In the late 19th century, while delivering a prominent lecture, Sir William Osler, regarded by many as the father of modern medicine, made a huge mistake.
Speaking in front of a class of aspiring doctors, Osler described patients with “recurring paroxysms of severe, even agonising cardiac pain.” In men, these symptoms were typical of angina, he explained.
However, these same symptoms in women usually prompted a diagnosis of ‘pseudo-angina’. Anxiety was a hallmark of this condition, according to the case reports he cited:
“Miss C, aged twenty-two years… is evidently a high-strung, nervous girl.”
“Miss A, aged twenty-two years, belongs to a nervous family, and she has never been very strong.”
“These patients do not die,” he reassured the audience.
Even today in 2025, over 120 years later, women presenting with chest pain are still frequently misdiagnosed with anxiety and are denied life-saving treatment – as reported by an international collaboration of medical experts. Meanwhile, cardiovascular disease is the leading cause of death in women.
It seems the myth of ‘pseudo-angina’ endures.
Women’s symptoms have long been underestimated, even belittled. The male body was typically considered the default – and therefore men’s symptoms worthier of careful diagnosis rather than casual dismissal.
This short-sightedness has led to a failure to recognise that women’s bodies differ in biology and, therefore, so too do their symptoms and types of illness.
In fact, women process pain differently from men and have distinct immune responses. They clear pathogens more quickly and see more effective vaccine responses than in men, but they have increased susceptibility to autoimmune diseases, such as lupus. Women account for 80 per cent of these conditions.
These examples only scratch the surface. But where does the gender health gap stem from? Here are the top five things we’re getting wrong in women’s healthcare – and what we can do about it.
1. The research blind spot
Our knowledge of the human body has its roots, primarily, in research on men – women have long been underrecruited in trials or excluded to protect their so-called ‘childbearing potential’ (as detailed in a 1977 report by the US Food and Drug Administration, or FDA).
Today, research funding still goes disproportionately to diseases that are significantly more common in men, such as hepatitis or AIDS, at the expense of those that affect primarily women, such as endometriosis (a condition where cells similar to the ones in the lining of the womb are found elsewhere in the body) or anorexia.
A 2021 study found that in 75 per cent of cases where a disease affects predominantly men or women, US funding was skewed towards conditions that impact men.
Despite increasing recruitment, women are usually outnumbered by men in trials, and conclusions fail to distinguish outcomes between sexes. This underrepresentation is particularly marked in stroke and cardiac disease trials, and even more so in minority groups.
So foundational is the problem that – astonishingly – even the test mice are male. Why? Researchers are less likely to use female mice in studies on neurological diseases, pain and heart disease because their reproductive cycles are (incorrectly) assumed to make them ‘more variable’ participants.
Then there’s the long-held assumption that including mice of both sexes requires twice the number of mice – adding to the expense of a trial – because it was thought that smaller subsamples of each sex would compromise the experiment’s statistical power. That idea has now been refuted.
Nevertheless, the result of these myths is that a lot of the knowledge gleaned from mouse studies – impacting doses, diagnoses and care – may produce different results in women.
2. One dose does not fit all
Surely, you might argue, women’s bodies are not so different from men’s. What’s the worst that could happen if you treat women with medicines designed for male bodies? For starters, a ‘one-size-fits-all' approach does not work with drug types and doses.
Women have slower gastric transit times, which decreases the absorption of some drugs, and drug processing is also likely altered because women have higher body fat, lower plasma volume, smaller organ sizes and reduced organ blood flow.
Both pharmacodynamics (what a drug does to the body) and pharmacokinetics (how your body uses a drug) are different in men and women – yet the lack of trial data means we still don’t know how big a problem this is in clinical care.
But here’s a clue. If a woman receives the same drug dose as a man, even if their body weights are equal, the results may dramatically diverge.
One study analysing reactions to dozens of medications (including cardiovascular drugs, antidepressants, and anti-seizure drugs) found giving women ‘standard’ doses led to higher blood concentrations and longer drug elimination times than men – an outcome tightly linked to a near doubling of negative drug reactions.
What essentially becomes ‘overdosing’ in women does not improve prognosis either. In a study in medical journal The Lancet, women receiving just half the internationally recommended doses of drugs for heart failure had better survival rates and fewer hospitalisations than women on higher doses.
Meanwhile, the lowest number of deaths or hospitalisations in men happened when patients were given 100 per cent of the target dose. What’s right for men is not necessarily what’s right for women.
3. The diagnosis dilemma
Forget the right dosage if you don’t even have the right diagnosis. When women are the recipients, diagnostic tests are often looking for the wrong thing.
For example: doctors will investigate potential heart attacks using a test called a coronary angiogram, which often finds a blockage of blood vessels (known as obstructive coronary artery disease). Such a discovery would generally lead to definitive treatment like the insertion of a tube, known as a stent, that keeps the vessel open.
Yet women are more likely to have normal angiograms (10.5 per cent of women compared to 3.4 per cent of men) – even when other tests confirm that blood flow has been reduced to their heart.
Why? Women are more likely than men to experience non-obstructive causes, like an artery tear (known as a ‘dissection’) or a coronary artery spasm, instead of blocked vessels. Angiograms often don’t pick these up – and so many women are mistakenly sent away with a clean bill of health.
Modelling, such as risk prediction models for cardiovascular disease, often omits female risk factors like polycystic ovary syndrome, premature menopause, pre-eclampsia, and preterm birth. If we can’t predict, we can’t prevent.
And it’s not just heart health we’re talking about here. Women with renal cancer are almost twice as likely than men to visit their family doctor at least three times with blood in their urine before being referred to a specialist.
Women with stroke and multiple sclerosis are more likely to experience misdiagnosis and delayed diagnosis. Almost one in three patients visit a doctor more than five times before receiving their diagnosis of a brain tumour, with women experiencing longer delays. The list goes on.
There are a number of reasons this may be happening, but a key one is medical bias.
Osler’s lecture may seem old fashioned in connecting women’s cardiac pain with a ‘nervous’ disposition – but even today, numerous studies show that when women report pain, they are consistently more likely than men to be seen as exaggerating, dramatising or fabricating their symptoms.
A 2024 study analysing 22,000 discharge notes (documents that summarise a patient’s treatment during their time in hospital) found that women were less likely than men to receive painkillers even with equivalent pain scores. This is irrespective of whether their doctor was male or female.
What starts as misunderstanding can lead to misdiagnosis.
Signs of a heart attack
Recent research shows that women, contrary to myth, do not inevitably develop ‘atypical’ heart attack symptoms.
Instead, men and women should watch out for the most common symptoms in both sexes (chest pain or pressure, and pain radiating to both arms, particularly the left) alongside other symptoms, as described by the National Health Service: anxiety, coughing, shortness of breath, unusual fatigue, dizziness or feeling faint, sweating, nausea and pain in the shoulder, neck, back, tummy or jaw.
Women are more likely to delay seeking care, possibly due to historically embedded low estimations of personal risk.
If you experience any of the symptoms listed above, regardless of your sex, seek medical assistance immediately.
Read more:
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- Women might not remember pain as much as men
- The real reasons women are losing more sleep than men
4. Invisible patients
At the heart of this, women are going unheard. According to a UK Government survey in 2022, 84 per cent (that’s more than four in five) of women said there were times when they had not been listened to by healthcare professionals.
A House of Commons committee report, published at the end of 2024, found that women with debilitating pain and bleeding from endometriosis and adenomyosis are told their symptoms are “normal”.
One woman with ovarian cysts and endometriosis told the committee she had been dismissed by two gynaecologists, and her symptoms were ignored: “It was hell. The third gynaecologist changed my life but I’ll never get my fertility back or those 11 years of pain, fatigue and misery.”
On average, it takes 8–10 years for a woman to be diagnosed correctly with endometriosis. In the meantime, relationships, careers and physical and mental health suffer.
Stigma around menstruation and sex compounds this. In a recent survey, over half of women with symptoms of pelvic floor dysfunction – such as incontinence – did not seek help from a healthcare professional. Of these, 39 per cent thought their symptoms were normal, and 21 per cent felt too embarrassed to go to a doctor.
So could sharing personal experiences help to bring more focus to women’s symptoms and conditions? Sadly not, it would seem. In many cases, the more women speak up, the less chance they have of being believed.
The podcast series ‘The Retrievals’, from Serial and The New York Times, documents the story of a dozen women who underwent fertility procedures at the Yale Fertility Center in 2020. For months, they endured excruciating pain during and after egg retrieval, despite being prescribed fentanyl.
They were dismissed and disbelieved. That is, until the truth came out – a nurse had been stealing the fentanyl and replacing it with saline (salty water).
As the podcast’s host Susan Burton said: “There’s a balance you have to strike as a woman patient. You have to complain just the right amount to be taken seriously, but not so much that you seem shrill.”
5. Unequal ground
But let’s take a moment to challenge the idea that the culprit here is medical misogyny. Here’s one example: you may shout ‘discrimination’ in the face of the fact women are less likely to receive clot-busting treatments (called thrombolysis) for stroke.
Digging a little deeper, though, you discover thrombolysis must be given quickly – typically within a ‘window’ of four and a half hours– for the potential benefits to outweigh the risks (including catastrophic brain haemorrhage).
The catch is: there’s a higher prevalence of stroke in women living alone, and living alone delays their arrival to hospital. If the window is missed, administering thrombolysis could be very dangerous.
What’s more, women with stroke may have worse outcomes because they tend to be older and have more severe strokes. Clearly, there are other factors at play here, before a patient even comes in for care.
The truth is, it’s complicated. Until trials are specifically designed to analyse sex differences and account for confounding factors like age and social support, we’ll be none the wiser – and women will pay the price.
There are also wider systemic issues at play. Funding for medical training is often diverted to long-term conditions, for example, meaning there are shortfalls in key issues for women.
The impacts of this were revealed in a 2020 survey of 518 US paediatricians, which found just under a third knew about national guidance suggesting that a medical evaluation may be merited if periods have not started by the age of 15.
It’s long been known that, globally, women have fewer employment rights and educational opportunities, less financial independence and greater caring responsibilities – all of which affect availability or willingness to access medical care. These factors intersect with variables like race, ethnicity, and income.
For instance, a report by the UK’s National Health Service (NHS) – published at the end of 2024 – found that areas with higher levels of deprivation report worse health outcomes for women.
Back to bias. If this really is the culprit – then, well, bias extends beyond sex.
A study in journal Science revealed that the US healthcare system was using an algorithm to guide health decisions that assigned the same level of risk to both black patients who were sick and white patients who were healthier.
Both men and women, who were not deemed by the system to be in need of extra care, were denied critical care.
There’s no argument here that men have it better or women have it worse. Worldwide, female mortality is lower than male mortality – and the gap is growing.
War and conflict, homicide, suicide, occupational hazards and susceptibility to behavioural factors (smoking and alcohol misuse, drug use and poor diet) continue to limit the average male lifespan more than that of women’s.
But women frequently miss out on life-changing medical care, and it matters. Although women live an average of four years longer than men, they spend a higher proportion and more years of their lives in poor health.
Your health, your voice
So what can you do? Well, firstly, it’s not up to you to cure someone’s misogyny or single-handedly address systemic bias. Doctors need to listen, too.
In her book Unheard, Dr Rageshri Dhairyawan asks doctors to reflect on their own listening practice: “What are your blind spots and potential biases? Think about how you can be more curious and open when listening. Is it possible that the patient’s point is valid, even if you don’t necessarily agree with it?”
But when it comes to your own health, there are some ways to empower yourself against potential bias. During my years as a doctor, patients have told me what’s helped them at their clinic appointments.
One of the most helpful things you can do is to write your symptoms down beforehand, if you feel well enough. When did they start and what makes them better or worse? You can also consider bringing someone with you – another pair of ears is useful.
The NHS and several healthcare charities (such as the British Heart Foundation and Macmillan Cancer Support) have lists of questions available online you may want to ask during your appointment, generally or about specific conditions.
If you think your doctor should be more concerned about your symptoms than they appear to be, Cancer Research UK suggests bringing along a copy of official symptoms. If you’re able to keep to one, a pain and symptom diary can also help at your appointment.
More than anything, you deserve to be heard. Dismantling myths about women’s health means listening to those who are living through illness. And if we understand those illnesses – and learn to listen – society as a whole will be all the better for it.
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