COPD in Women: Underdiagnosed and Undertreated

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In 1968, Philip Morris unveiled Virginia Slims, the first cigarettes that were designed to appeal specifically to women. The breezy slogan “You’ve come a long way, baby” helped drive sales of the new brand, as well as popularize smoking among women. Within five years, the rate of 12-year-old girls who had begun smoking more than doubled.

In recent decades, we have seen the consequences of that trend, with a dramatic rise in chronic obstructive pulmonary disease (COPD) among women. COPD is an umbrella term for two illnesses that involve deteriorating lung and respiratory function-emphysema and chronic bronchitis. While cigarette smoking is responsible for most cases of COPD, other known causes include exposure to toxic chemicals from occupational and other sources, as well as indoor air pollution.

In the United States, the annual number of deaths among women from COPD has increased fourfold since 1980. And in 2000, the number of women who died of COPD surpassed the number of men for the first time. Women now account for 53 percent of all COPD deaths.

According to the American Lung Association, almost 60 percent of the 15 million people currently diagnosed with COPD are women. Notably, more women now die from COPD than from breast cancer-although breast cancer garners substantially more media exposure and has greater public visibility.

Gender susceptibility

Because COPD develops gradually, millions of women-and men-suffer for years before seeking or obtaining a diagnosis. COPD symptoms include chronic congestion, coughing, and excess phlegm production. While shortness of breath is the defining symptom, many people attribute their wheezing and winded feeling to getting older and becoming less fit, not to disease.

But ignoring those symptoms may prove particularly perilous for women. A growing body of evidence suggests that females are more susceptible to COPD and its consequences than males. For example, women develop the illness at earlier ages and after fewer pack years of smoking. (A pack year is the number of cigarette packs smoked daily multiplied by the number of years smoked.) Compared with males with similar smoking histories, women require more healthcare resources and are up to three times as likely to be hospitalized for COPD. In general, women with COPD also experience more flare-ups than men, and they experience more shortness of breath.

Why the disparities? Researchers suspect that the fact that women have narrower airways and weaker respiratory muscles than men may lead to a greater concentration of cigarette smoke and other irritants in women’s airways. The female hormone estrogen, which causes nicotine to metabolize more quickly, may also play a role.

Women’s quality of life and emotional well-being are also more adversely affected than men’s. Females report lower quality of life and more major disruptions in emotional and social well-being compared with their male counterparts. Overall, COPD patients have significantly higher rates of depression and anxiety than people without the disease; among those with COPD, the rates reported for women are higher than those for men.

Overcoming gender bias

Because of COPD’s long association with male smokers, doctors may fail to recognize and diagnose the disease in women, often mistaking it for asthma, which can cause similar symptoms. To reduce the risk of missing the diagnosis in women, experts recommend that COPD be considered in any woman who presents with symptoms such as breathlessness, chronic cough, regular sputum production, or wheezing if she has: (a) a prior or current smoking history or exposure to secondhand smoke, or (b) other risk factors, such as respiratory infection and occupational exposure to harmful substances, including mineral dust and gas fumes.

Although a female patient’s history and a thorough physical examination are key to an accurate diagnosis, spirometry with bronchodilator response should also be performed. This simple test involves blowing through a tube into an instrument, called a spirometer, to assess lung capacity. Specifically, spirometry assesses how much air a person can inhale and exhale, and how quickly the air is exhaled. After an initial test, patients receive a bronchodilator (a medication that increases airflow in the lungs) and undergo a second round of spirometry to assess the changes in degree of obstruction and confirm or rule out a diagnosis of COPD. Spirometry can be performed in the office, but doctors often don’t use it. Research indicates that they are even less likely to perform the test with female patients.

What women should do

Although there is no cure for COPD, timely diagnosis and careful self-management are essential. If the disease is identified early enough, a range of strategies can help slow disease progression, prevent further lung damage, alleviate symptoms, reduce the risk of flare-ups, and improve quality of life and overall health status.

Kick the habit. The most beneficial intervention by far for all smokers with COPD is to quit smoking, and the positive effect of doing this is even greater for women. Unfortunately, studies have shown that quitting may be particularly difficult for COPD patients, most of whom have high levels of nicotine dependence. Talk to your doctor about smoking cessation options. Nicotine replacement therapy, prescription smoking cessation medications, and support can help. And keep in mind that few smokers succeed in their first attempt to quit; persistence matters.

Get medical treatment. It is not clear whether drugs used to treat COPD are less or more effective in women than men. Most studies on treatment have been performed primarily in men. Thus, the recommended treatment guidelines are the same for males and females.

Pulmonary rehabilitation. Many medical experts also recommend comprehensive pulmonary rehabilitation programs as an important part of COPD therapy. Pulmonary rehabilitation integrates exercise, self-management strategies, education, and counseling. These programs-which combine stretching, resistance training, and endurance training sessions-not only get people moving again, but also help boost sagging morale and improve quality of life.

Studies have shown that pulmonary rehabilitation has achieved some success in reducing COPD symptoms and improving daily functioning. And some research has shown that women, in particular, experience improvements with regard to shortness of breath.

If you don’t have access to a program, it’s likely that you will get some benefit from exercising on your own. A study of 252 people with moderate to severe COPD-half of whom underwent outpatient rehab and half of whom had home-based rehab-found that both groups had less trouble breathing when performing daily activities after participating in an eight-week program.

This study, reported in the Annals of Internal Medicine, also showed that both groups felt their overall health status had improved. The study participants performed various strength-training exercises (a maximum of three sets of 10 repetitions each, for 30 minutes) and aerobic exercise (stationary cycling for 25 to 30 minutes) three times a week for eight weeks.

Pulmonary rehabilitation is typically recommended for people with moderate to severe COPD (forced expiratory volume at one second [FEV1] 30 percent to 79 percent of predicted value). And the Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommends that doctors consider it for people with mild COPD (FEV1 at least 80 percent of the predicted value). One recent study reported that people with COPD found it easier to exercise after pulmonary rehab regardless of whether their condition was mild, moderate, or severe.

To find a pulmonary rehabilitation program near you, ask your doctor for a referral. Or contact the American Lung Association (800-LUNGUSA; lung.org) or the American Association of Cardiovascular and Pulmonary Rehabilitation (312-321-5146; aacvpr.org).

What else should women do?

When it comes to COPD, women must be ready to advocate for themselves. Don’t dismiss chronic shortness of breath, or congestion and coughing, as normal signs of aging. If you have not been assessed for COPD, ask for a spirometry test. If you have COPD, the sooner you obtain an accurate diagnosis, the more likely you and your doctor will be able to develop an effective strategy to help you function at your best.

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