Hormonal cycles may alter course of asthma for women

Physicians should be attuned to the possibility that women with asthma may experience a worsening or improving of symptoms in response to hormonal changes such as those that are part of the regular monthly cycle, menopause or pregnancy. And this may require changes in medication dosage, according to an expert panel at this month's American College of Allergy, Asthma & Immunology meeting in Anaheim, Calif.

"Twenty percent to 40% of women will have a premenstrual worsening of asthma, and this may require some modification of their therapy around that time. It's not broadly recognized but it's in the literature," said Nancy K. Ostrom, MD, chair of the symposium and co-director of the Allergy & Asthma Medical Group and Research Center in San Diego. "They may not be entirely comfortable bringing it up, but we need to ask about that and listen to them."

The symposium was convened in recognition of the growing amount of data that women are more likely to develop asthma as adults and are more likely to be hospitalized or need to visit the emergency department because of this disease.

"Common wisdom is that asthma presents in childhood, but I see a number of women who first present between 30 and 50 years of age," said Dr. Ostrom.

"We're becoming aware that there are decided differences in presentation, hospitalization and even death rates in women versus men," she said.

Experts are particularly focused on issues regarding asthma care during pregnancy. Specifically, some women may fear congenital anomalies and discontinue therapy without consulting their physicians.

"The patients are very concerned about the use of medications," said Michael Schatz, MD, one of the symposium's speakers and chair of the allergy department at Kaiser-Permanente Medical Center in San Diego. "Sometimes this leads to undertreatment of asthma in pregnancy, but the data suggest that the bigger risk is the asthma rather than the medications, which have a pretty good safety record."

Also, making the situation even more challenging for physicians is that women vary greatly in how their asthma responds to pregnancy. Some get worse. Some get better. Others stay the same. Some are asthma-free until they become pregnant.

"Asthma can begin during pregnancy, but the biggest issue is for women who have had it before they become pregnant," said Dr. Schatz. "Asthma can change course during pregnancy. Therefore, they just need to be followed a little more carefully."

Hormones are not, however, the only factor that can make asthma among women different. Several studies have suggested that obesity and smoking, which are known asthma triggers, may have more of an impact on women than men.

"It's not all specifically hormonal differences," said Dr. Ostrom. "We're not sure what all the factors may be. There's much research left to be done."

Constant reassessment

In other action, the ACAAI, in conjunction with the American Academy of Allergy, Asthma and Immunology, published "Attaining Optimal Asthma Control: A Practice Parameter" in The Journal of Allergy and Clinical Immunology. The paper was posted online last month and printed this month.

The practice parameter calls on physicians to fully assess asthma severity at every visit and advocates the use of objective measures of pulmonary function rather than patient self-reporting of symptoms.

"Asthma ... needs to be continually reassessed," said James T. Li, MD, PhD, lead author and chair of the division of allergic disease at the Mayo Clinic in Rochester, Minn. "It's still important to get that feedback from a patient, but there are really clear studies that indicate that a person's global assessment of their own asthma does not always correlate with the degree of airway obstruction."

Physicians praised the guidelines for clarifying how to respond to changes in the disease over a patient's lifespan and consolidating information on assessment of the disease.

"Asthma waxes and wanes, and we need to be on top of it," said Glenn Flores, MD, a pediatrician and director of the Center for the Advancement of Underserved Children at the Medical College of Wisconsin in Milwaukee, and who researches asthma. "It's a helpful document that stresses some of the key issues that have not gotten enough attention."

But while many physicians are looking for ways to improve overall symptoms in asthmatics, a paper published in the October Pediatrics suggested that better patient-physician communication may be a way to avoid the hospitalization that can happen when the disease gets out of control. A research team led by Dr. Flores found that most preventable hospitalizations related to asthma could be linked to a lack of patient knowledge about the condition, disease triggers and the need for follow-up care.

Problems with adherence to medication and failing to refill prescriptions were also cited as factors in preventable hospitalizations.

"This is a huge issue that results in $835 million in charges a year," said Dr. Flores, lead author. "We need to make sure the family is educated about the disease and the importance of coming back. Follow-up care is so crucial, but we're not getting that across.

"And we need to make sure that medication is available."

The American Medical Association encourages physicians to educate patients on the assessment, reduction of known risk factors, and the principles of self-management for asthma and advocates that, if necessary, patients be referred to comprehensive asthma education programs.