taking care of women: where are we? · cardiovascular disease in women 2011 update: a guideline...

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Michelle Berlin, MD, MPH

Vice Chair, Obstetrics & Gynecology

Co- Director, Center for Women’s Health

Taking Care of Women:

Where Are We?

National Conference of State Legislators

December 9, 2014

Overview

• Background

• Health Data (good & bad)

• Emerging Issues

• Next Steps

2

The proverbial 70 kg man

..is a woman

really just a

small(er)

man?

Cecil Medicine, 23rd edition

Chapter 117

MEN AND WOMEN ARE NOT THE SAME

• Biological

• Pharmacokinetic

– Drug metabolism

– Renal function

• Pharmacodynamic

– Efficacy

– Safety

• Differing disease onset,

prevalence, severity, etc.

P. Scott, Director, Research and Development

Office of Women’s Health, FDA (3/21/2013)

3

NIH

• NIH Office of Research on Women’s

Health established 1990

– Growing attention to women’s health

disparities & inequities

– Data difficult to find

• NIH now re-emphasized priorities in sex &

gender in basic science (Nature 2014)

What do we know?

• Start with health data

• Look for trends over time

• Look for correlations and associations

• Plan public health and research measures

4

Causes of Death, Adult Females, 2009-2011

3 year annual averages per 100,000, age 18+, age-adjusted

Source: CDC Health Data Interactive, NVSS

5

Number of Heart Disease Deaths, Women, 2010

Number Per 100,000; Nationwide average 143.3

Graphic source: Kaiser Family Foundation

Data source: CDC WONDER 2013

6

Lifetime Risk of Stroke

American Heart Association/American Stroke Association

Stroke kills more women than men

American Heart Association/American Stroke Association

7

Stroke Deaths, Women, 2011

Per 100,000 Women

Graphic: Health Indicators Warehouse

Data Source: NVSS-M (CDC/NCHS) and Census

Heart Disease and Stroke: Risk Factors

• Smoking

• High Cholesterol

• High Blood Pressure

• Physical Inactivity

• Obesity and Overweight

• Diabetes

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Obesity Trends* Among U.S. Adults BRFSS, 1990

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%



No Data <10% 10%–14% 15%–19%

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No Data <10% 10%–14 15%–19%



No Data <10% 10%–14 15%–19%

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No Data <10% 10%–14% 15%–19%



No Data <10% 10%–14% 15%–19%

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No Data <10% 10%–14% 15%–19%



No Data <10% 10%–14% 15%–19% ≥20%

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No Data <10% 10%–14% 15%–19% ≥20%



No Data <10% 10%–14% 15%–19% ≥20%

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No Data <10% 10%–14% 15%–19% ≥20%



No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

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No Data <10% 10%–14% 15%–19% 20%–24% ≥25%



No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

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No Data <10% 10%–14% 15%–19% 20%–24% ≥25%



No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

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No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%



No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

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No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%



No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

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No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Prevalence* of Obesity Among U.S. Adults BRFSS, 2011

*Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should not be compared to prevalence estimates before 2011.

15%–<20% 20%–<25% 25%–<30% 30%–<35% ≥35%

CA

MT

ID

NV

UT

AZ NM

WY

WA

OR

CO

NE

ND

SD

TX

OK

KS

IA

MN

AR

MO

LA

MI

IN

KY

IL OH

TN

MS AL

WI

PA

WV

SC

VA

NC

GA

FL

NY

VT

ME

HI

AK

PR GUAM

NH

MA

RI

CT NJ

DE

MD

DC

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15%–<20% 20%–<25% 25%–<30% 30%–<35% ≥35%



CA

MT

ID

NV

UT

AZ NM

WY

WA

OR

CO

NE

ND

SD

TX

OK

KS

IA

MN

AR

MO

LA

MI

IN

KY

IL OH

TN

MS AL

WI

PA

WV

SC

VA

NC

GA

FL

NY

VT

ME

HI

AK

NH

MA

RI

CT NJ

DE

MD

DC

PR GUAM

15%–<20% 20%–<25% 25%–<30% 30%–<35% ≥35%



CA

MT

ID

NV

UT

AZ NM

WY

WA

OR

CO

NE

ND

SD

TX

OK

KS

IA

MN

AR

MO

LA

MI

IN

KY

IL OH

TN

MS AL

WI

PA

WV

SC

VA

NC

GA

FL

NY

VT

ME

HI

AK

NH

MA

RI

CT NJ

DE

MD

DC

PR GUAM

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Diagnosed Diabetes, Females, U.S., Time Trend

Age adjusted rate per 100 adult females

Source: CDC Diabetes Atlas

4.4

per 100

in 1994

8.3

per 100

in 2012

Heart Disease and Stroke: Risk Factors

• Smoking

• High Cholesterol

• High Blood Pressure

• Physical Inactivity

• Obesity and Overweight

• Diabetes

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Percent of Adult Women who Smoke, 2012

Nationwide average: 16.4%

Graphic Source: Kaiser Family Foundation

Data Source: BRFSS 2012

Women with High Blood Pressure, 2009

Nationwide average: 28.3

Graphic Source: Kaiser Family Foundation; Data Source: BRFSS 2009

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Adults who participated in Vigorous Physical

Activity, 2011

(150 minutes or more per week) Nationwide average 51.4%

Graphic Source: Kaiser Family Foundation, Data source: BRFSS 2011

Diagnosed Diabetes, Females, 2012

Age adjusted rate per 100 adult females

Source: CDC Diabetes Atlas

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Adults with <5 fruits/vegetables per day, 2009

Nationwide average 79.7%

Graphic source: Health Indicators Warehouse

Data source: BRFSS 2009

Do medicines work the same way in

women and men?

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Prescription Drugs

• 1997 to 2000

– 80% of drugs removed from market were

withdrawn due to side effects in women

– Half: more commonly prescribed in women

– Half: side effects occurred more often in

women

ew

The Gender Gap in Pain Laurie Edwards

NYTimes 17Mar2013

“Women are more likely to

have their suffering

dismissed as emotional.”

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Emerging Problems: Opioid Overdose

CDC Vital Signs July 2013

WHAT SHOULD WE DO?

What should we do?

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Best Worst

Diabetes (per 100,000) 6

(Montana)

12

(Mississippi)

High Blood Pressure 20%

(Utah)

39%

(Mississippi)

Heart Disease Deaths (per

100,000)

91

(Minnesota)

205

(Mississippi)

Stroke Death

(per 100,000)

27

(New York)

50

(Arkansas)

Overweight & Obese 47%

(Hawaii)

67%

(Mississippi)

Smoking 12

(Utah)

28

(West Virginia)

Cholesterol Screening 85%

(DC)

69%

(Utah)

Physical Activity 63%

(Oregon)

36%

(Tennessee)

More than 5 fruits/vegetables a

day

36%

(Vermont)

17%

(Oklahoma)

Most Common Cancer (Deaths)

Best Worst

Breast Cancer

(per 100,000)

16

(Hawaii)

28

(Alaska)

Lung Cancer

(per 100,000)

13

(Utah)

68

(Kentucky)

27

If you ask the wrong question,

the answer doesn’t matter!

Gravity’s Rainbow by Thomas Pynchon

From Justina Trott MD – Univ of New Mexico

Only 15% of

clinical

practice

backed by

evidence

David Eddy, MD

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Who should take aspirin to prevent cardiovascular disease?

Aspirin use in men

•Can prevent cardiovascular

events: 4 men in 1000

(↓heart attack)

•Can cause significant

bleeding: 3

men in 1000

Aspirin use in women

•Can prevent cardiovascular

events: 3 women in 1000

(↓ stroke risk)

•Can cause significant

bleeding: 2.5

women in 1000

Berger JS, et al “Aspirin for the Primary Prevention of Cardiovascular

Events in Women and Men” JAMA, 2006, Vol 295, No. 3

Guidelines specifically for Women

Effectiveness-Based Guidelines for the Prevention of

Cardiovascular Disease in Women 2011 Update: A

Guideline from the American Heart Association

Journal of the American College of Cardiology,

March, 2011

Guidelines for the Prevention of Stroke in Women: A

Statement for Healthcare Professionals From the

American Heart Association/American Stroke

Association

Stroke, May, 2014

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On the Horizon

• Pregnancy may “uncover” risks for

cardiovascular disease later in life

– Diabetes

– High Blood Pressure

– Pre-Eclampsia

• Developmental Origins of Health and

Disease (DoHAD)

• “In large epidemiologic studies, preterm birth and small-

size-for-gestational age have been associated with

future development of maternal cardiovascular disease.”

• “...(G)uidelines..

– include a history of preeclampsia, gestational diabetes,

and pregnancy-induced hypertension as criteria for at-risk

classification for CVD,

– recommend that obstetrician-gynecologists refer patients

with pregnancy complications to other primary care

physicians postpartum.” Chireau M. http://my.americanheart.org/professional/General/

The-2011-Effectiveness-Based-Guidelines-for-the-Prevention-of-CVD-in-Women_UCM_432543_Article.jsp

(accessed 15Apr2013

Mosca et al Circulation 2011

http://my.americanheart.org/professional/General/The-2011-Effectiveness-Based-Guidelines-for-the-Prevention-of-CVD-in-Women_UCM_432543_Article.jsp

























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Institute of Medicine (July 2011)

IOM 2011 Recommendation to HHS:

Add 8 Women’s Preventive Health Services to ACA

1. Screening for gestational diabetes

2. Human papillomavirus (HPV) testing as part of cervical cancer

screening for women over 30

3. Counseling on sexually transmitted infections

4. Counseling and screening for HIV

5. Contraceptive methods and counseling to prevent unintended

pregnancies

6. Lactation counseling and equipment to promote breast-feeding

7. Screening and counseling to detect and prevent interpersonal and

domestic violence

8. Yearly well-woman preventive care visits to obtain recommended

preventive services

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Recommendation 8

At least one well-woman preventive care visit annually for adult women to obtain the recommended preventive services, including preconception and prenatal care. The committee also recognizes that several visits may be needed to obtain all necessary recommended preventive services.

Alcohol misuse counseling Blood pressure screening BRCA screening, counseling

about Breast cancer preventive

medication Breast cancer screening Breastfeeding counseling Cervical cancer screening Chlamydial infection screening Cholesterol abnormalities

screening

Colorectal cancer screening Depression screening Diabetes screening Folic acid supplementation Gonorrhea screening: Healthy diet counseling HIV screening Obesity screening and

counseling Osteoporosis screening STIs counseling Tobacco use counseling and

interventions Syphilis screening Diet and Physical Activity Establishing Pregnancy History of

CVD-related Conditions Mental health Metabolic Syndrome Preconception health . Prenatal Care STIs: Screening for Chlamydia

and gonorrhea

IOM Services Recommended for Inclusion in Well Woman Visit

Source: IOM, 2011. Clinical Preventive Services for Women, Closing the Gaps.

Overview

• Background

• Health Data (good & bad)

• Emerging Issues

• Next Steps

32

Where do we go from here?

Never doubt that a small group of

thoughtful, committed citizens can change

the world;

indeed, it's the only thing that ever has.

– Margaret Mead

Questions?

OHSU Center for Women’s Health

33

Resources

• Nature article:

http://www.nature.com/news/policy-nih-to-balance-sex-in-cell-and-

animal-studies-1.15195

• AHA/ASA Women & Stroke

http://www.strokeassociation.org/STROKEORG/AboutStroke/Wom

en-Have-a-Higher-Risk-of-Stroke---

Infographic_UCM_460403_SubHomePage.jsp

• CDC Vital Signs: Painkiller Overdoses

http://www.cdc.gov/vitalsigns/prescriptionpainkilleroverdoses/index.

html

Websites

• Kaiser Family Foundation http://kff.org/state-category/womens-health/

• Quick Health Data Online

HHS Office on Women’s Health http://www.healthstatus2020.com/

• Making the Grade on Women’s Health http://hrc.nwlc.org/

http://www.nature.com/news/policy-nih-to-balance-sex-in-cell-and-animal-studies-1.15195





















http://www.strokeassociation.org/STROKEORG/AboutStroke/Women-Have-a-Higher-Risk-of-Stroke---Infographic_UCM_460403_SubHomePage.jsp
















http://www.cdc.gov/vitalsigns/prescriptionpainkilleroverdoses/index.html

http://www.cdc.gov/vitalsigns/prescriptionpainkilleroverdoses/index.html

http://kff.org/state-category/womens-health/





http://www.healthstatus2020.com/

http://hrc.nwlc.org/

taking care of women: where are we? · cardiovascular disease in women 2011 update: a guideline...

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