Evolving Paradigms.ehoffman

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Evolving Paradigms in

Womens HealthEileen Hoffman, MD, FACP

Clinical Associate Professor of MedicineNYU School of Medicine

DGIM Grand RoundsApril 24, 2007


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Evolving Paradigms in Womens 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


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INITIAL (OLD) PARADIGM

womens health = reproductive health


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Hoffman. The Women-Centered Health Care TeamImplications for Multiprofessonal


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TRANSITIONAL PARADIGM

Womens health

Diseases, disorders and conditions thatare unique to, more prevalent among,or far more serious in women, or forwhich there are different risk factors or

interventions for women than men(ORWHand expanded by NAWHME)

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


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TRANSITIONAL PARADIGM

Limited to differences

Reductionist and organ-basedOld model of science

Old model of medicine

At best is multidisciplinary

Johnson & Dawson. Womens health as a multidisciplinary specialty: Anexploratory proposal. JAMWA 1990.


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Medical

Practitioner

Mental Health

Specialist

MedicalPractitioner

Mental HealthSpecialist

Traditional Collaborative Care Integrated Collaborative Care

Relational

Field

Co-location

Separate services offered

Facilitates screen and refer

Quality of collaboration depends

on quantity of interaction between

clinicians

Integration

Interaction blurring boundariesbetween mind & body

Facilitates immediate assessment

Quality of collaborative relationship

is a part of the therapeutic process

A + B = A' + B' A x B = C

Women-centered Collaborative Care: Be ond Co-Location. APA Proceedin s.2002


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NEWEST PARADIGM

Womens Health is

A sex- and gender-informedpractice centered on the wholewoman in the diverse contexts ofher life, grounded in aninterdisciplinary sex- and

gender-informed biospychosocialscience (ACWHP)

Hoffman, Magrane, Donoghue. Changing Perspectives on Sex andGender in Medical Education. Acad Med 2000.


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ACWHP Menstrual Cycle Concept Map

Concept Mapping A Tool for Knowledge-Management. Workshop on TheoreticalFoundations of Medicine. Santa Fe Institute. 2006.


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NEWEST PARADIGM

Uses difference differently

Not as sex- and gender-based variationsfrom a gender-neutral norm

A norm based on plasticity

Distinguishes living from non-living systems

Ability to customize genome to environment

Pediatrics-- discipline based ondevelopmental plasticity


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NEWEST PARADIGM

Womens Health A Norm of Her Own Maximal plasticity

developmental & reproductive plasticity Interaction between the 2 types of plasticity

Consistent with new trend in medicinesystems 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


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Plasticity in the Female

Anticipation of pregnant state Menstrual cycle

Luteal phase transformation to accommodateconception

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 plasticityMigeon. The Role of X Inactivation and Cellular Mosaicism in Womens Health and Sex-


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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 MaternalTissue. JAMA. 2004.


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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 plasticityfor 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.


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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.


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Failures in Plasticity and the

Epidemic of Chronic Disease

In hypercaloric environment whatenvironmental 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 & programsthe fetus for a trajectory toward chronic diseas

McGrath J. Doesimprinting with low prenatal vitamin D contribute to the risk of various

adult disorders? Medical Hypothesis 2001.Barker D. The develo mental ori ins of insulin resistance. Horm Res 2005.


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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


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C l i d N C l i


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Calcemic and Non-Calcemic

Actions of Vitamin D


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Vitamin D and Chronic Disease

Rickets/Osteomalacia Diabetes

Hypertension

CVD

PCOS

Cancer

Mental health

Osteoporosis Falls in the elderly

Periodontal disease Infection

Immune regulation

Autoimmune disease

Chronic liver disease

Fat Malabsorption

Parkinsons disease

Primary HyperPTH Psoriasis

Holick M. High Prevalence of Vitamin D Inadequacy and Implications forHealth. NEJM.2006


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Maximizing the fetal

environment improvethe health of both

women and men!


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Old Paradigm

New Paradigm

Reproduction Reproduction

Interdisciplinary Field

Re roductive & Develo mental Plasticit


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Summary

Womens 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 newunderstandings of health & disease in both

women & menApplication of this model provides

insights such as the role of vitamin D inthe epidemic of chronic disease

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Evolving Paradigms.ehoffman