Gender medicine

Content

Introduction

Numerous studies show that men and women are different in terms of disease sensitivity and health maintenance. We know that women live longer than men (average life of men 80.6 years and women 84.9 years - ISTAT 2017 data), but they get sick more, consume more drugs and, consequently, are more exposed to reactions unwanted reactions (adverse reactions) caused by medicines. They are also "disadvantaged" compared to men because they are more easily subject to unemployment, economic difficulties and physical and psychological violence. If we consider the years of life spent in good health, the advantage in favor of women decreases considerably. (Video)

Gender Medicine

The World Health Organization defines Gender Medicine the study of the influence of biological differences, indicated by the term sex, and socio-cultural and economic, defined as gender on the frequency, disorders and severity of the diseases that affect men and women and, in general, on the state of health and disease of each person.

Gender medicine also takes into account the health effects of lifestyles (smoking, alcohol, nutrition, physical activity, body weight, socio-cultural and environmental context) since these factors also have a strong impact on the development and evolution of diseases .

It is important to clarify that gender medicine is not only concerned with women's health, nor is it limited to diseases that affect the organs of reproduction, but is concerned with diseases that can affect both sexes. It is not a new area of ​​medicine, but it represents a new level of analysis to be included in all the already existing areas of medicine.

The knowledge of the differences, in fact, is fundamental for a correct prevention, a better assessment (diagnosis) of the disease and for the identification of the most appropriate therapy for each one.

Differences in the onset or progression of many diseases are determined by the presence of so-called chromosomes sex-specific: XX and XY.

Females have two copies of the X chromosome, which is present, however, in only one copy in males. Although there is a complex regulatory mechanism which, through the inactivation of one of the two X chromosomes, avoids the presence of double quantities of the genes located on this chromosome, the random way in which the inactivation takes place has a protective function. This mechanism in fact produces an individual mosaic (if we call the two X chromosomes, Xa and Xb, in some cells the Xa chromosome will remain active, in others Xb) and if a mutation occurs on the Xa chromosome (for example, Xa-mut) it will affect, in the woman, only the cells in which this chromosome remained active while the cells carrying chromosome Xb will be healthy. In men, however, since only one X chromosome is present, all cells will contain the mutation.

Although differences between males and females are already present in pediatric age when hormones still do not perform their functions, an important role in determining gender differences is played by sex hormones, mainly estrogen and progesterone in women and androgens in men. hormones, in addition to controlling the development of female and male secondary characteristics, perform numerous other important functions, including important effects on the responses of the immune system, which are generally more effective in women.

Brief history of Gender Medicine

Historically, medicine has always put man "at the center of studies, limiting female health only to aspects relating to reproduction. Only recently has it become clear that the development of medicine, which took place through studies conducted almost exclusively on men, was based on" the idea of ​​protecting the woman and on the erroneous scientific prejudice that she was different from man only in size.

The application of gender medicine is very recent: in 1991, the American cardiologist Bernardine Healy, director of the National Institute of Health (NIH), first published an article in the important scientific journal New England Journal of Medicine, entitled "The Yentl syndrome". The article highlighted the differences in the treatment of men and women with the same heart disease. In fact, the mistaken belief that it was a typically male disease led to delays in investigations (diagnosis) and treatment in women and, therefore, to inappropriate and discriminatory therapies.

From that moment a gradual, albeit slow, growth of this new approach to medicine has begun worldwide. The World Health Organization (WHO), together with other international bodies, has recognized the gender as one of the fundamental factors in determining health or disease.

In 2009, the WHO established a Department attentive to gender inequalities and, subsequently, established the gender as an essential theme of health planning 2014-2019. At the same time, also in Europe, various bodies have contributed to affirming that gender is a fundamental variable of health and disease, in particular through the Europe 2020 program aimed at achieving "gender equality."

In 2014, US law established the importance of ensuring balanced representation between men and women in clinical trials of drugs and medical products.

In the same years, in Italy, attention began to be placed on gender medicine for the interest of the Ministries of Equal Opportunities and Health with the contribution of AIFA, AGENAS and the Istituto Superiore di Sanità (ISS). In 2011 the "Istituto Superiore di Sanità" set up a working group within the Department of Drugs and subsequently, in 2017, it established the "National Reference Center for Gender Medicine", the first in Europe in this area. Italy, a network of active collaboration has also been set up for the support of Gender Medicine which includes, in addition to the ISS, the National Study Center on Health and Gender Medicine and the Italian Group on Health and Gender (GISeG), some universities, numerous medical federations, scientific societies and associations, as well as some Regions that have included the concept of gender in the Regional Health and Social Plans.

At the beginning of 2018, the approval of Law no. 3, published in the Official Gazette on February 15, 2018, definitively included the concept of gender in the National Health Service, with "Article 1" Regulations on clinical trials "and" Article 3 "Application and dissemination of gender medicine".

Importance of Gender Medicine

To obtain the best results in the field of health, it is important to re-evaluate many aspects of medicine, also taking into account gender, male or female, alongside the parameters usually considered (age, ethnicity, cultural level, religious confession, sexual orientation, social and economic conditions ). Only in this way will it be possible to identify the treatment that is truly most suitable for each individual, guaranteeing real equity in the possibility of being treated for all citizens.

For some time now, indications have been given on a world-wide level to correctly address all the phases of experimental research. In each of these moments, the importance of comparing the results obtained in cells, animals and individuals of both sexes is evident. Despite these suggestions, for a long time the concept of gender medicine was not taken into consideration: cells were used in laboratory studies regardless of their sex of origin, animal studies performed in the vast majority of cases on one sex only, and in clinical studies, men were preferentially enrolled.

Today, in the age of personalized medicine, interest in the variable "gender" is finally growing. It is therefore essential to provide adequate and correct information so that everyone definitively acquires the idea of ​​gender health.

Some examples of diseases for which gender differences have already been highlighted can clarify the concept. Indeed, the statistics highlight strong differences between men and women for the main groups of diseases such as, for example, cardiovascular disease and cancer. In Italy, more women than men die from diseases of the cardiovascular system (48% vs 38%).

Until recently, the importance of cardiovascular disease in women was little considered.Yet, apart from the period of life in which the woman is fertile, which sees men of the same age to be most affected, the frequency of these diseases is subsequently increasing in women until it surpasses the man after the age of 75. In part this it occurs because the protection of female hormones is lacking.

In tumors, however, the opposite occurs. In fact, on average, one in two men and one in three women will be likely to get cancer and one in three men and one in six women will be likely to die from cancer during their lifetime. In general, with the exception of thyroid cancer, incidence and mortality are lower in women.
A clear example is represented by colorectal cancer more frequent in men, at least compared to women of childbearing age, indicating that female hormones (estrogen) are a protective factor. The location may also differ, with women more likely to develop cancer on the right ascending side of the colon, and men on the left descending side. The different position means that the search for occult blood in the faeces can represent a better prevention in men than in women. Furthermore, depending on the site of development, the tumor is associated with different molecular characteristics that determine its aggressiveness. Finally, differences related to lifestyles, in particular to diet and physical exercise, can have a significant impact.

On the other hand, there are some diseases that are considered typically female, which are often not considered in men. An example is osteoporosis, which mainly affects women, but is also a threat to elderly men who, following major fractures, such as those of the hip and femur, have more serious consequences and higher mortality.

Similarly, depression appears to be less frequent in men, probably because it is not considered that they tend to delay the use of health care. Furthermore, since the studies have been mainly conducted on the female population, the assessment of psychiatric illness in men is more complex because they do not have the disorders (symptoms) indicated by current guidelines.

Women are known to develop more intense immune system responses than men and that this increased efficacy is favorable in responding to infections, but makes women more prone to rheumatic disease in general, and autoimmune in particular (e.g., lupus erythematosus systemic, rheumatoid arthritis, Sjogren's syndrome, autoimmune diseases of the thyroid gland and scleroderma, which are 7-10 times higher in women than in men).

Another area in which important differences between the two sexes have already been highlighted during prenatal development, therefore in childhood and adult life, is that of respiratory diseases. There are structural differences that affect respiratory function (in childhood and in " adolescence in favor of girls, in adulthood in favor of men). Certainly in the foreground there is the damage caused by cigarette smoking, which appears to be higher in women, at least in part due to the "interference of female hormones in the" elimination of toxic substances. The effects of the change in smoking habits, which in about 50 years passed from a 10 to 1 ratio between men and women (in the 1960s 60% of men and only 6% of women smoked) to current ratio of 1.5 to 1, led to a significant increase in the female sex of diseases that were mostly male. In Italy, according to the latest data (Surveillance PASSI), today 30.8% of men and 22.1% of women smoke.

Gender and lifestyles difference

Important gender differences with a strong impact on everyone's health can be seen in lifestyles. In fact, biological differences linked to sex determine different needs and a different metabolic response to foods, while socio-economic and cultural influences linked to gender influence behavior and, consequently, exposure to environmental risk factors.

Important examples are associated with smoking, nutrition, and alcohol consumption.

Although in general women smoke less than men, tend to use cigarettes with lower nicotine content and inhale less deeply, have a lower chance of being able to quit, and experience greater stress and anxiety following nicotine withdrawal. Furthermore, women smokers are more susceptible to the damage induced by cigarette smoking probably due to lower levels of protective factors (enzymes capable of eliminating toxic products, for example glutathione-S-transferase).

The influence of gender differences on food choices and lifestyle is equally evident and relevant. Women follow healthier diets, also because they are more attentive to aesthetic ideals and to maintaining an adequate weight. They eat more fruit and vegetables, but they are also more attracted to sweet foods. Men eat more protein, consume more alcohol and more packaged foods, and generally have a "more disordered" diet. While women seem more ready to change their eating habits, it is men who are more constant in following dietary regimes correctly, perhaps because, due to the male's better ability to metabolize fats, they obtain more evident results.

Regarding the consumption of alcohol, although they use it more limited on average, women become addicted more quickly with serious consequences.In fact, in women the activity of the enzyme (alcohol-dehydrogenase) necessary for the elimination of alcohol is less and, at the same dose, the alcohol (ethanol) remains in circulation longer. It can be considered at "low risk" "A daily quantity of alcohol to be consumed during main meals (not between meals) not exceeding 2 units for men and 1 unit for women. One unit corresponds to approximately 12 grams of pure alcohol, that is a glass of wine (from 125ml), a beer (330ml) or a glass of spirits (40ml). These doses are intended for adults, while before the age of 18 and after 65 it is necessary to pay even more attention.

Conclusions

Up to now it has been epidemiological research, which studies the different distribution and frequency of diseases and health events in a population, that has highlighted the differences between men and women. Research is currently seeking to understand the mechanisms responsible for these differences. In fact, only a real understanding of the differences will allow to ascertain (diagnose) diseases more and more quickly and correctly and, above all, to treat each person in the most advantageous way, remembering that taking into account gender improves not only women's health, but also that of men.

Gender medicine also represents a strategic objective for the National Health Service, which is moving towards personalized medicine, more in keeping with the specific needs of each person and therefore more effective and economical.

Bibliography

Ortona E, Delunardo F, Baggio G, Malorni W. A sex and gender perspective in medicine: a new mandatory challenge for human health. Monographic section. Annals of the "Istituto Superiore di Sanità" 2016; 52: p.146-239

Ministry of Health. Gender as a determinant of health. The development of Gender Medicine to ensure fairness and appropriateness of care. Notebooks of the Ministry of Health. 2016; 26 

Italian Association of Medical Oncology (AIOM). The Numbers of Cancer in Italy. 2018

National Institute of Statistics (ISTAT). Fair and sustainable wellbeing in Italy: 2018. National Institute of Statistics: Rome, 2018

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