Evolving ParadigmsExtraNOtE

7/31/2019 Evolving ParadigmsExtraNOtE

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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 & theircontributions 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 ofher parts

Use the new paradigm showing how itcontributes to the health of women & men


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VERY OLD PARADIGM

womens health = reproductive health


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Hoffman. The Women-Centered Health Care TeamImplications for Multiprofessonal


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NEW OLD 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 of

interventions for women than men(ORWHand expanded by NAWHME)

Goldman & Hatch. Women & Health. Academic Press2000.


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NEW OLD PARADIGM

Limited to difference

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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NEW 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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NEW 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

Pediatrics-- discipline based on

developmental plasticity


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NEW PARADIGM

Womens Health A Norm of Her Own Defined by maximal plasticity

Integration of developmental &reproductive plasticity

Maximal transmission of information on current& past environments to the next generationthrough the fetal environment

Consistent with new trend in medicinesystems biology Legitimizes the new paradigm


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Plasticity in the Female

Anticipation of pregnant state

Cyclic transformation for ovulation

Luteal phase transformation to accommodate

conception Adaptation to pregnant state

Flexible physiology and anatomy

Transformation by pregnant state

Microchimerism

Enhancement of health for survival

Mosaicism

Gatekeeper to developmental plasticity


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Failures of Plasticity

PCOS

Pre-menstrual Asthma Gestational Diabetes

Pre-eclampsia

Low birth weight Pre-term labor

Autoimmunity/Organ regeneration

Sex-linked diseasesWilliams 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.

Migeon. The Role of X Inactivation and Cellular Mosaicism in Womens Health and Sex-Specific Diseases. JAMA 2006.


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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 plasticity

for preventive intervention? Early warning signs

Failures in reproductive plasticity Failures in developmental plasticity

Starts with fetus Earliest stage fetal environment

Low birth weight proxy for fetal nutrition

Sattar & Greer. Pregnancy complications and maternal cardiovascular risk:

Opportunities for intervention and screening. BMJ USA. 2002.


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Failures in Plasticity and the

Epidemic of Chronic Disease

Hyperlipidemia, fast food & couch potato not enough to explain trajectory to CVD

What environmental factor contributes to

LBW as a prior condition for later lifestylefactors?

Lack of adequate sun exposure sinceindustrialization vitamin D deficiency

Vitamin D deficient fetal environment

The invisible factor in the epidemic of chronicdisease

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

Cancer

Mental Health

Osteoporosis

Periodontal disease Falls in the elderly

Infection Immune regulation

Autoimmune disease

Chronic liver disease

Fat Malabsorption

Parkinsons disease

Primary HyperPTH

Psoriasis PCOS

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, went throughdevelopmental stages Reproductive health

Sex differences based on male norm Interdisciplinary field based on plasticity

Systems biology model provides for newunderstandings of health & disease in bothwomen & men

Application of this model providesinsights such as the role of vitamin D in

the epidemic of chronic disease

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Evolving ParadigmsExtraNOtE