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Targeting Women's Health

by Debra Gibson

Consider the following:

These questions are part of a bold new focus on women's health at the University of Kentucky that includes $15 million in funding for new research as well as the establishment of the UK Women's Health Center and a center for biomedical research in women's health. This work could lead to crucial findings related to women's health and to improved clinical care for women.

Photo of Phyllis WiseThe Shih Chun Wang Professor in the Department of Physiology, Phyllis Wise has been researching the role of estrogen for more than a decade.

These new efforts will build from an already-solid foundation of research in women's health at UK. Phyllis Wise, the Shih Chun Wang Professor and chairperson of the Department of Physiology in UK's College of Medicine, has been researching the role of estrogen for more than a decade.

According to Wise, it has only been in the last 10 or 15 years that the National Institutes of Health began requiring that women even be enrolled in clinical trials. "It was assumed that results from fundamental and clinical studies that were performed in men could be applied to women," says Wise. "However, we now know that there are many aspects of our physiology that are gender dependent." Likewise, many diseases affect women more frequently than men and manifest themselves differently in women.

A new five-year, $8.2 million grant from NIH will enable Wise to expand the scope of the research under way at UK and allow a cadre of researchers to interact and address synergetic issues. It will also establish the Center for Biomedical Research Excellence in Women's Health (COBREWH) at UK, which Wise will head.

Collectively, COBREWH researchers will examine how estradiol (the predominant and most potent estrogen in adult premenopausal women) and drugs that are related to estrogen—selective estrogen receptor modulators (SERMS)—affect a woman's neuroendocrine, central nervous, cardiovascular, and reproductive systems as well as behavior.

"We want to understand what estrogens do in young women and what happens when a woman reaches middle age and experiences menopause, and estrogen levels decrease dramatically," says Wise. "Before, we thought it was a simple matter of a change with one hormone that affected only a few organs—the ovaries, uterus, cervix and a few others. Now we know it is much more complicated."

Wise likens the inner workings of a woman's body to an orchestra.

"For Beethoven's Third Symphony to be played successfully, all the instruments must come in at the right time," Wise says. "If the violas aren't there or don't come in at the right time, it won't sound right. This is also true with a woman's body. Estrogen triggers regular menstrual cycles. If the right signal doesn't come at the right time, the cycle is not regular," she says.

Wise adds that estrogen affects changes far beyond the ovaries and the reproductive system. "We now believe estrogen is critically involved in our cardiovascular system, the cerebral cortex, the hypothalamus, and the bones, for example, but we don't know precisely how it is involved."

This research will have implications for millions of women. Currently, more than 35 million American women are postmenopausal and more than one million will become menopausal each year.

"Until 100 years ago, women didn't live much past menopause, but now the average lifespan for women is 83 years," Wise notes. "Women now live 30 years not producing estrogen. Women in their 50s and 60s complain of memory loss and depression at menopause, and we know their risk of cardiovascular disease increases. Their risk of stroke is much greater, too, and the injury associated with a stroke is greater. We don't know very much about what estrogen does for us, good or bad. We need to understand how estrogen affects all of these areas."

The five-year studies will begin with fundamental cellular and molecular research, move into translational research using animals, primarily mice, then move into drug development and testing before concluding with clinical trials.

Wise has also received $3.75 million from the National Institute on Aging, part of NIH, for another project. This study will focus on what happens as women age that prevents the ovaries from functioning as they did during the reproductive years and whether estrogen continues to protect against injury during aging.

Ultimately, this research will be important not only to women but to their health-care providers as well. It will certainly be important at the newly established UK Women's Health Center. The result of five years of organization and planning, the center is the first of its kind in Kentucky. It officially opened in the fall of 2000 with five missions—clinical care, leadership, education, research, and community outreach. (See Under One Umbrella for details.)

These missions come together in a three-year, $821,000 grant from the U.S. Department of Education to develop a core multidisciplinary women's health curriculum. This educational reform could change the way all health-care providers diagnose problems of female patients. The curriculum will be tailored to the needs of each of UK's five colleges in the medical center.

"We started looking at this two and a half years ago," recalls Deborah Kwolek, director of the center, principal investigator on the curriculum project, and an assistant professor of internal medicine in the UK College of Medicine. "I was very much aware of Dr. Sandra Levison's work to establish the Women's Health Education Program at the Hahnemann School of Medicine in Pennsylvania. They have been making many advances in terms of women's health education.

Photo of Deborah Kwolek examining patientMedical director of the Center for Biomedical Research Excellence in Women's Health, Deborah Kwolek is developing a new curriculum for health-science students that she hopes will result in improved care for all patients.

"At UK we started by raising awareness and doing needs assessments among health science students. We also did some daylong faculty development workshops to help us better understand the major issues and what we could do. Then we developed a Women's Health Education Team, made up of two faculty members from each college. They have been meeting monthly for the past two years to consider possible curriculum changes."

Receiving the Department of Education grant enabled Kwolek and her team to do even more. Their work will ultimately affect a whole generation of health-care providers.

"We are concentrating on three areas," Kwolek says. "The first is a core lecture on women's health and gender-based medicine, which is included in the curriculum in each college. The second is professional development for faculty in women's health. This year, a 12-person team is developing core curriculum. Each of the five colleges has a task force that will then adapt core curriculum to the needs of their students."

The third aspect is hands-on workshops using what Kwolek calls "standardized patients," actors who describe symptoms associated with one of six problems common to women—heart disease, diabetes, depression, sexually transmitted diseases, osteoporosis, and domestic violence. The students must diagnose the problem and prescribe treatment.

The results from practice sessions using this technique reveal a gap between what the patients say and what the students hear as well as a gap in the students' knowledge about specific medical needs of women, according to Kwolek.

"Treatments for women may need to be different," she says. "Heart disease in women is different than in men, for example. If a woman has diabetes, she has a stronger risk factor for heart disease than a man. Many students don't know that. Our goal is for all students to know which treatments work better for women and which treatments work better for men. The goal isn't just to improve women's health, but to improve care for all patients. The students leave the exercise with core knowledge on all these very common conditions."

That knowledge will be disseminated to 15 collaborating institutions nationwide, according to Kwolek. Her work also ties directly into that being done in other departments on the UK campus.

Emery Wilson, dean of the UK College of Medicine, leads a program called Building Interdisciplinary Research Careers in Women's Health (BIRCWH). The program is funded by a five-year, $2.5 million grant from the National Institutes of Health.

The two primary goals of BIRCWH are to provide junior faculty with state-of-the-art multidisciplinary training in research relevant to women's health and to encourage new collaborative research focused on improving women's health.

"We are attempting to develop faculty members with an interest in research and to provide them with the skills necessary in order for them to be successful in doing research," Wilson says. "This also provides an opportunity to develop women's health at the university. We're trying to bring people to obstetrics, internal medicine, neurology, and other fields who are interested in women's health and developing research along those lines."

Photo of Emery WilsonEmery Wilson, dean of the UK College of Medicine, leads Building Interdisciplinary Research Careers in Women's Health, a program to provide junior faculty with state-of-the-art multidisciplinary training in research relevant to women's health.

Wilson says the project will particularly focus on areas that have not received much national attention.

"For example, we know that there are more instances of gynecological cancer (ovarian, uterine) in Kentucky than in any other state," he notes. "Is that a problem with women not getting adequate screenings or is it for some other reason?"

There are any number of research possibilities, according to Wilson, who says there are three areas of focus this grant will support: regulation of menopause and its repercussions on women's health, nutrition-related illnesses and their impact on women, and gender issues and drug abuse.

Phyllis Wise and Claire Pomeroy, chief of infectious diseases at UK, will coordinate the programs and the appointment of BIRCWH scholars. Each junior-faculty scholar will work with a senior researcher and participate in workshops in various aspects of research, including grant writing, statistics, and ethics.

"This program gives us an opportunity to bring all of these issues together," says Wilson, "and to do two things: develop new faculty members and focus efforts in women's health. It is important to get women involved in their own health care. Women are usually the ones who care for the entire family. If we can get them involved and begin to improve the health of women in Kentucky, we can, through them, begin to improve the health of all Kentuckians."

The focus on women's health will have a domino effect, according to James W. Holsinger Jr., chancellor of the UK Chandler Medical Center.

"We really leapfrogged into a significant national leadership position with the coming together of these grants," says Holsinger. "This prominence nationwide will encourage more people to come to UK to do research on women's health, which will build a major focus on women's health here and result in clinical advances. That cannot help but make a real difference in the health care women receive."

Under One Umbrella

The idea is so simple that it should be common practice: put all the primary health-care services that women need in one place. And this is exactly what happened at the University of Kentucky when the UK Women's Health Clinic opened in April 2000.

"We try to have one-stop shopping for women with primary-care medicine, gynecology, and psychiatry," says director Deborah Kwolek. "Our health-care providers have particular expertise and interest in women's health. They keep abreast of all national information on key findings. This is not generic medical care. It is more targeted to and sensitive to the needs of women. We have expertise in hormones and how women patients are distinctly different from male patients."

The reception from women is evident in one fact: the clinic already has more patients than the three physicians, three resident physicians and four nurse/practitioners can handle. They are hoping to expand soon to meet the demand.

"We are a small model clinic," Kwolek notes. "This isn't the solution to take care of all women. Our goal is to help other providers both in the UK network and the state emulate this model so the diverse needs of women can be taken care of throughout Kentucky."

The clinic is one of five missions of the UK Women's Health Center. In addition to the clinic and the research activities, the center is also developing leadership programs among women faculty, is involved in community outreach programs, and is conducting regular education programs.

Headed by Edythe Lach, the leadership program includes a monthly luncheon series and a training program called Circles of Power that immerses women in a yearlong, intensive study of leadership skills. There is also a regular recognition program to celebrate achievements of women in leadership positions.

Linda Kuder, associate director for education and community services at UK's Sanders-Brown Center on Aging, heads the community outreach program and its main event—an annual statewide summit on women's health. Now in its fourth year, the conference brings together legislators, health-care providers, and staff from public health departments to discuss the status of women's health.

Monthly women's health "grand rounds," which provide continuing medical education to health-care providers, and are transmitted to 13 sites across the state, feature national speakers addressing health-related issues important to women. There is also an annual women's health conference to provide continuing education on women's health topics.

"Health care used to look at women as men with a few added parts," Kwolek notes. "The 'normal' human was a 70-kilogram man. Now the paradigm is shifting. We see two sexes—two equal but very different sexes. Our new women's health initiative is about being advocates for women, and as we study women we learn more and more about the differences. This focus will put the University of Kentucky at the forefront of a new era in health care for women."