Respiratory health in women: why sex and gender matter in general practice
Life-course lung trajectories, asthma–COPD overlap, oral steroid stewardship, pregnancy, menopause, and lung cancer vigilance — a GP-facing summary of a respiratory women’s health seminar.
- Speaker
- Retired GP educator (name not stated in Otter; University of Melbourne lung-health / advocacy roles; Adelaide practice background — nearly 40 years clinical GP practice; special interest respiratory medicine).
- Host
- Briefly thanked as Matt in the Otter recording.
Why women’s respiratory disease is mainstream GP work
The familiar COPD mental picture — older man, heavy smoking history, progressive breathlessness — no longer matches many patients in Australian waiting rooms. Respiratory disease in women is common, under-recognised, and underdiagnosed. Women may have smoked less or not at all, often carry a long asthma history, and their spirometry may not look “dramatic” at first — yet symptom burden and disease trajectory can be real.
- In Australia, asthma is a leading cause of disease burden for women in their 20s–40s; the speaker cited it as the fourth leading cause of disease burden in women aged 35–44 — a busy life stage.
- Asthma prevalence is 60–80% higher in adult women than men.
- COPD prevalence, hospitalisation, and mortality in women have risen; COPD was framed as the second most common cause of death in Australian women aged 60–74, with lung cancer the leading cause of death in that age band and the leading cause of cancer death in Australian women overall.
Are we measuring early enough? Are we reassessing at the right inflection points? Do we recognise how sex and gender shape respiratory disease?
Case: Mrs AC and a 60-year trajectory
Mrs AC, just turned 70, grew up in Scotland with childhood asthma continuing into adolescence and adulthood. She emigrated to Australia in her mid-20s as an allied health professional. She smoked for many years but with fewer pack-years than many men diagnosed with lung disease, and quit permanently in her early 50s. One pregnancy was uncomplicated though asthma was “a little bothersome.” She had intermittent flare-ups needing oral steroids and antibiotics, never hospitalised.
On specific questioning she had decreased exercise tolerance walking with friends. Spirometry showed significant bronchodilator responsiveness (asthma history) and persistent airflow limitation post-bronchodilator — confirming coexisting COPD / asthma–COPD overlap (ACO). By the time that diagnosis is clear, the trajectory has been unfolding for decades.
The issue is not whether we can manage disease now — we can. The question is where along the life course we might have altered her trajectory (for example detecting obstruction 10–15 years earlier in her early 40s).
Lung-function trajectories and sex differences
Modern COPD thinking emphasises: multiple interacting adult risk factors; origins often in childhood; different pathways to COPD (not only accelerated decline); and a long latency between origin and diagnosis — room for prevention.
FEV₁ develops in utero and early life, grows through childhood and adolescence, peaks around 20–25 years, then gradually declines. Women often reach peak lung function earlier and at a lower level, start decline earlier, have smaller airway calibre for a given lung volume, and smaller lung volumes and diffusing capacity for age and height.
Women are more likely to develop COPD at a younger age, appear to have more severe disease and poorer prognosis, and may develop COPD at lower cumulative smoking exposure with greater symptom burden at similar airflow limitation. Smaller airways may concentrate tobacco smoke (and occupational biological dusts) per unit airway surface.
Hormones, puberty, menopause, and ACO
Hormonal influences on airway hyperresponsiveness help explain why asthma becomes more common in females after puberty. Menopause appears associated with accelerated lung-function decline and is a clinical trigger to reassess respiratory health. Longstanding asthma plus menopause links to asthma–COPD overlap — a group at particularly high risk of exacerbations and decline who need monitoring, ongoing inhaled corticosteroid therapy where indicated, and guideline-aligned asthma/COPD care (COPDX and Australian Asthma Handbook).
Oral corticosteroid stewardship (~1000 mg)
Many women with poorly controlled asthma or ACO accumulate repeated oral steroid courses over decades. Emerging evidence: even intermittent short bursts carry cumulative risk. The speaker cited a clear rise in steroid-related complications beyond a cumulative lifetime prednisolone dose of about 1000 mg — framed as roughly the equivalent of only about four standard steroid burst treatments.
Women are particularly vulnerable to postmenopausal bone loss plus fracture and metabolic consequences. Each oral steroid script should be treated as a risk marker and a signal of control failure — ask why the exacerbation occurred, check adherence and inhaler technique before escalating, consider home medicines review, align with COPDX guidelines, and strongly consider bone-density screening with repeated steroid exposure (especially peri-/post-menopausal and older women).
More than one oral steroid burst in the last 12 months → consider secondary referral and precision options such as biologics in asthma (where suitable) to reduce oral steroid need.
Asthma in pregnancy
An estimated 12–13% of pregnant women have asthma. About 40% experience worsening symptoms; at least 20% have an exacerbation needing medical intervention — most often in the second trimester. Most adverse outcomes relate to undertreatment, not medication toxicity. Stopping preventers is common and harmful.
- Aim for best possible control; continue inhaled corticosteroids and long-acting beta-agonists if indicated.
- Step up as needed; do not step down in pregnancy unless a dose is inappropriately high.
- Useful resources cited: Australian Asthma Handbook pregnancy medicine safety table; Asthma in Pregnancy toolkit (Centre of Excellence in Treatable Traits, University of Newcastle).
Spirometry and lung cancer vigilance
Low threshold for spirometry when there is chronic cough or breathlessness. Objective diagnosis matters for asthma and COPD — COPD is not confined to heavy-smoking men.
Lung cancer is the number-one killer of women aged 65–74 in Australia and the leading cause of cancer death in women overall. The speaker described the National Lung Cancer Screening Program (launched July of the prior year) for people aged 50–70 (Otter captured “15 to 70” — treat age band cautiously against current program criteria) with no lung-cancer symptoms, ≥30 pack-year history, current smokers or quit within 10 years, and no chest CT in the last 12 months.
Women may present without classic heavy smoking history and with non-specific symptoms. Persistent cough, fatigue, recurrent chest infections, unexplained breathlessness, voice hoarseness, unexplained DVT/PE, or persistent thrombocytosis deserve investigation. Resource cited: Cancer Australia / Lung Foundation Australia “Investigating Symptoms of Lung Cancer” guide; check HealthPathways.
Ten practical tips for primary care
- Think life course — childhood, reproductive years, pregnancy, menopause, ageing.
- Aim for asthma remission where possible — protect long-term lung function, not only today’s symptoms.
- Manage asthma actively in pregnancy — continue inhaled therapy.
- Reassess around menopause — symptoms may appear, reappear, or worsen.
- Consider asthma–COPD overlap in longstanding asthma with smoking/exposures and fixed obstruction.
- Order spirometry early — shorten the diagnostic journey.
- Investigate persistent symptoms rather than normalising them.
- Optimise inhaled therapy to COPDX and Australian Asthma Handbook.
- Use oral corticosteroids cautiously — minimise cumulative exposure.
- Proactive lung cancer risk assessment — screening where eligible; investigate symptoms with or without classic smoking history.