Beyond Bikini Science

In 2003, Judy O’Neill had her first “spell”—intense chest pain, shortness of breath, a shooting pain in her left arm and vomiting.

It marked the beginning of seven years of regular trips to the emergency room, countless tests and procedures—and, at times, dismissive attitudes from her doctors.

 Eventually, the 69-year-old O’Neill reached cardiologist Pamela Ouyang, MD. Ouyang, director of the Johns Hopkins Women’s Cardiovascular Health Center, diagnosed coronary vasospasm (a coronary artery constriction).

More common in women, the condition causes some of the classic symptoms of heart disease, but tests don’t necessarily show severe coronary artery atherosclerosis causing obstruction to blood flow, which is more often found in men.

It’s not uncommon for clinicians to fail to recognize that women can experience heart disease—and many other medical conditions—differently than men. This fact highlights the need for research with a women’s health focus, say members of the Women’s Health Research Group (WHRG) at Johns Hopkins. Ouyang and her WHRG colleagues are committed to bridging the research gaps in women’s health. From the schools of Public Health, Nursing and Medicine, this band of scientists seeks to discover the health implications of fundamental sex-based differences and to better understand health issues unique to women.

“We know there are mechanisms impacting health differently for the sexes, and this makes it important to study health in women as well as men.” —Karen Bandeen-Roche

“Our group represents diversity—from policy and behavior to cancer, immunology, infectious disease and other aspects of women’s health,” says Sabra Klein, PhD, MS, an associate professor in Molecular Microbiology and Immunology. Klein’s own investigations into the ways that male and female hormones affect susceptibility to infection have gained national attention.

The group’s interests include reframing pregnancy as an opportunity to shape a woman’s long-term health, diagnosing and preventing frailty, and discovering how basic physiological sex differences affect diseases of the immune system.

WHRG’s research reflects the slow evolution of women’s health science beyond a reproductive focus. “When our office was formed in 1990, women’s health was really viewed as ‘bikini medicine,’” says Janine Clayton, MD, director of the Office of Women’s Health Research at NIH, explaining that decades of women’s health research often led by men focused primarily on the areas of the body covered by a bikini.

It wasn’t until 1990 that Congress mandated that women be adequately represented in NIH-supported research. Until then most clinical trials only enrolled men, assuming that the findings applied equally to both sexes—when the reality was quite different.

Morgana Mongraw-Chaffin, PhD ’13, MPH, a cardiovascular epidemiologist and WHRG member, says she has benefited from the WHRG’s collective experience and support. She wants to see sex-based research evolve from its status as a growing field to standard practice.

“My hope is that at the end of every talk I go to, I won’t have to raise my hand and say, ‘That’s great, but did you look at the differences between men and women,’” says Mongraw-Chaffin. “It should be as standard as any of the other research methods we use.”

WHRG members investigate a wide range of issues related to women’s health. 

Look for Depression Early to Prevent It Later

During puberty and adolescence, young people transition from the highly structured childhood years to the exhilarating and sometimes frightening first years of independence. The transformation brings challenges and occasional turbulence. Social relationships, concerns with body image and self-identity begin to take on increasing importance for the young.

Recent research indicates that it’s also a time when girls begin to show increasing rates of depressive symptoms, saysDonna Strobino, PhD, a professor in Population, Family and Reproductive Health(PFRH). Until puberty, the rates for depression are similar for both sexes, says Strobino.

A greater understanding of this early vulnerability could prove valuable in the prevention, diagnosis and treatment of depression in young women, a group that experiences higher rates of the disorder than men.

“Recognizing the divergence gives us a window into identifying risk and identifying it really early,” says Strobino. “Early identification is particularly important because one of the strongest risk factors for major depressive disorder in adults and postpartum is a history of depression.”

Can Pregnancy Lead to a Healthier Life?

For WHRG director Wendy Bennett, MD, MPH, the postpartum period is a “window of opportunity” to motivate women to make smart choices about food, exercise and healthy behaviors, particularly women who experienced complicated pregnancies.

There’s an increasing recognition that preeclampsia, gestational diabetes or other pregnancy-related conditions put women at greater risk for developing chronic diseases later in life, says Bennett, an assistant professor in General Internal Medicine with a joint appointment in PFRH.

“It’s not just a matter of telling women, ‘You delivered your baby, you’re fine.’ We need to discuss ways to prevent diabetes and heart disease,” she says.

Bennett and her colleagues are designing a pilot project, based at Johns Hopkins Bayview Medical Center, to better understand how to broaden postpartum care. Researchers plan to recruit women from East Baltimore to receive postpartum care that not only includes the relevant medical care, but offers additional health screenings and education.

“It’s not just thinking about a one-time intervention,” says Bennett, “but how to influence the next stage in life.”

Taking Care of Mom, Too

Depression in a new mother can disrupt a child’s well-being from the earliest days of life. Mothers who suffer from the disorder may be overly anxious, reserved emotionally and less likely to play with their babies—all factors that can impact a child’s early development.

“If a mom is depressed it’s really difficult for her to be present and responsive to an infant,” says Tamar Mendelson, PhD, an associate professor in Mental Health.

Based on recent findings by Mendelson and her research partners, a group-format, mental health program to prevent postpartum depression—the Mothers and Babies Course—shows promise in helping pregnant women and new mothers at risk of depression. In a randomized trial led by S. Darius Tandon, PhD, an associate professor in the School of Medicine, the cognitive-behavioral intervention was delivered to low-income women receiving home-visitation services.

Researchers showed that the intervention could be effective in the context of home-visiting programs and reported a significant reduction in depressive symptoms among women in the study group. Equally important, the women showed continued progress at a six-month follow-up.

Planning for Safety

Family planning clinics offer a range of services to women—access to contraceptives, cervical cancer screenings and HIV testing, to name a few.

Michele Decker, ScD, MPH, assistant professor in PFRH, is exploring whether the clinics can also serve as effective entry points to educate women about physical and sexual abuse and link them with support services.

“Evidence increasingly shows that young women bear the brunt of partner violence, and violence is associated with unintended pregnancy as well as other aspects of poor sexual and reproductive health,” she says.

In a pilot study at four Northern California family planning clinics, Decker and colleagues found significant declines in reports of reproductive coercion at clinics that screened for abuse. Reproductive coercion by a partner includes preventing a woman from using contraception or sabotaging her birth control method.

The study used “enhanced” screenings that emphasize education about abuse and referral to services. Clinicians also distribute wallet-sized “safety” cards to all women, listing hotlines, shelters and other resources.

“It removes the burden on the patient to disclose violence in that moment,” says Decker, who is working on a larger study to advance the pilot findings.

Comparing Apples to Pears

When it comes to matters of the heart, cardiovascular disease is not created equal.

“Heart disease in men and women looks different, and we’re not sure why,” says Morgana Mongraw-Chaffin.

While pain is a common heart attack symptom in both sexes, for example, women are more likely to experience atypical symptoms, including abdominal stress, back pain or shortness of breath—sometimes in the absence of chest discomfort.

“The way women put on fat is subcutaneous, whereas men put on fat more viscerally,” reflected in the traditional apple and pear shapes in men and women, explains Mongraw-Chaffin, whose research focuses on possible connections between sex hormones and body fat composition in men and women.

“Why do they put on fat differently, and does that help explain some of the differences we’re seeing in cardiovascular disease later in life?”

Mongraw-Chaffin hopes that her work can contribute to the development of more precise body mass index classifications in both men and women and among different racial groups.

“If we can better understand differences in risks, we can better tailor research and population-level interventions to the people who need it most,” she says.

Holding Back Frailty

Geriatricians have long known what frailty looks like: hunched posture, halting movements, a slow gait and the loss of muscle mass.

However, instead of viewing frailty as separate symptoms, the Women’s Health and Aging Study (WHAS) team defined it as a syndrome and developed precise metrics (a frailty assessment) to identify it.

WHAS research, conducted at Hopkins from 1991 to 2011, has important implications in caring for a rapidly aging population—particularly for women who are disproportionately affected by frailty, says Karen Bandeen-Roche, PhD, Biostatistics chair. Frailty, for example, is associated with more severe responses to falls and other stressors.

Bandeen-Roche and WHAS colleagues Linda Fried, MD, MPH ’84, dean of Columbia University’s Mailman School of Public Health, and Jeremy Walston, MD, a professor of Medicine, hope to see the assessment adopted more widely as a diagnostic tool by clinicians.

Researchers now are exploring the biological determinants of frailty, which could lead to treatments to delay its onset. “The key idea is that it doesn’t result from a single insult to the body, but from widespread dysregulation in the system,” she says.