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Evolving Paradigms in Women’s Health. Eileen Hoffman, MD, FACP Clinical Associate Professor of Medicine NYU School of Medicine DGIM Grand Rounds April 24, 2007. Evolving Paradigms in Women’s Health. Review the recent history of the field

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evolving paradigms in women s health

Evolving Paradigms in Women’s Health

Eileen Hoffman, MD, FACP

Clinical Associate Professor of Medicine

NYU School of Medicine

DGIM Grand Rounds

April 24, 2007

evolving paradigms in women s health1
Evolving Paradigms in Women’s 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
initial old paradigm

women’s health = reproductive health


Hoffman. The Women-Centered Health Care Team –Implications for Multiprofessonal Interdisciplinary Education. J Women’s Health. 1998.

transitional paradigm

Women’s health

  • Diseases, disorders and conditions that are unique to, more prevalent among, or far more serious in women, or for which there are different risk factors or interventions for women than men (ORWH…and expanded by NAWHME)

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

transitional paradigm1
  • Limited to differences
  • Reductionist and organ-based
    • Old model of science
    • Old model of medicine
  • At best is “multidisciplinary”

Johnson & Dawson. Women’s health as a multidisciplinary specialty: An exploratory proposal. JAMWA 1990.


Traditional Collaborative Care

Integrated Collaborative Care

Medical Practitioner



Mental Health Specialist

Medical Practitioner

Mental Health Specialist

  • Co-location
  • Separate services offered
  • Facilitates “screen and refer”
  • Quality of collaboration depends on quantity of interaction between clinicians
  • Integration
  • Interaction blurring boundaries between mind & body
  • Facilitates immediate assessment
  • Quality of collaborative relationship is a part of the therapeutic process

A x B = C

A + B = A' + B'

Women-centered Collaborative Care: Beyond Co-Location. APA Proceedings.2002

newest paradigm

Women’s Health is

  • A sex- and gender-informed practice centered on the whole woman in the diverse contexts of her life, grounded in an interdisciplinary sex- and gender-informed biospychosocial science (ACWHP)

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


ACWHP Menstrual Cycle Concept Map

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

newest paradigm1
  • Uses “difference” differently
    • Not as sex- and gender-based variations from a “gender-neutral” norm
    • A norm based on “plasticity”
      • Distinguishes living from non-living systems
      • Ability to customize genome to environment
    • Pediatrics-- discipline based on “developmental plasticity”
newest paradigm2
  • Women’s Health – A Norm of Her Own
    • Maximal plasticity
      • “developmental” & “reproductive” plasticity
      • Interaction between the 2 types of plasticity
  • Consistent with new trend in medicine “systems 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
plasticity in the female
Plasticity in the Female
  • Anticipation of pregnant state
    • Menstrual cycle
    • Luteal phase transformation to accommodate conception
  • 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 plasticity

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

failures of plasticity
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 Maternal Tissue. JAMA. 2004.


applying the new paradigm failures in plasticity risk for cvd
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

Sattar & Greer. Pregnancy complications and maternal cardiovascular risk: Opportunities for intervention and screening. BMJ USA. 2002.

applying the new paradigm failures in plasticity risk for cvd1
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.

failures in plasticity and the epidemic of chronic disease
Failures in Plasticity and the Epidemic of Chronic Disease
  • In hypercaloric environment what environmental 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 & programs the fetus for a trajectory toward chronic disease

McGrath J. Does”imprinting” with low prenatal vitamin D contribute to the risk of various adult disorders? Medical Hypothesis 2001.

Barker D. The developmental origins of insulin resistance. Horm Res 2005.

populations with vitamin d deficiency
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

Calcemic and Non-Calcemic

Actions of Vitamin D

vitamin d and chronic disease






Mental health Osteoporosis

Falls in the elderly

Periodontal disease


Immune regulation

Autoimmune disease

Chronic liver disease

Fat Malabsorption

Parkinson’s disease

Primary HyperPTH


Vitamin D and Chronic Disease

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


Old Paradigm


Reproduction +

New Paradigm

Interdisciplinary Field Reproductive & Developmental Plasticity

  • Women’s 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 new understandings of health & disease in both women & men
  • Application of this model provides insights such as the role of vitamin D in the epidemic of chronic disease