Women and asthma

MS RUTH MORROW, Registered Advanced Nurse Practitioner (Primary Care); Respiratory Nurse Specialist (WhatsApp Messaging Service Asthma Society of Ireland); and Nurse Educator and Consultant.

This article explores the care and management of women who have or develop asthma, including asthma during pregnancy and menopause, as well as addressing common situations which women encounter throughout their lifetime whilst living with asthma.

During childhood, boys have near twice the risk of developing asthma over girls. This changes once children reach the age of 12/13 years. Sex hormones, genetics, social and environmental factors, and responses to asthma treatments are important factors in the sex differences observed in asthma incidence, prevalence, and severity. In childhood, obesity, regardless of physical fitness, is associated with higher asthma prevalence and morbidity in girls, but not in boys. In girls older than 11 years and women, asthma is five-to-seven times more common in obese people compared to those of normal weight (Koper et al, 2017). 

Asthma prevalence is higher in women who have multiple pregnancies, women whose periods started earlier in life and women with hormonal disturbances, such as polycystic ovarian syndrome (Morales-Estrella et al, 2018). Women who are diagnosed with endometriosis also have an increased risk of asthma. A study by Morales-Estrella et al (2018) showed that 23.8 per cent of women who had endometriosis developed asthma, compared with 13.2 per cent of women who were taking oral contraceptives (OCS). 

Testosterone, which increases in boys from the age of 12/13 years, has an anti-inflammatory effect in the airways and is thought to be one of the reasons why asthma is less prevalent in boys at this age. Female hormones increase at this age in girls, which is thought to increase the risk of developing asthma and increase symptoms in those who are already diagnosed with asthma. 

As adults, women have an increased prevalence and severity of asthma. For women, fluctuations in sex hormone levels during puberty, the menstrual cycle, pregnancy, and menopause are associated with asthma (Nowrin et al, 2021). Later in life, asthma incidence and severity are higher in women than in men, and highest in women between the fourth and sixth decade of life. During adulthood there is a shift to a female predominance, which affects mainly non-atopic asthma. In the elderly, the gender-related differences decrease. As testosterone levels decrease in older men, the incidence of asthma can also increase in this age group (Koper, 2017) 

In addition, pathophysiological abnormalities can be seen which includes blood eosinophilia, which seems to be more prominent in girls with asthma, but in adipose tissue. Girls with asthma tend to have a higher prevalence of non-eosinophilic asthma (60 per cent) compared to corresponding boys (30.8 per cent). 

Is asthma worse for women? 

Severe asthma affects primarily boys before and at school entry age as well as women around the time of menopause. Women also develop ‘corticosteroid-resistant’ or difficult-to-treat asthma more often than men (Moore et al, 2007). Studies show that compared to men, women can have worse symptoms more often: 

• Women are more at risk of acute asthma flare-ups and are admitted to hospital more often with their asthma. 
• Women who develop asthma for the first time later in life, after menopause, are more likely to have asthma that is difficult to control, and to need specialist care and treatments to help deal with their symptoms. 
• Lung function starts to decline after about the age of 35 years in both males and females. For women it declines more quickly after the menopause. 
• Statistics show that women with asthma over 65 years of age, are more at risk of life-threatening asthma attacks. 
• Women who develop asthma at peri-menopause tend to be less atopic, less corticosteroid responsive, and obese, with steroid refractory asthma (Moore et al, 2007, Wu et al, 2014). These women frequently require high doses of inhaled corticosteroids (ICS) to manage their asthma. Their asthma tends to be difficult to manage and have a higher rate of healthcare utilisation and poorer health outcomes. 

Hormones and asthma 

Women are more likely to notice worse symptoms around times of hormonal change like puberty, menstruation, pregnancy, and perimenopause. Not all women are affected. 

• One-third of women report worse asthma symptoms before or during a period. 
• Some women, particularly those with severe asthma, have worse symptoms during pregnancy. Although many women notice an improvement or no change at all when they’re pregnant. 
• Asthma symptoms can get worse during peri-menopause. 
• Women who have never had asthma can develop asthma at peri-menopause. 
• Hormones can be an asthma trigger in their own right, but they can also make the woman more sensitive to other triggers, such as hay fever or colds and flu. It is not yet clear why this is the case. It could be because it increases inflammation in the body and causes inflammation in the airways. 

Do women have different asthma triggers? 

Women can also have all the same triggers as men, but some of these triggers may be worse for women or affect them more often. For example: 

• Food allergies are more common in women than men with female hormones making them worse. 
• Cigarette smoke can affect women more than men. Women and girls may be more sensitive to cigarette smoke and girls with asthma who start to smoke may take longer and need more help to quit. 
• Stress, anxiety, and depression are more common in women, particularly older women who tend to be carers more often. 
• Indoor triggers, such as cleaning products, cooking fumes and house dust mites may affect women more as statistics show they’re more likely to be doing the cleaning at home. 

How can women lower their asthma risk? 

Having an annual asthma review including assessment of symptoms, checking adherence and inhaler technique and a review of their asthma ‘Action Plan’ can benefit women. At other times women should be advised that as they approach the peri-menopause, symptoms and asthma control may worsen and they should be advised to have an asthma review with adjustment of treatment if required. 

Risk can also be lowered by: 

• Taking the controller medicine every day as prescribed so that they are less likely to react to any asthma triggers, including hormones. 
• Keeping a symptom diary to help find out if hormones are triggering asthma symptoms around their menstrual period. 
• Keeping an eye on weight. Being obese increases the risk of asthma symptoms worsening as women get older. It also increases the risk of women getting asthma for the first time around menopause. 
• Discussing the woman’s risk of osteoporosis. Being on higher doses of inhaled steroids or needing regular or long-term courses of steroid tablets increases the risk of osteoporosis. Women are four times more at risk than men of developing osteoporosis. In women who have asthma, the chances of developing osteoporosis are slightly higher than average. 
• Being aware how other conditions could make asthma worse – for example, acid reflux, which is more common in women. 

Pain relief, contraceptives, HRT and asthma 

Around 20 per cent of women with asthma experience worsening of their asthma premenstrually. These women tend to be older and have more severe asthma, a higher BMI and have had asthma for a longer time (GINA, 2021). They also tend to have more menstrual abnormalities, such as dysmenorrhoea, shorter menstrual cycles, and longer menstrual bleeding. Paracetamol is usually safe, but non-steroidal anti-inflammatory tablets (NSAIDs), such as ibuprofen (eg, Nurofen), and mefenamic acid (eg, Ponstan), and aspirin, may worsen asthma symptoms or trigger an asthma flare-up in some women. Oral contraceptives and leukotriene receptor antagonists may be helpful for these women. 

Oral contraceptives (either the combined pill or the progestogen-only pill) are safe to take. Taking them at the same time as usual asthma medication will not affect the efficacy of either medication. 

The morning-after pill, ellaOne, is not recommended for women with severe asthma. Some oral contraceptives are not recommended for women taking theophylline as plasma concentrations of theophylline are increased. 

Data from 3,257 pre-menopausal Scottish women showed that hormonal contraceptives reduced asthma incidence and decreased asthma-related healthcare utilisation, driven by a significant decrease in lean women, as well as decreased wheezing in asthma patients (Nwaru BI, Sheikh A, 2015). In a study by Morales-Estrella et al (2018), the prevalence of asthma was higher in women taking OCS than those who weren’t (14.3 per cent vs 8.8 per cent). 

HRT also has asthma benefits and asthma risks: 

• Some research shows that HRT may increase the risk of women getting asthma for the first time. 
• Some studies show that HRT improves symptoms in women who already have asthma. 
• Generally, symptoms improve after the menopause, but this is not the case for women taking HRT. 

Asthma and pregnancy 

Asthma control often changes during pregnancy – in approximately a third of women their asthma symptoms worsen, a third may improve, and the remaining third remain unchanged. 

Exacerbations are common in pregnancy, particularly in the third trimester. Uncontrolled asthma and exacerbations may be due to mechanical or hormonal changes or due to the stopping or reduction of medications due to concerns by the mother or healthcare provider. 

Pregnant women appear to be more susceptible to viral respiratory infections including influenza. 

Poor asthma control and exacerbations are associated with worse outcomes for the baby (low birth weight, pre-term weight, increased perinatal mortality) and the mother (pre-eclampsia). If asthma is well controlled during pregnancy, there is little or no increased risk of adverse maternal or foetal complications (GINA, 2021). 

The advantages of actively treating asthma in pregnancy outweighs any potential risks from regular controller and reliever medications. Using medications to achieve good asthma control and prevent exacerbations is justified even if their safety in pregnancy has not been proven. The use of ICS, montelukast or theophylline is not associated with an increase of foetal abnormalities. There is plenty of evidence which shows that ICS reduce the risk of exacerbations during pregnancy and stopping ICS during pregnancy is a significant risk factor for exacerbations. 

During labour and delivery, women should be advised to continue their usual controller medications and use their reliever if needed (GINA, 2021). Acute exacerbations are not common during labour, but bronchoconstriction may be induced by hyperventilation and should be managed using short-acting bronchodilators. 

References on request