Are Women and Men With Rheumatism Treated Equally?

LEIPZIG, Germany — Women eat more healthily, visit their physician more often, and accept offers of prophylactic treatment more frequently than their male counterparts. Nevertheless, they are generally diagnosed with a rheumatic disease much later. “With systemic sclerosis for example, diagnosis occurs a whole year later than for male patients,” said Uta Kiltz, MD, senior physician at the Ruhrgebiet Rheumatism Center in Bochum, Germany, at a press conference for the annual congress of the German Society for Rheumatology.

In addition, certain markers and antibodies can be detected earlier in men’s blood — for example in systemic sclerosis. “What’s more, women exhibit a more diverse array of symptoms, which can make an unequivocal diagnosis difficult,” Kiltz explained.

Differences between the sexes in terms of disease progression and clinical presentation have been described for most rheumatic diseases. Roughly speaking, women often exhibit a much wider range of symptoms and report a higher disease burden, whereas men tend to experience a more severe progression of the disease.

Comorbidities also occur at different rates between the sexes. Whereas women with rheumatoid arthritis (RA) suffer more frequently from osteoporosis and depression, men are more likely to develop cardiovascular diseases and diabetes.

Gender-Sensitive Approach

Like Kiltz, Susanna Späthling-Mestekemper, MD, PhD, of the Munich-Pasing Rheumatology Practice, also advocates a gender-sensitive approach to diagnosis and therapy. Späthling-Mestekemper referred to this during the conference, stating that women are still treated more poorly than men. The difference in treatment quality results from gaps in knowledge in the following areas:

  • Sex-specific differences in the diagnosis and therapy of rheumatic diseases and in basic and clinical research

  • Sex-specific differences in communication between male and female patients and between male and female physicians.

Späthling-Mestekemper used axial spondyloarthritis (axSpA) as a “prominent example” of false diagnoses. “Men more commonly fulfil the modified New York (mNY) criteria – involvement of the axial skeleton, the lumbar spine, and increasing radiological progression.”

In contrast, women with axSpA exhibit the following differences:

  • It is more likely for the cervical spine to be affected.

  • Women are more likely to suffer from peripheral joint involvement.

  • They suffer more from whole body pain.

  • They have fatigue and exhaustion.  

  • They exhibit fewer humoral signs of inflammation (lower CRP).

  • They are rarely HLA-B27 positive.

“We also have to completely rethink how we make the diagnosis in women,” said Späthling-Mestekemper. The current approach leads to women with axSpA being diagnosed much later than men. “Depending on the study, the difference can range from 7 months to 2 years,” according to Späthling-Mestekemper.

A 2018 Spanish study reported that the most common incorrect diagnoses in women with axSpA were sciatica, osteoarthritis, and fibromyalgia.

However, it is not just in axSpA that there are significant differences between men and women. There is evidence that women with systemic lupus erythematosus suffer more from musculoskeletal symptoms, while men with lupus exhibit more severe organ involvement (especially more serositis and nephritis).

For systemic sclerosis, women have the higher survival rate. They also exhibit skin involvement more frequently. Men, however, are more likely to have organ involvement, especially with the lungs.

TNF Blockers

Using the example of axSpA, Späthling-Mestekemper also showed that men and women respond differently to tumor necrosis factor (TNF) blocker therapy. “The duration of therapy with TNF blockers is shorter for women: 33.4 months vs. 44.9 months. They respond less to this therapy; they stop and change more frequently.”

Data from March 2023 show that, in contrast, there is no evidence of a difference in response to Janus kinase inhibitor treatment.

The presence of enthesitis has been discussed as one reason for the worse response to TNF blockers in women, since they have it more often than men do. “In fact, a better response to TNF blockers is associated with HLA-B27 positivity, with the absence of enthesitis and with TNF blocker naivety. In women, higher fat-mass index (FMI) could also play a part, or even abdominal weight gain, which also increases in women after menopause,” said Späthling-Mestekemper.

She mentioned the following other potential reasons for a delayed therapy response to biological drugs in women:

  • Genetic, physical, or hormonal causes

  • Widespread pain or fibromyalgia

  • Late diagnosis or late application of therapy, which lowers the chances of remission.

Even the science itself has shown the following sex-specific shortcomings:

  • Disregarding sex-specific differences in animal-experimental studies (which, until recently, were only conducted in male mice to avoid hormone fluctuations)

  • Women in clinical studies are still underrepresented: only 37% of the populations in phase 3 studies are women; 64% of studies do not describe any sex-specific differences

  • Most of the data come from epidemiological analyses (not from basic research)

  • Gaps in medical textbooks

Communication Differences

Female patients are looking for explanations, whereas male patients describe specific symptoms. Female physicians talk, while male physicians treat. They sound like stereotypes, but they have been substantiated in multiple studies, said Späthling-Mestekemper. In general, the study results show that male patients behave in the following ways:

  • Describe their symptoms in terms of specifics

  • Do not like to admit having mental health issues

  • Are three to five times more likely to commit suicide due to depression than women

On the other hand, female patients behave in the following ways:

  • Look for an explanation for their symptoms

  • Often do not have their physical symptoms taken seriously

  • Are often pushed in a psychosomatic direction.

Female physicians focus on the following questions:

  • Prevention, communication, shared decision-making, open-ended questions, “positive” discussions, patient self-management (chronic diseases such as diabetes: female physicians are better at reaching the therapy goals set by the ADA guidelines than male physicians)

  • Psychosocial situations: consultations last one minute longer (10%).

Male physicians focus on the following questions:

  • Medical history

  • Physical examination (cardiac catheterizations after a heart attack are arranged much more commonly by male rather than female physicians)

  • Diagnostics

Recognition and Training

A large-scale surgical study in 2021 made a few waves. The study analyzed whether it makes a difference if women are operated on by men or by women. The results showed that women who had been operated on by men exhibited a higher level of risk after the surgery, compared with men who had been operated on by men or by women. The risk took the following forms:

  • 15% higher risk for a worse surgery result

  • 16% higher risk for complications

  • 11% higher risk for repeat hospitalization

  • 20% higher risk for a longer period of hospitalization

  • 32% higher risk for mortality.

The study authors provided the following potential reasons for these differences:

  • Male physicians underestimate the severity of symptoms in their female patients.

  • Women are less comfortable indicating their postoperative pain to a male physician.

  • Different working style and treatment decisions between female and male physicians

  • Unconsciously incorporated role patterns and preconceptions

“Our potential solutions are recognition and training. We need a personalized style of medicine; we need to have a closer look. We owe our male and female patients as much,” said Späthling-Mestekemper.

This article was translated from the Medscape German Edition.

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