Differences Between Women and Men .. in the Rate of Diagnosed Diseases After a Diagnostic Intervention is Conducted ... , 2022, Rosmalen et al

Full title: Differences Between Women and Men Are Present in the Rate of Diagnosed Diseases After a Diagnostic Intervention is Conducted in Primary Care

Abstract

Background: Recently it was shown that the relative lack of diagnostic interventions conducted in women mediated the negative association between female sex and diagnosed disease. However, it remains unknown whether women and men receive disease diagnoses in an equal frequency after diagnostic interventions have been performed in general practice.

Methods: We used generalized linear mixed-effect models to assess the association between diagnostic interventions and disease diagnoses when patients presented with common somatic symptoms and studied whether the association differed between female and male patients.

Results: In 34,268 episodes of care (61.4% female) physical examinations and specialist referrals were associated with more disease diagnoses (OR = 2.32; 95% CI = 2.17–2.49 and OR = 1.38; 95% CI = 1.27–1.49, respectively), whereas laboratory diagnostics were associated with fewer disease diagnoses (OR = 0.50; 95% CI = 0.47–0.54). Significant interaction terms showed that women presenting with back pain, tiredness, arm and/or leg symptoms and tingling extremities were provided with fewer disease diagnoses after diagnostic interventions were performed than men. We found no significant interaction term that indicated that men were provided with fewer disease diagnoses after a diagnostic intervention than women.

Conclusion: Especially when patients present with the mentioned symptoms, general practitioners should be aware that diagnostic interventions yield fewer disease diagnoses in female patients than in men. Yet, performing fewer diagnostic interventions in women with these symptoms will further exacerbate sex differences in disease diagnoses.

Open access, https://www.jabfm.org/content/35/1/73

 

Back pain - is poorly treated in both men and women. Patients of both sexes get told they have "lumbago", need more exercise, should sit less, eat less, and move more. Using an n=1 sample (my husband) an obvious difference between the treatment of back pain in men and women is that men are unlikely to be told the pain is all in their heads, that they are depressed and anxious, and they need anti-depressants. Nor are they told their problems are caused by their age, or their job, their parenting status, and how much housework they do.

Tiredness - assuming that tiredness does not indicate a medical problem causes more misery for more women than anything else, in my opinion. Doctors are reluctant to test for low iron. To do that they would need to do an iron panel. But normally they do a Full Blood Count, check to see if the haemoglobin is in range and declare the patient to be fine if it is, and all the patient needs is anti-depressants. If doctors test ferritin before or after treatment with iron supplements they think a level of 30 is absolutely fine and the patient doesn't need supplements.

This link from NICE is worth reading :

https://cks.nice.org.uk/topics/anae.../investigations/#interpreting-ferritin-levels

(My bold)

Some other links on this subject that might be of interest :

Iron deficiency without anemia - a clinical challenge

Effect of iron supplementation on fatigue in nonanemic menstruating women with low ferritin: a randomized controlled trial

Tingling extremities - This could be caused by Vitamin B12 deficiency or folate deficiency or both. Women outnumber male sufferers of Pernicious Anaemia (PA) by 4 to 1. I don't know the ratio for B12 deficiency without PA. There is no global agreement on what is a good level of B12 and UK doctors often don't know any of the symptoms of deficiency or consider really low levels to be absolutely fine because the reference ranges are so ridiculously low. In Japan a level of B12 of 400ng/L for B12 would get you treatment for deficiency. In the UK you'd (possibly) be offered anti-depressants and would then be shown the door.

 

Very seldom do generalists perform a physical exam these days (without considering the pandemic)- if you have your blood pressure measured, it is almost a miracle.

 

A point made in the conclusion is the one which immediately came to mind when reading the thread title.

Furthermore, as women are thought to seek help earlier in their disease process than men, they may present with more atypical complaints in general practice. These pose a challenge to diagnose, as the symptoms may have not yet progressed enough to be readily attributed to an organic disease, or diagnostic interventions may not be sensitive enough to detect disease. Therefore, further research could focus on sex differences in help-seeking behavior for common somatic symptoms.

You’d have thought that they could have adjusted for presenting history from the outset.

 

Agreed. Physical exams are rare.

 

More than 30 years ago, someone I know was exhausted all the time. They were advised their hemoglobin was good, so their iron level was good. Turns out their ferritin was very low - in the single digits.

Fast forward 30 years, and doctors are still just testing hemoglobin etc., and not ferritin.

If the hemoglobin etc. is good, then iron status is assumed to be good. Ferritin is still ignored. The patient goes away still very fatigued, with other iron deficiency symptoms, and none the wiser about what's wrong.

 

Interesting about B12.

Some pwME are advised to try B12 supplementation or B12 injections. I know some doctors recommend these.

 

Another issue for women in relation to iron is that once a woman is past menopause doctors assume they can't be deficient in iron, which is total nonsense.

 

Agreed.

 

Ferritiin is an inflammation marker.
Both my aunts' ferritin is high ( my ME aunt is 10 x out of normal range). Iron panels are normal

 

I've just received a blood test back from medicheck and my ferritin is low at 15. I can't seem to find a thread on how to correct for this? Is there one? I already cut out iron blockers like caffiene and eat plenty of iron rich foods which is what the Medichecks Dr recommended along with a Lysiene supp. . My TSH is also nearly 7, TPO A normal but TG A high. Active B12 excellent folate good but although vit d is low optimal, am surprised it's not higher since I am on 6,000 iu a day for many months.

 

Thank you. That's a good idea to use a food calculator to have a bit more of an accurate idea of intake. I am pre-menopause. The Medicheck Dr said ferritin should be at least at 27 (ref range is 13-150). It would be amazing if this could be fixed and would improve my health.

I don't know why lysiene was recommended. It's really hard trying to trawl through everything. I don't know it it would be contraindicated with ME or not.

 

He obviously hasn't read the NICE guidelines which say anything under 30 is evidence of iron deficiency. See post #2 above.

 

Yes I saw that, Arnie. It can all get a bit confusing! I've just rechecked the report and it does say "For a female we'd ideally like to see ferritin over 27, so you can see you're a little low today". He just says that "iron stores are towards the low end of normal". It doesn't state iron deficiency at all. Perhaps out of date a little?

This is the first time I have ever been tested for Ferritin. I am going to guess my iron is good but I expect I should get an iron panel done. Don't want to pay the £39. What I don't yet understand is why those whose iron is good but ferritin low can have really bad symptoms. In my poor understanding of this ferritin is just low storage levels but iron availability is there.

 

I have been on the waiting list for months to see an ME Doctor. I wanted to get a few blood tests done so it's not a wasted appt. I will see what he says. My husband with LC has been left on the scrap heap and was also diagosed with satisfactory iron studies (SE) but mild anaemia, I think because his Haemoglobin estimation was 138 (140-180). He was told to take very strong iron supps without a cut off date. What he wasn't told is to retest every month. He came off the tablets and I think that might have been lucky because I've read it can be fatal. I can't get him in to see a Dr or get advice from his surgery and his Dr has now left as the surgery is overwhelmed. When I rang on Friday for another 'push' he actually hasn't yet even been put on the LC waiting list which I thought was automatic after his ECG test weeks ago. I said we would use econsult but they told me they have had to turn it off for now.

ETA Yes it says on his NHS blood test Serum ferritin (SE) - NEW IRON 29 ug/L (30-400) NEW IRON DEFICIENCY ANAEMIA urgent follow-up. Last year in June 2021. I think they thought it could be cancer which was kind of ruled out. Such a mess.

 

I start feeling out of breath and dizzy when my ferritin dips below 20. Our ferritin should be at 60 (minimum).

 

My understanding of iron/ferritin is simplistic. Ferritin is a measure of your iron stores. When iron in the blood is too low a healthy body should take what it needs from ferritin. When the blood has too much iron it should transfer it to ferritin.

But it isn't quite as simple as that once someone becomes infected with something. When someone is infected with a virus, bacteria, fungus, mould or whatever, that infection will probably need iron to reproduce - most things of that kind do, as far as I'm aware. If the immune system (?or something else?) detects a pathological invader it will reduce the level of iron in the blood and shovel it into ferritin. (Most? All?) pathological invaders cannot get iron from ferritin to help them reproduce. So, in a diseased state ferritin gets higher, serum iron gets lower, and haemoglobin reduces to a lower level.

If you google "iron withholding defense system" you'll find loads of links on it.

There are other reasons for ferritin being high or low besides having pathological invaders. But it needs to be seen in conjunction with serum iron levels, transferrin saturation, total iron binding capacity, haemoglobin to get an accurate understanding of what is going on with iron in the body.

I don't know if my experience is common, but my doctors do a Full Blood Count and make all their decisions based on that. Ferritin is rarely done. And I don't think my NHS GPs have ever done an iron panel, although a hospital did it once and reported below range iron to my GP. My GP never mentioned it to me, obviously didn't think it was important, and never repeated the test. I only found out this had happened when I bought as complete a copy of my GP records as I was allowed.