The female heart: if you acknowledge it, you can cure it

Cardiologist Dr. Domenico Miceli, describes some physicians' attitude towards female patients, calling for greater attention to sex and gender specificities.

Translated from the original Italian version

The "discovery" of the women's heart

Bernardine Healy, cardiologist and the first US woman to head the National Institute of Health, published an article in 1991 entitled The Yentl Syndrome. The cue was a character from a novel by Isaac B. Singer about a girl who is forced to pretend to be a man in order to be able to study the Talmud, the Jewish sacred text, in a school reserved for boys.

This reference was picked up in 1992 by an American cardiologist, Marianne Legato, who first coined the term 'female heart', marking the birth of gender medicine and emphasising that beyond the anatomical differences between the male and female heart, it was necessary to highlight the attitude of doctors towards the female sex, basically concluding that only when a woman presents herself as a man, she is taken into consideration.

Looking at these dates, therefore, doctors have recently "discovered" the female heart, despite it having been for millenia sung about by poets and studied by philosophers, psychologists and sociologists.

More specifically, women's hearts, more so than men's, have traditionally been seen as a kind of seismograph of emotions, an amplifier of feelings that have the brain as their conductor, with feelings and emotions more in the hands of the female sex than the male.

The "bikini vision"

But it is precisely the exclusive focus on the feelings and emotions of the female heart that has generated, in the medical sphere, a widespread attitude of underestimation, underdiagnosis and undertreatment. For many parts of society, and unfortunately also for the medical profession, women have been and still are seen as predominantly susceptible to breast or genital diseases, forgetting that women also have a heart. This is what is known as the 'bikini vision'.

In fact, heart symptoms receive more attention when reported by a man than by a woman. Yet women suffer heart diseases just like men, and, unfortunately, when they suffer from it, such instances present themselves with greater severity.

Certainly, heart disease affects women to a greater extent today, partly because their lives, especially those in working careers, increasingly resemble those of men, including the acquisition of harmful habits such as smoking and alcohol, with the only advantage for the female sex of being protected by the umbrella of oestrogen, at least until menopause. Estrogens, however, (it now seems clear after decades of clinical observations), cannot be given to all women as hormone replacement therapy (HRT), due to the known risks of thrombosis and breast cancer.

Today it is believed that there is a good therapeutic window to support menopause with HRT, and this window, in order to derive maximum benefit without risk, seems to correspond to the first five years of the menopause and no later than the age 60.

Gender equality and medical scepticism

The focus on women has become more and more relevant. Equality, therefore, has been an increasingly supported goal. But a veil of scepticism persists on the part of doctors: the cardiologist in particular is still led to underestimate symptoms if they are complained of by a woman. A simple experiment conducted in the United States testified to this. A group of cardiologists was shown a video starring an actress in which she presented herself as a housewife and complained of chest pain; the assessment of this pain was different and more careful when the actress, in another video, presented herself as a career manager, in essence a modern-day Yentl.

Treating women's hearts

The increased prevalence of heart disease in women compared to men is now well known to cardiologists. Field observations over the past decades have established that up to the onset of menopause, heart disease 1. affects men more prevalently, 2. by the age of 64 there is a break-even, and 3. between 70 and 75 even an overtaking occurs.

The woman's heart anatomically weighs less (about 250gr. on average as opposed to 350gr. in men), and the coronary arteries are smaller in calibre, thus more prone to restriction in the event of the appearance of plaques. Among the cardiovascular risk factors, smoking presents an almost threefold increased risk in the female sex, rising five-fold in the presence of high cholesterol values, especially LDL.

A factor that apparently affects the female sex to a greater extent is stress, particularly in connection with the double job that still traditionally remains in the female sex, i.e. working outside at the same time as looking after the home and caring for children.

Finally, a heart disease that almost exclusively affects women and brings to mind the female heart as a treasure chest of emotions and feelings, is the Tako-Tsubo syndrome, also known as 'broken heart syndrome', where Tako is 'octopus' and 'Tsubo' is basket in the Japanese language. The affected heart, mainly that of postmenopausal women, has a bottleneck in its middle part that makes it resemble the tool used by Japanese fishermen to catch octopuses, and the cause of this pathology, which can simulate a myocardial infarction, is a rush of catecholamines resulting from severe stress.

In fact, today we can say that the equality of the sexes must be taken into account for better or for worse, but that above all, we doctors must always be reminded of our obligation to never underestimate a patient who reports symptoms like chest pain, breathlessness, or palpitations, just because many in the medical field are stuck in and blinded by the "bikini vision".