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Dr. Jones: Why can't a woman be more like a man? In the musical "My Fair Lady," Professor Higgins for singing his frustrations in his research project to turn Eliza into a proper lady. But in healthcare the, difference is important. This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health Care and this is The Scope.

Announcer: Covering all aspects of women's health. This is "The Seven Domains of Women's Health" with Dr. Kirtly Jones on The Scope

Dr. Jones: Men and women aren't the same. However, in the history of research into health outcomes in medicine, men's biology was the default mode. Except in Obstetrics and gynecology, of course. Researchers were wary of including women in the studies because they knew that there could be variations in how the body worked and how drugs were metabolized during the menstrual cycle. And men, of course, were the same every day, which was not quite true.

Also, women might become pregnant and for untested drugs undergoing research into dosing and side effects, that would be a problem until drug safety was established. So we counted on men to go into the risky drug development battlegrounds, but not anymore. Gender health medicine has become a significant focus at the National Institutes of Health. Research funding requires that a woman be included where appropriate. For instance, not necessary on prostate research but very important in diabetes research. Okay. Well, what are some of the differences?

Body size. Of course, we know that men are often bigger than women, but not always. If body size alone were a bigger factor, we should be dosing drugs by body mass index, or body surface area or just weight. But body size does predict lung size, heart size, artery size and kidney size and the size of the organs may predict how it metabolizes drugs or how it's affected by disease. For instance, a woman's heart vessels are smaller and they might clog up a little more easily and more quietly. Women are less likely to have a massive heart attack and more likely to quietly have heart damage leading to heart failure.

What about body composition? Women carry more fat than men, usually. This may affect how some drugs are stored. Some drugs are distributed in water and some are bound by fat. This can be somewhat important in anesthetic agents, which are fat soluble and might be taken up by fat in women leading to a lower effect per weight in women.

Anatomic shape. Well, we know girls are curvy, but some girls are more curvy than others. Most women have a different hip configuration than men. They have wider hips and that is hip bones, not just fat on the hips. This means that the angle from the hip to the knee is bigger and men's legs are straighter from the knee to the hip. Now, this is important in the rate of knee injuries in female athletes, which is greater than men. And a knee replacement in women doesn't have to be smaller, it has to have a different angle. This is important for your orthopedic surgeon to know.

Absorption. We absorb pills through our stomach in our intestines. Women have slightly less stomach acid and slightly lower gut transit time, which can make some drugs stay around longer to be absorbed more. Of course, there are some men who have lower stomach acid and lower transit times as well.

Metabolism. Women make more of certain kinds of metabolic enzymes in the liver, particularly women on oral hormonal contraception or women who are pregnant. This is particularly important in certain anti-seizure drugs, which may be less effective in women and doses may need to be changed. On the other hand, women have smaller kidneys and less kidney function as they age. So drugs metabolized by the kidneys can hang around much longer in older women.

Another important difference is in narcotics, for which women have a greater effect at lower doses. The same thing with alcohol, women have a greater effect at lower doses. The same is true for some prescription sleeping pills, for which the FTAs implemented labeling to make sure that doctors and patients know that women should be prescribed lower doses.

Now there is the "we don't know why" core category, one of my favorite categories. In this category, we don't really know why there is a difference. We don't know why women have less serotonin than men in their brains. So anti-depressants and anti-anxiety drugs like selective serotonin reuptake inhibitors, SSRIs, have a greater effect, are more effective in depressed women than in depressed men.

All these differences can lead to different side effects in women compared to men. Women have more side effects in drug studies than men. They have more nausea as a side effect. So what should we do about this as clinicians and as patients? First, we should be wary of assuming that all men are alike and all women are alike. We've already been in trouble to say all people are the same, they're all like men. But not all women are the same and not all men are the same. The differences between men and women are evident when we look at large groups of each sex, but individuals may be larger, smaller more or less fat, have different metabolisms than average for their sex.

If our medicine isn't working in the way we hoped, we should take a look at the individual and ask if different dosing or a different drug should be better. If you're having a side effect from a drug, you should let your clinician know. If you're being prescribed a drug or a course of the action like physiotherapy or joint replacement, you should ask your clinician if there are differences between men and women and how should their recommendations be modified.

I read a research study from Japan where there words like "obese" or "fat" or "overweight" were flashed in front of the eyes of men and women in functional FMRI. In men, the brain activity went right to the language center of the brain. "What was that word?" In women, the brain activity went all over to the language center, to the emotion center, to the judgment center. I hope they didn't spend too much money on that study because every woman and man I know could have told them that women are different than men.

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Interviewer: Men and women are very different. Nobody would ever argue that, but up until recently, in the eyes of researchers, they're exactly the same and that's a problem. We'll discuss that next on the scope.

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Interviewer: It might shock you to find out that when it comes to research, a lot of times, women aren't even considered in research and we're going to find out more about that now from Jean Shipman. She's the director of the Spencer S. Eccles Health Sciences Library. Let's talk a little bit about this what is it called, gender bias in research?

Jean Shipman: Sex and gender differences in research.

Interviewer: All right. So explain a little bit what that means.

Jean Shipman: Well, sure, sex and gender. Sex means male or female, the biological difference between the two, and gender is more who you identify with. So you can be male, but have more feminine tendency or desire or understanding of the world. And so, lately, researchers are becoming more aware that there is a need to look at these populations differently.

Interviewer: Okay. And, what, give me in real terms what that means.

Jean Shipman: Yeah, let's say I'm a researcher and I'm looking at the population. Most of the time, I'm referencing the male population. Historically in literature, that's who has been documented. Now, I need to pay attention that there are differences physiologically between men and women and it could affect dosage, it could affect physiological uptake of medications, but there is a difference that has to be recognized.

Interviewer: So wasn't there a story on 60 Minutes recently about this very thing?

Jean Shipman: There was. It was Ambien, the common drug is diagnosed, they found, double the dosage for women. And who knew, but they found out that everyone was being given the same dosage, but the uptake of it is twice as much in women, so they were being double dosed.

Interviewer: So if I understand correctly, they were just looking at, you give this much per body weight, and it was all based on men, but women actually process it differently, so that was inaccurate.

Jean Shipman: Exactly.

Interviewer: And I'd imagine that happens in a lot of other instances as well.

Jean Shipman: I'm sure we're just starting to uncover how often that's happened.

Interviewer: Yeah. Wow. So is it really that widespread that research, so when we're researching any of our health concerns, we really just look at men for the most part?

Jean Shipman: Well, I think in the study design, people are asked to look at all kinds of subjects - men, women, children, and document, but when you're actually looking at tissue or specimens, I think male tissues have been used and not so much women. And, also, I think we're seeing that women's needs are very different as far as the healthcare that they receive.
Another example is in developing medical devices. With surgical staplers, who knew that there would need to be a difference between men and women, but women have less pressure...

Interviewer: Yeah, like hand strength.

Jean Shipman: Yeah, hand strength so...

Interviewer: And smaller hands many of the times.

Jean Shipman: Exactly. So they have difficulty getting the stapler to work in surgeries and yet more women are becoming surgeons, so. We need to take that difference into account.

Interviewer: Wow. It's kind of shocking, isn't it? That nobody has really done this before so...

Jean Shipman: Yes.

Interviewer: You've received a grant from the NIH. Tell us a little bit about that grant and what it hopes to do.

Jean Shipman: Sure. The Office of Research of Women's Health and the National Library of Medicine have recognized this need to encourage more researchers to think about the differences between men and women and gender differences. So they have solicited about ten libraries across the country and given us subcontract money to make our university personnel a lot more familiar with this issue.

Interviewer: Yeah.

Jean Shipman: And we've gotten two rounds of funding and we've looked at social media as a mechanism for making people more aware of this need and the differential research. We've looked at videos. We're looking at the podcast that we're doing today as a way to educate people about the importance of this. We also will be having a symposium on campus in September.

Interviewer: Okay and all the goal is to just get people to start thinking, researchers, specifically, to start thinking in terms of gender, not sex.

Jean Shipman: Or both.

Interviewer: Or both.

Jean Shipman: Yeah. The idea that you do need to account for the physiological as well as the social, economic, cultural differences.

Interviewer: Yeah, that, that there are differences, just to be aware of that. Ultimately, what's the goal of this program then? What do you hope would come out of it at the end of the day?

Jean Shipman: The ultimate goal would be everybody I talk to would understand that there is a need to think about these two things differently. Personally, I didn't realize the difference between sex and gender until getting this contract money.

Interviewer: And you're a woman. You should...

Jean Shipman: I know.

Interviewer: ...be more sensitive to this, right?

Jean Shipman: I know. I had the inkling that we weren't be represented equally but let me just say that it did surprise me that sex was biological and gender was more of a cultural.

Interviewer: Yeah.

Jean Shipman: That I always heard them being interchanged and, if you look at the literature, it's misconstrued a lot of times as being one in the same, and they're not, so.

Interviewer: So I think an important thing is if you are a researcher, you now know a little bit better. If you're not a researcher, you know somebody that is, share this podcast with them. And you're just looking for at, first for a paradigm change.

Jean Shipman: Right.

Interviewer: Just to start considering it.

Jean Shipman: And, as a consumer, I would say you could ask your doctor, "Well, you know, I am a woman. Does this make a difference in how I should be taking this medication that you're treating me with," or you know, be a little more assertive in asking that question.

Interviewer: Yeah. And just talking about it in general, I think...

Jean Shipman: Right.

Interviewer: ...would be a good idea.

Jean Shipman: Right. And I think we'll see more and more in the news about this. I know NIH is starting to require researchers include tissue samples from women as well as men in their basic science studies. So there'll be more governmental, kind of, endorsement, of encouragement of this use of the difference in the terms.

Interviewer: Who knew that women were still being discriminated against? We thought we thought we got past this whole thing didn't we?

Jean Shipman: Oh, I think we have a long way to go. But, but I'm pleased to hear that there is more awareness being built about this and that libraries, particularly, were addressed as a unit that could be the educators within their universities, being neutral and central.

Interviewer: And because you have a contact with a lot of researchers that use you as a resource.

Jean Shipman: Exactly, and that we can help to shape the evidence of the future.
Announcer: We're you're daily dose of science, conversation, medicine. This is The Scope. University of Utah Health Sciences Radio.

Announcer: Medical news and research from University Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: There are new requirements for researchers to consider sex and gender differences in their research designs. We're going to learn more about that right now and also about the 2014 info fair, Women's Health, Sex, and Gender Research Conference. Jean Shipman is the director of the Spencer S. Eccles Health Sciences Library. Let's talk about the info fair that's coming up and why is this important to researchers?

Jean Shipman: Scott, this is really going to be an issue for anybody applying for research grants and subcontracts, because it's going to be required more and more than researchers indicate how they're accounting for both sex and gender differences in their research.

Interviewer: This is kind of a new trend.

Jean Shipman: New in that NIH is going to start requiring that people look at tissue differences between men and women, particularly. Also, we've gotten funding to raise awareness about this issue from NIH and the Office of Research and Women's Health, particularly in the National Library of Medicine, as this is important that people become more aware.

Interviewer: Why does the NIH believe it is so important?

Jean Shipman: Every generation discovers something new, but we've discovered that we've been biased in our research in the past in using male reference standards for a lot of the design of research protocols and also not recognizing that there may be differential physiological differences in the research for men and women.

Interviewer: How has this played out in real world ways?

Jean Shipman: Well, an example is on 60 Minutes. They had an Ambien example where women were being double dosed because they were receiving the same dosage as men, but their physiological makeup requires less. We're seeing it highlighted more and more in the public culture as well as in true research.

Interviewer: Eventually this is going to become the way researchers are judged on their research if I understand correctly. Could you explain that?

Jean Shipman: I really predict that this could be a criterion in scoring for research grants, how much a researcher has considered these differences between men and women physiologically and biologically as well as their gender tendency. Where is their socioeconomic fallout for how they consider themselves and conduct their lives?

Interviewer: Let's talk a little bit about the 2014 info fair which deals with women's health, sex, and gender research. What types of things could a researcher learn at this conference?

Jean Shipman: We're hoping to make it a local application as well as national. Our keynote speaker is Dr. Caroline Clancy from the National Office of Veterans' Affairs, who is a well known researcher in this area. She's going to speak about her research but also the importance of considering this research difference in your protocol. We kick off the day with local experts, and we put a call out for contributors for posters and we'll have about 15 examples of research being conducted here at the University itself that deals with this topic. Those researchers are sharing their presentations for their research but also looking for partners in crime, other researchers who may have an interest that could join in their efforts.
Then we're going to have a keynote and then a follow-up panel of experts from the campus, both campuses of the University, who will talk about the resources that are available to local researchers and then we'll also have another panel that will highlight five of the posters with the researchers talking more specifically about how they have accounted for these differences in their research.

Interviewer: So some real good information on something that's going to be a concern of all researchers here very quickly, it sounds like.

Jean Shipman: It is. It will also highlight the need as well as get some real life examples and also identify resources available for you in the future.

Interviewer: What about the general public? Can the general public also attend?

Jean Shipman: We welcome the general public. In fact, this is sponsored by the Snyder Family's endowment to the library. It's a lecture series. The info fair has happened for about 25 years now. With their generous support, we offer this to the community as an awareness for them, too. As a general consumer, I hope that people can come away from this symposium saying to their private practice provider, "Hey, have you considered the difference in this dosage before you give me a treatment for a medication if I'm a woman?" Just to cause a little bit more conversation to happen between providers and consumers on this topic.

Interviewer: Any final thoughts on this info fair or this issue in general?

Jean Shipman: I really hope that people will leave with a different mindset. If we have encouraged our University as library partners, the Marriott Library and the Eccles Library are working together on this symposium along with the Center of Excellence in Women's Health on the campus, if we can just say that we've affected 20% change in people's opinion on this or their knowledge of this, we will consider it to be a very successful event.

Announcer: We're your daily dose of science, conversation, medicine. This is The Scope, University of Utah Health Sciences Radio.