The report is a product of the VA/HSR&D Evidence Synthesis Program.
Gender Differences in Intervention Effects for High-Impact Conditions among Women Veterans
Women are entering the military at unprecedented rates and comprise a rapidly increasing segment of Veterans Health Administration (VHA) enrollees. In response, the VHA Women's Health Service requested an evidence map to:
- Identify effective interventions for women,
- Better understand sex differences in intervention effects for high-impact medical conditions, and
- Identify gaps in the evidence about the efficacy of interventions in women.
Using a stakeholder-driven approach to identify high-priority conditions and interventions, an initial list of 36 conditions was used to identify 3 for evaluation: depressive disorders, type 2 diabetes mellitus, and chronic pain conditions (chronic low back pain [CLBP], chronic knee osteoarthritis [OA], and fibromyalgia [FM]). Treatments were evaluated in broad categories, including medications, behavioral interventions, supervised exercise, and quality improvement interventions, along with certain condition-specific interventions.
The report was created by the Evidence-based Synthesis Program (ESP) Center at the Durham Veterans Affairs Healthcare System and included evidence from 313 systematic reviews. Among eligible reviews, 268 systematic reviews underwent full data abstraction: 86 addressing interventions for depression, 114 addressing diabetes, and 68 addressing the three chronic pain conditions. A summary of the results is outlined in Table 1.
While there were a large number of systematic reviews included in the evidence, fewer than half summarized the sex distribution of the populations of the included studies, although women were well-represented in the reviews where those data were shown. The authors point out that sex effects were reported in only 10% of eligible reviews, and individual patient data (IPD) meta-analysis—the analysis method best suited to evaluate sex effects—was rarely used (n=16 of 268 abstracted reviews, 6%).
Table 1. Summary of Sex Effects Identified in Systematic Reviews
|Condition||Possible differences in treatment effects between men and women||Possible lack of differences in treatment effects between men and women
Greater improvement in depressive symptoms
SSRIs in older adults
More adverse effects on sexual dysfunction
Antidepressants overall, quality improvement, self-helpa
Combined antidepressant and psychotherapy for dysthymia
Adverse effects overall
Lower for sulfonylureas (compared with thiazolidinediones)
Greater improvement in CLBP
a Findings are from IPD meta-analysis.
b Fibromyalgia is not listed because studies predominantly enrolled women. Knee osteoarthritis is not listed because no reviews were identified.
Abbreviations: CBT = cognitive behavioral therapy; CLBP = chronic low back pain; OA = osteoarthritis; SSRI = selective serotonin reuptake inhibitor
The authors also note that while there is a large body of evidence for many of the examined interventions—particularly medications, psychotherapy, and exercise—systematic reviews and primary randomized controlled trials (RCTs) examined sex effects infrequently. When examined, sex effects generally favored greater benefits in women, but the report concludes that differential effects were small and the analysis approaches were often less than ideal. The report suggests that all future RCTs and systematic reviews should identify the proportion of men and women enrolled, and sex effects should be examined in adequately powered RCTs or IPD meta-analyses.
Duan-Porter W, Goldstein K, McDuffie J, Clowse M, Hughes J, Klap R, Masilamani V, Allen LaPointe NM, Williams Jr JW. Mapping the Evidence: Sex Effects in High-impact Conditions for Women Veterans. VA ESP Project #09-009; 2015.
View the full report — **VA Intranet only**:
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A cyberseminar on "Mapping the Evidence: Sex and Gender Differences in Treatments for Depression, Diabetes, and Chronic Pain" was held on December 9, 2015 and can be accessed 24/7 in the HSR&D cyberseminar archives.
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