© © Magda Ehlers
Alone in terms of metabolic pathways, there are significant differences between men and women.
January 1, 2023
Philip Reichardt
Cardiologist Prof. Sievers explains why women often receive incorrectly dosed medication and their heart symptoms are overlooked. A plea for gender medicine.
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In the interview, cardiologist Prof. Dr. Burkhard Sievers explains why heart attacks in women are often overlooked and depression in men is not recognized. He also talks about the central role estrogen plays in medicine.
The last patient of the day has just left the practice in Meerbusch near Düsseldorf. Burkhard Sievers takes off his white coat to focus entirely on answering questions on a topic that has occupied him for twenty years, but is only gradually gaining importance in public perception: gender medicine.
Professor Sievers, what difference does it make whether a man or a woman comes into your practice?
Actually none. Every patient is welcome and treated individually, regardless of gender.
How does the patient consultation with a man differ from that with a woman?
Women's complaints are often relatively unspecific and not such that they can easily be assigned to a category. That’s why you need to be willing to listen very carefully. It requires more sensitivity, sometimes also reading between the lines. That is a significant difference. Of course, you also have to listen carefully to men, but their statements about complaints can usually be classified more easily.
Why?
This is mainly because most diseases in textbooks have been described based on male symptoms.
What role does it play if a woman sits across from a male doctor instead of a female doctor?
For the gender to which you belong yourself, you naturally have a different basic understanding than to another. However, I believe that the difference is not that big. If, as a doctor, you can draw on clinical experience and human knowledge, engage with the patient as a person, then you should be able to classify their complaints. When you look at someone, you can already discover some risk factors. When a patient begins to speak, you learn something about their lifestyle and education.
When you ask about previous illnesses, you know their risks. And when the person talks about complaints, you can sort it out in your mind: What is the problem? The key is the willingness to engage with the person. It is important not to be too easily satisfied and not to shift non-specific complaints to the psychosomatic track. Unfortunately, this often happens.
Women are sick differently from men. This insight, which underlies gender medicine, is considered relatively new in science and research. How can that be? Have the biological differences between men and women been overlooked until now?
The differences have been known for a long time. But they were ignored. Just regarding metabolic pathways, there are big differences. Men have little estrogen, women a lot. But what follows from this is not considered. This applies to the population as well as to doctors and medical staff. They are not taught this.
Hard to believe.
It is said that more women die from cardiovascular diseases than men, which always surprises people. Or that more women die from cardiovascular and vascular diseases than from all cancers combined. Women generally require a 30 to 50 percent lower medication dose because they have a much stronger, faster, and longer immune response than men.
How can it be explained that these findings have not been considered for so long? All a result of a traditional understanding of roles?
This is a key point. Along with ignorance, lack of awareness, and unwillingness to change.
It is widely known that women have a smaller heart, lighter bones, a better immune system, and a higher life expectancy.
Right, but that's often where it stops. No further thought is given, because there is no evidence or studies that address it. There are guidelines for treating certain diseases. But worldwide, these do not differentiate between men and women. This is not the subject of research.
How did you come across the approach of gender medicine? Originally, you are a cardiologist and angiologist.
During my studies, I was undecided for a long time about which specialty to choose. My main interest was in internal medicine and cardiology as well as gynecology and obstetrics. Due to my doctoral thesis, I ended up in cardiology. It was in the USA that I first encountered the concept of gender medicine. The awareness of it is much greater there.
What impressed you the most back then?
That estrogen plays a central role. Could it be, I asked myself back then, that a hormone controls and influences so many processes, leading to such significant differences? Until I came to the conclusion: Yes, it plays a crucial role. And the differences that arise from this must be considered in daily practice.
An important aspect of gender medicine is the dosage of medications. For which diagnoses is this particularly noticeable?
There are studies showing that in cases of heart failure, half the usual dose is sufficient for women to achieve the same efficacy as in men, with the advantage of significantly lower side effects.
What can overdose cause?
Overdose mainly leads to increased side effects. And these often lead to medications no longer being taken, resulting in non-adherence to the therapy. Thus, illnesses that actually need to be treated remain untreated, advance unchecked, and in the worst case, lead to premature death.
Before a medication is brought to market, it is researched for years and must go through approval processes. Isn't gender-specific dosing considered in this process?
For a gender-specific analysis of case studies, they would need to study the group of women separately. This means they have to test different dosages and also consider the hormonal phases in a woman's life: the phase before menopause and the phase after menopause, ideally also the phase during menopause. In these phases, hormone levels fluctuate significantly. Taking this into account would significantly increase the number of female participants, the study duration, and the costs.
And that's where it gets complicated.
Complicated and costly. In other words, the regulations are not so strict that pharmaceutical companies have found it necessary to evaluate tests in this way.
Of course, with any medication, there is a range within which a doctor can adjust the dosage. The problem is just that the starting dose for women is often already too high. And that's why the studies should actually test half the dose again to find out if effectiveness for women is achieved just with that.
In your book "How to Heal Today," you recommend deviating from the given dosages.
Yes, if they have a medically reasonable justification for it. A lower dose does no harm. As a patient, you lose nothing by initially starting with half the dose.
Women have significant disadvantages, especially with heart diseases, mainly because their symptoms are different from those of men.?
Richtig, Männer haben häufiger Herzerkrankungen, aber Frauen sterben häufiger daran, weil diese bei ihnen seltener entdeckt werden als bei Männern, sie oft zu spät in die Klinik kommen und Infarkte verkannt werden. Aber Frauen sterben insbesondere häufiger an Herzschwäche, an Herzerkrankungen und an Herzrhythmusstörungen. Und das deutlich häufiger als Männer.
Was hat das für Ursachen?
Ich gebe Ihnen ein Beispiel aus meiner Praxis. Vor Kurzem hatte ich eine Patientin, Mitte 50. Vor einem Jahr habe sie einen Herzinfarkt gehabt, erzählte sie, und jetzt wolle sie noch mal nachsehen lassen. Sie sagte, es gehe ihr ganz gut, aber hin und wieder habe sie so ein komisches Gefühl. Manchmal spüre sie auch ein bisschen Druck, aber das gehe dann wieder weg. Sicher sei das psychologisch, sagte sie.
Im Gespräch stellte sich heraus, dass sie vor zwei Jahren ihren Ehemann verloren hatte und sich seitdem in Dauerstress befand. Sie wirkte niedergeschlagen und überfordert. Ich machte einen Ultraschall, ein EKG und sah mir die Halsschlagader an. So weit war nichts auffällig.
Zur Sicherheit nahm ich noch Blut ab. Als die Blutwerte kamen, wiesen sie erhöhte Entzündungswerte auf. Schließlich stellte sich heraus, dass sie einen Herzinfarkt hatte, wenn auch keinen lebensbedrohlichen. Ein paar Stunden später war sie im Krankenhaus und ich setzte ihr einen Herzkatheter und drei Stents.
Warum ich das erzähle? Weil sie komplett durch das Raster hätte fallen können. Eine Bitte um Kontrolle, keine Auffälligkeiten bei den Tests, keine typischen Beschwerden, nichts weiter als ein komisches Gefühl. Deshalb ist es so wichtig, Patienten und Patientinnen zuzuhören und aufmerksam zu sein.
Gender medicine is occasionally equated with women's medicine. But men are also incorrectly treated for some common diseases, such as osteoporosis. How does this happen?
The algorithm in the head says: Woman, menopause, estrogen deficiency, osteoporosis. You read this again and again. But from the age of 65, 70, the frequency of osteoporosis in women and men is about the same.
It's actually logical, because bone loss begins at 40, and of course that also applies to men. If an older man breaks his lower leg while gardening, he goes to the emergency room, gets a cast, and goes home.
But all too often no one asks: Why is this actually so? It's a shame, because osteoporosis can at least be reduced, compensated with physiotherapy and muscle building, and bone loss can also be prevented with appropriate medication.
Even in the diagnosis and treatment of depression, men are at a disadvantage. Signs of a depressive disorder are often not recognized. Why is that?
Men often have different symptoms of depression, such as addiction and increased aggressive behavior. However, the classic questionnaire used to diagnose depression does not ask about this. It is oriented towards women. Therefore, depression in men is not recognized as often.
Women in Europe suffer from depression twice as often as men. But the suicide rate is three times higher in men than in women. Does this support the thesis?
Absolutely. And men tend to isolate themselves more during depression and find it significantly harder to take the first step than women. Often they fear being seen as psychopathic, encountering difficulties at work, no longer being the strong man, or being vulnerable. And they escape into addictions.
That's why it's so important for family, friends, and acquaintances to address the person about it. And ideally, take them to where they can get help, be it with a psychologist, psychiatrist, psychotherapist, or neurologist.
How confident are you that the approach of gender medicine will prevail in the coming years?
Pharmaceutical companies will have to adjust their studies. This will provide corresponding data, the gender data gap will shrink. This will lead to package inserts containing different dosages for women and men. The topic will also have a future in science.
Gender medicine differentiates between sexes. But there are other criteria that influence diseases.
The goal of gender medicine is not to stop at distinguishing between male/female/diverse. But to consider a portfolio of parameters, including factors such as genetics, environmental influences, height, body mass, muscle, and fat content.
Gender medicine is a medical approach that considers the biological and physiological differences between genders in diagnosis and treatment. It is based on the recognition that men and women respond differently to medications, exhibit different disease symptoms, and have different risk factors. The aim is to provide more individualized and effective medical care that goes beyond traditional "one-size-fits-all" medicine.
Women have a stronger, faster, and longer-lasting immune response than men. As a result, they generally require 30 to 50 percent lower medication doses to achieve the same effect. Additionally, women have different metabolic pathways and higher estrogen levels, which affect how medications are processed in the body. Overdoses often lead to increased side effects, causing women to stop taking medications and interrupt important therapies.
Unlike men, women often do not show typical symptoms such as severe chest pain during a heart attack. Instead, they report nonspecific complaints: a strange feeling, mild pressure that disappears, fatigue, depression, or general discomfort. These symptoms are often dismissed as psychosomatic or not taken seriously. As a result, women frequently arrive late to the clinic, and heart attacks are overlooked – sometimes with fatal consequences.
Yes, men are also incorrectly treated for certain diseases. Osteoporosis is considered a typical women's disease, although men aged 65 to 70 are equally affected. When an older man breaks a bone, the causes are rarely investigated. In depression, men are often overlooked as well, as they show different symptoms – such as addictive behavior and increased aggression instead of classic depressive mood. The suicide rate among men is three times higher than among women, highlighting how serious these misdiagnoses can be.
Most diseases were described in medical textbooks based on male symptoms because studies were predominantly conducted with male subjects. These differences were known but ignored for various reasons: traditional gender roles, ignorance, reluctance to change, and lack of studies. Even today, there are hardly any guidelines worldwide for treating diseases that differentiate between men and women. The so-called "Gender Data Gap" in medical research still exists.
More information on this topic: Prof. Dr. med. Burkhard Sievers runs the YouTube channel Sievers Sprechrunde.
Prof. Dr. med. Burkhard Sievers has been the Chief Physician of the Medical Clinic I at Sana Klinikum Remscheid since 2013. Additionally, he runs Cardiomed 24 in Meerbusch near Düsseldorf with a colleague. Sievers is on the board of the German Society for Gender-Specific Medicine.
Prof. Dr. med. Burkhard Sievers' latest work: "This is How We Heal Today – Better Treating Common Diseases by Gender" (Zabert Sandmann, €24.99)
