Tuesday, June 20, 2006

Yentl Syndrome

Think Barbara Streisand dressed as a Polish boy in search of a Talmudic education in that vintage gender-bending film. Now think of a woman with coronary artery disease who must present symptoms like a man in order to get the same treatment. First described in 1991, Yentl Syndrome highlights the differences between men and women with respect to heart attack (myocardial infarction or MI) treatments and outcomes.

Studies suggest that women receive less intensive treatment than do men. They are less likely to be referred for testing, and once identified with heart disease, they are less likely to receive certain standard therapies such as daily aspirin, beta-blockers, and cholesterol-lowering drugs. As a result, fatality rates for women after MI are higher both in the hospital and in the year that follows.

The College of Cardiology has issued Guidelines Applied in Practice (GAP) to standardize post-MI care. These recommendations include a discharge document that forces a thoughtful process while releasing MI patients from the hospital. For example, physicians following each step in the GAP procedure must either prescribe aspirin, beta-blockers, angiotensin-converting enzyme inhibiotrs, and cholesterol-lowering drugs or supply a reason why these agents were not used. A GAP usage study in Michigan found the death rate post-MI for women in the program dropped by over 50%, but the tool was used slightly less often in women than in men!

Doctors in Europe found a "Reverse Yentl Syndrome" operative in osteoporosis prevention and treatment. We now know that any fracture in a woman of age--think broken wrist after a roller-blading fall--should trigger an investigation of bone density. These investigators found that none of the old dudes who fell and fractured in the study were warned of the risk of osteoporosis, scanned for loss of bone mass, nor offered bone protective treatment. A study author commented, "Men accounted for 17 percent of presentations but the complete absence of advice and appropriate investigation and treatment of osteoporosis among males is striking."

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