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Sex Matters in Healthcare | Dr. Alyson McGregor

Dr. Alyson McGregor is a physician, researcher and writer. She is also the director for the Division of Sex and Gender in Emergency Medicine at Brown University. She has written over 70 peer-reviewed publications and is the lead editor for the textbook Sex and Gender in Acute Care Medicine. Her TEDx talk, “Why Medicine Often Has Dangerous Side Effects for Women” currently has over 1.6 million views and she has recently released a new book titled Sex Matters: How Male-Centric Medicine Endangers Women’s Health and What We Can Do About It.

Georgie Kovacs: tell us about your background.

Alyson McGregor: I was born and raised in Rhode Island. I always wanted to be a doctor. I don’t know why but it was something that was always inside me. I realized that it was a very challenging goal. I went through all the training, did medical school at Boston University and then a residency at Brown University in Emergency Medicine. I’ve stayed there as faculty ever since and I love it. It’s a very busy, level 1 trauma center and I get to see lots of patients with different conditions and it’s very fulfilling.

Georgie: tell us about how you got into having such a passion around women’s health and how that plays out in medical practices.

Alyson: I was always very in tune with women’s rights and the women’s health movements of the 60s and 70s. I always felt very grateful to the women then who fought so hard to fight for equality for women. I kept that as always something of an interest. When I finally finished all of the training and started to work as a physician, I stayed on at Brown University. I wanted to do clinical research. It thought, “here’s my chance to meld my interest in improving lives for women and medicine.” As I began to create project ideas and seek out advisors, everyone thought that my interest in “women’s health” meant reproductive health or obstetrics and gynecology. There was this assumption that that was equal to women’s health. I was in the emergency department. Women are there for many things other than their reproductive systems. Heart attacks, strokes, infections. I started to wonder why there was this assumption that women were distilled down to their reproductive organs. About that time, the cardiovascular literature started to declare that women can present differently when having a heart attack than men. It was perfect timing for me because I thought that was very interesting. I wondered: why was this the case? If that was the case, what about all of the other conditions I see when I’m on shift? That was the moment where I thought, “I’m going to explore this more.” I started to develop sex and gender as my clinical research focus.

Georgie: with the work that you’ve done at Brown, you’ve taken it to the next level. You had a very popular TEDx talk and then wrote an amazing book. With what you’ve seen in the field of medicine, what drove you to write this book and do all of this research?

Alyson: I spent the last decade or so researching and publishing in scientific literature and adding to the evidence that these differences are important. These can mean life or death for women. I’ve also worked very hard to bring that knowledge into education in the health profession. That’s where we really learn and teach our healthcare providers. I want them to appreciate how important these differences are and to think about them in a very natural way. It really needs to be included in medical education.

Then, I would show up for another clinical shift and see the health disparities that women face right in front of me every day. We just don’t have time to waste. I couldn’t wait for research to catch up and for medical education to catch up. I want women to be able to learn about this in a way that they can feel empowered to be their own advocates in the healthcare system.

Georgie: there’s a quote from your book that really brings this home: “this isn’t only a women’s perception of how they are treated by their doctors and providers. This is a scientifically validated reality in the world of medicine, because women are misdiagnosed, under-treated and underserved in part because providers don’t believe them when they say something is wrong.”

I appreciate that you’re a physician who did the research and wrote about this. This way, it doesn’t come across as an angry patient. You share so much data.

Maybe you can talk about a couple of the data points that you share in your book to really hone in on the challenges at hand.

Alyson: if you look at the big ones: heart disease. Women are less likely to be diagnosed when having a heart attack and treated with evidence-based medicine. They are less likely to undergo basic diagnostic testing compared to men which means they have higher mortality rates.

With just that one example, it’s because the public has been taught male patterns of disease. The messaging is that if you have a large elephant sitting on your chest that radiates down your left arm, it could be a heart attack. But that’s now how women present most of the time. Women present with shortness of breath or fatigue or discomfort. Women themselves don’t recognize it and delay care. When they finally go to the doctor, the doctor or nurse won’t recognize it right away. Testing isn’t ordered right away. They’re sent home and they get worse.

We have used men as our model for health and disease. We have this assumption that it’s “close enough” to apply to women. That has not turned out well for women’s health.

Georgie: one fairly famous example is Ambien: the dosing for men and women needed to be different.

Alyson: every medication, really, is at-risk for having unknown or bad effects against women. The real flagship for that is the sleep drug Ambien. This has been on the market for 25 years now. The studies were originally done in men and the drug was actually prescribed more for women because they have more sleep disorders than men. What happens is, after a drug has been approved and is widely used in the market, the only thing that physicians/pharmacists/patients can do is to go online and put in a report. So, the drug monitoring system looks at these. What they started to see was about 1,000 reports of women who, the morning after taking Ambien, had motor vehicle crashes related to being impaired. They woke up hoping to be well rested and then would get into the car and suffer from a motor vehicle crash.

I work in an emergency department. I see motor vehicle crash results. We’re not talking about a backache or a neck sprain. We’re talking about life and death. Real, traumatic consequences. What happened was the drug company started to look at this. They wanted to make a new formulation of the drug. They gave it to both men and women and then waited the amount of time the bottle says you should get sleep. Then they put men and women in driving simulation studies. These are the same type of studies we use to determine safe levels of alcohol in driving. The women did horrible in these simulations. They stopped and took blood serum concentrations of the drug and found that women had two times the concentrations compared to men, even though they had been given the same dose. Women metabolized it differently than men, leaving higher amounts in their system.

This demonstrates how important this is. We need to make sure that we test drugs in both men and women because the metabolism can be different. We want sex-specific dosing and to understand what side effects may be different.

Georgie: we can say basically that women have cycles and hormones but you also talk in the book about how women process things differently, separate from hormones.

Alyson: from the moment you take a medication, your body starts to break it down. It wants to break it down so that it can be absorbed and travel through your whole system. That medication will have its action. Then the body says, “ok, we’re ready to excrete it” and breaks it down in a different way. The liver enzymes and your kidney function tries to get rid of the medication. What we have found is that there are very important differences in every single one of those steps between men and women that can actually affect how the drug works, toxicity and side effects.

This is very important for many medications. For instance, the hormones that occur during women’s cycles can turn on or off certain enzymes. There are a couple of drugs that are used for seizure disorders. What we have recently discovered is that, during certain phases of the menstrual cycle, that particular drug may drop down and not be as effective because of hormone levels. What happens is those women are now susceptible to having a seizure during certain times of the menstrual cycle. But we don’t really take that into account. Instead, the woman will be told that she can’t drive or the dose needs to be increased for the entire month (which makes her more susceptible to side effects). These are things that we should be taking into account. Women have unique physiology.

Georgie: my passion for women’s health came in the 90s when the FDA started talking more about women taking part in clinical trials. Maya Dusenberry, in her book Doing Harm, talks about how that didn’t actually happen. From what you’re saying, it still hasn’t fully happened.

There are a couple more quotes from your book I’d love you to talk about.

One is, “we are no longer in the era of ‘doctor knows best.’”

The second is, “while I don’t advocate for self-diagnosis via the internet, having a baseline understanding of your current prescriptions and how they may function in your female body is a great way to start a conversation with your provider.”

What kind of research should a woman be doing to be prepared and ensured she’s not only on the right medication but the proper dose?

Alyson: I really do believe that women should do research, even with the internet or reading prescription package inserts. Women can take ownership of the accuracy of their own personal medical records. Because of electronic records, things are copy and pasted and shared across systems. If they aren’t accurate, you may not be receiving the correct care.