The medical profession has become increasingly aware that differences between men and women have implications for diagnosing diseases. For example, society’s expectations for female behavior results in underdiagnosis of autism, hormones may cause migraines, and heart attacks in women often have very different symptoms than in men.

In the following articles, we learn from local experts that girls are four times less likely to be diagnosed as on the autism spectrum, migraine headaches occur three times more often in women, and heart attacks are the cause of death in women five times more often than breast cancer.

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Girls Have Autism, Too

They just look different

Jane Beriont, MD, FAAP, Children’s Hospital of Philadelphia

Julia Parish-Morris, PhD, University of Pennsylvania

When you imagine a child with autism, who comes to mind? A nonverbal boy who lines up toys? Or an awkward young man with a passion for computers? This is because most of what we know about autism comes from studying boys, and because there are currently four boys for every girl diagnosed with autism worldwide. It’s only natural we associate autism with males.

For years, researchers and families have wondered about the skewed gender ratio in autism. Are females less likely to be autistic? Or is there something about autistic girls that makes them hard to recognize?

Fortunately, there’s been increased interest in understanding the experiences of females with autism. As the scientific community engages with and learns from autistic girls and women, it’s become clear that autism is much more common in females than previously thought.

Experts increasingly agree that autistic girls, especially highly verbal girls, often look different from their male counterparts. They’re hiding in plain sight because they don’t look the way we expect an autistic person to look. In fact, females with autism are more likely than males to be identified late, misdiagnosed or not recognized at all!

With this in mind, here are some characteristics to look for in girls who might be autistic.

Toddler and Preschool-Age: Motivated, Sensitive and Rigid

In early childhood, many parents of autistic girls sense something is different but don’t know what it is. Young girls later diagnosed with autism often have no developmental delays and may even learn to read early (a trait called “hyperlexia”). They may have subtle differences in eye contact or use gestures less frequently, but this often doesn’t register as out of the ordinary.

Autistic girls are often socially interested in their peers, which can manifest in different ways. They might observe other children on the playground or engage in parallel play (playing close to but independently from another child). They’re more likely to engage in imaginative play, but the plot may be the same every time, copied from movies or TV, or overly rigid. When these girls play with others, they can seem “bossy” or “controlling,” since it can be hard to be flexible and incorporate their playmate’s ideas. They may prefer playmates who are much older or younger than themselves.

In terms of behavior, autistic girls are less likely to use obvious repetitive movements like rocking back and forth or hand-flapping. Instead, they may enjoy more subtle self-stimulatory behaviors like toe-walking or spinning in circles. Similarly, girls are less likely to have obvious special interests, and even when they do, they may stand out less than typical male interests. Rather than fixating on cars, dinosaurs or ceiling fans, young girls with autism may be fascinated with dolls, animals or doctor’s kits. The interest is distinguished by its intensity, not the subject itself.

One difference seen in both boys and girls is sensory processing. Autistic girls may be either hypersensitive or under-sensitive to aspects of their environment, including lights, sounds, or textures of food or clothing. Similarly, they may differ in how they experience sensations inside their body (called “interoception”). They may be less sensitive to sleep or hunger cues or have very intense experiences of pain or emotion. Sensory differences can cause challenges in everyday life including problems with sleep, feeding and constipation and can affect how a child tolerates hygiene tasks including brushing teeth, clipping nails and hair care.

Early School Age: A Honeymoon Period?

When these girls enter kindergarten, their autistic traits may seem to decrease. They’re often highly motivated to fit in at school and make great effort to do so. Through a phenomenon called “camouflaging” or “masking,” they develop coping strategies for social situations by studying peers or even fictional characters.

Socially, girls with autism tend to be overlooked rather than overtly rejected by their peers. For example, a girl may look engaged on the playground from afar but may actually just be hovering on the edge of the group. Friendships that autistic girls make are often weaker than others’ and may not translate to playdates outside school.

Also, girls on the autism spectrum are less likely to have disruptive behaviors like hyperactivity or aggression that call attention to their difficulties. Social withdrawal or passivity may be interpreted as shyness, and rigid adherence to rules and fairness may make them appear to be model students.

Early school age can be a sort of honeymoon period for autistic girls, as their social difficulties are effectively hidden and overlooked.

Late School Age and Adolescence: A Challenging Social Milieu

Often, autistic girls’ challenges come to light in early adolescence. Difficulty with executive function is common, so they may struggle with the added complexity of switching classes. Social dynamics also become more complicated, and girls who were able to get by with faking it in elementary school are suddenly struggling.

Because these girls still very much desire friendship, they tend to work hard to make friends and initially succeed. But it can be hard to understand the nuances of what makes a good friend or how to keep one over time. They often have one or a few intense friendships, but due to trouble handling conflict, these may break down when issues arise.

These girls may relate more easily to male than female peers, possibly because male social dynamics tend to be more straightforward. In fact, in studies of autistic and neurotypical (non-autistic) adolescents, interactions of autistic girls look most similar to those of typically developing males.

Older girls’ special interests usually still differ from classic male autistic interests. Instead of trains, history or outer space, female interests tend to be more relationally focused, such as celebrities, novels, fashion or manga. Again, because these interests are often similar to neurotypical peers’, they may not stand out, except for their intensity.

Perhaps because of this increase in social difficulty during high school, autistic adolescent girls are at increased risk for mental health conditions like anxiety, depression and eating disorders. When these girls are ultimately identified and diagnosed, it’s usually in the context of seeking mental health care.

Autistic girls and women are also more likely to suffer from central sensitivity syndromes like fibromyalgia, irritable bowel syndrome (IBS), chronic headache and temporomandibular joint (TMJ) disorder, which may also prompt them to seek care.

Look, and Ye Shall Find

Even when autistic girls and women seek help for their challenges, their autism often goes unrecognized because clinicians — like many others — don’t think of autism as a “girl thing.” By increasing awareness of how autism presents in females, we can move toward a future where all autistic girls receive the acceptance and support they deserve.

Jane Beriont is a fellow in the Developmental- Behavioral Pediatrics program at CHOP. She earned her medical degree from Thomas Jefferson University, completed residency at NYU Grossman School of Medicine, and worked as a hospitalist at CHOP before her fellowship.

Julia Parish-Morris is an Assistant Professor of Psychology at the University of Pennsylvania. She studies clinical language and communication phenotypes in individuals with neurodevelopmental or psychiatric differences, focusing on understudied groups like autistic girls.

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Migraine and Women

More than just a headache

Seniha Ozudogru, MD, Assistant Professor of Neurology, University of Pennsylvania, Director of Headache and Facial Pain Fellowship

Rachel Seligman, MSN, CRNP, Department of Neurology, Headache Program, University of Pennsylvania

It’s 10:30 on a Monday morning. You’re sitting at your desk, staring at the computer, when you start to feel the familiar twinge of pain in your temple. You try to push on through work, but the overhead light starts to bother your eyes. It becomes increasingly difficult to focus on the computer screen. You’re hit by a wave of nausea and realize this is more than just a headache.

It’s a migraine.

What is a Migraine?

Migraine is a common but complex neurological disorder characterized by recurrent attacks of head pain. Attacks are accompanied by nausea, difficulty concentrating and sensitivity to light, sound or smell. Worsening head pain during physical activity is another symptom. Pain is typically located on one side of the head, but may involve both sides, and it’s often described as pounding or throbbing. Episodes of migraine may last from hours to days depending on response to treatment.

There are four distinct phases of migraine: prodrome, aura, headache and postdrome. While some may experience all four phases during an attack, others may experience fewer.

First is the prodrome or “preheadache” phase, which usually lasts from a few hours to 48 hours. Symptoms vary, but may include fatigue, changes in mood, difficulty focusing, nausea, vomiting, neck and shoulder pain, and constipation or diarrhea. Unique symptoms include increased yawning, specific food cravings and increased urination.

The second phase is aura, which about 25% to 30% of sufferers experience. Aura refers to a series of sensory changes that typically occur right before the onset of head pain. During this phase, some people experience visual disturbances such as twinkling lights, flashes, bright spots or zigzag patterns. Others experience difficulty speaking or tingling on one side of the body. Symptoms lasting from 5 to 60 minutes are typically followed by head pain, but not always. Aura symptoms may not occur with every migraine attack.

Headache is the third phase. Sometimes the second aura phase can start or continue during headache phase. Pain typically occurs on one side of the head but may affect both sides. Or pain may start on one side of the head and move over to the other side. This head pain may last for several hours or several days, and the intensity may vary from one attack to another. Some episodes may be mild, while others may be debilitating. Other symptoms — nausea, change in mood, difficulty sleeping, and sensitivity to light, sound and smell — can begin in any of the first three phases. Physical activity may intensify pain during this phase.

The final phase, postdrome or the “migraine hangover,” occurs in about 80% of patients yet doesn’t occur with every attack. Duration and severity of symptoms can vary and include fatigue, difficulty concentrating, body aches, dizziness and continued sensitivity to light.

Impact of Migraine

Worldwide, migraine is rated as the second leading source for years lived with disability and rated first among young women based on the Global Burden of Disease Study 2019 data. This neurological condition may start at any age, but most often begins around puberty and peaks in the late 30s. Approximately 40 million people living in America experience migraine. Yet, only a third ever speak with their healthcare provider about treatment. Migraine is underdiagnosed and undertreated.

Recurrent episodes of migraine and severe headache can have a significant impact on people’s lives, affecting school attendance, job productivity, as well as time spent with friends and family. The economic burden of migraine in the United States is estimated to be between $13 and $17 billion annually.

Why Do More Women Get Migraines?

Migraine disproportionately affects women. Prior to puberty, girls and boys are affected at about the same rate. After puberty, women are three times more likely than men to have migraine. Around 43% of women will experience at least one attack of migraine in their lives, compared to 18% of men.

So why do women experience migraine at such a higher rate than men? The answer lies in the difference in hormones between women and men. Estrogen is most likely the main reason, although researchers believe other hormones may play a role as well. When estrogen levels fluctuate through a woman’s lifespan, the frequency of migraine can fluctuate too.

Onset of migraine increases with the first menstrual period. Drops in estrogen levels during menses are thought to trigger migraines. Frequent changes of estrogen levels during perimenopause may also lead to an increase in the frequency and severity of migraines. And there’s often a rapid decline after menopause.

How to Manage Migraines

People with migraine have a genetic predisposition that makes them more sensitive to biological and environmental factors. Factors such as stress, diet, dehydration and unhealthy sleeping habits can trigger migraine. As a result, it’s important to follow a healthy life style to reduce the frequency and severity of migraine attacks. Maintaining a consistent sleep schedule, staying hydrated, engaging in physical activity and managing stress may help prevent migraines.

It’s also helpful to keep a headache diary to track the frequency and severity of migraines and to document any triggers (stress, lack of sleep, menses) that contribute to each attack. Identifying symptoms and triggers can help you recognize when an attack will occur. Early treatment with acute medication is an important part of treatment.

If you’re experiencing multiple headache episodes per month or a disruption to your normal routine because of headache, speak with your healthcare provider. There are preventive and acute treatments available to treat migraine and other headache disorders. If your headaches have not been responding to treatment, it may be time for an evaluation by a neurologist or headache specialist.

Seniha Ozudogru is an Assistant Professor of Neurology at the University of Pennsylvania, and Director of Headache and Facial Pain Fellowship.

Rachel Seligman is a nurse practitioner in the Department of Neurology, Headache Program at the University of Pennsylvania, where she earned her nursing degrees and has spent more than 20 years working at specialty headache practices. She’s a member of the American Headache Society and American Academy of Neurology.

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How Women Can Stay Heart-Healthy

Strategies for a Stronger Tomorrow

Michelle Lu, NP, Primary Care Practitioner at Patina

Heart disease has long been considered a man’s disease, but the disease doesn’t discriminate. Heart disease is the leading cause of death for all adults in the United States, claiming the lives of men and women in nearly equal numbers. Approximately 695,000 Americans — one in every five adults — died from heart disease in 2021.

Heart disease can be deadly for anyone, but heart-related illness and death affect U.S. women at unacceptable and avoidable rates. Nearly five times more women die from heart attacks annually than die from breast cancer, despite what many believe. In a survey conducted by the American Heart Association, less than half of women (44%) knew that heart disease is their leading cause of death — a concerning decline of nearly 20% from 2009. Only 13% of women believed it to be their greatest personal health risk.

While heart disease can affect women at any age, women aged 65 and older are particularly susceptible. As women age, their risk of developing heart disease increases, making it crucial to address and understand the unique factors that contribute to their cardiovascular health.

The more women know about heart disease, the better chance they have of preventing it and surviving and thriving into their golden years. Learn how to help the women in your life protect their hearts by understanding the signs, symptoms and risk factors associated with heart disease in women.

Understanding the Aging Heart

Heart disease is a catch-all phrase for a variety of conditions that affect the heart’s structure and function. Health conditions, lifestyle and family history all play a role in determining your risk for heart disease. Nearly half of all Americans have at least one of the key risk factors for heart disease: high blood pressure, high cholesterol, diabetes or smoking.

Like much of your body, your cardiovascular system and its blood vessels — arteries, veins, capillaries — can stiffen over time. As a part of the normal aging process, your heart and blood vessels become more susceptible to changes, such as “leaks” in the heart valves that direct blood flow.

The aging heart might also experience changes in heart rate or rhythm. If not managed well, chronic conditions like high blood pressure can cause “remodeling,” where the heart muscle itself can change in shape, making it harder to pump blood and nutrients throughout the body.

Knowledge is Power

Until recently, experts’ knowledge of heart attacks was based primarily on research and data gathered from men. But with better and more extensive research on the differences between men and women, we’re beginning to understand that differences also exist between women and men when it comes to heart disease.

For example, menopause is a unique risk factor for women due to declines in the hormone estrogen. And some risk factors such as obesity, diabetes, metabolic syndrome and depression occur more often in women. Research has also found that women are more likely to have heart disease in the smaller arteries of the heart — called coronary microvascular disease — which can make the disease harder to identify, diagnose and treat. In addition, women typically have symptoms of heart disease about 10 years later than men.

Recognize the Warning Signs

Understanding the symptoms of a heart attack is crucial for timely intervention. Don’t wait to get help if you experience any of the common warning signs below. Some heart attacks are sudden and intense, but others start slowly, with only mild pain or discomfort. Pay attention to your body and call 911 if you experience:

Squeezing chest pressure or pain

• Jaw, neck or back pain
• Nausea or vomiting
• Shortness of breath.

In women, symptoms of a heart attack can be more subtle and different, including:

• Chest pain (but not always)
• Pain or pressure not always in the chest, but in the upper abdomen or upper back
• Fainting
• Indigestion
• Extreme fatigue.

Managing Your Heart Health After 65

Keeping your heart healthy is one of the most important things women can do as they age. If you’re 65 or older, there are lifestyle changes you can make to improve your heart’s longevity, lower your risk of heart attack and live a longer, healthier life, including:

• Eat a heart-healthy diet
• Stay active
• Manage your weight and build muscle
• Get healthy and consistent sleep
• Manage your blood pressure
• Screen for and treat diabetes
• Lower your cholesterol
• Avoid smoking
• Manage or reduce stress and anxiety
• Build social connections — loneliness is a risk factor for heart disease!

Small Steps, Big Impact

Heart disease is the number one killer of women in the United States. The more a woman knows about heart disease, the better chance she has of preventing, treating and reversing it. Knowing the signs, symptoms and risk factors can make all the difference. Making healthy lifestyle changes, following up regularly with a trusted primary care provider and understanding your unique risk factors can help you prioritize your health — and keep your heart strong at any age.

Michelle Lu, NP, is a Primary Care Practitioner for Patina, which delivers primary care exclusively for adults 65+ enrolled in traditional Medicare or participating Medicare Advantage plans in the Philadelphia five-county area. She’s a graduate of the University of Pennsylvania School of Nursing & The Wharton School and has been a clinician for more than 10 years.