By Dina Weinstein

The Health of Women Conference at VCU Health together over a dozen speakers for a day and a half of engaging lectures and discussions with a wide variety of healthcare practitioners to learn about the challenges and nuances of sex and gender medicine from leading experts.

The virtual conference, which took place in May, covered a broad range of issues in women’s health including heart disease, diagnostic radiology, diabetes and metabolism, and neurology, among others.

“The goal of the conference is to translate the latest women's health research into clinical practice,” said Susan G Kornstein, M.D., professor of psychiatry and obstetrics and gynecology at Virginia Commonwealth University School of Medicine, where she is co-founder and executive director of the VCU Institute for Women’s Health. “We educate health care professionals from across the country on how to take the best care of their women patients.”

Kornstein is co-chair of the Health of Women Conference along with co-chairs Wendy Klein, M.D., MACP, Lisa Ellis, M.S., M.D., MACP, and Phoebe Ashley, M.D. The audience included physicians, nurse practitioners, pharmacists and other health care workers.

The annual Health of Women Conference is presented by the VCU Institute of Women’s Health in partnership with VCU Health Continuing Education Office and in collaboration with the Journal of Women's Health (Kornstein is editor-in-chief and Klein is deputy editor), Women's Health Reports and the Society for Women's Health Research.

Organizers planned sessions aimed to help clinicians provide a greater understanding of general health issues through the lens of caring for women. This specific focus can create a higher level of care for patients using evidence-based research to determine the best treatment options. Additionally, presenters – many of whom care for patients at VCU Health, the academic health system connected to VCU – shared examples of health disparities women face and what clinicians can do to reduce negative health outcomes.

Health disparities facing women and how providers can address them

In a talk on multiple sclerosis (MS) in women and advances in diagnosis and care, Myla Goldman, M.D., division chief of VCU’s Department of Neuroimmunology and professor and vice chair for faculty development in VCU School of Medicine Department of Neurology, detailed the specific ways women with MS face the condition while experiencing pregnancy, menarche and menopause, as well as issues around MRIs and breastfeeding.

According to the National Multiple Sclerosis Society, MS is three times more common in women than men, and it is more common in women of childbearing age than any other age group.

“Pregnancy has not been shown to adversely affect the disease.... In general, we see that relapse rates or disease activity decline during pregnancy and that this is most marked during the third trimester, which we think is related to those increasing estrogen levels,” said Goldman. “MS does not appear to increase the risk pre-term delivery or pre-eclampsia. It's not related to an increased risk of cesarean, low birth weight, child mortality or congenital abnormalities. So the disease itself is not particularly complicating to the pregnancy itself and having MS does not necessitate high-risk health care. However, it may require specific attention and management due to medications and other complications.”

Over the years, Goldman says there has been an explosion of new treatments and therapies for MS patients, from medications to lifestyle changes and rehabilitation support.

Key to her approach as a provider is asking her patients which symptoms trouble them most, to prioritize her patient’s top issues.

“If fatigue is a major issue and spasticity is a minor issue, giving them a medication which could increase fatigue may not be the right strategy,” Goldman said. “I like to try to choose one drug that maybe does more than one thing. I always start low and go slow. The aim is to improve function and quality of life.”

Goldman says providers should also think about risk tolerance for these medications when caring for women through their lives as it is a critical factor that impacts MS medication selection, with the risks associated with the drug side-effects is one aspect of this. Oftentimes, risk tolerance will change over a patient’s lifetime.

“Another, challenging aspect is guiding patients to prioritize the risk of the disease itself,” Goldman said. “Some medications are more effective at addressing inflammation and others neurodegeneration. There can be a lot of uncertainty about which medication will work best for a patient in terms of disease course, treatment efficacy, and individual tolerance to the medication. All of these factors can be shaped individually and collectively by a patient’s personal risk-tolerance.”

The most common form of irregular heartbeats is atrial fibrillation, or AFib for short. While men are more often diagnosed with this condition, Kenneth A. Ellenbogen, M.D., director of clinical cardiac electrophysiology at VCU Health Pauley Heart Center, notes that women are often referred to providers and diagnosed when they are older. This later diagnosis can cause more adverse health effects, such as stroke or heart failure, before or after a medical procedure.

“In addition to the gender differences noted in procedural outcomes, the studies have highlighted the fact that women are underrepresented in research trials in general, particularly in AFib interventional trials and left atrial appendage occlusion trials,” Ellenbogen said.

The gap in research, Ellenbogen says, is troubling because cardiovascular mortality and AFib risk factors, such as diabetes and hypertension, are rising for women.

“Additional research must continue to evaluate gender differences in procedural outcomes and patients with AFib. Women should be considered as soon as men for referral for [surgeries]. Intentional work must also be done to equalize representation of women in all cardiovascular clinical trials, so that study results are as accurate a reflection of our population as possible,” Ellenbogen said.

There are also challenges in diagnosing breast cancer, the second most common cancer among women following some types of skin cancer.

In a presentation on current challenges in breast imaging, Priti Shah, M.D., director of breast imaging at VCU Health and VCU Massey Comprehensive Cancer Center and assistant professor in VCU School of Medicine’s Department of Radiology, detailed some of the barriers to conducting routine screening mammography, as well as follow up imaging and biopsies necessary to confirm a diagnosis of breast cancer.

She has seen women cancel appointments because of financial and insurance challenges. Other obstacles include confusion about screening guidelines among patients and providers; lack of nearby imaging centers; “hidden costs” such as time away from work, transportation to appointments, and childcare; and anxiety about the tests themselves.

Shah also shared information about the issue of false positives identified in mammograms, one of the perceived harms of annual screening mammography. For example, out of every 100 women who get a screening mammogram, 90 will be told that their mammograms are normal. The last 10 will be asked to return for additional mammograms or ultrasounds.

Out of those 10, Shah says six will be reassured that their mammograms are normal or benign, and two will be asked to return in six months for a follow up exam. The last two may be recommended to have a needle biopsy.

“When it comes to false positives with breasts and with mammography, we have to remember that breasts are dynamic,” Shah said. “They are ever changing over a week, over a month over our lifetimes, and benign fibrocystic changes come and go. But a mammogram is just a snapshot in time. So, when we call back a patient and work them up, and we find a cyst or some other benign fibrocystic change, technically that counts as a false positive because it wasn't cancer, even though it was a new finding warranting evaluation.”

Shah echoed many other presenters during the Health of Women Conference, encouraging clinicians to absorb the latest studies to help give patients guidance on their treatment options.

“When we talk about shared decision making, we want to make sure that our providers also have the most recent information and guidance to guide their patients,” Shah said.

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