Whether or not men and women really hail from two different planets, gender-based differences do affect manifestations and risk profiles for certain neurologic conditions. Research in this field, however, is severely limited and studies are often not powered to adequately address these discrepancies.
The AAN's Section on Women's Issues in Neurology has hopes of changing that, and incorporating these differences into study design from the outset. Section Chair Barbara Swartz, MD, PhD, FAAN, spoke with Neurology Today about the recently published American Heart Association/American Stroke Association guidelines for preventing stroke in women as an example of why gender differences should be part of a constant and ongoing discussion among researchers. [See Neurology Today's article on the Stroke guidelines: http://bit.ly/1mqisi8.]
The guidelines, which were published in the February edition of the journal Stroke, pointed out risk factors that were unique or more common to women — such as pregnancy, preeclampsia, migraines, atrial fibrillation, diabetes, and hypertension — which all treating clinicians should know. The authors also recommended the development of a female-specific risk score to reflect stroke risk across the lifespan. Dr. Swartz hopes the stroke guidelines will elicit a much broader discussion about the need for research on women's neurologic health.
“All practicing neurologists need to be more aware of these guidelines and be more proactive with the women in their practices to prevent future strokes. The guidelines help guide prevention and treatment in special populations like women with migraine with aura and pregnant women,” she said.
Dr. Swartz commended the authors of the stroke guidelines for looking at risk factors which are unique for women — like reproductive issues — and things that are more common in women — such as migraine with aura.
“I think we need to look at that in other conditions, too,” she said. “We need to focus on the sexual dimorphism of disease — what are the different risks for the two sexes, why do the differences exist and what are the different outcomes? Do we need to treat them differently?”
In the past, Dr. Swartz explained that the Section was focused largely on important issues of women's career parity, leadership, and recognizing trauma and abuse. Dr. Swartz, who is an epileptologist at Renown Hospital in Reno, NV, said her training as a basic scientist gave her the idea to use the Section to encourage the study of gender differences throughout neurological disease types. “I thought it would be interesting to start to look at how neurological diseases affect women differently than men. In some areas, like epilepsy, we know quite a bit about that, but in most areas of neurology there hasn't been as much attention.”
Among her plans for the Section, she hopes to create a registry comprising the Section membership's research interests and have them perform a review of their particular discipline, “say multiple sclerosis (MS), and how women's issues affect MS, and how MS may affect women differently than men — and so on.” The registry can also be a platform for more interaction with women or men doing research on women's neurology across the country so that they may be able to find experts to collaborate with on different projects.
Ultimately, the goal would be to advocate that funding agencies require that grantees properly plan their studies so that they are powered to look at male-female differences, she said. Much of the data that currently exist on gender differences in neurologic disease were not based on “a primary endpoint or even a secondary endpoint to look at male-female differences, so the studies do not have large enough populations to answer these important questions.”
IMPROVING WOMEN'S STROKE CARE
Dr. Swartz noted that the sexual dimorphism in different conditions, particularly stroke, is not properly addressed in residency programs. “Our residents know that there are conditions like eclampsia which are particularly risky for stroke, for example, but some of these other data about the outcomes of women with all types of stroke and the increased risk to women, especially after the age of 65, definitely needs to be taught.”
There need to be more studies on the epidemiology of stroke in women and why the risk changes so dramatically after a certain age. “We need to find out why that is so we can address the real cause. It doesn't seem to be simply hormonal changes, so we need to find out what other factors are causing that increased risk. That's going to take a fair amount of basic science, as well as clinical trials.”
In order to improve patient care, there needs to be interaction with obstetricians and perinatologists for pregnancy and stroke risks, she said. “For epilepsy, we also interact with geneticists and the neonatologists. I think we should also be interacting more with the psychiatrists and other disciplines that deal with women,” she added.
The Stroke guideline is a reminder that “we need to keep getting the word to women to be aware of the signs of stroke and heart attack, because a lot of times these signs may be pretty subtle. We also need to make women aware of the risks of untreated hypertension, which is usually a silent condition, and the need for screening.”
A lot of this preventive work is done at the primary care level, she said. Looking forward, she continued, “hopefully, some of the ‘medical homes’ that will arise out of the new health care plans may be a venue for addressing educational and preventive issues.”
Dr. Swartz invited fellow neurologists to attend the Section on Women's Issues in Neurology meeting in Philadelphia at the AAN Annual Meeting this month, and welcomed additional participants for the women's neurology resource list.
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•. Bushnell C, McCullough LD, Awad IA, et al. on behalf of the American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Council for High Blood Pressure Research. Guidelines for the prevention of stroke in women: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014. E-pub 2014: Feb. 6.