Author: Patricia Nicholson

On May 5, Women’s College Hospital hosted The Spirit of Discovery in Women’s Health Research as part of the hospital’s 100th anniversary celebrations. The day-long event showcased some of the groundbreaking research taking place at the hospital and at WCRI.

As people live longer, chronic conditions are becoming more common than ever, noted Women’s College Hospital physician-in-chief Dr. Gillian Hawker. And women are more likely than men to be affected by chronic disease, especially low-income women and those with lower education levels. That’s why WCRI scientists are researching some of the chronic conditions that affect women most.

The number one cause of disability

Musculoskeletal conditions such as osteoporosis and osteoarthritis are arguably some of the most important chronic diseases that affect women as they age, Dr. Hawker said.

‘These are conditions that affect your bones, muscles, ligaments and joints, and they cause significant pain which limits your physical function and obviously affects your quality of life,’ she said. ‘They are the number one cause of short- and long-term disability among Canadians.’

Two of the most common musculoskeletal conditions are osteoporosis, which affects bones, and osteoarthritis (OA), which affects the joints.

‘Osteoarthritis is the most common type of arthritis, affecting one in 10 Canadians,’ Dr. Hawker said.

Dr. Hawker’s osteoarthritis research follows two groups of patients: one in rural Ontario and one in urban Ontario. By following these patients, Dr. Hawker and her colleagues have identified unmet needs in OA patients – especially in women, people with low incomes and people with lower education levels. Only about half of OA patients were receiving comprehensive care for their condition.

Dr. Hawker’s discoveries about access to joint replacement surgery (one of the most effective treatments for serious OA), and about OA pain and its relationship to disability, sleep and fatigue have led to new approaches to managing the condition.

‘We’ve developed new tools for the measurement and evaluation of osteoarthritis pain that are now used internationally,’ Dr. Hawker said. She and her colleagues have also developed tools to help doctors and patients make well-informed decisions about treatment strategies.

In 2006, Women’s College Hospital opened the first interprofessional clinic to manage patients with complex osteoarthritis. The clinic provides comprehensive care plans for people whose OA is complicated by factors such as having other chronic diseases.

Probing gender disparities

WCRI scientist-in-training Cornelia Borkhoff, PhD is investigating questions raised by Dr. Hawker’s research. One of the important discoveries that Dr. Hawker’s team made about OA treatment is that women are much less likely than men to have joint replacement surgery for knee osteoarthritis. Dr. Borkhoff is trying to find out why.

Patient willingness is not the issue: women are just as willing to have the surgery as men. However, women are less likely to have talked about the surgery with their doctor. They are also less likely to be advised by friends and family to ask their doctor about surgery.

To explore the possibility that there might be bias among doctors when recommending knee replacement surgery, Dr. Borkhoff and her colleagues sent one man and one woman with moderate knee OA to 67 different doctors. The male and female patient each presented the individual doctors with medical cases that were identical except for gender.

The same group of doctors recommended surgery for the male patient twice as often as for the female patient. Compared to the male patient, the female patient was also less involved in treatment decisions with the doctors than the male patient.

These results suggest that bias among health-care providers may be contributing to the gender gap in care. However, it’s probably not because doctors are withholding care from women.

‘They are just not recognizing the seriousness of women’s symptoms,’ Dr. Borkhoff said. One strategy to help close the gender gap in knee replacement surgery is to focus on patient-doctor interactions. This could include using tools that help doctors and patients make decisions together, based on input from both that includes the patient’s medical needs as well as her priorities and values.

Getting down to the bones

Osteoporosis, a condition marked by low bone mass and weak bones, affects one in four women as they grow older, said WCRI scientist Dr. Sophie Jamal, who is director of the Multidisciplinary Osteoporosis Research Program at Women’s College Hospital.

As the population ages and the number of older people grows, osteoporosis will become more prevalent. Current treatments have limitations, including side-effects and cost. They also aren’t very effective on cortical bone, which includes most bones except the spine, Dr. Jamal said.

‘So if we really want to decrease hip fractures, we really need to find agents that are going to include cortical bone,’ she said.

Dr. Jamal’s research is doing just that: she’s been studying the use of nitric oxide for treating osteoporosis. Nitric oxide has been used for years to treat angina. It is very inexpensive and available worldwide. And Dr. Jamal’s research shows that it boosts bone mass.

‘Our data have shown that it has unique effects on bone density,’ she says. ‘It increases density at the hip and spine. It improves bone structure and it actually increases cortical bone. And that leads to huge improvements in bone strength.’

Matters of the heart

Cardiovascular disease is now the leading cause of death for women in Canada, the U.S. and globally, said Dr. Paula Harvey, WCRI scientist and director of the Cardiovascular Research Program at Women’s College Hospital. It kills about 40,000 women in Canada per year.

Cardiovascular disease affects women differently than men: they often fare worse than men following a heart attack. Women under 65 who have a heart attack have worse outcomes than men of the same age, Dr. Harvey said. Their mortality rate from heart attack is twice that of men, and they are twice as likely to have another heart attack within six years.

‘One of the most important treatment strategies for cardiovascular disease is cardiac rehabilitation,’ Dr. Harvey said. Cardiac rehab – supervised programs that help heart patients maintain health – improves survival following a heart attack by 50 per cent. It also reduces the likelihood of needing bypass surgery or angioplasty, improves physical functioning and reduces disability.

‘Despite all of these benefits, only about 30 per cent of patients who qualify actually participate, and of those, only a miserable 12 to 24 per cent of participants are women,’ Dr. Harvey said.

In 1996, Women’s College Hospital established the Women’s Cardiovascular Health Initiative, the first comprehensive assessment and lifestyle program for cardiovascular rehabilitation for women in Canada.

The program was designed for the specific needs of women with cardiovascular disease and cardiovascular risk factors, and to make it possible to research heart disease in women. A database and clinical registry has collected comprehensive data on all the participants in the program, creating an invaluable research resource.

‘At the time the program was developed, and even until very recently, clinical studies of cardiac rehab and health promotion in cardiovascular disease have been done almost exclusively on middle-aged men. We have very little research in women,’ Dr. Harvey said.

Women’s College Hospital’s unique program and database have made it possible to evaluate the barriers that prevent women from taking part in cardiac rehab, and factors that make them drop out – two major problems with cardiac rehabilitation in women, Dr. Harvey said. And the program continues its record of innovation.

‘We’ve got a recently developed home-based cardiac rehab program, and we’re also working to develop cross-disciplinary collaborations so that we can expand cardiovascular prevention to women who have co-morbidities or chronic disease, such as diabetes or osteoarthritis,’ Dr. Harvey said.

This research is becoming more and more relevant as more and more Canadian women are developing cardiovascular risk factors, she added. The growing prevalence of overweight, obesity and sedentary lifestyles is reversing the gains made in cardiovascular disease treatment and prevention in recent decades.

‘We have an ongoing pressing need to develop cardiovascular disease research and treatment programs for women,’ Dr. Harvey said. ‘We will continue to be at the forefront of these endeavours.’