Evolving Paradigms in

Women’s Health
Eileen Hoffman,MD, FACP
Clinical Associate Professor of Medicine
NYU School of Medicine
DGIM Grand Rounds
April 24, 2007
 VERY OLD PARADIGM

Women’s health = reproductive health

 NEW OLD PARADIGM

Women’s health (Health?)

• Diseases, disorders and conditions that
are unique to, more prevalent among,
or far more serious in women, or for
which there are different risk factors of
interventions for women than men
(ORWH…and expanded by NAWHME)
 NEW OLD PARADIGM

• Limited to difference
•Reductionist and organ-based
 Old model of science
 Old model of medicine

•At best is “multidisciplinary”

Johnson & Dawson. Women’s health as a multidisciplinary specialty: An

exploratory proposal. JAMWA 1990.
ACWHP Menstrual Cycle Concept Map
Traditional Collaborative Care Integrated Collaborative Care

  Medical
Practitioner

 Relational

Field

Mental Health
Medical Mental Health Specialist
Practitioner Specialist

Co-location  Integration

 Separate services offered  Interaction blurring boundaries

between mind & body
 Facilitates “screen and refer”
 Facilitates immediate assessment
 Quality of collaboration depends
 Quality of collaborative relationship
on quantity of interaction between
is a part of the therapeutic process
clinicians

A + B = A' + B' AxB=C

 NEW PARADIGM
Women’s Health is
 A sex- and gender-informed
practice centered on the whole
woman in the diverse contexts of
her life, grounded in an
interdisciplinary sex- and gender-
informed biospychosocial science
(ACWHP)

Hoffman, Magrane, Donoghue. Changing Perspectives on Sex and

Gender in Medical Education. Acad Med 2000.
 NEW PARADIGM
 Uses “difference” differently
• Not as sex- and gender-based variations
from a “gender-neutral” norm
• Female is the norm based on “plasticity”
 NEW PARADIGM
 Reflects the new model of science as
systems biology
• Parts that interact - plasticity
• Gives rise to new properties (emergent)
• Cannot be attributed to any single part
(irreducible)
• A basic science model that allows us to
view women from the perspective of the
complex whole (ACWHP definition)
Hoffman E. Women’s Health and Complexity Science. Acad Med 2000.
 NEW PARADIGM
Developmental & Reproductive Plasticity
• Adaptation to the pregnant state
• Determining the fetal environment
 Gene-environment interactions that “program” the
fetus influencing its health trajectory later in life
• Changed by the fetal environment
 Microchimerism –
 Leads to autoimmune diseases but found in normal
woman too
 Do fetal stem cells contribute to female health?
• Mosaicism
 Physiologic diversity (metabolic cooperation)
• Interaction between the parts necessitates
“Interdisciplinary”
Johnson & Hoffman. Women’s Health: Designing and Implementing an
 NEW PARADIGM
Tests of Plasticity (Maladaptations)

 PCOS
 Premenstrual asthma
 Pregnancy – CVD stress test
• GDM
• Pre-eclampsia
• Low birth weight
 Autoimmune diseases

Sattar & Greer. Pregnancy complications and maternal cardiovascular risk:

Opportunities for intervention and screening. BMJ USA. 2002
 USING THE NEW PARADIGM
IN REAL TIME

Can we identify insulin resistance

early on in the life of a woman while
there is still enough “plasticity” in
the system to prevent the system
from going over the tipping point
into a fixed state?
 NEW PARADIGM
Early Identification of Risk for
Insulin Resistance in Women
 Did you have irregular periods?
 Did you have any complications of
pregnancy?
• GDM
• Pre-eclampsia
• Low birth weight
• Pre-term delivery
 Were you born at low birth weight?
Williams D. Curr Opin Obstet Gynecol. 2003
 NEW PARADIGM
Early Identification of Risk for
Insulin Resistance in Women

 Metabolic Syndrome
• Waist circumference > 35 inches
• Blood pressure > 130/85
• Fasting blood sugar >110
• HDL <50
• Triglycerides >150
 NEW PARADIGM
Early Identification of Risk for
Insulin Resistance in Women
 Presence of Metabolic Syndrome
• Factors more predictive if they cluster
• Cluster of 3 or more factors predicted 20% of
CVD events in men and 48% in women
• Cluster of all 5 factors predicts risk of death
2-3 fold in men and 10 fold in women
• Dominant cluster is waist circumference and
dyslipidemia (30% variance)
Schneider et al.The Metabolic Syndrome in Women. Cardiology in Review 2006.
Hanley et al. Diabetes 2002; Trevisan et al. Am J Epidemiol 1998; Lakka et al
Once insulin resistance is detected,
can we intervene and treat it early
on in the life of a woman while there
is still enough “plasticity” in the
system to prevent the system from
going over the tipping point into a
fixed state?
 NEW PARADIGM
Reducing CVD Risk for Women with
Insulin Resistance
 Exercise
 Weight Loss
 Low glycemic index diet
 Omega-3-fatty acids
 Vitamin D
 Nutraceuticals
 Pharmaceuticals
 Metabolic Syndrome and Vitamin D
 Odds ratio of having MBS decreased
progressively across increasing quintiles of 25
OHD (NHANES III)
 Prevalence of MBS lower in women in the
highest quintile of calcium and vitamin D intake
(WHS)
 TBF inversely related to 25OHD& positively
associated with PTH
• Race, season, %TBF predicted 25OHD
• Melanin absorbs UVB radiation needed for cutaneous
production of Vitamin D
• UVB availability varies with season
Martini & Wood. Vitamin D Status and the Metabolic Syndrome. Nutrition
 Vitamin D and Chronic Disease
 Rickets/Osteomalacia  Infection
 Diabetes  Immune Regulation
 Hypertension  Autoimmune Disease
 CVD  Chronic Liver Disease
 Cancer  Fat Malabsorption
 Mental Health  Parkinson’s Disease
 Osteoporosis  Primary HyperPTH
 Periodontal Disease  Psoriasis
 Falls in the elderly  PCOS
 Mental Health
Holick M. High Prevalence of Vitamin D Inadequacy and Implications for
Health. NEJM.2006
Populations with Vitamin D Deficiency
 Healthy adults, children, adolescents
 Sunscreen users
 African Americans
 Obese
 Elderly/limited sun
 Living at northern latitude
 Immigrants from southern to northern
latitude
 Veiled women
 Medical inpatients including nursing homes
 Osteoporotics on bisphosphonates
 HIV positive on PI
 Smokers
 Caffeine Users
 Vitamin D Deficiency & the
Reproductive Woman
 Pregnant women and their offspring
 Breastfeeding women and infants
• Especially among African-Americans
 Pregnant women with pre-eclampsia
 D deficiency in the fetal environment
can program for long latency
(chronic) diseases as well as rickets
McGrath J. Does”imprinting” with low prenatal vitamin D contribute to the
risk of various adult disorders? Medical Hypothesis 2001.
Barker D. The developmental origins of insulin resistance. Horm Res 2005.
 Old Paradigm

›
Reproduction ≠ Women’s Health

›
New Paradigm
Ability to adapt to pregnant state is a powerful
systems biology approach to Women’s Health