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Eliseo Pascual, MD, PhD: Exploring Sex and Gender in Rheumatic Diseases

Eliseo Pascual, MD, PhD, discusses sex and gender regarding the diagnosis, treatment, and management of rheumatic disease.

Eliseo Pascual, MD, PhD, talks about his upcoming European Alliance of Associations for Rheumatology (EULAR) 2022 presentation, “When RMDs are studied by sex and gender, this is what happens.” Pascual is associated with the University of Alicante.

The presentation, which will be conducted in a round table and discussion format, serves as a reminder to consider gender bias during the diagnosis, treatment, and management of rheumatic diseases, including which diseases are more likely to be affected by bias and what rheumatologists can do about it.

Rheumatology Network: Why did you decide to examine rheumatic diseases in the context of sex and gender?

Eliseo Pascual, MD, PhD: My wife is an active professor of Public Health and Epidemiology at the University of Alicante and has been working on this subject for the last 20 years or so. Clearly, my exposure to the subject has been high. In 1991, a paper was published by Harvard (an institution expected to have the highest standards of care) showing that at their hospitals, as well as hospitals in Maryland, women who were presetting with coronary episodes had a 28% chance of receiving a coronarography, a technique used to find coronary lesions amenable to revascularization, and were significantly less likely to receive this procedure when compared with similarly presenting men. The odds of having a revascularization procedure were 45% and 27% higher for men than for women, respectively. This could easily be interpreted as a poorer diagnostic and therapeutic effort in women versus men.

Moreover, this phenomenon is likely present in other diseases and other specialties. As a rheumatologist, I suggested studying the spondyloarthropathies, a group of diseases which are predominantly focused on men and in which the disease in women is considered unusual and “atypical.” We found that the diagnostic delay, from the start of symptoms to diagnosis, was larger in women than in men (median, 7.5 years in women versus 4 in men) and that women had gone through a larger number of alternative diagnoses prior to the start of a proper treatment.

Interestingly, although low back pain was considered to be more common in men, during interviews with patients we discovered that both genders reported similar percentages. Previous records, following perhaps what is written, had formerly reported a higher percentage of low back pain in men when compared with women.

Rheumatic diseases are characterized by pain and evident discomfort. If left untreated, these conditions can result in severe sequelae, such as spinal loss of motion and peripheral joint damage in the hips or knees. As this damage is now avoidable with proper treatment, such diagnostic delay is difficult to accept.

Many rheumatological diseases have not been analyzed from the gender perspective and likely will benefit from it. It is especially important to define which diseases are more likely to be impacted by sex and explore the differences in clinical features that may mask diagnosis in either sex (such as osteoporotic fractures in men).

Pascual goes on to say that gender impacts diagnosis and treatment options because if diseases are either unsuspected or underdiagnosed, the consequences for the patient can be dire.

As a part of his continued research, Pascual plans on creating a study focusing on the prevalence of and risk factors for developing gout in females, as it is potentially an underdiagnosed and undertreated condition within this patient population.