Evolving Paradigms in

Women’s Health
Eileen Hoffman, MD, FACP
Clinical Associate Professor of Medicine
NYU School of Medicine

DGIM Grand Rounds

April 24, 2007
Evolving Paradigms in Women’s Health
 Review the recent history of the field
 Describe the developmental stages & their
contributions to improving care
 Describe the newest paradigm - plasticity
• Provides a lens for looking at the whole woman
across the life cycle that is not just the sum of her
parts
 Use the new paradigm showing how it
contributes to the health of women & men
 INITIAL (OLD) PARADIGM

women’s health = reproductive health

Hoffman. The Women-Centered Health Care Team –Implications for Multiprofessonal
 TRANSITIONAL PARADIGM

Women’s health
• Diseases, disorders and conditions that
are unique to, more prevalent among,
or far more serious in women, or for
which there are different risk factors or
interventions for women than men
(ORWH…and expanded by NAWHME)

Goldman & Hatch. Women & Health. Academic Press, 2000.

 TRANSITIONAL PARADIGM

• Limited to differences
•Reductionist and organ-based
 Old model of science
 Old model of medicine

•At best is “multidisciplinary”

Johnson & Dawson. Women’s health as a multidisciplinary specialty: An

exploratory proposal. JAMWA 1990.
Traditional Collaborative Care Integrated Collaborative Care

  Medical
Practitioner

 Relational

Field

Mental Health
Medical Mental Health Specialist
Practitioner Specialist

Co-location  Integration

 Separate services offered  Interaction blurring boundaries

between mind & body
 Facilitates “screen and refer”
 Facilitates immediate assessment
 Quality of collaboration depends
 Quality of collaborative relationship
on quantity of interaction between
is a part of the therapeutic process
clinicians
A + B = A' + B' AxB=C
Women-centered Collaborative Care: Beyond Co-Location. APA Proceedings.2002
 NEWEST PARADIGM
Women’s Health is
 A sex- and gender-informed
practice centered on the whole
woman in the diverse contexts of
her life, grounded in an
interdisciplinary sex- and gender-
informed biospychosocial science
(ACWHP)

Hoffman, Magrane, Donoghue. Changing Perspectives on Sex and

Gender in Medical Education. Acad Med 2000.
ACWHP Menstrual Cycle Concept Map

Concept Mapping – A Tool for Knowledge-Management. Workshop on Theoretical

Foundations of Medicine. Santa Fe Institute. 2006.
 NEWEST PARADIGM

 Uses “difference” differently

• Not as sex- and gender-based variations
from a “gender-neutral” norm
• A norm based on “plasticity”
 Distinguishes living from non-living systems
 Ability to customize genome to environment
• Pediatrics-- discipline based on
“developmental plasticity”
 NEWEST PARADIGM
 Women’s Health – A Norm of Her Own
• Maximal plasticity
 “developmental” & “reproductive” plasticity
 Interaction between the 2 types of plasticity

 Consistent with new trend in medicine

“systems biology”
• Systems are comprised of parts that interact
• Emergent phenomena are properties of the whole
• Not reducible to sum of parts
• Must be studied as a whole
 Plasticity in the Female
 Anticipation of pregnant state
• Menstrual cycle
• Luteal phase transformation to accommodate
conception
 Adaptation to pregnant state
• Flexible physiology and anatomy
 Transformation by pregnant state
• Microchimerism – link between generations
 Enhancement of health for survival
• Mosaicism – buffers sex-linked disease
 Gatekeeper to developmental plasticity
Migeon. The Role of X Inactivation and Cellular Mosaicism in Women’s Health and Sex-
 Failures of Plasticity

 PCOS
 Pre-menstrual Asthma
 Gestational Diabetes
 Pre-eclampsia
 Low birth weight
 Pre-term labor
 Autoimmunity/Organ regeneration

Williams D. Pregnancy: A Stress Test for Life. Current Opin Obst Gyn 2003.
Khosrotehrani et al. Transfer of Fetal Cells with Multilineage Potential to Maternal
Tissue. JAMA. 2004.
 Applying the New Paradigm
Failures in Plasticity & Risk for CVD
 Chronic disease -- a fixed state
 Prior states have some plasticity
 Which prior state has maximal plasticity
for preventive intervention?
 Early warning signs
• Failures in reproductive plasticity

Sattar & Greer. Pregnancy complications and maternal cardiovascular risk:

Opportunities for intervention and screening. BMJ USA. 2002.
 Applying the New Paradigm
Failures in Plasticity & Risk for CVD

 Earliest stage for intervention

• in utero – fetal environment
• “Low birth weight”
 Proxy for fetal nutrition
 Potent predictor of CVD risk/mortality
 Sets the stage for future life style risk factors

Godfrey & Barker. Fetal Programming and Adult Health. Public Health Nutrition 2001.
 Failures in Plasticity and the
Epidemic of Chronic Disease
 In hypercaloric environment what
environmental factor contributes to LBW?
 Epidemic of chronic disease began with shift
from agrarian to industrialized society
 Industrialization led to low sun exposure
 Low sun exposure causes Vitamin D deficiency
 Vitamin D deficiency leads to LBW & programs
the fetus for a trajectory toward chronic disease

McGrath J. Does”imprinting” with low prenatal vitamin D contribute to the risk of various
adult disorders? Medical Hypothesis 2001.
Barker D. The developmental origins of insulin resistance. Horm Res 2005.
Populations with Vitamin D Deficiency
 Healthy adults, children, adolescents
 Sunscreen users
 African Americans
 Obese
 Elderly/limited sun
 Living at northern latitude
 Immigrants from southern to northern latitude
 Veiled women
 Medical inpatients including nursing homes
 Osteoporotics on bisphosphonates
 HIV positive on PI
 Smokers
Calcemic and Non-Calcemic
Actions of Vitamin D
 Vitamin D and Chronic Disease
 Rickets/Osteomalacia  Periodontal disease
 Diabetes  Infection
 Hypertension  Immune regulation
 CVD  Autoimmune disease
 PCOS  Chronic liver disease
 Cancer  Fat Malabsorption
 Mental health  Parkinson’s disease
Osteoporosis  Primary HyperPTH
 Falls in the elderly  Psoriasis

Holick M. High Prevalence of Vitamin D Inadequacy and Implications for

Health. NEJM.2006
Maximizing the fetal
environment improves
the health of both
women and men!
 Old Paradigm

Reproduction
› Reproduction +
›

›
New Paradigm
Interdisciplinary Field
Reproductive & Developmental Plasticity
 Summary
• Women’s Health, as a field, is evolving &
is going through developmental stages
 Reproductive health
 Sex differences based on male norm

 Interdisciplinary field based on plasticity

 Systems biology model provides for new

understandings of health & disease in both
women & men
• Application of this model provides
insights such as the role of vitamin D in
the epidemic of chronic disease