Evolving Paradigms in Evolving Paradigms in Women’s HealthWomen’s Health

Eileen Hoffman, MD, FACPEileen Hoffman, MD, FACPClinical Associate Professor of MedicineClinical Associate Professor of Medicine

NYU School of MedicineNYU School of Medicine

DGIM Grand RoundsDGIM Grand RoundsApril 24, 2007April 24, 2007

Evolving Paradigms in Women’s HealthEvolving Paradigms in Women’s Health

Review the recent history of the fieldReview the recent history of the field Describe the developmental stages & their Describe the developmental stages & their

contributions to improving carecontributions to improving care Describe the newest paradigm - plasticityDescribe the newest paradigm - plasticity

• Provides a lens for looking at the whole woman Provides a lens for looking at the whole woman across the life cycle that is not just the sum of her across the life cycle that is not just the sum of her partsparts

Use the new paradigm showing how it Use the new paradigm showing how it contributes to the health of women & men contributes to the health of women & men

INITIAL (OLD) PARADIGMINITIAL (OLD) PARADIGM

women’s health = reproductive healthwomen’s health = reproductive health

Hoffman. The Women-Centered Health Care Team –Implications for Multiprofessonal Interdisciplinary Education. J Women’s Health. 1998.

TRANSITIONAL PARADIGMTRANSITIONAL PARADIGM

Women’s healthWomen’s health• Diseases, disorders and conditions that Diseases, disorders and conditions that

are unique to, more prevalent among, or are unique to, more prevalent among, or far more serious in women, or for which far more serious in women, or for which there are different risk factors or there are different risk factors or interventions for women than men interventions for women than men (ORWH…and expanded by NAWHME)(ORWH…and expanded by NAWHME)

Goldman & Hatch. Women & Health. Academic Press, 2000.

TRANSITIONAL PARADIGMTRANSITIONAL PARADIGM

• Limited to differencesLimited to differences

•Reductionist and organ-basedReductionist and organ-based Old model of scienceOld model of science Old model of medicineOld model of medicine

•At best is “multidisciplinary”At best is “multidisciplinary”

Johnson & Dawson. Women’s health as a multidisciplinary specialty: An exploratory proposal. JAMWA 1990.

Medical Practitioner

Mental Health Specialist

Medical Practitioner

Mental Health Specialist

Traditional Collaborative Care Integrated Collaborative Care

Relational

Field

Co-location

Separate services offered

Facilitates “screen and refer”

Quality of collaboration depends on quantity of interaction between clinicians

Integration

Interaction blurring boundaries between mind & body

Facilitates immediate assessment

Quality of collaborative relationship is a part of the therapeutic process

A + B = A' + B' A x B = C

Women-centered Collaborative Care: Beyond Co-Location. APA Proceedings.2002

NEWEST PARADIGMNEWEST PARADIGM

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

Hoffman, Magrane, Donoghue. Changing Perspectives on Sex and Gender in Medical Education. Acad Med 2000.

ACWHP Menstrual Cycle Concept Map

Concept Mapping – A Tool for Knowledge-Management. Workshop on Theoretical Foundations of Medicine. Santa Fe Institute. 2006.

NEWEST PARADIGMNEWEST PARADIGM

Uses “difference” differentlyUses “difference” differently • Not as sex- and gender-based variations Not as sex- and gender-based variations

from a “gender-neutral” normfrom a “gender-neutral” norm• A norm based on “plasticity”A norm based on “plasticity”

Distinguishes living from non-living systemsDistinguishes living from non-living systems Ability to customize genome to environmentAbility to customize genome to environment

• Pediatrics-- discipline based on Pediatrics-- discipline based on “developmental plasticity”“developmental plasticity”

NEWEST PARADIGMNEWEST PARADIGM

Women’s Health – A Norm of Her OwnWomen’s Health – A Norm of Her Own• Maximal plasticityMaximal plasticity

““developmental” & “reproductive” plasticitydevelopmental” & “reproductive” plasticity Interaction between the 2 types of plasticity Interaction between the 2 types of plasticity

Consistent with new trend in medicine Consistent with new trend in medicine “systems biology”“systems biology”• Systems are comprised of parts that interactSystems are comprised of parts that interact• Emergent phenomena are properties of the wholeEmergent phenomena are properties of the whole• Not reducible to sum of partsNot reducible to sum of parts• Must be studied as a wholeMust be studied as a whole

Plasticity in the FemalePlasticity in the Female Anticipation of pregnant stateAnticipation of pregnant state

• Menstrual cycleMenstrual cycle• Luteal phase transformation to accommodate Luteal phase transformation to accommodate

conceptionconception Adaptation to pregnant stateAdaptation to pregnant state

• Flexible physiology and anatomyFlexible physiology and anatomy Transformation by pregnant stateTransformation by pregnant state

• Microchimerism – link between generationsMicrochimerism – link between generations Enhancement of health for survivalEnhancement of health for survival

• Mosaicism – buffers sex-linked disease Mosaicism – buffers sex-linked disease Gatekeeper to developmental plasticityGatekeeper to developmental plasticity

Migeon. The Role of X Inactivation and Cellular Mosaicism in Women’s Health and Sex-Specific Diseases. JAMA 2006

Failures of PlasticityFailures of Plasticity

PCOSPCOS Pre-menstrual AsthmaPre-menstrual Asthma Gestational DiabetesGestational Diabetes Pre-eclampsiaPre-eclampsia Low birth weightLow birth weight Pre-term laborPre-term labor Autoimmunity/Organ regenerationAutoimmunity/Organ regeneration

Williams D. Pregnancy: A Stress Test for Life. Current Opin Obst Gyn 2003.

Khosrotehrani et al. Transfer of Fetal Cells with Multilineage Potential to Maternal Tissue. JAMA. 2004.

.

Applying the New Paradigm Applying the New Paradigm Failures in Plasticity & Risk for CVDFailures in Plasticity & Risk for CVD

Chronic disease -- a fixed state Chronic disease -- a fixed state Prior states have some plasticity Prior states have some plasticity Which prior state has maximal plasticity Which prior state has maximal plasticity

for preventive intervention? for preventive intervention? Early warning signsEarly warning signs

• Failures in reproductive plasticityFailures in reproductive plasticity

Sattar & Greer. Pregnancy complications and maternal cardiovascular risk: Opportunities for intervention and screening. BMJ USA. 2002.

Applying the New Paradigm Applying the New Paradigm Failures in Plasticity & Risk for CVDFailures in Plasticity & Risk for CVD

Earliest stage for interventionEarliest stage for intervention• in utero – fetal environmentin utero – fetal environment• ““Low birth weight” Low birth weight”

Proxy for fetal nutritionProxy for fetal nutrition Potent predictor of CVD risk/mortalityPotent predictor of CVD risk/mortality Sets the stage for future life style risk factorsSets the stage for future life style risk factors

Godfrey & Barker. Fetal Programming and Adult Health. Public Health Nutrition 2001.

Failures in Plasticity and the Failures in Plasticity and the Epidemic of Chronic DiseaseEpidemic of Chronic Disease

In hypercaloric environment what In hypercaloric environment what environmental factor contributes to LBW? environmental factor contributes to LBW?

Epidemic of chronic disease began with shift Epidemic of chronic disease began with shift from agrarian to industrialized societyfrom agrarian to industrialized society

Industrialization led to low sun exposureIndustrialization led to low sun exposure Low sun exposure causes Vitamin D deficiencyLow sun exposure causes Vitamin D deficiency Vitamin D deficiency leads to LBW & programs Vitamin D deficiency leads to LBW & programs

the fetus for a trajectory toward chronic diseasethe fetus for a trajectory toward chronic disease

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.

Populations with Vitamin D DeficiencyPopulations with Vitamin D Deficiency Healthy adults, children, adolescentsHealthy adults, children, adolescents Sunscreen users Sunscreen users African AmericansAfrican Americans ObeseObese Elderly/limited sunElderly/limited sun Living at northern latitudeLiving at northern latitude Immigrants from southern to northern latitudeImmigrants from southern to northern latitude Veiled womenVeiled women Medical inpatients including nursing homes Medical inpatients including nursing homes Osteoporotics on bisphosphonatesOsteoporotics on bisphosphonates HIV positive on PIHIV positive on PI SmokersSmokers

Calcemic and Non-Calcemic

Actions of Vitamin D

Vitamin D and Chronic DiseaseVitamin D and Chronic Disease Rickets/OsteomalaciaRickets/Osteomalacia DiabetesDiabetes HypertensionHypertension CVDCVD PCOSPCOS CancerCancer Mental health Mental health

OsteoporosisOsteoporosis Falls in the elderlyFalls in the elderly

Periodontal diseasePeriodontal disease InfectionInfection Immune regulationImmune regulation Autoimmune diseaseAutoimmune disease Chronic liver diseaseChronic liver disease Fat MalabsorptionFat Malabsorption Parkinson’s diseaseParkinson’s disease Primary HyperPTHPrimary HyperPTH PsoriasisPsoriasis

Holick M. High Prevalence of Vitamin D Inadequacy and Implications for Health. NEJM.2006

Maximizing the fetal environment improves the health of both women and men!

Old Paradigm

››

New Paradigm

Reproduction Reproduction +

››

Interdisciplinary Field Reproductive & Developmental Plasticity

SummarySummary• Women’s Health, as a field, is evolving & Women’s Health, as a field, is evolving &

is going through developmental stagesis going through developmental stages Reproductive healthReproductive health Sex differences based on male normSex differences based on male norm Interdisciplinary field based on plasticity Interdisciplinary field based on plasticity Systems biology model provides for new Systems biology model provides for new

understandings of health & disease in both understandings of health & disease in both women & men women & men

• Application of this model provides Application of this model provides insights such as the role of vitamin D in insights such as the role of vitamin D in the epidemic of chronic diseasethe epidemic of chronic disease