Lung Disease Isn’t a Male Problem—So Why Is It Often Overlooked in Women?
Take a deep breath and consider these facts: Lung cancer is more common in women under 55 than in men the same age. Nonsmoking females are more likely to be diagnosed with chronic obstructive pulmonary disease (COPD) than nonsmoking males. And among adults, asthma is largely a woman’s disease.
There’s a pronounced sex difference in lung diseases, and most often that’s not in women’s favor. And it’s a rare thing for lung disease treatment to recognize these variabilities. While there are at least 40 dedicated women’s heart centers at American universities, you could easily count the number of women’s lung disease institutes on one hand. This matters: As with heart disease, it appears that doctors underdiagnose women with lung issues, and a major reason is that they tend to think of some serious lung conditions as male problems. “Women may present with the exact same symptoms as men, and providers fail to recognize that their condition is related to lung disease,” says Jamie Garfield, M.D., an interventional pulmonologist at the Temple Lung Center at Temple University Hospital in Philadelphia. One result is that women are often diagnosed at a more advanced stage of lung disease than are men, Dr. Garfield says. Generally, the earlier a condition is diagnosed, the more successful its treatment. To protect the health of your lungs, you need to arm yourself with information your physicians might not possess.
Girls have a head start with lung health—but it doesn’t last
Sex differences in our bodies begin early. “Girls walk sooner than boys. They talk sooner. They develop more quickly—which is also true in utero,” says Joy Lawn, M.D., Ph.D., director of the Centre for Maternal, Adolescent, Reproductive & Child Health at the London School of Hygiene & Tropical Medicine. During the last two months of women’s pregnancies, girls are about one week ahead of boys in lung development, according to a report in Nature: Pediatric Research. For a preterm baby, “the difference of a few days’ maturity can mean the difference between having and not having major lung complications,” Dr. Lawn says.
This head start newborn girls get is a major reason they have an early edge over newborn boys. “Baby boys are more likely to be born preterm, and even at the same gestational age, boys are more likely to die from preterm birth, especially from more severe lung complications. Preterm baby boys who survive are more likely to have long-term disability, including chronic lung disease,” says Dr. Lawn. The lungs of both genders contain receptors for sex hormones, and these play a role in the risk of death and lung disease. Male hormones like testosterone can hinder the production of surfactant, a mix of fat, protein, and carbs that keeps small airways from sticking together, and female hormones like estrogen promote surfactant production. In babies, a shortfall of surfactant causes serious lung problems, contributing to boys’ disadvantage at birth. (However, babies’ early lung complications are mainly driven by lack of maturity, says Dr. Lawn.)
At birth, boys do have one lung advantage over girls, and it lasts throughout their lives: Their lungs and airways (the paths that let air in and out of the lungs) are larger, says Manuela Cernadas, M.D., codirector of the Women’s Lung Health Program at Brigham and Women’s Hospital in Boston. Adult women’s lung volume is about 10% to 12% smaller than that of men of equal height and age. And even when lung sizes are the same, women have narrower airways than men do. This means women have less spare tissue that can function when parts of the lungs are damaged by asthma, lung cancer, and COPD.
There’s a connection between asthma and hormones
Ten percent of adult American women currently have asthma, “a chronic disease that causes your airways to become inflamed, leading to shortness of breath, wheezing, chest tightening, and coughing,” says Melanie Carver, chief mission officer at the Asthma and Allergy Foundation of America. If you’re one of them, your day-to-day life has been affected by your sex hormones much more than you probably realize. For instance:
- In childhood, boys are more likely than girls to suffer from asthma, but after puberty, girls outpace boys.
- Girls who get their periods at a young age are at twice the risk of others of having asthma during young adulthood.
- Adult women have twice the risk of severe asthma, more ER admissions, and twice the risk of hospitalization and death compared with men.
- Of asthmatic women, 30% to 40% show an increase in symptoms either before or during menstruation.
- Mothers who’ve had a large number of children have higher odds of becoming asthmatic.
- After menopause, asthma rates plateau in women, though they continue to increase in men as they get older.
Here’s why sex hormones affect these life-cycle changes: “Androgens like testosterone are thought to have anti-inflammatory properties, and female sex hormones, especially estrogen, are thought to be pro- inflammatory,” says Joe Zein, M.D., Ph.D., a pulmonologist at the Cleveland Clinic. Translation: In boys, asthma frequency and severity declines as they’re flooded with male hormones that may reduce lung inflammation during puberty, but exposure to female hormones in girls at the same time has the opposite effect. Girls and women who are exposed to female hormones for a long time, such as girls who get their periods early and women who have had several babies, are prone to having asthma attacks. One of many factors explaining why asthma attacks get worse for some women around their periods is the effect of the female hormone progesterone on the hairs (cilia) that move mucus out of the lungs, says Dr. Zein. High amounts of progesterone during menstruation reduce the rate at which the cilia beat, leading airways to clog with mucus, making breathing difficult.
Where smoking fits in
If women smoke now or did in the past, they’re more likely to have asthma than comparable men. Similarly, “Women develop lung cancer after less tobacco exposure and at an earlier age than their male counter parts,” notes Mara Antonoff, M.D., an associate professor in the department of thoracic and cardiovascular surgery at the University of Texas MD Anderson Cancer Center in Houston.
Cigarettes hit women harder “possibly because they have smaller airways than men, or they metabolize smoke differently because of their hormones, or they may have different inflammatory responses,” speculates Dr. Cernadas. Lung cancer among those who have never smoked is less common, but still, 30% of lung cancer deaths among women happen in lifetime nonsmokers, says Dr. Antonoff.
Why do nonsmokers get lung cancer? People can be exposed to hundreds of potentially carcinogenic substances, including secondhand smoke, air pollution, radon (a soil-borne radioactive gas), and other chemicals. And nonsmokers may have some genetic vulnerability. But experts don’t know exactly why nonsmoking women are more at risk than nonsmoking men. “Radon, household pollution, wildfires—there’s no reason to assume women are exposed to these more,” Dr. Garfield says. The mystery remains unsolved.
How to avoid being misdiagnosed
Lung cancer and COPD have long been thought of as diseases of old men, and that’s one of the reasons doctors may neglect to thoroughly check out women who show up in their offices with coughing, difficulty breathing, and similar symptoms. COPD is an umbrella term for lung diseases (including emphysema and chronic bronchitis) that obstruct airflow and interfere with breathing. “Women are screened less often for lung cancer and COPD,” Dr. Garfield notes. What’s more, says Dr. Cernadas, “providers may not recognize that women who smoke are at higher risk.”
“Research has shown that medical providers do have a bias toward diagnosing men with COPD and women with asthma, and not using spirometry for women,” says May-Lin Wilgus, M.D., a pulmonologist at UCLA. A spirometry test measures how much air you can breathe in and out as well as how fast you can blow air out. And emphysema is diagnosed less often in women than in men with the same lung dysfunction, says Dr. Cernadas. One encouraging sign: The U.S. Preventive Services Task Force, which issues screening guidelines, recently broadened the pool of people eligible for lung cancer testing by lowering the minimum age from 55 to 50 and reduced the pack years from 30 to 20. (Pack years is a calculation based on the number of packs of cigarettes smoked per day times the number of years smoked.) “The expanded criteria are incredibly important for women and Black patients, as these groups tend to develop lung cancer after less tobacco exposure than white men and at an earlier age than them,” explains Dr. Antonoff. When lung cancer is diagnosed at early stages, the chance of cure is greater and less aggressive therapy is required. And, notes Dr. Cernadas, women in particular benefit from annual screening: Among smokers and ex-smokers who get the low-dose CT scan for screening, there’s a 33% drop in mortality for women, versus 24% for men.
Because screening is recommended only for individuals who currently smoke or who quit within the last 15 years (as well as for those who meet criteria based on age and pack years), one result is that in 62% of nonsmokers with lung cancer, it’s diagnosed at Stage IV (the most advanced stage). The same is true for only 49% of smokers. “It is well demonstrated that workup and diagnosis for younger women who are nonsmokers is often delayed when they have symptoms that may be consistent with lung cancer,” Dr. Antonoff says.
But even women who do smoke may not be taken seriously when they go to their doctors with breathing problems. “Women may be told that they’re anxious, that they are having a panic attack,” Dr. Garfield says. Their symptoms, such as fatigue, may be more subtle, notes Dr. Cernadas. “Make sure you talk with your doctor about lung screening if you smoke or have smoked.” In addition, bring up any history of lung troubles in your relatives. Nonsmokers with a family history of lung cancer are more likely to develop the disease.
Another topic to discuss: what you breathe in during the day. “There’s a lung disease for every exposure you can think of,” Dr. Garfield says. “Do you bake a lot? You’re exposed to flour. Do you paint often with oil paints? Their fumes can harm your lungs. What’s the air pollution like where you live? Are you in an area with a lot of wildfires? Are you vaping or smoking marijuana? All these may lead to lung diseases.
“The goal is for you to communicate clearly with your doctors about all your symptoms, exposures, and risks,” Dr. Garfield says. “Diagnoses of lung diseases need to be made early. Make sure you are taken seriously.”
Simple tips for protecting your lungs
You can’t do much to change your genes or hormones, but you can reduce your odds of developing or worsening a lung disease.
Test your home for radon
This naturally occurring radioactive gas that forms when radioactive metals like uranium break down in the soil. It enters homes through cracks in walls and foundations and can sometimes be found in well water. Radon is the third leading cause of lung cancer (after smoking and exposure to secondhand smoke), and exposure to it poses a much bigger risk to smokers than to nonsmokers.
Maintain a healthy weight
Obese women are more likely than obese men to develop asthma, says Dr. Cernadas. Belly fat in particular has been linked to poorer lung function, possibly because it boosts inflammation, research has found.
Give up smoking
Since secondhand smoke can also cause lung disease, don’t let people smoke in your home or office or anywhere near you.
Consider putting on a mask
Even if COVID mandates have been lifted, a mask can be a wise choice. During the pandemic, flares of COPD and asthma plummeted, presumably because of social distancing and mask wearing. This is especially important if you have a chronic lung disease.
Exercise
“Any aerobic workout, even just walking, strengthens your lungs,” says Dr. Wilgus.
Open your windows
Keep the air moving when you use cleaning products or are painting, says MeiLan Han, M.D., a professor of medicine in the division of pulmonary and critical care at the University of Michigan. But close them when pollution outside is intense—for instance, when wildfires are raging or there’s a huge traffic jam near you.
Improve indoor air with a purifier
Look for one with a HEPA filter, says Carver, of the Asthma and Allergy Foundation of America.
Eat more fruits and veggies
“Some evidence suggests that a diet high in fruits and vegetables may help protect against lung cancer in both people who smoke and those who don’t,” states the American Cancer Society.
Visit a doctor if you experience these symptoms
- Shortness of breath
- A cough that doesn’t go away
- A respiratory infection that doesn’t improve with antibiotics
- Wheezing
- Trouble breathing when you exercise or otherwise exert yourself
- Chronic phlegm
- Chest pain
- Coughing up blood
- Unintentional weight loss