From Hysteria to Medical Gaslighting and the Path Forward with Dr. Elizabeth Comen

Comen explains the historical dismissal of women's chest pain as 'neurotic angina' by William Osler, a founding figure in cardiology, who wrote that 'these women do not die.' This legacy persists today: women are more likely to have their heart attack missed, less likely to get an EKG, and more likely to die within the first year. She urges women to trust their bodies and advocate for themselves, noting that the default diagnosis of 'panic attack' is a modern echo of hysteria. She also highlights that risk factors like preeclampsia are not routinely communicated as cardiovascular red flags.

Comen shares the story of Anne, an 80-year-old patient who confronted her about vaginal dryness ruining her sex life with her vibrator. She admits she had subconsciously dismissed the importance of sex for an older woman. She now advocates for asking patients what brings them joy and how treatment affects that. She notes that NYU has resources for sexual health, and that the field must move beyond the 'you're alive' mentality. She also points out the historical roots: women's sexuality has been pathologized and controlled, and this legacy makes it difficult for both patients and doctors to discuss sexual function openly.

Comen discusses the history of 'bicycle face' and the medical establishment's warnings that exercise would make women unattractive or damage their uterus. She contrasts that with the current need to prevent frailty. She mentions her friend, a physical trainer, who was criticized behind her back for getting 'too bulky,' and how she now tries to keep up with her. She advocates for lifting heavy as a health imperative, noting that even in medical training, there was no education on exercise for women beyond 'work out more, eat less.' She sees strength training as a key tool for longevity and independence.

Comen tells the story of Ellen, a dying patient who apologized for sweating on her, and notes that almost all women apologize for something when disrobed—unshaved legs, smells, unpainted toenails. She connects this to cultural shame and the history of medicine controlling women's bodies. She encourages women to find their people and stop apologizing, and notes that the younger generation doesn't have to wait until menopause to set boundaries. She herself still folds her underwear neatly at the doctor's office, showing how ingrained this behavior is.

Comen argues that anatomy is taught on male forms except for reproduction, and that specialties like cardiology, neurology, and immunology must integrate women's health. She points out that 80% of autoimmune patients are women, yet it's not considered a women's health field. She calls for mandatory menopause education for every specialty that touches a woman. She notes that in her own training, she never learned that preeclampsia increases heart disease risk. She sees this educational reform as essential to closing the gaps in care.

Comen acknowledges that while systemic hormone therapy is often contraindicated, there are non-hormonal medications that can reduce hot flashes. She also stresses the importance of bone health management, as cancer treatments can accelerate bone loss. She encourages patients to have informed discussions with their doctors rather than accepting suffering as inevitable.

Comen connects this revelation to the broader dismissal of women's mental and cognitive health throughout history. She points to the legacy of asylums where women were confined for 'hysteria' or 'premenstrual mania,' and notes that even today, menopause-related brain fog and cognitive decline are often minimized. She cites Lisa Mosconi's work emphasizing that we have centuries of research to make up for. The statistic that Alzheimer's is twice as common in women is not widely known even among physicians, which she finds alarming. She ties this to the underfunding of women's health research and the need to prioritize brain health in midlife and beyond. Her own grandmother suffered from dementia, reinforcing her personal urgency to change the narrative.

Comen explains that many breast cancer treatments, such as aromatase inhibitors or ovarian suppression, induce a medical menopause that can cause severe vaginal dryness, pain, and recurrent UTIs. She emphasizes that vaginal estrogen is not systemically absorbed and has been shown in multiple studies to be safe, yet many oncologists remain uninformed or reluctant to prescribe it. She argues that this reluctance stems from a long history of devaluing women's sexual function—while men with prostate cancer are routinely counseled about erectile dysfunction, women's sexual side effects are ignored. She also advocates for studying systemic hormone therapy in triple-negative breast cancer, which has no estrogen receptor, because there is no biological rationale for withholding it. The lack of research, she says, is because 'no one has cared.' She urges patients to have informed conversations with their doctors and to seek out resources like those at NYU.

Comen discusses how the medical community once debated whether women should ride bicycles, claiming it could cause 'bicycle face' (a frozen grimace), uterine prolapse, or masturbation. This fear of women exerting themselves and developing muscles persisted into modern times, with women being steered toward Pilates and away from heavy lifting. She contrasts that with the current epidemic of frailty and sarcopenia in older women. She now advocates for heavy resistance training to build bone density and prevent osteoporosis. She mentions her friend, a physical trainer, who was criticized behind her back for getting 'too bulky,' and how she now tries to keep up with her. Comen sees strength training as a critical, under-prescribed intervention for women's long-term health.

Comen describes the Mignone Women's Health Collaborative as a place where an orthopedic surgeon can talk to a cardiologist and a gynecologist to address the whole woman. It focuses on three pillars: research, education, and clinical care delivery. She highlights that NYU medical school is tuition-free, which she believes will help diversify the physician workforce. She contrasts this supportive environment with her previous job, where she faced pushback for writing her book and for her media presence. The collaborative has given her hope and a platform to drive change from within the system.

Comen recounts how she put an 80-year-old patient, Anne, on an aromatase inhibitor without discussing sexual side effects, subconsciously assuming sex didn't matter at that age. Anne later confronted her, saying her vagina felt like sandpaper and her vibrator was no longer enjoyable. This forced Comen to re-evaluate her practice. She notes that we are twice as likely to ask men about sexual side effects, and that there is a pervasive ageism and sexism in assuming older women are not sexually active. She now advocates for asking every patient what brings them joy and how treatment affects that, and for integrating sexual health resources into oncology care.

Comen discusses how the lack of funding is not just a moral failing but an economic one. She recounts her experience as a founder, where male venture capitalists would relate to the problem only through their mothers or daughters, never as a global issue. She argues that if investors truly care about returns, they should pour money into under-researched areas like menopause, autoimmune disease, and women's cardiovascular health. She also points out that even within cancer research, the focus on breast cancer has overshadowed other women's health issues, creating a false sense that women's health is well-funded.