The prevalence of asthma in the U.S. continues to grow, with 18.7 million adults and 6.8 million children affected, according to the Centers for Disease Control and Prevention. Each case of asthma is unique, but women with the disease have some common and particular challenges to contend with.
“Typically, women with poorly controlled asthma report more symptoms and worse overall quality of life, despite having similar or better lung function than men. This suggests that men and women may experience asthma differently,” said Cathy Benninger, MS, CNP, AE-C, an adult nurse practitioner and asthma educator in the Division of Pulmonary, Allergy, Critical Care and Sleep Medicine at Ohio State University Wexner Medical Center in Columbus. “Often they will have more nighttime awakenings and feel more limited in their activities due to shortness in breath.”
A number of theories have been proposed to explain these differences. According to Benninger, research suggests that women have higher obesity rates and more often report comorbidities, such as acid reflux and sinus disease, which could exacerbate asthma symptoms. Additionally, evidence supports a possible link between asthma severity and hormone fluctuations.
Impact of Hormones
During puberty, a gender switch occurs in asthma incidence. From puberty throughout adulthood, asthma occurs more commonly and tends to be more severe in women. The fluctuation of estrogen may cause inflammation in the airways, which can contribute to the exacerbation of asthma symptoms, said Marcy D. Markes, APRN, FNP-BC, AE-C, who practices at Columbia Allergy Asthma Specialists in Columbia, Mo. Common effects of estrogen on asthma are described below.
Menstrual Cycles: A women’s hormone levels change significantly over the course of her menstrual cycle, and women can develop worsening asthma symptoms during menstruation. “Some women may find that their asthma gets worse up to a week before menstruation begins,” Benninger said.
Pregnancy: For women with asthma, pregnancy can have varying effects on their disease. One-third of women experience worsening of asthma symptoms, one-third experience improvement, and one-third experience little to no change in symptoms, according to Benninger.
“It is the group of women who have worsening symptoms we are most concerned about and whom we need to identify as soon as possible,” she said. “It is vital providers monitor this patient population closely and address uncontrolled asthma.”
Menopause: Asthma in perimenopausal and menopausal women can sometimes become more difficult to control. “Women in this stage of life are dealing with peaks and valleys in their estrogen levels,” Markes said. “We have witnessed increased exacerbations in this patient population, which suggests a link between asthma and hormonal fluxes.”
National guidelines provide evidence-based treatment plans for asthma management, but given the potential for additional complications, some women may need a more specialized plan.
“Management, in general, can be similar among men and women,” Markes said. “They should always be on a controller therapy, and the gold standard remains inhaled steroids, even during pregnancy.”
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“Identifying triggers is an important component of asthma care,” Benninger pointed out. “It is vital to help patients determine what makes their asthma worse and then have a plan in place for when exacerbations occur.”
Beyond typical management techniques, women may require additional therapies and support. “Given that women often deal with more severe symptoms, providers must consider nontraditional approaches,” Benninger said. “For instance, women who suffer from pre-menstrual exacerbations may benefit from oral contraception. . Additionally, hormone replacement therapy may help reduce asthma symptoms among women going through menopause.”
However, Benninger cautions providers to first use traditional approaches outlined in asthma guidelines. “Risks and benefits must be assessed before determining the best course of action,” she stressed. “For those not responding to traditional therapy it is best to consult an asthma specialist for input.”
Older women can be particularly difficult to manage due to an abundance of comorbidities. “Women over 65 are four times more likely to die from asthma than any other group, and their mortality rate is 30% higher than asthmatic men of the same age,” Benninger said. “They are extremely high risk and yet their asthma can be a challenge to manage because it can be difficult to differentiate their symptoms from their other conditions.
“To successfully treat this patient group, providers must have a detailed medical history that includes all of their medicines,” she continued. “You must be prepared to provide education to this group, problem solve barriers, as well as collaborate with their other providers.”
Another patient population that warrants caution is pregnant women. “It can be a challenge to balance care of the disease with potential risks to the fetus,” Benninger said. “However, we promote treating exacerbations aggressively, just as you would with a nonpregnant person.
“Stay true to the guidelines; inadequate control is a greater risk to the fetus than having them controlled on multiple medications,” she added. “Our philosophy is not to attempt reductions in medication during pregnancy because that increases risk of an exacerbation or worsening of asthma.”
Maintaining control of asthma symptoms and monitoring any changes is essential. “Due to the potential for increased exacerbations during pregnancy, controller medicines are vital,” Markes said. “My motto is always, ‘If mom’s not breathing, baby’s not breathing,’ so we have to make sure mom is breathing the best she possibly can.”
Markes and Benninger suggest continued spirometry for pregnant women, as well as a clear symptom management plan. “It is crucial to the health of both mom and baby to ensure that we provide support and education,” Benninger said. “We educate pregnant women on the importance of staying on their medicines.
“This group tends to stop medicines own their own because they get scared and don’t want to expose the fetus,” she continued. “It is imperative to stress to women that the greatest risk to their child is uncontrolled asthma.”
Given the increasing incidence of asthma and the additional challenges women with this disease face, it is important that providers continue to cultivate their knowledge.
“Asthma is on the rise and its impact will only continue to grow,” Markes said. “Which is why, as providers, we must be prepared to provide the necessary care and support to these patients.”
Trends support a correlation between hormones and asthma symptoms among women. However, Benninger believes more research is needed to completely understand why this disease affects women differently.
“Hormones play a part in asthma exacerbations among women, but we still must pinpoint the underlying cause, because not all women with asthma are symptomatic during hormonal fluctuations,” she said. “Additional research will give us the tools we need to find the right medicines to provide targeted care to this patient group.”
“Our patients look to us for answers,” Markes concluded. “We must do everything in our power to provide the medicine and knowledge they need to successfully manage their disease and live healthy, happy lives.”
Catlin Nalley is the associate editor. Contact: firstname.lastname@example.org.