We can all identify someone having a stroke, can’t we? A sudden loss of function on one side of the body, drooping face, slurred speech, numbness. Sure we can — but that someone will most probably be a man.
With women, stroke symptoms are very different. They may present as a migraine-like headache, light-headedness, possibly a drop in co-ordination. Transient ischaemic attacks, or mini strokes, are often described by women as, “I felt funny for five minutes, but now I’m fine” or, “I had total brain fog for an hour, but I’m OK.”
The critical thing, says Dr Alyson McGregor, an emergency medicine consultant, is that these unique female symptoms are only now being pinned down. Many doctors, let alone the public, don’t recognise them, meaning women’s strokes are often misdiagnosed or undiagnosed.
Unsurprisingly, although men are more likely to suffer strokes, more women die of them; twice as many, in fact, as die from breast cancer. Strokes are the third leading female cause of death, but their symptoms are often brushed off as urinary tract infections, migraine or anxiety. This means proper treatment is frequently delayed, anticoagulants are prescribed at a lower, less effective dose than they are for men, and outcomes are poorer.
McGregor is one of America’s experts in the male-centric bias in the medical profession, which for years has nurtured doctors with the false belief that apart from the sex organs, men and women are biologically identical. While everything from textbooks and medical tenets to drug research and dissection mannequins treat male bodies as the human norm, she says women’s bodies react differently from their DNA up. (In fairness, a leading US medical school puts a wig on a mannequin to flag it as female.)
The unconscious sex bias in medical knowledge, which first came to my attention in Caroline Criado Perez’s book Invisible Women last year, is fairly jaw-dropping stuff. Heart attacks, for instance: men often get the classic symptoms of pain down the left arm, chest pressure, nausea, cold sweats, while women may present with only mild pain and discomfort, fatigue, possible shortness of breath and a strong feeling “something isn’t right”. They’re often told they’ve got a panic attack and anxiety, and sent home.
One study of cardiac misdiagnosis in 100,000 people showed that women under 55 who went to A&E with significant heart-attack symptoms are seven times more likely to be sent home than men, doubling their risk of death. Overall, women are three times more likely than men, in the US at least, to die after a serious heart attack.
Women’s hearts fail differently. After cardiac arrest, unlike men, their hearts have pulseless electrical activity — they flatline and they’re not shockable. Any TV hospital drama featuring doctors waving electric paddles on a woman is cobblers. (Apparently the only tools are CPR and adrenaline.) Plus, while men gather big clots of plaque in their blood vessels, women’s vessels absorb it, weakening and stiffening. This microvascular dysfunction stresses the heart, but — guess what? — angiograms aren’t designed to detect it. And, poignantly, women are the primary victims of Takotsubo cardiomyopathy — broken heart syndrome — thought to be caused by a massive surge of fight or flight hormones after a stressful event, such as a family death. Suddenly the left ventricle of the heart balloons and cannot beat properly.
Women are less likely to be treated for sepsis, arrhythmia and chronic pain conditions such as fibromyalgia. They’re less likely to be referred for tests for irritable bowel syndrome (IBS), and autoimmune and various neurological disorders. In other words they’re undertreated and underbelieved.
Women metabolise prescription drugs differently from men 40 per cent of the time, but most drugs are still tested almost exclusively on men. It’s cheaper and easier. The catastrophe of thalidomide tightened regulations to protect women of child-bearing age and many researchers then chose to exclude them completely. Big Pharma’s testing protocols are developed to identify male-pattern symptoms.
Take statins. A prominent female cardiologist, quoted in the book, says they have little benefit for the millions of women who take them — and there is zero evidence that they lower the risk of heart attack or stroke for women. Or aspirin: the anti-blood-clotting benefits of aspirin have been observed only in men; with women, they don’t outweigh the risks. Another study shows naltrexone, an anti-addiction drug, reduced the use of alcohol and drugs in men, but increased it in women.
Most roads in women’s health, though, lead back to a male idea of female anxiety. Women are more likely to receive a psychiatric diagnosis — always remembering “hysteria” is derived from the Greek word for uterus, “hystera” — and there is “a pervasive unconscious belief in medical culture that women are prone to illogical and unreasonable outbursts”. In other words, they’re attention-seekers and their complaints less believed. McGregor sees this implicit bias everywhere in medicine.
In one study of IBS, men were more likely to be offered x-rays, women anti-anxiety medicine and lifestyle advice. Another study showed severely injured women were less likely even to be brought to A&E (49 per cent women, 62 per cent men). The researchers ruled out all other factors and found subconscious gender bias.
In the same way, the emphasis on anxiety as the go-to female condition means women themselves discount their inner wisdom and apologise for their feelings instead of trusting them. They “talk themselves down”. McGregor has seen women with heart-attack symptoms leave emergency waiting rooms because they or their husband persuaded them it was just anxiety. On similar lines, the Yentl syndrome describes the vicious circle whereby the more women try to explain their pain, the more doctors tune out. She is convinced women that process pain differently — but because the physiology is not understood, their pain isn’t properly tackled by existing drugs.