COMMENTARY

Stress, the Heart, and the Sexes

Sharon Mulvagh, MD; Anjali Bhagra, MBBS

Disclosures

April 11, 2016

Editorial Collaboration

Medscape &

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Sharon Mulvagh, MD: I'm Sharon Mulvagh, professor of medicine and director of the Women's Heart Clinic at Mayo Clinic. During today's Trending Topics, we will be discussing stress and its effects on the heart. I'm joined by Dr Anjali Bhagra, associate professor of medicine, who is a stress management and resiliency expert in integrative medicine and health. Welcome, Anjali.

Anjali Bhagra, MBBS: Thank you. It's a pleasure to be here.

What Is Stress?

Dr Mulvagh: You have become quite an expert in this area, which is very needed in our everyday practice. We're talking today about cardiology patients mostly, but this affects everyone. What exactly is stress, and is all stress bad?

Dr Bhagra: That's a great question. Let me start by demystifying the concept of stress. Stress is a struggle with what is, what was, or what may be. It usually stems from a demand/resource mismatch. It generally involves two big phenomena happening around us: either a lack of control around a situation, or a lack of meaning.

You asked whether all stress is bad. The answer is no, because we actually thrive on stress. We all need some stress to perform, and we call that "good stress," or "eustress." An example is the stress of packing for a vacation. Have you ever experienced that?

Dr Mulvagh: Oh, yes.

Dr Bhagra: I would classify that as "good stress," because it's not that we have to do it; we get to do it.

On the other hand, when the stressors of daily life either become too big or are prolonged, or we lack an appropriate coping mechanism, our stress becomes "bad stress," or "distress." What that does to our brains is force them to go into wandering mode—the mind wandering when we tend to fixate on imperfections or insecurities in our lives. These could be relationship insecurities, work-related issues, or geopolitical concerns.

Dr Mulvagh: It sounds as though it's an imbalance, when things get a little out of whack.

Men, Women, and Stress

Dr Mulvagh: Are there ways that stress is perceived differently, depending on whether you're a man or a woman?

Dr Bhagra: There are a lot of differences, not just in how men and women report stress but also in how they perceive stress. According to a large 2011 survey by the American Psychological Association[1] more women—close to 30%—reported a great deal of stress in their lives, compared with about 20% of men. In terms of perception of stress, women tend to report stress related to financial and economic issues, whereas men more often cite stress around work-related issues. So, there are differences in perceptions and reporting of stress.

Dr Mulvagh: We seem to have a lot of observational information about stress. Are there biological bases for how stress occurs, and what, if any, differences exist between the sexes?

Dr Bhagra: There are plausible, not well-understood biological as well as social reasons that potentially cause these observed differences in perception, as well as in reporting of stress. Starting with biological differences, structurally and functionally, male brains are different from female brains.

Dr Mulvagh: That's probably a good thing.

Dr Bhagra: Yes; it adds to diversity and variety. A lot has been written about it in scientific and not-so-scientific terms. So, are men really from Mars and are women from Venus? I won't get into the details, but there are structural differences.

Functionally, however—which is where the concept of stress being perceived differently feeds in—women actually have greater functional connective density in their brains, as measured by functional MRI studies.[2]

Not just that, but the way female brains are connected looks different from how male brains are connected. Women tend to have more interhemispheric connectomes, which actually allow for more connectivity between analytical and intuitive processes, whereas men tend to have more intrahemispheric connections—on the same side of the brain—which facilitates more connectivity between kinesthetic tasks and motor skills.[3]

Dr Mulvagh: That's extraordinarily interesting. So, both functional and structural differences have been recognized?

Dr Bhagra: Absolutely. Furthermore, there are neurohormonal differences. Women go through premenstrual, postpartum, postmenopausal [phases], and experience a variety of hormonal changes in their life cycles. On top of that, are the social differences. Life, and the caregiving demands on women in the 21st century, are different from [those of] even a couple of decades ago. The literature increasingly shows women in less important leadership roles; women aren't in positions to make policies. They are not in stakeholder positions as often as men. It's a complex but very interesting biological and social model.

Dr Mulvagh: This brings it to the level of the diversity that you mentioned earlier, and how important it is to have diverse stakeholders at the table to be able to look at all of the options.

Managing Stress for Heart Health

Dr Mulvagh: We've been talking in generalities and how we can think about stress affecting all of us, and the unique gender-related aspects of stress. Are there differences in how men and women deal with stress? Have patterns been recognized? What can we learn from them, and how can we empower our patients? Obviously, stress has an impact from a cardiac standpoint. Individuals who are highly stressed are unlikely to follow through on the advice we give them.

Dr Bhagra: Absolutely, and there are a lot of implications in terms of prevention of cardiac disease. Men in general tend to report that the impact of stress on health is not as strong compared with [that on] women. More women feel that stress strongly affects their health.

In terms of dealing with stress, women are more motivated than men to act on their stress. Does that lead to more action on behalf of women? The answer is no. Both men and women have a fairly high thought/action gap in stress management. To manage stress, it has been shown that women tend to engage in such activities as reading and spending time with family. Men engage more in physical activities, playing sports, and working out.

Dr Mulvagh: You've been very active in the Integrative Medicine Program here at Mayo. Because of your expertise in this area, we can share with our audience that we have developed a stress management program within our Women's Heart Clinic, specifically to address these unique aspects of gender differences in the response to stress.

Dr Bhagra: That's a great opportunity for us, given how much we understand about the differences in how men and women perceive stress and how stress affects their cardiac health overall. Many studies[4,5] have found that women are more predisposed to mental stress-induced myocardial ischemia compared with men. Furthermore, women experience much lower overall health compared with men when they have these events.

Dr Mulvagh: The VIRGO study[4] showed that very nicely.

Dr Bhagra: The REMIT study,[5] which was done in young and middle-aged patients with ischemic heart disease, showed once again that women are more predisposed to developing ischemia. Moreover, women are more likely to have a lingering effect of negative emotions, which worsens outcomes as well.

So, I definitely feel that [the stress management program] is a great step forward. It's a huge opportunity for us to intervene at the right time to prevent this as much as possible.

Dr Mulvagh: Anjali, it's wonderful to have you as a colleague, and I want to thank you very much for sharing these very important insights with our viewers. Thank you to our viewers for tuning in to Mayo Clinic at theheart.org on Medscape.

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