The Right Medicine for Women and Men

In their younger years, men are more frequent sufferers of heart attacks than women, but in later life that reverses. Women are diagnosed with depression or migraine far more often than men. How people fall ill and what ails them are partly a matter of a person’s sex. This was demonstrated also by the coronavirus pandemic. Men fell more severely ill with COVID-19 and died from it at a higher rate than women. One reason why may be because the female immune system reacts faster and more aggressively to pathogens than the male immune system does. Women, in contrast, faced a greater risk than men of becoming infected during the pandemic because their work – as nurses, salespersons, schoolteachers or child caregivers, for instance – exposed them more to the virus. Those examples make it clear that sex- and gender-specific differences in biology and social behavior play an important role when it comes to sickness and health and are closely interrelated with both.

Gender medicine takes those differences into account. “Gender medicine is a vital part of precision medicine, which is a research priority of University Medicine Zurich (UMZH),” UZH professor and Vice President Medicine Beatrice Beck Schimmer says. The goal of precision medicine is to develop more personalized diagnoses and therapies in order to accelerate and improve recuperation. Sex- and gender-specific differences in biology and social behavior are key factors to consider when it comes to developing therapies as personalized as possible for patients. That’s why they should always be taken into account in research and clinical practice and should be taught in basic and advanced medical training.

That sounds reasonable, but it’s not yet a matter of course in medical practice today. “In many areas of medicine, males were the prototype,” Beck Schimmer says, which is why in the past diseases in women were recognized late or even not at all because medical diagnosis was biased mainly toward male symptoms. Some heart attack symptoms in women, for example, are different than those in men.

Heart-attack symptoms in women are often more vague than in men and present as “stomach, back or jaw pain, for instance,” cardiologist Carolin Lerchenmüller says. This is why women exhibiting such symptoms are often first sent to a neurologist or an orthopedist instead of directly to the cardiology unit. “We need to learn to view sex- and gender-specific symptoms as being typical and to not brand them as atypical so as to avoid prescribing a wrong treatment or unconsciously delaying the right therapy,” Lerchenmüller says. She points to a study showing that female heart attack patients receive optimal therapy less often than men and that if they do get optimal therapy, it often comes late. However, Lerchenmüller explains that it’s not just important to better sensitize healthcare personnel, but stresses that the general public also needs to be aware that there is a wide range of different symptoms associated with heart attacks. That awareness can save lives because women often die as a result of a wrong or too-late diagnosis. Moreover, the healing process takes longer and is more arduous when a heart attack is not recognized in time.

Sex- and gender-specific blind spots of that kind exist not just in cardiology, but also in many other fields of medicine, ranging from neurology to pharmacology and psychiatry. The gender medicine research that is being built out at the university and at University Hospital Zurich aims to change that. UZH created the first-ever professorship for gender medicine in Switzerland for this purpose. Carolin Lerchenmüller will take up the professorship in May 2024. The University of Zurich is thus playing a nationwide pioneering role in this area.

Gender medicine originated in the 1980s when US cardiologist Marianne Legato was the first to recognize that heart diseases have different effects on and symptoms in women and men. With her popular science book titled Eve’s Rib, Legato sensitized a wide audience to gender-specific differences in medicine. The subject has increasingly gained momentum in the world of science since then, uncovering more and more glaring gender-related gaps in knowledge in medical research and clinical practice.

The male prototype has a long tradition in research, “similar to Leonardo da Vinci’s famous artistic drawing of the Vitruvian Man, which depicted the ideal proportions of the human body using the example of a man,” Beatrice Beck Schimmer says. In medicine, preclinical studies were predominantly conducted on male lab animals and clinical trials were conducted on men. The female menstrual cycle is one reason why. Researchers feared that the hormonal fluctuations associated with the menstrual cycle would lead to inhomogeneous results. They therefore shunned experiments with female laboratory animals and eschewed testing on women in later stages of research projects such as clinical trials, which are mandatory for drug approval. “That had some fatal consequences in the past,” says Sarah Scheidmantel, who researches sex and gender issues in the history of medicine at UZH and holds lectures and seminars on the subject for med students.

One example of disastrous consequences was the thalidomide scandal in the 1960s. The blockbuster-selling sedative, which was taken by pregnant women at that time in part to alleviate morning sickness, harmed fetuses and caused babies to be born with severe deformities. “Thalidomide was a textbook case for gender medicine. It vividly demonstrated what can happen when drugs aren’t tested on a diverse sample population,” medical historian Scheidmantel says. Clinical trials at the time showed that thalidomide was effective, but since they were conducted only on men, the dangerous side effects caused by the drug during pregnancy were unknown. In retrospect, the thalidomide debacle contributed to raising awareness of gender-medicine considerations in research.

“Research today rarely works with males as the prototype anymore,” says UZH neurology professor Susanne Wegener, who conducts headache, migraine and stroke research, including from a gender medicine perspective. In research and clinical trials, the increasingly prevalent standard is that study samples must be representative of both sexes unless the subject being investigated is a specifically male or female disorder such as prostate diseases or ovarian cancer. “Today when papers on studies conducted using only male mice are submitted to medical journals for publication, they get rejected with instructions to redo the studies using female mice,” Wegener says.

This change in consciousness was arguably also brought about in part by a social factor: men had long dominated in the medical profession and medical science. “If only one gender conducts research, that narrows the view,” medical historian Sarah Scheidmantel says. Times have since changed. Today, female medical students outnumber their male counterparts, and there is a growing number of women doctors in leadership positions and heading research groups. However, this change has not occurred in equal measure at the top rungs of the hierarchy, where men still outnumber women.

Publications in medical journals also reflect this. Carolin Lerchenmüller examined how often authorship of journal articles is attributed to women and men. Her research revealed that women are far less underrepresented today than they were 20 years ago, but not as last authors. Authorship order is arranged hierarchically. The researchers who did the actual work are listed first. They are usually PhD candidates or postdoctoral researchers. The people in charge of a research project – professors, for example – are listed last. “Today there are still too few women in those managerial positions,” Lerchenmüller stresses. Unlike the number of female students and PhD candidates, the share of women in senior roles is stagnant.

That has consequences because women’s research interests may differ from those of men. This is corroborated by a study published in the prestigious journal Science, which found that research teams headed by women explore more subjects that are relevant to women. Lerchenmüller draws an obvious conclusion from that: “If we want better and more equitable medicine, research teams need to become more diversified.” She says it’s not just about getting more women involved in medicine, but increasing diversity in principle. “Diversified research teams bring a broader variety of perspectives to the same problem and thus potentially deliver better solutions,” Lerchenmüller explains.

What, then, has to happen so that more women rise to leadership positions? One way, she says, is to actively recruit women to apply for leadership roles. That’s what happened to her personally with the professorial chair in gender medicine at UZH, Lerchenmüller adds. “That has a big impact because someone may not have the courage on her own to apply for a certain position.” Women often need more encouragement to have confidence in their ability to handle leadership positions and to aspire to them, Lerchenmüller says.

The culture in large hospitals and medical centers also has to change, the gender medicine specialist stresses. She says that greater comprehension of women’s needs and corresponding structures to suit them are called for, for instance with regard to reconciling work and family life (Lerchenmüller has three children). That’s a management task, she says, so people in managerial positions – oftentimes still men – should be sensitized to that.

And what can women do themselves? They can support and encourage each other and dare to speak their minds and take on managerial functions, Lerchenmüller says, even if that often isn’t easy because women, for example, give a lot more thought to how it comes across when they have a different opinion than their male colleagues. “Men more often have no qualms about speaking up,” she says. The new professor of gender medicine stresses that she doesn’t like the term “equality.” “What we want is equal opportunities.” She calls for “evidence-based equality of opportunities” because equality isn’t necessarily just.

With the new professorship, UZH is buttressing research in gender medicine. But Lerchenmüller also wants to look beyond the confines of her field and work together with arts and humanities scholars and sociologists, for example. Research on sex- and gender-specific medical issues in connection with migraine, stroke, depression, cancer and heart disorders, for example, is already being conducted today at UZH. “Many assumptions in gender medicine are still hypothetical,” Beatrice Beck Schimmer says, “so we absolutely need more evidence-based knowledge about why diseases present and progress differently in women and men.” Future research projects aim to produce that knowledge, and it will be increasingly integrated into the training of physicians and other healthcare professionals, she adds.

In order to pool, coordinate and reinforce scientific work nationwide, UMZH and other academic partners are striving in the longer term to set up a joint Swiss institute for gender medicine. “We want to get as many people as possible involved to cultivate a mutual passion for gender medicine,” Lerchenmüller says. The national Gender Medicine and Health research program launched in late 2023 by the Swiss National Science Foundation, for which neurologist Susanne Wegener sits on the steering committee, will also yield new insights.

“Gender medicine research still focuses primarily on biological sexes,” Beck Schimmer says, adding: “We absolutely should also include transgender aspects as soon as we’ve gained more well-founded knowledge in this area.” Gender medicine research findings are to be directly integrated into everyday clinical practice in the future. “Guidelines on how to optimally treat female and male patients from a sex- and gender-specific standpoint are to be established in all areas of medicine,” Vice President Medicine Beck Schimmer says, so that gender medicine becomes ever more precise for the benefit of everyone.