A FRAMEWORK FOR THE CONSIDERATION OF CHRONIC DEBILITATING CONDITIONS IN WOMEN

慢性衰弱性疾病是妇女健康的重大负担，部分原因是预期寿命较长。在2018年的全国健康访谈调查中，超过50%的美国成年人报告了10种常见慢性疾病（关节炎、哮喘、癌症、慢性阻塞性肺病、冠心病、糖尿病、肝炎、高血压、中风和肾功能障碍）中的至少一种，超过四分之一的成年人报告了一种以上的此类疾病。这些疾病包括贯穿一生的一系列疾病和失调，男女之间在慢性病的患病率和临床表现方面存在差异。有些慢性病是妇女特有的（例如，子宫内膜异位症或多囊卵巢综合征），而其他慢性病在妇女中发病率较高（例如，心脏病），或者在妇女中比在男子中更常见（例如，抑郁症）。自身免疫性疾病、关节炎、哮喘、痴呆、高血压和骨质疏松症在女性中也比男性更常见；事实上，一些自身免疫性疾病的男女比例高达6:1。免疫系统的性别差异可能影响疾病风险和对预防和治疗措施的反应。女性可能表现出与男性不同的慢性病症状，对药物的反应也可能不同（例如，对一线治疗的反应率较低）。此外，激素变化（例如，怀孕和更年期）对这些情况的影响尚不清楚。患者-提供者互动中的性别差异也会影响女性的慢性病诊断和治疗。

Chronic debilitating conditions are a significant burden on the health of women, in part because of longer life expectancies. More than 50 percent of U.S. adults reported at least 1 of 10 commonly diagnosed chronic conditions (arthritis, asthma, cancer, chronic obstructive pulmonary disease, coronary heart disease, diabetes, hepatitis, hypertension, stroke, and renal dysfunction) in the 2018 National Health Interview Survey, and more than a quarter of adults reported more than one such condition. These conditions include a range of diseases and disorders across the lifespan, and there are differences in both the prevalence and the clinical manifestation of chronic conditions among men and women. Some chronic conditions are specific to women (e.g., endometriosis or polycystic ovarian syndrome) while others have higher morbidity among women (e.g., heart disease) or are more common in women than in men (e.g., depressive disorders). Autoimmune diseases, arthritis, asthma, dementia, hypertension, and osteoporosis are also more common in women than in men; in fact, some autoimmune diseases have female-to-male ratios up to 6:1. Sex differences in the immune system may affect disease risk and response to preventative and therapeutic measures. Women may exhibit different symptoms of chronic conditions than men and can have different responses to medications (e.g., lower response-rate to first-line treatments). Further, the effects of hormonal changes (e.g., pregnancy and menopause) on the course of these conditions is not well understood. Gender differences in patient–provider interactions affect chronic condition diagnosis and treatment among women as well. Multimorbidity is the occurrence of two or more chronic conditions that may or may not have the same cause. Women are more likely than men to experience multimorbidity, and when they do, are more likely to have multiple organ systems involved. The initial chronic condition diagnosed and the pattern of accumulation within multimorbidity also differ by sex and gender. The additive and interactive nature of chronic conditions in multimorbidity among women are not well understood and therefore the conditions are often not adequately treated. Risk factors for multimorbidity include lower educational attainment and socioeconomic status; women of historically underrepresented populations are at additional risk. The evidence base for the prevention, diagnosis, and treatment of chronic conditions among women is underdeveloped. This is in large part because of a lack of intentional research on the health of women and an historical overrepresentation of men in clinical research. For example, clinical research traditionally has not been appropriately designed to obtain data on women (e.g., study end points and inclusion criteria); there is also limited research on femalespecific chronic conditions. A 2010 IOM report (Women’s Health Research: Progress, Pitfalls, and Promise) highlighted advancements in some areas of women’s health research; many of the gaps the IOM report emphasized remain and are described in a 2022 NASEM report (Improving Representation in Clinical Trials and Research: Building Research Equity for Women and Underrepresented Groups). Additional basic, translational, and clinical research on chronic conditions in women is needed. Basic biological research on sex differences at the cellular level (IOM, 2001, Exploring the Biological Contributions to Human Health: Does Sex Matter?), for example, could lead to innovations in understanding different chronic condition manifestations and experiences, as well as treatment and prevention methods. NIH recognizes the need to focus on chronic debilitating conditions in women, including it as a priority topic at the Advancing NIH Research on the Health of Women conference in 2021. The resulting report highlighting conference discussions noted the challenges in defining chronic debilitating conditions in women and in developing a framework for considering them. Specific research gaps and opportunities related to these conditions were also identified. The conference report also highlights similar challenges and gaps in chronic condition research in women as described in a 2022 NASEM report on autoimmune research sponsored by NIH (Enhancing NIH Research on Autoimmune Disease, 2022). NIH seeks assistance from the National Academies of Sciences, Engineering, and Medicine in reviewing literature on chronic debilitating conditions specific to women, assembling evidence-based findings, describing current gaps in evidence, and providing a research agenda for the future.