INTRODUCTION by
Rodolfo Paoletti, President of the European Society of Gender Health and Medicine

Years ago a “gender challenge” was launched by WHO to nations and international organizations. It was a call for: A better appreciation of risk factors involving women’s health; the development of preventive strategies to lessen the impact of diseases that disproportionately plague older women (e.g. coronary heart disease, osteoporosis, and dementia); and an increased emphasis on understanding why men die sooner than women. (World Health Organization, 1998, The World Health Report 1998, Geneva).

The strengths of this challenge were to focus attention in many countries on the lack of awareness of gender differences, which generated more inequalities for women than men and to better understand the specific explanations of gender differences in life expectancy which continue to elude scientists because of the apparent complex interplay of biological, social, and behavioural conditions. Nevertheless there were a number of negative actions-reactions as a result of the WHO challenge. In fact, to repair the inequalities, the gender medicine culture shifted its focus to women issues; the gender concept was used for a more concentrated approach to the pathology and treatment of women; and mixing of the gender medicine concept with medicine for women – all of which led to the biased approach of “pink medicine” as opposed to the formerly “blue” one. The scientific community needs to develop a multidisciplinary approach which integrates different competences and players such as physicians, researchers and experts in economics, clinical governance, communications, regulatory issues, health organization, education and training, and many sectors of industry. Gender medicine culture needs to be an active component in the daily practice of physicians who expect support and direction in the use of guidelines (if they exist) and the results of large clinical trials for the management and treatment of the individual patient. The aim of the scientific session, “Integration of Gender Medicine in the Clinical Practice,” organized by the European Society of Gender Health and Medicine, is to contribute to the transfer of gender knowledge into practice. This was accomplished through its flow of discussion from basic research through clinical practice to therapeutic approach on three levels: a) the cell and its gender-oriented biology, presented by Walter Malorni (Italian National Institute of Health, Department of Therapeutic Research and Medicines Evaluation, Rome, Italy); b) the patient and a gender-clinical approach: presented by Giovannella Baggio (Internal Medicine Department, University Hospital, Padua, Italy); and c) drugs and their gender-driven use: presented by Flavia Franconi (Department of Pharmacological Sciences, University of Sassari, Italy).

 

 

CELL SEX: A NEW LOOK AT CELL FATE STUDIES

Elisabetta Straface, Paola Matarrese and Walter Malorni

Italian National Institute of Health, Department of Therapeutic Research

and Medicines Evaluation (Rome, Italy)

 

Different pathways involved in the complex machinery implicated in determining cell fate have been investigated in the recent years. Different forms of cell death have been described: apart from the “classical” form of death known as necrosis, a well-characterized traumatic injury of the cell, several additional forms of cell death have been identified. Among these, apoptosis has been characterized in detail. These studies stem from the implication that the apoptotic process plays a key role in human pathology. In fact, defects in the mechanisms of cell death, i.e. either an increase or a decrease of apoptosis, have been associated with the pathogenesis of a number of human diseases. Some new insights also derive from the study of autophagy, a less-characterized form of cell damage mainly associated with cell survival strategies but that also leads, as final event, to the death of the cell. Interestingly, very recently, a gender difference has been found in this respect: cells from males and females can behave differently. In fact, they seem to display several different features (reactive oxygen species formation, cytoskeleton assembly etc.), including those determining their fate. The idea that primary cultured cells or ex vivo cells could maintain their sexual features can disclose new scenarios in preclinical and clinical studies in the field of both disease pathogenesis and pharmacology.

Cells apoptosis is described in: cancer (colorectal, glioma, hepatic, neuroblastoma, leukaemia and lymphoma, and prostate); autoimmune diseases (systemic lupus erythematosus, autoimmune lymphoproliferative syndrome, and thyroid diseases); inflammatory diseases (bronchial asthma, inflammatory intestinal disease, and pulmonary inflammation); viral infections (adenovirus, baculovirus, and AIDS); neurodegenerative diseases (Alzheimer’s disease, amyotrophic lateral sclerosis, Parkinson’s disease, Huntington’s disease, and epilepsy); haematologic diseases (aplastic anaemia, myelodysplastic syndrome, T CD4⁺ lymphocytopenia, and G6PD deficiency); and tissue damage (myocardial infarction, cerobrovascular accident, ischemic renal damage, and polycystic kidney).

Cell autophagy was initially considered as a cell death program. Now it is considered a survival strategy of cells under metabolic stress. It is described in: cancer, autoimmune diseases, viral infections, bacterial infections, neurodegenerative diseases, and cardiovascular diseases.

Additionally free radicals, mainly ROS, are known to induce a number of intracellular lethal and sublethal alterations including DNA damage, oxidative alterations of proteins, oxidative alterations of (membrane) phospholipids, and apoptosis as well as autophagy.

A number of human diseases have been associated with oxidative stress including: degenerative, cardiovascular, autoimmune, infectious, and genetic diseases.

Hypertension, atherosclerosis, and diabetes are associated with increased ROS formation and cytopathological alterations of vascular smooth muscle cells (VSMC). “Male cells” are more susceptible to death than “female cells,” whereas female cells undergo senescence more easily. Oxidatively modified cytoskeleton (e.g. cross-links confer increased rigidity) facilitates cell detachment and anoikis (anoikis: ana-oikoV, homeless).

A form of apoptosis is associated with, or due to, the detachment from a substrate, e.g. from the extracellular matrix. The resistance to anoikis is often due to better adhesion (e.g. to cytoskeleton plasticity). Female cells have anoikis resistance more than male cells. Autophagy induction is normally higher in male cells. Under stress female cells develop a more pronounced autophagic (protective) response

Conclusions: Freshly isolated cells, e.g. smooth muscle and endothelial cells (3-8th passage), maintain a “memory” of their sexual origin – in particular: i) a different “basal” redox state and ii) a different susceptibility to stress. This susceptibility appears associated with a different fate: “male cells” appear more “apoptotic-prone” whereas “female cells” survive better, appear more “autophagy-prone” cells, and thus, exhibit a higher ability to adapt to environmental changes (behavioral plasticity), such as age and stress.

 

Take home messages:

• Cells have a sex, which could be relevant in their responses to stressors.
• It is important to re-consider some aspects of the use of stabilized cell lines as a model system in preclinical studies (e.g. response to drugs, toxicity).
• There is a need to develop a gender cytology for the studies on the pathogenesis of the diseases as well as for pharmacological and toxicological studies.

DIFFERENT GENDER IMPACT OF RISK FACTORS IN CARDIOVASCULAR DISEASES, DIABETES AND METABOLIC SYNDROME: DO WE HAVE DATA ENOUGH TO DIFFERENTIATE TREATMENT IN WOMEN?

Giovannella Baggio

Internal Medicine Department, Padua University Hospital, Padua, Italy

 

CHD is the first cause of mortality in women in all industrialized countries. Classical risk factors for atherosclerosis have been studied more in men than in women, and their impact is different between genders: diabetes is much more dangerous for cardiovascular complications in women; lipid profiles influence atherogenesis differently in women (HDL-cholesterol, triglycerides, and non-HDL cholesterol are more important than total cholesterol and LDL-cholesterol); inflammation biomarkers such as CRP and cytokines seem to be higher in the presence of risk factors in women. Metabolic syndrome is one of the stronger clusters of risk factors and has a prevalence of 60% in women over 65 years of age. However, women are under-treated for diabetes, dyslipidemia, hypertension, and obesity and the goal of treatment is often not reached. From the biological point of view, the endothelial function is the main target of risk factors, resulting in the damaged arterial wall. Estrogens have a positive influence on endothelial function and thus vulnerability to atherosclerosis; therefore, this may be one the most important differences between genders. This also supports the fact that women develop CHD 10 years after men. However, a recent research on acute myocardial infarction in young women and men describes significant differences in the extent of coronary artery lesions as well as the risk factor profile, and suggests gender-related differences in the mechanisms underlying the atherosclerosis process that need further evaluation. Evidence-based medicine for prevention of CVD in women is scanty, and population-based guidelines specifically for women do not exist in the “real world”. Therefore, how should women be treated in primary and secondary prevention of CVD in our routine daily work?

What about life expectancy and mortality?

What about diabetes and CVD events?

Diabetes increases risk for CHD by 2-3 times in men. Diabetes increases risk for CHD by 3-7 times in women. In diabetic women CHD mortality has not been reduced in the last three decades.

What about Lipids?

Non-HDL Cholesterol seems to be a better predictor for CVD mortality in women. High triglycerides and low HDL-C are strongly associated to CVD mortality in women. Small and dense LDL increase after menopause. No statistically significant gender-specific differences data on hypolipidemic drugs is available.

What about hypertension?

The prevalence of hypertension is higher in elderly women than in elderly men. Hypertension in young premenopausal women is more associated to CVD mortality than in elderly women. Hypertension in women increases CVD and total mortality risk more than in men.

What about smoking?

What about Metabolic Syndrome?

“Chronic inflammation may represent a triggering factor in the origin of the metabolic syndrome: stimuli such as over-nutrition, physical inactivity, and ageing would result in cytokines hypersecretion and eventually lead to insulin resistance and diabetes in genetically or metabolically predisposed individuals. Alternatively, resistance to the anti-inflammatory action of insulin would result in enhanced circulating level of pro-inflammatory cytokines resulting in persisting low grade of inflammation….” Nutr Metab Cardiovasc Dis 2004,14:228

What about Vitamin D?

 

How should women be treated in our routine work for primary and secondary prevention of CVD ?

 

 

GENDER-SPECIFIC SAFETY OF PHARMACOTHERAPY

Flavia Franconi

Department of Pharmacological Sciences, University of Sassari, Sassari, Italy

The numerous gender and sex differences regarding incidence, prognosis, development, treatment, and mortality described in the last few years have led to an increasing awareness that they, in fact, have been ignored for so many years. With regard to pharmacological treatments, pharmacokinetic and pharmacodynamic differences have been noted, even though few women have been enrolled in clinical studies. The increasing knowledge of gender differences has not yet been translated into gender-specific guidelines and recommendations. Nor are curricula for a gender-specific clinical approach available. Furthermore, because of the lack of hard data, it is not surprising that adverse reactions are more common in women. Thus far in Europe too few women have been historically enrolled in clinical studies , therefore it was necessary to perform preclinical studies in a gender-specific way, such as selecting the most appropriate model of diseases to consider the pharmacokinetic differences and the variations induced by the complex biological aspects of women. Moreover, women should be enrolled in all phases of clinical studies. This strategy should reduce the incidence of sex/gender- specific side effects and adverse drug reactions. Some critical issues deserve specific attention:

 

What about gender differences in pharmcokinetics parameters?

 

What about age and gender ?

 

What about ADRs?

The incidence of adverse drug reactions (ADRs)] due to CYP2D6-dependent β-blockers is higher in female patients because of the lower sensitivity of CYP2D6 to the drug in women, and the consequently higher plasma levels of this drug in their blood (Clin Pharmacol Ther 2006; 80 (5):551-3). Thus, it could be safer for women to use β-blockers which are metabolized less by CYP2D6, such as carvedilol or nebivolol (Dtsch Med Wochenschr 2004; 129 (15):831-5) or atenolol, which is not metabolized at all by this enzyme.

More attention should be paid to periods specific to women, such as menopause, pregnancy, pre-and post delivery, and lactation. The menstrual cycle and oral contraceptive (OC) use are particularly relevant. Two classes of interactions have been described with OC: i) those that have an impact on their effect (e.g. rifampicina, phenythoin, hypericum) and ii) those in which OC interacts with the metabolism or activity of other drugs. In women, the use of OC modifies many biochemical parameters which can be used as biomarkers to measure the drug efficacy. OCs, in fact, are able to modify DNA methylation.

 

What about gender differences in drug activity?

ANG II infusion in females is not associated with either a change in the activity of NADPH oxidase or the expression of p67phox, a subunit of NADPH oxidase, both of which were increased in males receiving ANG II (Lopez-Ruiz A et al Am J Physiol Heart Circ Physiol 2008; 295: H466–H474).

ACEI enhances basal t-PA release in women, independent of menopausal status, but not in men. (Arterioscler Thromb Vasc Biol 2005; 25: 2435-2440.). Among 21 large studies with ACEI and ARB, 12 trials did not report gender-specific outcomes. Among these, only 3 trials tried to account for potential gender-differences by conducting gender-adjusted analysis. Among the ACEI and ARBS trials, women accounted for 37.5% and 48.5% of trial participants, respectively.

The majority of trials did not have adequate power to evaluate gender differences. In the treatment of congestive heart failure with ACEI, “Men receive more benefit with respect to mortality reduction than women” (Eyhan G et al Eur J Heart Fail 2007; 9: 594-601; Miller JA et al J Am Soc Nephrol 2006; 17: 2554-60, Rabi DM et al Can J Cardiol 2008; 24(6)); “Cough occurs more frequently in females than in men” [Os I et al Am J Hypertens 1994; 7: 1012–1015]; “Angioedema has been suggested to be more frequent in females on ACE inhibitors than men” (Miller DR et al Hypertension 2008; 51: 1624-1630).

 

What about primary prevention?

Only 26% of women have been included in primary prevention

 

Conclusions

More studies on gender differences can help in better profiling the pharmaco-therapeutic approach for women. More studies on gender differences can decrease the number of ADRs both in men and women.