In countless ways, men and women are different. When it comes to chronic obstructive pulmonary disease (COPD), there has been research over the years suggesting a gender trend in certain aspects of COPD, as well. A 2007 journal article identified an increasing prevalence of COPD among women. It suggested that the trend correlated with an uptick in women smokers, but also recognized that women may be at greater risk of smoking-induced lung function impairment and more severe dyspnea. A recent review of data further highlights how gender plays a role in COPD.
COPD is the third leading cause of death in the U.S. Review of data from the National Health and Nutrition Examination Survey (NHANES) confirms the increasing prevalence of COPD in women. It’s also interesting to note that mortality rates for men (from COPD) have declined overall between 1999 and 2006, while no changes were noted in the female patient population. In fact, in the year 2000, female mortality rates passed male rates. This shift has resulted in the medical community rethinking its understanding of COPD; reexamining the “male disease” label long attached to the condition; recognizing that women are at significant risk of developing this disease.
Smoking is the primary risk factor for developing COPD, and it’s clear that women did increase their use of cigarettes over the last few decades, but there seems to be more at play — actual gender physiologic differences — that put a woman at higher risk of COPD if she smokes. In fact, data shows that women have a higher risk of progressing to develop COPD, even if they smoke fewer packs overall than their male counterparts. Women have differences in symptoms and comorbidities, too.
One way to explain the gender-specific outcomes for COPD is to look at how women differ from men. A woman’s airway tends to be smaller than a man’s, so smoking the same amount of cigarettes may result in “more concentrated exposure.” Experts also note that men and women differ when it comes to the brands of cigarettes they choose, how they inhale, the depth of each drag on the cigarette, and their amount and response to exposures of secondhand smoke (social smoking engagements).
Another difference is a phenomenon called “bronchial hyper responsiveness” which is usually associated with asthma, but may be present in women as they interact with cigarettes, but also with other contaminants associated with COPD. Women in recent decades have entered work force areas that were initially dominated by men — mining, textile, brassware, glassware, ceramic and painting, especially in developing countries — and that work may now expose them to agents that cause chronic airway damage.
When it comes to clinical expression of the disease, women seem to be at higher risk of concomitant depression and anxiety, compared to men. This can cause higher rates of diminished quality-of-life issues in women. One cohort study, The Evaluation of COPD Longitudinal to Identify Predictive Surrogate Endpoints, (ECLIPSE) showed increased comorbid rates of diabetes and heart disease in men, while rates of comorbid osteoporosis, depression and inflammatory bowel disease were higher in women. Women had higher rates of associated seasonal rhinitis, body mass index (BMI), impaired nutritional status compared with men. As mentioned previously, women also had a higher dyspnea index compared to men, and that translates to poorer prognosis.
Men with moderate to severe COPD were shown to have higher rates of heart disease, dyslipidemia, alcoholism and sleep apnea.
Poorer prognosis in women with COPD may also be linked to lower rates of diagnosis and treatment, even when the women have spirometry readings that meet the diagnosis criteria of COPD. COPD has also been linked to lower socio-economic status, and women are routinely paid lower salaries compared to men working in similar professions, which may mean a higher risk of COPD based solely on living circumstance. According to a journal article in Chest, "Improving the Management of COPD in Women," by Christine Jenkins, M.D., evidence suggests that women diagnosed with COPD tend to be younger, smoke less, have lower BMIs and lower socio-economic status, compared to their male counterparts. A smoking habit in younger women is often used as a dieting tool.
The ECLIPSE study also showed that rates of exacerbation of COPD in women appear to be higher than in men, and "time to first exacerbation" was shorter in women compared to men.
The takeaway from this discussion is the urgent need for the health care community to recognize these COPD findings and apply them specifically to the female population. Early intervention and treatment are crucial to limiting this disease and extending the life of patients, so if women are under-recognized, they are literally “patient losers” in the game called COPD detection. Presenting the data in a comprehensive way may also help to convince a woman who smokes to give up the habit. Women do tend to frequent doctors more than men, so there is ample opportunity for intervention. We, as doctors, need to improve COPD detection, especially in the female population.
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Eli Hendel, M.D. is a board-certified Internist/pulmonary specialist with board certification in Sleep Medicine. An Assistant Clinical Professor of Medicine at Keck-University of Southern California School of Medicine, and Qualified Medical Examiner for the State of California Department of Industrial Relations, his areas of expertise include asthma, COPD, sleep disorders, obstructive sleep apnea, and occupational lung diseases. Favorite hobby? Composing music. His Twitter handle is @Lung_doctor