In response to a previous blog "The 10 Real Reasons Men Don't Go to the Doctor," I have received emails from men suggesting that men's issues are underrepresented in medicine. This has brought up an issue worth raising: should there be a men's health specialty and are we paying too much attention to women's health?
First, until very recently, studies done on stroke and heart disease prevention and treatment DIDN'T enroll women at all or women were represented in very limited numbers. Even today it is well known in academic medicine that women are underrepresented in studies on heart disease (whether it is aspirin for prevention of heart disease, the use of ace inhibitors, immediate coronary angiogram intervention for unstable angina, etc). Now that we have clinics with a women's health emphasis are we pouring too many resources into women and ignoring the needs of men? Should there be Men's Health Clinics? I'll be honest, I have always felt that in the field of medicine men were highly represented and taken care of. Maybe they feel they are not?
1) Women's Health is not a recognized subspecialty of medicine as is cardiology, oncology, endocrinology, and pulmonary for example. Women's health clinics were started with the idea of combining OB/GYN issues and preventative care for women. Women's health clinics are usually Primary Care Doctors (Internal Medicine doctors, family medicine doctors) who take care of serving the needs of women that men don't need: menopause, contraception, breast cancer screening, cervical cancer, etc.
2) It has been proposed that Men's Health Centers, if they did exist, focus on prostate and erectile dysfunction issues. The question here is whether these issues are being properly addressed by primary care providers without having separate dedicated Men's Health Centers.
3) What needs are not being met for men in Primary Care clinics? Screening for cholesterol, blood pressure, blood sugar, weight and exercise regimen are all part of a General Internal Medicine Practice so this should meet the needs of men for preventative care.
4) How we are different other than the obvious ways: Heart disease prevention and treatment are different for men and women. There are significant differences between men and women in the epidemiology, diagnosis, treatment and prognosis of coronary heart disease that should be taken into account in the care of women with known or suspected disease. Unfortunately, data from clinical trials about the management of women with an acute coronary syndrome (myocardial infarction or unstable angina) are limited, since women are generally underrepresented in randomized controlled studies. A repeating theme in the literature is that unadjusted outcomes are often worse in women than men; for example 30 day mortality after bypass surgery is higher in women than men. We should all know this: recommendations for screening and treatment of heart disease are largely based on data conducted predominately on men so the needs of men should be served here by their Internal Medicine or Family Medicine doctor.
5) Screening for Prostate cancer. I heard complaints that relatively little is spent on men's health as compared to women's health. I have lost several patients close to me from complications due to prostate cancer or surgery for it but certainly don't think prostate cancer is being ignored. In fact it appears we may be over-treating and over-screening, performing too many surgeries for prostate cancer when there is no single trial that shows screening for prostate cancer with PSA prevents death from prostate cancer. As many of you have heard recently in the press, in March 2009 the results of two large studies were released and after these the consensus is that there are many patients who are diagnosed with prostate cancer that do not need to be treated, can be observed safely, and will not die of their cancer. Yet most of them are being treated with surgery.
6) What are the real downsides of PSA screening resulting in prostate biopsies and surgeries? The real issue here is that aggressive screening, biopsies and surgery results in immediate effects for men: incontinence and erectile dysfunction among them. This is real, and distressing, and if we aren't preventing mortality or morbidity from these surgeries we should think long and hard about it.
7) Are the needs of men being overshadowed by research into breast cancer, hormone replacement therapy and other women's health issues? There is huge funding in cardiology research (with most studies still enrolling a higher percentage of men) as well as prostate cancer. I'll be honest this is not an argument I hear often in academic medicine but maybe there are many out there who feel this to be true? Let me hear your voice.