Turning It All Around: Women and Health

Two thuds in the snow. That’s what a stroke sounded like to Heather Nutt-Christensen, a working mother, at the time only 33. When her right arm went numb, causing her to drop her purse and shopping bag in the driveway of her Ballantrae, Ontario, home, she didn’t understand what was happening. Neither did her 12-year-old son, whom she had just picked up from hockey practice. He chuckled at his mother’s clumsiness and picked up her belongings. It was then Nutt-Christensen realized she couldn’t speak. “I could see the words in my head: ‘Andrew, please help me!’” she says now, eight years later. “But everything that came out was gibberish.” Luckily, her son quickly noticed something was wrong and alerted his father, who rushed her to the nearest hospital.

Nutt-Christensen, it turned out, had unknowingly been living with a patent “foramen ovale”—a small hole between the upper chambers of her heart that didn’t close the way it should have after birth. Although not an uncommon condition, it is usually only discovered when an person suffers a heart attack, stroke or some other trauma. Nutt-Christensen’s doctors hypothesized that a blood clot passed through the chasm and into her brain, causing the stroke that left her paralysed on her right side and unable to speak.

Nutt-Christensen spent the next eight weeks at York Central Hospital, and many months following at home, learning to walk and talk again. “It was like going back to kindergarten,” she says, describing the simple worksheets that helped her rebuild her vocabulary. Eight years later, she has made great strides in both her physical and mental fitness, but still the lingering effects of her stroke have prevented her from returning to her career as an executive assistant and account manager for a food and pharmacy broker, a job that often required her to work late and on weekends in order to juggle her roster of clients. “If I exhaust myself, I experience these gap-outs,” she says, a symptom her doctors explained as extreme mental fatigue. “It’s hard to find employment at a company that would be sensitive to my needs—I can only work a few hours a day.”

Unfavourable odds

Few of us consider the possibility of sudden brain damage ending our careers. But nine in 10 Canadians have at least one risk factor for stroke, and women may face graver outcomes. Although both sexes experience stroke at similar rates, according to a 2005 study of the registry of the Canadian Stroke Network, women experience more severe post-stroke disability than men. Data from the Alzheimer’s Society of Canada paints an equally grim picture: women make up almost three-quarters of Canadians living with the incurable dementia.

It would be easy to dismiss this as symptomatic of women’s longer lifespan—the older we get the greater our chances of developing brain diseases. But while life expectancy certainly is a factor, it’s not only in age-related diseases that the disparity exists, and it’s not only stroke and Alzheimer’s where we’re at a disadvantage. Mental illness is most prevalent among women between puberty and menopause (during this period we are twice as likely as men to experience depression). Clearly, something else is going on.

We know that estrogen plays a role, but to what extent is still uncertain. According to Dr. Kathleen Hegadoren, a professor at the University of Alberta studying stress-related disorders, estrogen increases the concentration of certain neurotransmitters, such as serotonin, believed to contribute to feelings of well-being. Sounds like we’re at an advantage, until you remember our hormones are never stable. Indeed, women tend to be at higher risk for mood disorders during periods of significant fluctuation in estrogen levels: pregnancy, postpartum and perimenopause. But, Dr. Hegadoren points out, women are also more often the victims of poverty and abuse, and typically bear the burden of child and elder care while also working outside of the home—do these societal stressors more accurately explain the higher reports of mental illness among women?

In her book The Memory Clinic, behavioural neurologist Dr. Tiffany Chow explores to what extent estrogen is responsible for our brain health, particularly when it comes to memory loss. She references a phenomenon many mothers will remember, colloquially referred to as “pregnancy brain”—the sudden word-finding difficulties and trouble concentrating that some women experience during and immediately after pregnancy. Later, when women hit menopause, those bouts of confusion crop up again. We often laugh and tease each other about these symptoms, but the science behind them raises important concerns.

Dr. Chow explains that estrogen is known to bolster the function of the hippocampus, the area of the brain responsible for laying down new memories, and where Alzheimer’s disease strikes first. Knowing this, logic would follow that treating postmenopausal women with hormone replacement therapy could reduce their chances of developing Alzheimer’s—but curiously, this isn’t the case. In one study, women in their seventies taking hormone replacement therapy drugs actually experienced brain volume loss, especially to the hippocampus. So, while estrogen protects the brain in younger women, it may actually be toxic to older women. Whether this is true for all of us, and to what degree, is still a mystery. We know that about a third of women are less estrogen-dependent in general—they are the lucky ones who don’t experience hot flashes during menopause. But are their hippocampi less sensitive to estrogen too? This, Dr. Chow says, is an important question, one that has not yet been explored in any rigorous way.

Deemed irrelevant

Part of the reason we are only just investigating these questions now is that it wasn’t until the 1990s that the Canadian government mandated gender-based analysis be included in federally funded studies, and not until 2000 that the Institute of Gender and Health was created along with thirteen other organizations which foster studies that explore how sex and gender influence health.

Although women are now represented in greater numbers in clinical trials, that may not be enough. Dr. Hegadoren explains, “In studying a mixed population, all of the biological and societal differences are hidden when you collapse everything to mean values.” Translation:  unless women and men are studied separately, taking into account both sex and gender differences, we may never fully understand the unique issues encountered by either sex.

Enter Lynn Posluns, Canadian businesswoman and founder of the Women’s Brain Health Initiative (WBHI). “I’m at that stage where I sometimes can’t find my car in the parking lot,” she admits with a laugh. “And when I read some of the statistics about Alzheimer’s, and that very little research is focused on women in this area, I thought ‘Well, I can do something about this.’ ”

In the spring of 2012 Posluns began to raise money for the Baycrest Health Sciences Centre in Toronto, where Dr. Chow conducts her work. Quickly Posluns realized that this issue is bigger than merely one institution—it’s a global concern. So she set out to create a global initiative, with the goal of sponsoring 10 research chairs at institutions around the world.

Perhaps the WBHI’s greatest accomplishment to date was becoming a funding partner, along with the Institute of Gender and Health, of an important new research enterprise, the Canadian Consortium on Neurodegeneration in Aging. By contributing to this multimillion-dollar initiative, the institute is ensuring that sex and gender are featured prominently on the agenda of this important endeavour, which brings together the nation’s top researchers in the field of neurodegenerative diseases.

Doing it for ourselves

But research doesn’t happen over night, and it may be many years before we have clear insights into our unique biological risks. We do, fortunately, already know of many lifestyle factors that are proven to have a positive effect on the brains of both women and men. “Part of our mandate now is not only funding research, but also educating people about what they can do to stay brain healthful,” says Posluns.

Proper nutrition, as well as exercise, both mental and physical, are proven to aid in brain function and reduce the risks of pretty much every affliction out there, including stroke, Alzheimer’s and even depression. Another major influencer—one that many of us find more difficult to control than our craving for trans-fatty snacks—is stress.

“I was working in an extremely high-stress job,” recalls Heather Nutt-Christensen. “And I basically spent all of my time taking care of everyone else [at home and at work]. That’s what we do as women—we put ourselves on a backburner. I see the stroke now as a warning sign.”

The science behind Nutt-Christensen’s revelation is clear: when we’re really stressed out, our body releases more cortisol, the hormone responsible for activating our “fight or flight” response. That increases glucose levels in the bloodstream, giving us fuel, but also takes a toll on our hearts and brains by raising our blood pressure and causing the hippocampus to shrink. Learning to manage stress, then, is critical to maintaining good mental health. But it may not be as simple as the typically lauded lore that tells us to find time to meditate, says Dr. Chow.

“Yoga is not for everyone. For a high-strung person, trying and failing at meditation may actually cause more stress.” She instead advocates for a personalized approach to stress management, which could include activities such as going to a movie to distract yourself from trying times, or meeting a friend for coffee so you don’t feel alone with your problems.

Dr. Simone Vigod, a Scientist and Assistant Professor in the department of psychiatry at Toronto Women’s College Research Institute, advocates for the importance of seeking help when stressful situations become too much to handle. “I still see many people in my office who feel ashamed to talk about [their mental health issues]—and this is a real barrier to accessing the support that could help them.”

Society’s prevailing stigma around mental illness may also be a big part of why so many people face unemployment. According to the Mood Disorders Society of Canada, of those individuals suffering from serious mental illness, 70 to 90 percent are out of work. “It’s easier to disclose to an employer that you need time off because you have breast cancer,” says Dr. Vigod. And while she explains that for some people it may actually be detrimental to continue working while battling serious depression, for many a reduced workload or modified hours could present a balance that preserves their confidence while allowing them time to heal. “If I had a wish list,” she says, “it would include more willingness from workplaces to accommodate people struggling with depression.”

For Nutt-Christensen our perspective, both as a society and on an individual level, is critical. “Recovery is 50 percent physical, 50 percent attitude,” she says, crediting her determination and strong network of support as key to her success. After reading extensively about brain plasticity (read more for yourself on page 25), she resolved to take every measure to ensure her future is a healthy one. “I was never much of an athlete, but two years ago I did the 25-km Ride for Heart bike race.” For anyone this would be a feat, but considering the uphill battle Nutt-Christensen had already won simply regaining her basic mobility, it is especially impressive. “It was one of my greatest achievements,” she says. “This year I’m going for 50 km.”