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P&S Journal

P&S Journal: Winter 1998, Vol.18, No.1
Clinical Advances
Women's Health

By Devera Pine

Four years ago, Columbia-Presbyterian was severely disadvantaged in the area of women's health. Dr. Elsa-Grace Giardina, professor of clinical medicine, set out to change that, establishing the Center for Women's Health, which she now directs. Today, two years after it officially opened its doors at Columbia-Presbyterian/Eastside, the center serves 4,000 clients a year, providing an array of medical services the New York Times called "the equivalent of a medical mall.

Among the types of medical services offered: primary care, cardiology, breast services, surgery, infectious disease and travel medicine, endocrinology, diabetes, obesity and weight management, gastroenterology, cholesterol management, a program in Alzheimer's disease, osteoporosis and metabolic bone diseases prevention and management, nutritional counseling, and reproductive services and gynecology. "As the baby boom generation is maturing, new areas of concern for women are becoming obvious," says Dr. Giardina. "These women raise health issues about the next decades of their lives. They are concerned with living longer and, more importantly, living well--without broken bones, heart disease, or diseases that affect the central nervous system, such as stroke or Alzheimer's disease.

A unique aspect of the Center for Women's Health is its team approach. Doctors collaborate to provide the best care to patients, referring patients to appropriate specialists when necessary and then including specialists in conferences--both formal and informal--on treatment choices. Having all the specialists on site means that patients can access specialized tests and exams in one day. The center even offers a program called "A Day in Your Life"--a comprehensive physical evaluation service modeled to fit each woman's personal health profile.

In addition to providing clinical care, the center participates in clinical research. For instance, Dr. Giardina is conducting three studies examining the action of estrogen on the heart. One study uses PET scans to look at blood flow in the hearts of women with chest pain and will help determine whether estrogen enhances blood flow. A second study examines the effect of estrogen on the formation of clots to determine whether estrogen helps thin the blood, thereby helping protect women against heart attacks. This is a paradox, notes Dr. Giardina, since women on oral contraceptives are more likely to develop blood clots. The difference may be dose-related, she says. Finally, Dr. Giardina is involved in a study of estrogen and exercise performance in normal postmenopausal women. The preliminary study, which was published in a September 1997 issue of the American Journal of Cardiology, found that estrogen helps reduce blood pressure, reducing the workload on the heart. "This is the first study to look at the effect of estrogen on exercise in normal postmenopausal women," says Dr. Giardina. "It's an example of how women have been underserved." Dr. Giardina is conducting a follow-up study of postmenopausal women who have had heart attacks.

The Center for Women's Health is actively involved in community education: It publishes a quarterly newsletter, has a new state-of-the-art resource room, and offers luncheon seminars for the lay public and CME courses for medical professionals. The center's web site is at http://cpmcnet.columbia.edu/dept/cwh/.

Several unique divisions fall under the Center for Women's Health, including the Center for Menopause, Hormonal Disorders and Women's Health and the Partnership for Women's Health.

Gender-Specific Medicine

Although women comprise the majority of the population, consume more health care than men, and make most of the health care decisions for families, research has been based on a male model of disease. At Columbia, however, the Partnership for Women's Health is taking a different approach.

The partnership is a one-year-old collaborative effort led by P&S and Procter & Gamble, which provided a $4 million start-up grant to support research on gender-specific medicine. The goal of this new approach to women's health is to improve understanding of the physiological differences between men and women and, ultimately, improve disease prevention and treatment for both sexes, says Dr. Marianne J. Legato, director of the partnership and associate professor of clinical medicine. Research supported by the partnership will emphasize gender as a natural perturbation and will compare how diseases develop, progress, and respond to treatment in men and women.

Women with diabetes, for instance, have four to six times the risk of developing coronary artery disease than women without diabetes. Men with diabetes, on the other hand, have only two to three times the risk. "What is it about women with diabetes that makes them paradoxically more vulnerable? asks Dr. Legato. "Is it the fact that diabetes drives HDL levels down in women? We would have to test that idea.

Two areas of research under study are the influence of gonadal hormones on the electrical behavior of the heart and on bone metabolism. Two associate directors of the partnership, Drs. Michael R. Rosen, professor of pharmacology and pediatrics, and John Bilezikian, professor of medicine and pharmacology, lead efforts in each of these areas. A $1 million grant from Procter & Gamble funds the studies.

The partnership has established a database called Genspec, which will provide a comprehensive and up-to-date summary of information on gender-specific biology. Scientists can then identify gaps in knowledge and be able to chart directions for future research. Procter & Gamble supports the formation of the database on bone. Other universities, including Duke, Cornell, the University of Cincinnati, and the University of California at San Diego, have expressed interest in joining the partnership.

Procter & Gamble is providing leadership in establishing a broad base of corporate support, says Dr. Legato. "Many companies have expressed interest in the partnership and the unique character of women as a basis for developing new gender-specific products, she says. "Procter & Gamble isn't interested in owning the program. The company thinks the partnership is important enough to push it forward as a powerful program for women.

The partnership's first symposium, on gender- specific aspects of depression, will be held May 1 and 2, 1998."We want to shift the paradigm of women's health to gender-specific medicine," says Dr. Legato. "What we learn about women will provide new questions and insights into how human biology and disease work in everyone.


Menopause and Hormonal Disorders

A new center, the Center for Menopause, Hormonal Disorders, and Women's Health, can help address the needs of women as they near the end of their reproductive lives and treat hormonal disorders that occur at other stages of life. The center focuses on easing the transition into the menopausal years, preventing and treating diseases associated with the postmenopausal years, and treating hormonal disorders at any age. It is the first such center in the New York area.

There is a great need for a center like this, says Dr. Michelle P. Warren, medical director and professor of medicine and of obstetrics and gynecology. Most women's health centers focus on the well woman. But women often need treatment beyond routine obstetrical and gynecological care.

For instance, one area that doctors often overlook is the perimenopausal period, when a woman's body begins undergoing changes that will lead to menopause.Perimenopause has not been addressed by the medical community, but hormonal problems during this time period can result in disability later on, says Dr. Warren. For instance, irregular and abnormal bleeding, often due to changing hormone levels, can be treated with medical therapy, averting costly surgical intervention.

For menopausal and postmenopausal women, the center offers treatments that can help prevent or delay problems in later life, including osteoporosis, heart disease, Alzheimer's disease, depression, and dental degeneration. For women who are not candidates for conventional hormone replacement therapy, the center can offer new hormones or alternative therapies. For instance, the center conducted clinical trials on Crinone, a vaginally delivered natural progesterone approved by the FDA in May 1997. Other ongoing clinical trials focus on the effectiveness of an estrogen skin lotion and the use of an estrogen and fosamax combination to prevent bone loss.

The center also treats hormonal disorders that occur in women of all ages. One such disorder, polycystic ovary syndrome, is the most common endocrine disorder of reproductive age women. It occurs in approximately 6 percent to 10 percent of the population; 22 percent of the population have polycystic ovaries on sonography. In this syndrome, cysts grow within the ovaries, upsetting the balance of hormones. Women with this syndrome have eight times the risk of heart disease at menopause and a higher incidence of diabetes, infertility, and cancer of the uterus. Dr. Warren; Dr. Edward Ditkoff, assistant professor of obstetrics and gynecology; and Dr. Rogerio Lobo, the Willard C. Rappleye Professor and Chairman of Obstetrics and Gynecology, are conducting a clinical trial of the drug troglitazone, which decreases insulin resistance. (Women with polycystic ovary disease are generally insulin-resistant, which can make the ovaries function abnormally.) "Generally, women with this syndrome are put on birth control pills to regulate their hormones," says Dr. Ditkoff. "This is an option for women who don't want to go on the pill."

 

Other studies at the center focus on the effectiveness of estrogel--a gel formulation of estrogen available in Europe--against hot flashes, hormone replacement therapy in obese women, and new markers for menopause.

The center also treats urinary incontinence, which affects almost all women by the time they reach age 75, and offers a number of specialists in minimally invasive surgery. Counseling and psychiatric services also are available for a range of concerns, including the loss of an infant under age 1, cancer, mid-life problems, and menopause.


Resources

The Center for Women's Health
Columbia-Presbyterian/Eastside

(212) 326-8540 or 1-800-91-WOMEN

Center for Menopause, Hormonal Disorders, and Women's Health
Columbia-Presbyterian/Eastside

(212) 326-8548

Children's Pulmonary Hypertension Center
Dr. Robyn J. Barst, Director
(212) 305-8509



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