is having a heart attack, but what happens next in the ER? They make her fill out paperwork, and then wait before being seen. When she is eventually evaluated, her tests are not conclusive. Her doctors decide that either she is experiencing something else, like heartburn or anxiety and stress, or sheâs just a hypochondriac doctor. So the cardiologist asks about her stress at home and at work. In the end, she has to undergo very risky open-heart surgery that almost kills her.
Of course, because this is television, Dr. Bailey lives and goes on to perform miraculous surgeries. I have seen what happens to her too many times in my career, however, and in real life there is one significant difference from the made-for-TV version: the victim usually doesnât make it out of the hospital. Men and women are not the same when it comes to heart diseaseâwhether in how it evolves, how it presents, or how they respond to treatment.
The fictional Greyâs Anatomy story is not far from reality. From what Iâve seen, if a husband and wife go into the emergency room after dinner, both of them complaining of chest discomfort, the man is likely to be given a stress test to see if he is having a heart attack and the woman is likely be diagnosed with something elseâjust like Dr. Bailey in Greyâs Anatomyâand given heartburn medicine to relieve stomach or gallbladder upsetâjust like Sue.
Starting in the 2000s, the institution of medicine finally slapped its collective forehead with its collective palm and asked: What were we thinking? Even researchers who were typically not prone to making statements about what we should or should not do began to take a stand on the issue of womenâs heart health. In a 2010 article titled âGender Differences in Coronary Heart Disease,â the authors stated: âThe under-recognition of heart disease and differences in clinical presentation in women lead to less aggressive treatment strategies and a lower representation of women in clinical trials. Furthermore, self-awareness in women and identification of their cardiovascular risk factors needs more attention, which should result in a better prevention of cardiovascular events.â
A recent study showed that between the ages of forty-five and fifty-four, more women have strokes than men. Young women with diabetes have quadruple the risk of heart attack compared to young men with diabetes. And with the recent revelations about brain disease, ailments like Alzheimerâs and depression are now understood to be closely related to heart health. The fact that two-thirds of Alzheimerâs and depression victims are women thus raises the question: If women were advised on heart-healthy lifestyle choices by their doctors with the same regularity as men, would fewer women suffer from depression and develop Alzheimerâs?
I answer this question by telling female patients at my clinic: yes, if you improve your heart health, your risk of Alzheimerâs and depression will decrease. Science has not yet answered this question with absolute certainty, but remember: it took fifty years for science to prove that smoking causes cancer, yet doctors working with lung cancer patients quickly made the connection. From my extensive work with patients suffering from all of these terrible diseases, I can say with certainty that heart health is brain health is body health.
We now know that heart disease risk is different for women and men, not that women are at less risk of heart disease. Yes, more men have heart disease, but with heart disease killing more women than any other ailment, the fact that the disease is more prevalent in men is hardly relevant to womenâs health. Without a doubt, medicine has been making mistakes in womenâs heart health for over a century.
To complicate matters, the American lifestyle today is a breeding ground for chronic disease. Throughout Part II, you will learn about the heart health ramifications of foods that are poison to optimal functioning, our exposure to hundreds of toxic chemicals (starting before birth), and living the most sedentary lives in human history. Although we live twice as long as our ancestors, a strong argument can be made that we are truly healthy for fewer years than our ancestors were.
Despite widely disseminated health information that makes us more aware than ever that our lifestyle will influence our future health, most people today continue to lead lives and eat foods that greatly increase their risk of chronic disease and decrease the quality of their lives. I can say with complete conviction that, for optimal health, mos...
