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MD Consult: Books: Goldman: Cecil Medicine: MORBIDITY AND MORTALITY IN WOMEN

Goldman: Cecil Medicine, 23rd ed.

Copyright © 2007 Saunders, An Imprint of Elsevier

MORBIDITY AND MORTALITY IN WOMEN

Mortality

At the turn of the 20th century, the average lifespan of women in the United States was 48 years, compared with 46 years in men. Since then, the life expectancy in women has increased more than 30 years and is now close to 80 years, compared with 74 years in men. The reasons for the dramatic increase in overall life expectancy are thought to be related to the control of infectious diseases and progress in the treatment of chronic diseases such as diabetes and cardiovascular disease.

Table 254-1 shows the leading causes of death in U.S. women of all ages and races.


TABLE 254-1   — 
LEADING CAUSES OF DEATH AND NUMBER OF DEATHS IN U.S. WOMEN: UNITED STATES, 2002

Cause of Death Deaths Percentage of Total Deaths
All causes 1,244,123 100.0
Cardiovascular diseases 356,014 28.6
Malignant neoplasms 268,503 21.6
Cerebrovascular diseases 100,050 8.0
Chronic lung diseases 64,103 5.2
Alzheimer’s disease 41,877 3.4
Diabetes mellitus 38,948 3.1
Accidents (unintentional injuries) 37,485 3.0
Pneumonia, influenza 36,763 3.0
Nephritis, nephrotic syndrome, nephrosis 21,279 1.7

From National Center for Health Statistics: Health, United States, 2004, with Chartbook on Trends in the Health of Americans. Hyattsville, MD, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2004.

Heart Disease

Despite a dramatic decline in mortality rates for heart disease that has occurred in both sexes during the past two decades, heart disease remains the leading cause of death for women and accounts for 30% of all deaths in women. Heart disease occurs 10 to 15 years later in women than in men. This delayed onset is thought to be due primarily to the protective effect of estrogens in premenopausal women and accounts for the fact that 90% of heart disease mortality in women occurs after the menopause. There are significant racial and ethnic differences in mortality among women. Black women are more likely than white women to die of heart disease up to the age of 85 years; thereafter, death rates are higher in white women. In contrast, Hispanic, Native American, and Asian–Pacific Islander women have significantly lower rates of death from heart disease. Evidence suggests that heart disease, once it develops, is more serious in women than in men, resulting in higher mortality rates. In addition to biologic factors, the poorer survival of women may be due to the older age of women at the time of diagnosis and increased prevalence of comorbid conditions as well as less well defined social factors that influence the diagnosis and treatment of heart disease in women.

Cancer

Cancer is the second leading cause of death in women and is the most common cause of premature death. The mortality rate for all cancers combined in women changed little during the last half of the 20th century. Major advances in the diagnosis and treatment of cervical and uterine cancers in women were offset by an increase in mortality rates for lung and breast cancer. Although breast cancer is the most common cancer diagnosed in women, lung cancer is the overall leading cause of cancer deaths. It is estimated that 90% of lung cancer deaths can be attributed to cigarette smoking and are therefore potentially preventable. Whereas deaths from lung cancer in men have begun to decline as the result of a decrease in male cigarette use, death rates for women continue to rise.

Breast Cancer

Breast cancer is the second overall leading cause of cancer deaths in women and the most common cause in women younger than 55 years. Although the incidence of breast cancer continues to rise, mortality rates have begun to decline for the first time since cancer registries began tracking this disease in the 1940s. This disparity is thought to be related partly to the widespread use of screening mammography and the detection of cancers in earlier stages that have a more favorable prognosis. There are significant racial differences in breast cancer incidence. White women continue to have the highest rates of breast cancer, followed closely by black women. Hispanic and Asian–Pacific Islander women are at intermediate risk, and Native American women are at lowest risk. There are also significant racial differences in breast cancer mortality. Although breast cancer incidence rates are 22% higher in white women than in black women, mortality rates are 36% higher in black women. Reasons for racial differences in breast cancer incidence and mortality are unclear but may be related to socioeconomic and biologic factors as well as certain health behaviors, such as participation in screening mammography. Although it has been shown that breast cancer screening with mammography and clinical breast examination decreases mortality from breast cancer and that 70% of American women 40 years and older report having had a recent mammogram, screening rates are lower in women who are poor or less well educated.

Stroke

Although stroke-related deaths have declined by more than 60% in the United States during the past 25 years, deaths from stroke still account for 8% of all deaths in women and rank third as a cause of mortality. Striking racial differences exist in stroke mortality; death rates in black women are almost twice those for white women up to the age of 75 years. Most of the stroke deaths in women result from thromboembolic disease and occur in older women. However, aneurysmal subarachnoid hemorrhage, a less frequent form of stroke that is more common in women than in men, contributes to stroke mortality, particularly in younger or pregnant women.

Respiratory Disease

Death rates from chronic lower respiratory diseases have increased steadily for both women and men during the past 25 years; however, the increase has been greater in women. Because this increase has been linked to patterns in cigarette smoking, death rates in women for pulmonary disease as well as for lung cancer are expected to continue to rise. Death rates from pneumonia and influenza closely parallel pulmonary-related deaths and vary over time on the basis of the epidemiology of these acute illnesses.

Diabetes

Diabetes has consistently ranked as a leading cause of death in women. Moreover, the reported death rate from diabetes most likely underestimates the impact of this disease on mortality because of its strong association with other life-threatening medical conditions, such as cardiovascular disease, stroke, and kidney failure. Close to 9% of all women 20 years or older have diabetes; however, prevalence rates are higher in black, Hispanic, and Native American women. Separate from disease-related death rates, diabetes is a significant cause of morbidity and, in women of childbearing age, has important adverse effects on pregnancy and pregnancy outcome, resulting in an increased risk of toxemia, macrosomia, hydramnios, congenital malformations, cesarean section, and fetal and perinatal mortality.

Human Immunodeficiency Virus Infection

Although mortality rates from HIV infection and acquired immunodeficiency syndrome (AIDS) began to decline in the mid-1990s as a result of highly effective combination treatment of HIV infection and better prevention of opportunistic infections, HIV infection remains a leading cause of death in younger women. Women overall account for an increasing proportion of AIDS cases, and ethnic minority women are disproportionately affected. As the features of this epidemic change, with heterosexual transmission accounting for the majority of new cases of HIV infection in women, these rates are expected to continue to rise.

Morbidity

Mortality rates alone do not provide a complete picture of women’s health status. Although women live longer than men do, overall measures of health status are worse in women. On the basis of estimates from the 2002 National Health Interview Survey, more women than men report symptoms or seek care for acute medical conditions and are more disabled by these self-limited illnesses as measured by number of bed days or days lost from work. In addition, several chronic conditions occur more frequently in women and cause significant disability, such as arthritis, pain syndromes (including migraine and neck, back, and face pain), and chronic respiratory disorders (including chronic bronchitis, sinusitis, and asthma). Women are also more likely than men to experience severe psychological stress. Data from the National Institute of Mental Health show that affective disorders, especially major depressive episodes, and the anxiety disorders are significantly more prevalent in women. Most important, women’s perception of their health status is lower than men’s. According to estimates from the National Health Interview Survey, women are less likely than men to rate their health excellent and more likely to rate it poor to good.

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