Special Feature: Gender Medicine and the Obstetrician-Gynecologist
Special Feature
Gender Medicine and the Obstetrician-Gynecologist
By Sarah L. Berga, MD, Professor and Chair, Department of Obstetrics and Gynecology, Vice President for Women's Health Services, Wake Forest Baptist Health, Winston-Salem, NC, is Associate Editor for OB/GYN Clinical Alert.
Dr. Berga reports no financial relationships relevant to this field of study.
It might sound obvious to a reproductive medicine specialist to say that "every cell has a sex." On the other hand, even an obstetrician-gynecologist might be surprised to know how much of a contribution sex differences make to health and disease. A recent editorial in the Lancet, titled "Taking Sex into Account in Medicine," highlighted that gender-diverse teams have higher team IQs and promote innovation, and remarked that "being male or female might be a more important determinant of health, illness, and response to treatment" than is currently known or appreciated.1 One important biological concept is that sex differences are more than just hormonal in origin. For instance, the transcription factor XIST (X-inactivation-specific transcription) is a long, noncoding RNA that does more than inactivate the "extra" X chromosome. The absence or presence of XIST regulates cellular molecular machinery in ways just now beginning to be defined. Recently, we have witnessed the launch of two new journals — the Biology of Sex Differences (2010) and Gender Medicine (2006). In January 2012, the Institute of Medicine released a report entitled, "Sex-Specific Reporting of Scientific Research" that advocated the reporting of the sex of cells and animals used in biomedical science.2 The report also called for studies, particularly clinical trials, to determine the presence or absence of sex differences. To which specialists does the field of women's health and gender medicine belong? And what is the role of the obstetrician-gynecologist in ushering in this new era in which we seek to discover how sex modifies disease presentation, diagnosis, and treatment?
I would suspect that most obstetrician-gynecologists consider their core expertise to be in conditions that are unique to women such as pregnancy, endometriosis, anovulation, and cervical dysplasia. Recently it was reported that XY neurons die by a caspase-independent pathway and XX neurons by a caspase-dependent pathway.3 Does this mean that we need to treat men and women who experience a stroke with different interventions or medications? Does this explain why acute and chronic sequelae of stroke differ in men and women? Clearly, the treatment of stroke is outside the typical practice pattern of an obstetrician-gynecologist. On the other hand, who is going to ensure that the neurologist knows that the neurons of men and women die by different pathways and thus necessitate different treatment approaches? To help address the knowledge deficit, the National Institutes of Health recently released a RFA soliciting applications to elucidate the neurobiology of sex differences.4 But what about sex differences in other tissues and organs? And who is going to raise awareness about the need to specify the effects of sex when treating patients? I hasten to add that it is important to recognize that both men and women will benefit from this expanded knowledge-based and focused treatment approach. It seems to me that obstetrician-gynecologists will play a role in determining sex-appropriate interventions and that our role will be as a member of an investigative or clinical team.
Allow me to share another molecular nugget. The genes expressed by cells of male and female rats exposed to glucocorticoids vary by sex. In female rats, glucocorticoids lead to a much greater expression of genes that regulate inflammation than in male rats. Further, when exposed to an infectious challenge, male rats given glucocorticoids survived while female rats died because of an exuberant inflammatory response. Think of the many conditions for which we prescribe glucocorticoids without any consideration that there may be sex-specific effects. Indeed, glucocorticoids could well exacerbate rheumatological conditions in women and suppress them in men. Clearly, we must understand sex-specific responses to interventions to optimize health for men and women. The bottom line is that we need to understand conditions found only in women, conditions more common in one sex over the other, conditions that present differently in men and women, and how sex modifies treatment responses.
These are early days in the field of the biology of sex differences. But what of gender medicine? First, we must get our nomenclature straight. Sex is commonly understood as a biological quality based on genetics or morphology. Gender is a sociocultural process or behavioral expectation associated with one's perceived sex. Thus, the field of obstetrics and gynecology has evolved from one in which only the conditions unique to women were the focus to one that serves to advocate for better health for women and men. Obstetrician-gynecologists are logical partners for multidisciplinary teams that aim to evolve best practices according to both sex and gender.
References
- Taking sex into account in medicine. Lancet 2011;378:1826.
- Wizemann TM; Board on Population Health and Public Health Practice. Sex-specific reporting of scientific research. Available at: http://books.nap.edu/openbook.php?record_id=13307. Accessed Feb. 10, 2012.
- Liu F, et al. Sex differences in caspase activation after stroke. Stroke 2009;40:1842-1848.
- http://grants.nih.gov/grants/guide/rfa-files/RFA-MH-13-021.html.
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