Women’s Neurology

Women’s Neurology examines neurologic disorders through a gender-based lens. There is a lack of knowledge about how sex and gender may affect neurological illnesses as much of the research in this area is emerging or not widely publicized.

Gender-specific neurologic issues clearly vary at different portions of a woman’s life; these issues might include questions about reproductive health, pregnancy, or healthy aging. Many providers think that women’s issues in medicine only relate to pregnancy. In fact, gender concerns are important throughout a woman’s life. Of course, the factors important to consider vary as to where patients are in their life cycle.

Neurological disorders that are more prevalent in women including migraines, multiple sclerosis, functional neurologic disorder/conversion disorder, and Alzheimer’s disease, to name a few.  The differences in prevalence may be due to many factors, from direct hormonal effects on the disorder to sex differences in autoimmunity or epigenetics — that is, the effect of the environment on genetic tendencies. Further, there are disorders such as epilepsy which affect men and women equally, but because the disorder occurs in women of reproductive age, it raises substantive issues around pregnancy and contraception.

Why is a sex-based approach to treatment important?

Many of the medications used to treat neurologic disorders may interact with contraceptives, have teratogenic side effects, and have long-term side effects on women’s health. For instance, estrogen-containing contraceptives are contraindicated in a migraine with aura, stroke, and clotting disorders. Choosing appropriate medications needs to be individualized, based on both the patient’s current reproductive desires as well as the best treatment for the underlying disorder.

Pregnancy may affect neurological disease and the converse is also true neurologic disease may affect pregnancy outcomes. Let’s look at migraines as an example. Migraines often improve during pregnancy, especially in the second trimester, and may worsen postpartum. This is related to changes in estrogen levels which stabilize by the second trimester and rapidly decline postpartum. As regards outcomes in pregnancy, migraine sufferers have an increased risk of eclampsia. This requires increased vigilance during pregnancy for signs of this disorder.

Risk factors for disease are different between the sexes. For instance, the odds ratio of suffering stroke decades after pregnancy is 2- 5 times increased in those women who had a pregnancy complicated by eclampsia. Atrial fibrillation is a more powerful risk for stroke in older women as compared with men. Another example is Alzheimer’s disease, where the risk is more prominent in women where there appear to be hormonal, genetic, immunological, and psychosocial reasons driving this difference. These differences in disease risk both give insight into the disease pathophysiology and offer potential treatment options.

How does a gender-based approach modify disease?

A focus on gender differences in medical evaluation, diagnosis, implementation of treatment, and care improves women’s neurologic outcomes. At the Brigham and Women’s Hospital, we consider how hormonal and reproductive changes throughout a woman’s lifespan, including pregnancy and menopause, as well as the use of oral contraceptives and assisted reproduction, impact neurological health and disease.  This is best done by a multidisciplinary team of experts working collectively to improve our female patient’s neurologic health.

Conclusions

Concerns regarding gender differences are important to give the best care to all our patients. Special considerations regarding planning pregnancy and potential teratogenic effects of medication are extremely important in women of reproductive age. As we begin to better understand the role of gender in disease manifestation, risk, and best treatment options, we can really begin to practice personalized neurologic care.

These findings are described in the article entitled A Review of Women’s Neurology, recently published in The American Journal of Medicine. This work was conducted by Mary Angela O’Neal, Director of the Women’s Neurology Program at Brigham and Women’s Hospital.