As I reflected on my
pulmonology elective at its conclusion, I noticed something peculiar: during my
four weeks, with anywhere between 2 to 6 hours of ambulatory pulmonology
patient exposure per day, a large chunk of the COPD patients were women. I
remembered a handful of male patients with severe disease, but overwhelmingly
the patients were female. I thought there could be any number of reasons for
this; perhaps women were more likely than men to follow up with their
outpatient pulmonologists, or they were healthier than their male counterparts
and were able to stay out of the hospital. My inquisitive mind sent me on a
search of the literature, and I was surprised with what I found. There has been
a striking rise in COPD rates in the female population.
COPD, or chronic
obstructive pulmonary disease, is a long-term destructive lung process most
commonly associated with smoking. Traditionally thought of as a disease for
older white men due to the prominence of tobacco smoking in this population,
recent evidence has shown alarmingly increasing rates of COPD diagnoses in
women. The etiology appears to be similar in women as it is in men, with
tobacco smoking the main culprit. Smoking rates increased in the mid-1920s with
specific targeting of women and began to decline in the 1960s with the Surgeon
General’s report on the consequences of smoking. Nonetheless, TV and newspaper
advertisements targeting women in the 1970s described cigarettes as liberating
and slimming. These advertisements have resulted in increasing cases of new
COPD diagnoses in women that were once targeted. When comparing the percentage
of male to female smokers over the last century, it appears that the highest
percentage of male smokers (>55%) was in the mid-1950s. Compared to men,
roughly 35% of women smoked during this time. Both genders experienced a
decrease in smoking over the next several decades, but this decline was less
pronounced in women; by the 2010s, both men and women had roughly the same
percentage of smokers in their respective populations (20-30%).
Women experience more lung damage than men from the toxins
in cigarette smoke and other environmental irritants. There are several
biological explanations for this, including smaller airway diameter and altered
nicotine breakdown via estrogen. Women also have increasing environmental
exposures, via secondhand smoke and outdoor or workplace pollutants, and
subsequent increased susceptibility. Despite greater susceptibility to chronic
lung damage, women oftentimes do not get properly diagnosed. They are less
likely than men to get spirometry testing, the gold standard for COPD
diagnosis, when they present to their primary care provider with respiratory
complaints.
Most concerning perhaps is the fact that COPD exacerbations
are more common in women than in men, contributing to overall decreased lung
function and, eventually, death. The number of women dying from COPD related
lung decline exceeds that of men.
With overall worsened quality of life compared to men, women
living with COPD require special recognition and attention from providers. We
need to be better at diagnosing the disease in women, with prompt delivery of
spirometry to those presenting with typical (and atypical) respiratory
complaints. Providers need to be aggressive to prevent exacerbations and
preserve lung function as much as possible. Treatment needs to be holistic,
addressing all components of the illness- including anxiety and depression that
oftentimes cause detrimental effects to quality of life. There should be
increased awareness and motivation to address this health disparity, and with
the trend in research and advocacy I believe we are moving in the right
direction.
Mehnaz Ali Khan DUCOM 2020
