From medicine to insurance: closing the women’s health and protection gap

The expert interview featured here once again highlights the urgent need for action to close gender-specific gaps in healthcare. It underscores the critical role of insurers—not only in developing innovative products, but also in raising awareness and mobilizing the entire ecosystem to deliver better health outcomes for women. Sustainable change requires collaboration across all stakeholders.

Women’s health is not just a demographic category; it’s a powerful force shaping the insurance landscape. By understanding the nuances, embracing innovation, and fostering inclusivity, insurers can thrive in this evolving ecosystem. Let’s ensure that women receive the protection they deserve, and in doing so, strengthen the fabric of our insurance industry.

As part of these efforts, Thomas Trompetter, Head of Client Services and Portfolio Solutions at SCOR Life & Health, sat down with Dr Daniel Krause, a practicing cardiologist, to explore the current state of gender-specific treatment for cardiovascular disease in Germany. 

Historically, women have been underrepresented in medical studies, so there is often a lack of evidence for gender-specific guidelines. How do we try to address this problem in current medicalstudies?

An EU regulation came into force in 2022. This stipulates that all participants in a clinical trial must be representative of the population groups that will use the drug under investigation. For example, if 70 per cent of men suffer from the disease for which the drug is intended to treat, 70 per cent of the trial participants should also be male. It is therefore not about a 50:50 distribution as with other gender quotas. Instead, the ratio should be based on the actual gender distribution of the diseases. The Federal Joint Committee (G-BA), which assesses the additional benefit of new drugs, also requires a gender-based evaluation of the authorization studies for new drugs.

For some drugs, it may be necessary to adjust the dosage according to gender, as men and women absorb, distribute and metabolize drugs differently. Even after a drug has been approved, data will continue to be collected and analyzed to ensure that it remains safe and effective for both sexes.

Analyses of patient data show clear differences between men and women. For example, women suffer heart attacks less frequently and on average 10 years later than men. However, for comparable events, the 30-day mortality rate for women is almost twice as high as for men. How can that be?

Various aspects certainly play a role. In my opinion, however, the main reason is the delay in diagnosis. The classic symptoms of a heart attack are a feeling of tightness or pressure in the chest area, often radiating into the left arm. This may be accompanied by slight nausea and sweating. This is how the warning symptoms of a heart attack are often described in the literature.

The problem is that (in all patients) these classic symptoms only occur in a third of cases! One third of patients feel nothing at all, the last third has very unspecific symptoms such as nausea, abdominal pain or, for example, just sweating.

The proportion of the last group (unspecific symptoms) is probably significantly higher in women than in men. This certainly leads to a later diagnosis and a poorer outcome. In cardiology, we always say: "Time is muscle", as heart muscle tissue is destroyed every minute during an acute heart attack. Logically, delays are therefore associated with greater damage and therefore a poorer outcome. The delayed diagnosis also includes the delayed perception of the patient himself, who initially does not think of a heart attack.

You see the main reason in the delayed diagnosis. In addition to other parameters such as physical examination, ECG and imaging procedures, enzyme values such as troponin also play a role in the diagnosis of a heart attack. Until recently, there were no different standard ranges for men and women for the highly sensitive cardiac troponin in Germany, unlike in the USA, where the standard value for women was significantly lower early on. Has this perhaps led to fewer heart attacks being recognized in women in Germany in recent years?

To the best of my knowledge, both for rapid tests in the practice as well as wet chemistry in the hospital or in the emergency room, the highly sensitive troponin or highly sensitive troponin tests are almost exclusively used in Germany nowadays. This is also recommended by the guidelines of the European Society of Cardiology (ESC). These are positive or elevated even in the case of the slightest myocardial damage.

I can't really imagine that there has been a significant underdiagnosis in the past due to non-gender-corrected values, as these tests are always significantly elevated in the event of an infarction. Even in the USA, an improved outcome could not be shown in all cases by using different threshold values.

In addition, the European guidelines also recommend a second determination of the (highly sensitive) troponin and the additional assessment of the change in the value (so -called rule-out algorithm) if there is a corresponding suspicion.

There are various risk scores (e.g., Euro-Score) that calculate the cardiovascular risk of having a heart attack or dying from cardiovascular disease in the next few years, based for example on the PROCAM or Framingham study. None of these studies take gender into account when calculating the risk, although it is known that smoking and diabetes pose a relatively greater risk in women. Shouldn't the scores be adjusted for gender in order to improve patient education and prevention?

In principle, the wish for every medical score is that it predicts risks as accurately as possible. For this reason, it is of course desirable that gender is also recorded if it is relevant - as is the case with cardiovascular risk, for example.

The challenge in everyday life is, of course, that the more parameters should be analysed, the larger the sample must be in order to achieve statistically valid results. In the case of cardiovascular risk, there is also the fact that the risk differs significantly between pre-menopausal and post-menopausal women, which further increases the demands on the statistics and the sample size.

Despite these challenges, the ESC, for example, now provides a risk score for estimating cardiovascular risk with the Score2 algorithm, which also takes gender into account. Data from over 670,000 test subjects was analysed for this, 56% of whom were women. It will be exciting to see whether and to what extent the digitalisation of the healthcare system will provide even more usable data in the future in order to be able to answer complex statistical questions even better.

We have already said that guidelines for the treatment of cardiovascular disease currently pay little attention to gender differences. One exception to this, however, is the guideline on the treatment of cardiac arrhythmias. How do women benefit from these gender-specific treatment guidelines in detail?

The current guideline on the management of atrial fibrillation, which is by far the most common cardiac arrhythmia, clearly shows that there are gender-specific differences here too. On average, women are significantly older than men at the time of diagnosis and both symptoms and concomitant diseases are different.

Accordingly, there are also gender-specific recommendations for treatment: For example, the guidelines in the current 2024 version point out that complications occur more frequently in women undergoing therapy with antiarrhythmic medication and criticize the fact that fewer catheter ablations are performed in women compared to men. Slowly but surely, we are therefore moving towards gender-specific therapy in many areas.

In addition to too little therapy, too much therapy should also be avoided: For the concomitant therapy of atrial fibrillation with blood thinners, it has been the case in the past that the item "female gender" in the risk score has meant that women have potentially been treated too often with blood thinners. Accordingly, the "female gender" item has now been removed from the risk score to avoid possible over-therapy.

The conversation with Dr Krause underscores the importance of gender-specific research, diagnostics, and treatment, particularly in cardiovascular medicine. While progress is being made through regulatory updates, clinical guideline revisions, and increased awareness, there is still much work to be done to ensure women receive equitable and effective care.

In addition to too little therapy, too much therapy should also be avoided: For the concomitant therapy of atrial fibrillation with blood thinners, it has been the case in the past that the item "female gender" in the risk score has meant that women have potentially been treated too often with blood thinners. Accordingly, the "female gender" item has now been removed from the risk score to avoid possible over-therapy.