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
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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
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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
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 PARADIGM
• Limited to differences
•Reductionist and organ-based
Old model of science
 Old model of medicine
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•At best is “multidisciplinary”
Johnson & Dawson. Women’s health as a multidisciplinary specialty: An
exploratory proposal. JAMWA 1990.
Traditional Collaborative Care

Medical
Practitioner

Integrated Collaborative Care
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Medical
Practitioner
Relational
Field
Mental Health
Specialist
Mental Health
Specialist
Co-location
 Integration
 Separate services offered
 Interaction blurring boundaries
between mind & body
 Facilitates “screen and refer”
 Quality of collaboration depends
on quantity of interaction between
clinicians
A + B = A' + B'
 Facilitates immediate assessment
 Quality of collaborative relationship
is a part of the therapeutic process
AxB=C
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 genderinformed 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 PARADIGM
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Uses “difference” differently
• Not as sex- and gender-based variations
from a “gender-neutral” norm
• A norm based on “plasticity”
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Distinguishes living from non-living systems
Ability to customize genome to environment
• Pediatrics-- discipline based on
“developmental plasticity”
NEWEST PARADIGM
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Women’s Health – A Norm of Her Own
• Maximal plasticity
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“developmental” & “reproductive” plasticity
Interaction between the 2 types of plasticity
Consistent with new trend in medicine
“systems biology”
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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
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Anticipation of pregnant state
• Menstrual cycle
• Luteal phase transformation to accommodate
conception
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Adaptation to pregnant state
• Flexible physiology and anatomy
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Transformation by pregnant state
• Microchimerism – link between generations
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Enhancement of health for survival
• Mosaicism – buffers sex-linked disease
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Gatekeeper to developmental plasticity
Migeon. The Role of X Inactivation and Cellular Mosaicism in Women’s Health and Sex-
Failures of Plasticity
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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
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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 CVD
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Earliest stage for intervention
• in utero – fetal environment
• “Low birth weight”
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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
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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
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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
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Rickets/Osteomalacia
Diabetes
Hypertension
CVD
PCOS
Cancer
Mental health
Osteoporosis
Falls in the elderly
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Periodontal disease
Infection
Immune regulation
Autoimmune disease
Chronic liver disease
Fat Malabsorption
Parkinson’s disease
Primary HyperPTH
Psoriasis
Holick M. High Prevalence of Vitamin D Inadequacy and Implications for
Health. NEJM.2006
Maximizing the fetal
environment improves
the health of both
women and men!
Old Paradigm
Reproduction
›
Reproduction +
›
›
New Paradigm
Interdisciplinary Field
Reproductive & Developmental Plasticity
Summary
• 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
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• Application of this model provides
insights such as the role of vitamin D in
the epidemic of chronic disease