Some twenty or so years go a concerted effort was made to improve the quality of women's medicine by increasing the proportion of women practicing medicine in the US, particularly within the field of women's healthcare, so as to presumably reduce sexism & gender bias. 

And it worked, at least in the sense of increasing the percentage of women doctors, but it failed abysmally in terms of making women's healthcare inherently less sexist or more progressive.  

The deep & hidden biases built in to women's healthcare

Gynecology is no more nor less sexist than any other field of women's medicine.  Instead its particular problems relate to other, more specific, far less political biases.  The most fundamental, broad-based problem has to do with the rapidly widening discrepancy between medical science & technology, which have been advancing by leaps & bounds, and medical practice, which has being going perversely backwards, because of the mediocrity of standardized care. 

Paradigms are formalized expressions that define our worldviews, the way we look at things.  And traditional medical paradigms, even when they become obviously antiquated, are difficulty to dislodge, having been subconsciously embedded & continually reinforced by educational & regulatory bodies bent upon compliance.  This pattern of rigidity gets worse as medical practices become increasingly standardized under the growing pressures of insurance companies & government bureaucracies that have conjured up crude maps to represent a complex reality, then started to worship their over-simplified maps while forgetting the actual territories they so erroneously represent.  We globally move ever closer to a Stalinist form of medical care for which everyone will qualify but which won't be worth having.

The gynecologic paradigm

The world view that dominates women's healthcare is a gynecological one, a fundamentally sexualized one that sees female health through sexual/reproductive glasses. And it works fine for sexual & reproductive health problems but its success in the reproductive clinic sows the unconscious seeds for a great flaw.  That's because its viewpoint, its mental model denies sex hormones from having either a widely systemic influence that extends beyond the overtly sexual, or one that appreciates how fluctuations in the patterns or fluxes of hormones taking place over the short or even the very short term might themselves fuel real, troublesome medical problems such as anxiety or migraine headaches.  The fact however, is that they really do so, because hormones, even the sexual ones by their very nature integrate the body not only over space but time while targeting mind, brain & body.   

So the special problem associated with gynecology is the overriding emphasis it  places on the integrity of the static (or seemingly static) non-plastic, innately sexual/reproductive structures, both solid & rigid while ignoring the dynamic patterns traced out by these sexual hormones, as they target the body at large while fueling the kinds of medical problems that are by their very nature fluctuating & paroxysmal, coming & going, such as anxiety, seizure disorder, asthma or migraine headaches. 

Not so long ago the science behind reproductive medicine would have validated this narrow, now disproven viewpoint.  For example, the estrogenic hormones were perceived operating only in a slow, sluggish & lingering fashion.  This was accomplished by triggering the activation of classical estrogen receptors located in the nuclei of their target cells, situated in sexual targets such as the breast & endometrium.  Once hormonally activated these receptors would then alter the expression of sections of the genome known as estrogen responsive units, leading in turn to changes in the way the genome sends its dictats to the tissues being targeted.  From this perspective hormonal flux was afforded little or no significance, and sadly this is still true even today, at least in the realm of clinical practice.

Common Sense 

Whatever the beliefs of the powers that be in clinical practice, sensible physicians have long been aware that sex hormones have a rapid, short acting impact in addition to their classical one.  For example the vasomotor symptoms of menopause reflect the negative delta of an estrogen withdrawal rather than the steady state of estrogen depletion & estrogen withdrawal has been linked with acute vascular syndromes including coronary artery spasms in women.  Clinical research has validated the idea of estrogen withdrawal in the generation of migraine headaches.  And the validity of there clinical insights was finally confirmed when research showed the sex hormones working briefly & rapidly via novel mechanisms, opening up a broad panorama of non-sexual mechanisms.  This allows sex hormones to matter greatly at the brain, the blood vessels & the immune/inflammatory machinery.     

Vascular Headaches

Migraines are clearly sex hormone sensitive & sex hormone related. For example prior to puberty there is a 1 to 1 distribution between males & females but once the ovaries have kicked in, females experience 6 times more migraines than men do, obviously a major gender-based discrepancy.  The driving forces behind the intermittent appearance of these complex headache syndromes prominently include dipping estrogen levels (estrogen withdrawal or EW), hence the tendency for migraines in younger women to occur pre-menstrually, so it should come as no surprise that when these same women enter their 40's their migraines become more frequent & erratic, expanding outside the premenstrual week & occurring throughout the month, while also taking on a greater degree of severity & resistance to therapy.  Indeed women who in the past were vulnerable to menstrual migraines & in whom a family history of migraines was prevalent, involving sisters, mothers, aunts or female cousins, are far more likely to experience migraines during the pre-menopause or menopause as well.   

Migraines & hormone withdrawal

Migraine syndrome is a classical example of how our new, de-sexualized approach to hormones can have the power to paint a wonderful new picture of the mechanisms of an illness, but the same model works just as well for getting a better understanding of many other paroxysmal conditions, both physical & mental, including cardiac angina and major depressive disorder.  Migraine is a debilitating, miserable experience involving severe headaches, autonomic dysfunction (including the autonomic regulation of the gut) as well as neurologic symptoms such as visual "spots".  In the case of vascular headaches such as migraines, as with cardiac angina, nitric oxide (NO) is centrally involved.  That is why nitroglycerine tablets tend to relieve angina but generate vascular headaches as a side-effect, & why women get more angina than men even though they are protected from the plaques of obstructive coronary artery disease by the presence of estradiol. 

Nitric oxide is as important a regulator of blood vessel contraction in the brain as it is of the coronary vessels, promoting dilatation of the vessels.  And estradiol in turn is a critical regulator of NO-production & release, hence the tendency for dips in estrogen to fuel migraines.   It follows that stabilizing estradiol levels should not only treat migraines effectively after the fact but should even prevent them from occurring in the first place, & in practice this idea works out.  It doesn't matter whether we stabilize estrogen at a consistently high, low or mid-range level, either way the migraine is solved. This approach makes more sense to me than treating migraines after the fact & from the outside, when the horse is already out of the barn. 

I first discovered this hormonal arrangement back in the the 1980s when treating young women suffering from PMS/PMDD or whatever you want to call it.  I employed the drug Tamoxifen thinking that PMS was a drug-withdrawal process so that an anti-estrogenic drug might block exposure of the brain to estrogen excess & habituation in the first place.  Well the theory wasn't quite right but the drug worked beautifully for the prevention of PMS symptoms, both physical & emotional, while avoiding the use of anti-depressant drugs.  But then one of my patients revealed that her PMS-related headaches had also miraculously disappeared.  A clinical study promptly followed which I & neurologist Ed Davis presented at the national neurology meetings & published it in the journal 'Neurology' in 1991.

A local neurologist recently asked me why I wished to treat PMS or menstrual migraines hormonally when it was a simple matter to treat them with antidepressants & beta blockers instead? His attitude to me exemplifies a major component of what ails women's medicine today, as we treat labels instead of processes & spend more time building houses of cards out of our electronic medical records & far less time talking to or listening to our patients because after all, " its all in their heads".

Not all migraines are driven by estrogen withdrawal.  Some migraines might be called 'metabolic' being related to dipping blood sugar levels fueled by insulin resistance, the tip-off being their occurrence around the same time each day & relating to a consistent amount of time since one's last meal.  And since polycystic ovary syndrome is related to insulin resistance & insulin excess, it follows that the migraines experienced by a woman with PCOS might be insulin-related & could respond to the use of metformin.  In fact 40% of migraine sufferers have ovarian cysts compared with 18% of control women.  Progesterone may also play a part in female migraines.  A surge in progesterone fuels a dip in estrogen receptor status & may thus trigger a dip in the effect of estradiol.  Progesterone also has a pronounced anti-caffeine effect & caffeine ingestion often relieves migraines.    Finally dips in cortisol may also play a part in the migraine experience in women & may respond to re-calibration of the stress response machinery.  

Menopausal migraines

As hormone levels become markedly erratic during a woman's 40s, estradiol & testosterone levels go through dramatic excursions with frequent, unpredictable episodes of estrogen withdrawal.  And that is when women who used to suffer from menstrual migraines on a monthly basis, now begin to experiences frequent migraines in an erratic, unpredictable pattern.  That's because migraines tend to run in families but only appear when hormonally triggered.  In other words the ingredients required for developing migraines include inheriting a migraine-prone brain on the one hand & exposing this vulnerable instrument to dips in estradiol on the other.  That is why migraine syndrome has a 1 to 1 ratio between females & males prior to puberty, but this jumps to a 6 to 1 ratio as soon as puberty has arrived.

In conclusion, we shouldn't be calling these migraines 'menstrual migraines' in younger women & 'menopausal migraines' in older ones, because they are all the same headaches driven by the same mechanism, EW or estrogen withdrawal!  And when a woman with a past history or a family history of migraine syndrome experiences migraine headaches or migraine variants including nausea when treated with estrogenic products such as birth control pills or menopausal estrogens, this is a tip-off that these products, notably crude, amateurish preparations of "bioidentical hormone therapy" are potentially dangerous since they can equally fuel all other consequences of estrogen withdrawal including coronary artery spasm, arrhythmia & sudden death, edema, increased risk of breast cancer, panic attacks, anxiety & agitated depression.   Caveat emptor.  

PS:

This expose on the role of the short rapid influences of estrogen on migraine risk are just as applicable to other, paroxysmal disorders such as anxiety & depression.