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KEEPING OUR FOCUS Women-Centered in Traditional and Complementary/Alternative Medicine

What is "Women's Health?" This question provokes many types of answers. Women certainly vary in their answers, but so do gynecologists, internists, and family practitioners. I answer, "Women's Health is a medical science rooted in women's lives." Twenty-first century health care, however, often seems as if it is rooted in the lives of women at the turn of the 20th century. Professional medicine was being transformed at that time from a trade to a profession, and the one that formed to serve women's needs was Obstetrics and Gynecology.

In 1901, if a woman was lucky enough to have survived being born (for many infants didn't), and she was lucky enough to have survived the infectious diseases that ravaged children, the leading cause of death was childbirth. A woman at the turn of the century had, on average, 8 children, and each of her many pregnancies put her at risk of dying. Her reproductive life was different from that of contemporary women. She began to menstruate at the age of 17, married shortly thereafter, had multiple pregnancies, and breast-fed each baby for a long time. She had a rare menstrual cycle. Few women experienced menopause, which occurs, on average, at age 52, because the average life expectancy was 48 years.

If childbirth didn't kill her, it often left her with chronic disabilities. Birthing injuries often left her incontinent of urine and stool, with prolapse of the uterus so that she could not walk without it falling outside her body, or with chronic pelvic pain due to untreated venereal infections (pre-antibiotic days), which were often treated with morphine and led to addiction. Her social role was that of mother, and she relied on the institution of marriage for economic support.

Today in the United States and other developed countries, it is rare to die while being born, and the risk of dying from childhood infectious diseases has been virtually eliminated by vaccines and antibiotics. (Although in many parts of the world without access to adequate basic medical care, the death rate among infants and children is much higher.) In the year 2001, the average age for a girl's first menstrual period was 11. Women still enter menopause, on average, at age 52, but in this country, women have only, on the average, two children. A woman's reproductive life in current-day America is now characterized by 40 years of uninterrupted menstrual cycles and preventing pregnancy. The life span of an average American woman is now 85 and increasing, with many living to 100 years of age. Now women spend from one-third to one-half of their life spans beyond reproductive years. Today the leading causes of death in industrialized countries are cardiovascular disease, cancer, and stroke. Women still live with chronic disorders, but now they are more often hypertension, diabetes, asthma, and depression instead of reproductive disabilities.

While the 21st-century woman still maintains her reproductive role as a mother, most women also have productive roles in the paid workforce. Women throughout much of the world are economically able to support themselves without being married. Women may have children without a husband or even without a sexual partner, many availing themselves of assisted reproductive technologies.

When medicine was being transformed from a trade to a profession 100 years ago, the formation of obstetrics and gynecology in response to women's real health needs was appropriate. But at the turn of the 21st century, as medicine is being transformed from a profession into an industry, women need a medical approach and services that support their real lives. It is out of this need that the interdisciplinary clinical field of "Women's Health" was born and continues to evolve. This field is focused on whole women in the diverse contexts of their lives and it is grounded in sex- and gender-based medicine. ("Sex" refers to the biological designation of a person as male or female, while "gender" refers to the social aspect of being a man or woman.)

Interestingly, the medical approaches taken in different historical eras mirror the underling scientific perspectives of the times. One hundred years ago, scientific thought was represented by reductionism. The universe was thought of as a machine. Any complex subject could be reduced to its smallest parts, and if you understood each part, you could add them together and understand the whole. Reductionism guided the formation of the sciences that took form over the last century and produced incredible results. (For example, the identification of DNA greatly advanced the field of genomics; the discovery of sub-atomic particles made possible the development of nuclear energy.) The body was also considered a machine, and specialties grew around each organ as the physiology of each one became better known. Eventually our vision went beyond the organ, to the cell, the molecule, and ultimately the gene. The history of medicine over the last one hundred years describes how to a large degree those early physicians related all of women's health issues to their reproductive parts.

Living systems, however, cannot be fully understood using the machine metaphor. The body isn't a clock; the nucleus is not the master gear. An individual is more than the sum of organ systems. Living systems have parts capable of mutual interactions that not only sustain them but also allow them to learn, adapt, and innovate. Through the interactions of the parts, outcomes emerge that are characteristic, not of each part, but of the whole. While reductionism was a major feature of scientific thought of the last century, complexity characterizes science of the 21st century. The unit of study is no longer the smallest part, but the "complex adaptive system," and the focus has shifted to the interaction between the parts. Today this scientific perspective allows us to see how a woman's reproductive capacity relates to her health and illness as a whole.

There is one distinctive similarity among medicine practices of the 19th, 20th and 21st centuries: the competition between mainstream practitioners and other clinicians. A hundred years ago, what is today called "traditional" medicine was referred to as "regular" medicine. "Irregular" medicine was akin to "complementary/alternative" medicine of today. It was part of a popular health movement that had formed as a reaction to the exclusivity of medical professionals and their expert advice for harsh medicine, consisting mostly of purging, blistering, and bleeding!

One example of early 19th century popular health movements was the formation of Ladies Physiological Societies, where women gathered to learn about their own anatomy and functioning, similar to the "know your body" courses of the 1970s. Interestingly, medical historian Richard Shyrock says that the health and feminist movements were indistinguishable at that time.

There was also the movement known as Thomsonianism, which approached healing through "Friendly Botanical Societies." Thomsonianism was a simple system of health based on herbs and steam derived from Native American healing lore, but the movement was concerned with larger social issues like women's rights. It fought against practices such as "tight-lacing" (the wearing of corsets and other devises to narrow the waistline) and "heroic" obstetrical practices, such as using forceps during the delivery of babies, which often crushed or deformed the infant. It supported the use of midwives instead of male obstetrician/gynecologists. The societies were simply social gatherings where people shared info and studied the Thomsonian system.

The Hygienic Movement rejected drugs and botanicals and focused on vegetarianism.

Hydropathy favored the "water cure"--sending patients to spas to heal their ills.

Homeopathic medicine was the most serious threat to the regulars. It was formed as a direct reaction to traditional "heroic" therapy, in which doctors ordered high doses of medicines to produce a maximum toxic effect on the body's physiology. The homeopath did the opposite; he produced an infinitely diluted basic medicine (usually a plant extract), in the belief that substances gained in curative power as they were diluted. Homeopathic clinicians spent a great deal of time and effort diagnosing the patient and charged hefty fee. Therefore homeopathy, like regular medicine, was favored by people with financial means (whereas many of the other popular health movements were associated with more radical working class causes and groups). Homeopathy almost never produced any physical harm, since the herbs used were so extremely diluted.

To one degree or another, all of these forms of alternative medicine competed with regular medicine for patients. Eventually all groups sought professional recognition, developed their own schools, and required accreditation.

By the late 1800s the popular health movement became an assorted collection of organized medical sects: eclectics, botanicists, homeopaths, hydropaths-each with its own schools, journals, and claims to scientific superiority. Many of the practitioners of alternative medicine in the 1800s were women. At this time, women also began to enter the ranks of regular medicine in increasing numbers as physicians. The mid-19th-century movement of women into medical training became associated with crusades for female health, morality, and decency. By 1900 there were 5000 women "regulars," 1500 female medical students, and 7 medical schools exclusively for women.

Some of the regular physicians, mostly male, took aggressive action to define and restrict the "legitimate" practice of medicine. In 1847 they formed the American Medical Association (AMA), which quickly became a powerful organization. The AMA's first task was to survey the various forms of "non-regular" medical practices in existence. It created the system of state licensing and dictated who could and could not practice. The field of medicine grew more and more "professionalized" and became a part of university education instead of being accessible through trade schools. Germ theory, evolution, and "the body as machine" were the guiding scientific beliefs.

Today, in the 21st century, there are many forms of Complementary and Alternative Medicine available. Some of these have been in existence for many years, while others are newer. They include:

• Homeopathy, naturopathy, herbs, flower essences
• Chiropractic, Osteopathy
• Acupuncture, acupressure, shiatsu
• Chinese Medicine, Qui Gong, Taoist Healing, Tai Chi
• Manual Therapies--Rolfing, Reiki, craniosacral, massage
• Bioenergetics--therapeutic touch, polarity therapy, kinesiology
• Holistic medicine, ayurvedic medicine
• Meditation, guided imagery, relaxation therapy, yoga
• Creative arts therapies--drama, dance art, music, psychodrama

In a survey published in 1997, it was reported that up to 50 percent of people in the United States relied on both traditional and CAM. This was an increase from the 30 percent reported in 1993. What is the explanation? A simplistic answer is that traditional medicine doesn't feel good and never has. Mainstream medicine, especially emergency and acute care medicine, is crucial and necessary, but surgery, drugs, and invasive diagnostics are inadequate for helping with many of the functional and pre-pathologic health problems of today. Nor do they substantially improve the quality of life in people with chronic disease or prevent illness and promote optimal health.

There is another important question being asked today: "Is CAM 'scientifically' valid?" The Congressional Office of Technology Assessment estimated that only 20 percent of routine biomedical therapies have been rigorously tested in the way that many demand of CAM. And many of the modalities of CAM have been "field tested" by millions of people over many years. (1)

So, what makes complementary/alternative medicine different? Dr. Marc Micozzi (2) says there are five basic characteristics common to CAM healing systems. The first characteristic is that CAM focuses on being healthy. Health is seen as the balance between internal resources and the external environment rather than being a quality conferred by an outside intervention. This differs from the approach of traditional medicine, which tends to focus on patients who are "at risk for disease."

The second characteristic of CAM is a focus on self-healing, which is thought to be the basis of all healing. In CAM, external manipulations are used to mobilize the body's inner healing resources. For example, CAM might use the antibiotics of traditional medicine to slow the growth of infectious organisms just enough to allow the body's immune system to eliminate them.

Third is the concept of bioenergy--the force that makes us more than just the sum of our parts. The Chinese call it "Qi"; Ayurvedics call it "Prana"; 18th- and 19th-century American physicians called it "vital energy." Western traditional medicine measures this bioenergy in EKGs, EEGs, and EMGs, but doesn't enlist it for healing purposes.

The fourth aspect is reliance on nutrition, plants, and other natural products. Nutrients (the complex elements in whole foods, not isolated supplements) and natural products provide the body with energy and the material resources to stay healthy or return to health.

Lastly, there is an emphasis on individuality in CAM practices. These therapies place an emphasis on the whole person as a unique individual. Individual differences are expected when applying general principles that are determined in the population at large.

But then another question follows: "Is CAM women-centered?" In order to answer this question, it may be helpful to spell out some of the essential ideas of the developing science of women's health: The mind is not separate from the body. Sex differences exist in all organ systems; gender differences exist in how females and males live in and experience their worlds. There are complex interactions between reproductive and all other medical sciences, and women's capacity for reproduction holds important insights for more global medical applications.

Males and females experience their worlds differently. These social differences are referred to as "gender," whereas "sex" describes biological differences. As an example of gender difference, both men and women are exposed to trauma but women are more likely to develop Post-Traumatic Stress Disorder (PTSD). This may result in part from the fact that one of the major causes of PTSD, sexual trauma, is more common among women. Childhood sexual abuse, which is nine times more common in girls than in boys, can lead to a class of disorders of consciousness and identity integration called "dissociative disorders." Memories of such experiences may translate into physical or emotional illness, and they often bring patients into medical care with headaches, body pains, and gastrointestinal or gynecologic disorders, or with psychological disorders such as chronic pain and addiction.

Another example of gender difference is in the comparative rates of depression and hostility among men and women. Both males and females experience negative affectivity (depression, anxiety and anger/hostility). Women more frequently identify themselves as depressed and, since they also visit doctors more often then men, are more readily identified in the general medical system. On the other hand, men are more commonly diagnosed as aggressive (for violent behavior or alcohol and substance use), but by the criminal justice system rather than by medical or mental health professionals.

Biological sex differences exist in all organ systems, and we have been introduced to this concept over the last decade in the publicity around women and heart disease. Even in the absence of disease, many women normally have a variant in the heart cell that conducts electrical activity. This is seen as a lengthening in a part of the waveform shown on an EKG, something that has been identified as "normal" in women for a long time. Yet, what has not been taken into account until recently is that some commonly used medications can further prolong the electrical current and lead to a lethal arrhythmia.

Complex interactions exist between the reproductive system and all other organ systems, whether or not a woman is ever pregnant. For example, women with irregular menstrual cycles often have a condition called polycystic ovarian syndrome (PCOS). While the attention until recently has focused on menstrual regulation and fertility in these patients, PCOS happens to be the only sex-specific risk factor for coronary artery disease and should be a signal for aggressive cardiovascular risk reduction.

Similarly, if we look at how the woman's body adapts or fails to adapt to the pregnant state we may get insights into human physiology in a way that can help both sexes. Each organ system must shift its interaction with every other organ system along with the fetus and placenta to survive and to maintain the mother's overall structural integrity. In the disorder of late pregnancy called pre-eclampsia, blood vessels fail to transform structurally and show damage that resembles early changes of atherosclerosis (hardening of the arteries), resulting clinically in hypertension (high blood pressure). It is possible that the further study of pre-eclamsia might reveal clues about injury to blood vessels that could advance the health care of both women and men.

Over the last decade, the women's health movement has demanded that traditional medicine examine its scientific database for sex and gender differences. As a result, many more medical studies are now carried out in women, whereas in the past only men were studied and it was assumed, often incorrectly, that women would develop diseases at the same rate and in the same way as men and would respond identically to treatments. We need to be able to hold CAM to the same standard as traditional medicine. The most important contribution of CAM to the general practice of medicine is the fact that it is based on a view of the whole person in the context of his or her life. This is offers a significant contribution to women's (and men's!) health. At the same time we have to be careful about sex stereotyping wherever it manifests itself. For example, although the concepts of Yin and Yang are helpful in addressing the concept of balance, we need to be wary of how yin characteristics are characterized as "female" and yang characteristics as "male."

In conclusion, Einstein's comments about the old and the new physics seem appropriate to the relationship of obstetrics/gynecology to women's health:

"…Creating a new theory is not like destroying an old barn and erecting a skyscraper in its place. It is rather like climbing a mountain, gaining new and wider views, discovering unexpected connections between our starting point and its rich environment. But the point from which we started out still exists and can be seen, although it appears smaller and forms a tiny part of our broad view gained by the adventurous way up."

Whether the view of contemporary women's health care is broadened by complementary and alternative therapies or traditional ones, it must take into account the tenets of Women's Health expressed above and ultimately be rooted in women's real lives and experiences.

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(1) Eisenberg, Kessler, Foster et al. Unconventional medicine in the U.S.: Prevalence, Cost and Patterns of Use. NEJM. 1993;328:246-252.

(2) Dr. Micozzi, M.D., Ph.D., is Executive Director, College of Physicians of Philadelphia and Editor of Fundamentals of Complementary and Alternative Medicine (Churchill Livingston, 1996).

If you are interested in reading more about the history of medical care for women, a good source is the book "For Her Own Good -- 150 Years of the Experts Advice to Women," by B. Ehrenreich and D. English, published by Doubleday, New York, NY, 1978.

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