Numerous studies have shown that women have an increased susceptibility to chronic respiratory conditions.This presentation explores briefly into the epidemiology, the gender differences in disease presentation and its wider healthcare implications.

1. Women &
Lung Disease

2. Contents
1. Background and introduction
2. Burden of COPD in women
3. Asthma and the female lung
4. Lung cancer in females
5. Summary & take home message

3. Introduction
‐ There is growing evidence that a number of
pulmonary diseases affect women differently and
with a greater degree of severity than men
‐ Development and progression of certain common
respiratory diseases has been found to differ by sex
– especially COPD and asthma
3

4. 4
Women &
Lung Disease

5. Introduction
‐ Because most people with COPD have a history of
smoking, it was for many years thought of as a
disease of older men, who have, as a group,
smoked at higher rates over a longer time than any
other
‐ But as gender roles and smoking behavior have
changed in recent decades, so too has the profile of
COPD

6. Burden of the disease
‐ The number of deaths among women from COPD
has more than quadrupled since 1980, and since
2000, the disease has claimed the lives of more
women than men
‐ Women may be biologically more susceptible to the
lung damage caused by tobacco smoke and
environmental pollutants
‐ Women with COPD tend to develop the disease at
a younger age
6

7. Gender Bias in Diagnosis
‐ Women are also less likely to be diagnosed properly
with COPD than are men who go to their doctors
with the same histories and symptoms
7

8. ‐ Of the 14.7 million people
who have been
diagnosed with COPD,
58% of them are women
‐ After taking into account
the differences between
the sexes in age, ethnicity,
income, education and
smoking status, women
are 37% more likely to
have COPD than men
8

9. ‐ Women ages 45-64 are
51% more likely than men
of the same age to have
the disease.
‐ This drops to 21% more
likely when comparing
women and men 65 years
of age and older
9

10. ‐ Like tobacco use, COPD is
primarily a disease of the
poor, and prevalence rates
for both women and men
rise as income levels fall
‐ But poverty appears to
have a greater impact on
women, whose rates of
disease rise more sharply
as their income level falls
10

11. Knowledge, Attitudes and the Role of Stigma
‐ Patients with COPD, both men and women, have
also been shown to have low levels of knowledge
about their condition
‐ Patients are highly sensitive to the stigma
associated with a smoking-related illness like COPD
‐ This perception of stigmatization, can result in a
patient’s reluctance to seek care
11

12. differential susceptibility to tobacco smoke
‐ Women develop more severe COPD at younger
ages than men and with lower levels of cigarette
exposure
‐ In the NETT (National Emphysema Treatment Trial)
study, women had fewer pack-years of cigarette
smoking than men, but had similarly severe COPD
‐ A 2006 meta-analysis of smoking and COPD by
Gan et al found that female smokers had a faster
annual decline in FEV1 than male smokers
12

13. 13
Summaryoftheinfluenceofsexontheprevalence,
diagnosis,andoutcomesofchronicobstructive
pulmonarydisease(COPD)

15. Gender differences in COPD - DYSPNEA
Study and year Study design Summary
de Torres and colleagues,
2005
Cross-sectional;
53 men and women with COPD
recruited from pulmonary clinic
and matched on lung function
Women with COPD report more
dyspnea on the ATS-MMRC
scale than men (P = 0.0003)
Watson and colleagues,
2004
Cross-sectional;
randomly sampled population-
based telephone survey; self-
report of COPD diagnosis
Women with self-reported COPD
report severe dypsnea on the
MRC scale more frequently than
men (P < 0.05)
Di Marco and colleagues,
2006
Case-control;
patients with COPD attending a
pulmonary clinic compared with
non-COPD patients on
prevalence of symptoms
Women with COPD report more
severe dyspnea on the MRC
scale for a given lung function
compared with men (P = 0.003)

16. Gender differences in COPD – CHRONIC COUGH
Study and year Study design Summary
Watson and colleagues,
2006
Longitudinal study;
placebo arm of randomized
clinical trial of budesonide
Higher prevalence of ‘‘being
woken by an attack of coughing’’
(P < 0.001) and ‘‘chronic cough
during winter’’ (P = 0.03)
in women compared with men

17. Gender differences in COPD – SPUTUM PRODUCTION
Study and year Study design Summary
Cydulka and colleagues,
2005
Secondary analysis of
prospective cohort of patients
presenting to emergency with an
acute exacerbation of COPD
Men more likely to report
productive cough on most
days compared with women
(P = 0.02)
Watson and colleagues,
2004
Cross-sectional;
randomly sampled population-
based telephone survey;
self-report of COPD diagnosis
Men and women equally likely to
report sputum

18. Gender differences in COPD - DEPRESSION
Study and year Study design Summary
Di Marco and colleagues,
2006
Case-control;
patients with COPD attending
a pulmonary clinic compared with
non-COPD patients on
prevalence of symptoms
High prevalence of depression
compared with controls; women
had higher levels of depression
and worse symptom-related
quality of life compared with men

19. Gender differences in COPD – ANXIETY & FATIGUE
Study and year Study design Summary
Di Marco and colleagues,
2006
Case-control;
patients with COPD attending a
pulmonary clinic compared with
non-COPD patients on
prevalence of symptoms
High prevalence of anxiety
compared with controls;
Women had higher levels of
anxiety compared with men.
Gift and Shepard,
1999
Cross-sectional study of patients
attending a pulmonary clinic
Women and men were similar in
their psychological symptoms
except for anxiety, which was
higher in women.
Women reported greater fatigue

20. 20

21. Role of female hormones
‐ Women are relatively more prevalent in the
epidemiology of asthma, cystic fibrosis and COPD
and appear in general to have worse prognosis
than their male counterparts
‐ Emerging data suggest that female sex hormones
play a role in these inflammatory airway conditions,
through different but related mechanisms
21

22. Role of female hormones
‐ Studies have shown that estrogen promotes a TH2
response, while androgen promotes a TH1
response, which may be relevant in asthma
‐ Progesterone may augment airway inflammation
‐ Estradiol inhibits Cl- secretion in the Cystic Fibrosis
lung and up-regulates mucus production, which
may be very relevant in CF
22

23. Role of female hormones
‐ Cigarette smoke is de-toxified through Phase I and
Phase II enzymes and estrogens may preferentially
up-regulate Phase I enzymes, leading to
accumulation of toxic metabolites through a
process called bioactivation
‐ This may be relevant in the pathophysiology of
COPD
23

24. 24

25. Biomass exposure index
Biomass Exposure Index = Average hours spend on
cooking per day × Number of years of cooking
‐ This index 60 and above is considered high risk for
developing COPD
‐ Studies have shown that strength of association of
biomass fuel exposure and COPD was similar to
that of cigarette smoking

26. Conclusion of this study
‐ There is a need to increase more awareness for the
use of modified cooking stoves that reduces indoor
air pollution including the cost effectiveness to
develop preventive strategies, well ventilated
kitchen
‐ High suspicious index required for diagnosis of
COPD in such women to give proper treatment,
pulmonary rehabilitation and modification of their
cooking lifestyle 26

27. 27

29. 29

30. Distribution of patients according gender

31. Distribution of patients according to locality
31
Correlation of socioeconomic grading

32. Asthma &
the female lung
32

33. 33

34. The Role of Sex Hormones in Asthma
Susceptibility and Severity
‐ Among menstruating women with asthma, 30% to
40% experience perimenstrual worsening, with
increased symptoms and a greater likelihood of
hospitalization
‐ Although the mechanism behind perimenstrual
asthma remains elusive, it may involve the rise in
progesterone and estrogen during the luteal phase

35. The Role of Sex Hormones in Asthma
‐ Pregnancy is generally regarded as a state of helper T (TH)
2 cell dominance, and is characterized by a gradual
increase in progesterone and estrogen levels
‐ Because the hallmark of asthma is a TH2-type of
inflammation in the lung, pregnancy may predispose
women for asthma
‐ In a longitudinal study a higher number of pregnancies have
been associated with an increased risk of developing adult-
onset asthma in women

36. Conclusion of this study
‐ Because the disease is complex, no straightforward
single mechanism can explain the gender
differences found in asthma
‐ Generally speaking, male and female sex hormones
appear to exert opposite effects on resident lung
cells and immune function that, taken as a whole,
render women more susceptible to asthma
36

37. Increased risk of PAH &
lung cancer in females?
37

38. 38

39. Increased risk of PAH & lung cancer?
‐ Recent epidemiological studies have disputed
whether females are at increased risk of lung
cancer compared to males
‐ Women display higher levels of smoking-induced
bulky/hydrophobic DNA adducts which may be
related to an increased expression of CYP1A1 in
their lungs, compared to men

40. Increased risk of PAH & lung cancer?
‐ The combined results from the present in vitro and
previous in vivo studies provide evidence for an
increased susceptibility to PAH in female lung,
compared to male lung
‐ These results may also have implications for sex
differences in risk of lung cancer
40

41. Finding a Better Way
to Provide Care
41

42. Finding a better way
‐ In recent years, researchers and healthcare systems
have been experimenting with a patient centered
approach to care that is promising to yield better
health outcomes than the standard physician-
centered approach.
‐ Patient access is improved, disease self-
management is emphasized and hospitals and
physicians operate in integrated systems that
improve collaboration

43. Finding a better way
‐ The results are demonstrating better knowledge of
patients and their needs, improved quality and
greater efficiencies in the delivery of care