Becoming a Medical Feminist

I now call myself a medical feminist.

In a world of identity politics, that might sound like just another sensational claim. It’s actually a clinical evolution.

About 80% of the patients I see are women. Over the years, I started noticing a pattern in how they arrived: having already been through the system, already been tested, already been told that their labs were normal and their symptoms were stress or anxiety or just part of getting older. They’d done what they were supposed to do and come away with nothing. Sometimes for decades.

Our healthcare system has specific, documented blind spots when it comes to women. “Medical feminism” means understanding that women’s physiology isn’t just a variation on male physiology. It means knowing the same symptoms can mean different things in a female body. The same treatments carry different risks. The same standard of care that works reasonably well for one population has caused measurable harm to another.

Articles 1 and 2 introduced the underlying error: our medical system can’t hold uncertainty, so it misclassifies what it doesn’t understand. In this article I want to show that those errors aren’t randomly distributed. They’re concentrated in a specific population: women.

The reasons for that concentration go all the way back to how medical knowledge was built in the first place…

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Pattern 1: The Foundational Blind Spot

Women’s Health Was Never Fully Modeled

When I was doing my OB-GYN rotation at the Medical College of Virginia, I remember thinking: “This is it?”

Breast health. Uterine and cervical health. That was women’s health. Two systems. Two sets of organs. The rest of the female body, apparently, worked the same as a man’s.

It doesn’t.

Women’s sleep-wake cycles are different. Their protein requirements are different, and how they metabolize protein changes significantly through their forties and fifties. Their immune systems are calibrated differently. Their cardiovascular disease presents differently. Their nervous systems respond differently to the hormonal shifts that are unique to female physiology. None of that was part of what we were taught in the women’s health curriculum, because the women’s health curriculum was built around the organs that make women visibly different from men.

As Dr. Jenski put it: “they reduced it to the parts a two-year-old can point to.”

When a woman came in with symptoms that didn’t map to her reproductive organs, she was evaluated using diagnostic frameworks built on male physiology and male presentation patterns. When her results came back normal by those standards, the conclusion was that she was fine. But what if those standards didn’t apply to her physiology?

Think for a moment about what the female body is actually capable of. In order to carry a pregnancy to term, a woman’s immune system has to tolerate a genetically foreign organism inside her body without rejecting it. If we could understand exactly how that works, we could likely eliminate organ transplant rejection. We could probably make significant progress on autoimmune disease. The immunological sophistication required to do that is staggering.

And yet somehow the system concluded that the body capable of doing that could be adequately understood by focusing on two organ systems. That is the foundational error. Every pattern that follows in this article traces back to this: A model was built without women at the center of it. Everything downstream reflects that.

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Pattern 2: Misclassification

When Symptoms Don’t Map, the Patient Gets Labeled

Article 2 in this series described a mechanism: when medicine can’t categorize a condition, it recategorizes the patient. Symptoms become psychiatric. Real disease gets managed as a mood disorder.

That pattern exists across the population. But it concentrates in women. The reason traces back to the pattern above: if the diagnostic model wasn’t built on female physiology, then female presentations are more likely to fall outside what the model can see. And when something falls outside what the model can see, the explanation defaults to the patient.

Chronic fatigue and fibromyalgia are the clearest examples, and Article 2 covers them in depth. But misclassification shows up in places that are less obviously contested.

Perimenopause is one. I’ve had so many patients tell me they were told, in some form or another, “You’ll be fine, sweetie.” Hot flashes, brain fog, disrupted sleep, mood changes, joint pain … all dismissed as the inevitable inconvenience of getting older. The message was: “This is just what happens. Manage it.”

But I’m seeing younger and younger women hitting this wall. 42, 43 now, not 50.

What was actually happening, in many of those women, was a neurological and cardiovascular event. I tell patients that estrogen is a superpower. When it’s high, you can have a family, have a career, start a business, do all of it. Then you lose your superpower, and cortisol has been sitting there for 20 years. All of a sudden you’re like: “I’m miserable. I ache. I’ve got brain fog.” The nervous system is exposed in a way it wasn’t before. All those symptoms? These are not all-in-your-head phenomena.

And in the absence of a model, the explanation that’s always available is that the patient is anxious, overwhelmed, or simply experiencing the normal difficulties of being a woman. The patient goes home with that label. Over time, she believes it.

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Pattern 3: Under-Recognition

When the Presentation Doesn’t Match the Model

The most common cause of death in women in this country is heart disease. Not breast cancer. Heart disease.

And yet for decades, the diagnostic model for a heart attack was built around how a middle-aged man presents: substernal chest pressure, pain radiating down the left arm, the classic picture. Women can present that way, but they’re more likely to present with: nausea, abdominal pain, shortness of breath, fatigue, jaw discomfort. The symptoms are more diffuse, less dramatic, easier to attribute to something else. And so they were.

A colleague of mine had a female patient she’d been following for years. She knew something was wrong with this woman’s heart. The patient knew it too. They tried to get the right studies ordered. Insurance said no. The system kept coming back to the same conclusion: no significant cardiovascular risk. She finally became symptomatic enough to get a stress test. She went to the cath lab. She had over 90% occlusion in her left anterior descending artery. That’s the vessel cardiologists call the widowmaker.

She’s lucky to be alive.

Sadly, that story isn’t unusual. The disease was there the whole time, but the model was looking for something else. The system just wasn’t designed to see it.

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Pattern 4: Systemic Delay

When Research Fails Women

The Women’s Health Initiative study came out in 2002. Within weeks, practicing physicians were raising serious questions about the methodology: wrong population, wrong formulation, findings that didn’t hold up under scrutiny. The study used oral conjugated equine estrogen, synthetic progestins already known in lab research to cause tumors in rats, and an older smoking population. Blood levels weren’t monitored. The problems were visible early.

None of that mattered. The black box warning went up. Women were scared. Physicians didn’t want to get sued. And for 23 years, hormone replacement therapy was effectively taken off the table.

The estimated cost: 140,000 – 160,000 women who may have died prematurely from lack of access. Between 40 and 70 million women undertreated during that window. We now know that HRT can reduce cardiovascular disease risk in women by up to 50% and dementia risk by up to 38%.

Those are catastrophic numbers. And the mechanism is straightforward: institutional inertia. A badly designed study became clinical law. The correction came slowly, years after the evidence pointed toward it.

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Pattern 5: Mismanagement Under Uncertainty

When the System Acts Without Understanding

The failures so far are mostly failures of omission. The wrong label. The missed diagnosis. The withheld treatment. This pattern is different. This is what happens when the system doesn’t understand something and responds with action rather than humility.

Take mammograms. For years the standard recommendation was yearly screening starting at 35 – 40. The intention was protective. But when you look at the population-level data that UK and Scandinavian healthcare systems have been tracking for decades, the reality is more complicated. A woman who does yearly mammograms for 20 years increases her risk of breast cancer by about 25% from cumulative radiation exposure. The false positive rate on any given mammogram is around 10%. That means for every 100 scans, 10 women receive a result that leads to biopsies, lumpectomies, and a cascade of procedures from a reading that wasn’t actually positive. The biggest reason a radiologist gets sued is a missed breast cancer, so the system tilts toward over-reading. More flags, more procedures, more harm.

A major public health organization recommended cutting back to every other year. The response was immediate and fierce: “You hate women. Women are going to die.” The data said the opposite. But between legal exposure and the volume interests built around yearly screening, the recommendation was slow to take hold. Europe has been doing this for years.

The same mechanism runs through obstetric care. Continuous electronic fetal monitoring is standard in American labor and delivery. Every woman who’s had a baby in a US hospital knows it. The problem is that the evidence doesn’t support it. Countries like Ireland that use intermittent monitoring instead have better fetal outcomes. The American College of Obstetricians and Gynecologists has acknowledged this. The literature is clear. We still do it anyway, because if something goes wrong and there’s no continuous trace, you lose in court. The legal environment has overridden the clinical one.

In both cases, the harm was dressed as thoroughness. The patient felt cared for. The institution was legally protected. And women, at the population level, were being hurt by a system acting with confidence it hadn’t earned.

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Pattern 6: Fragmentation

Conditions That Fall Between Specialties

Several conditions with complex, multi-system presentations predominantly affect women. And they end up being handled the same way as every other thing the system can’t categorize: pushed to the fringe, or handed back to the patient as a psychiatric problem.

POTS

POTS (postural orthostatic tachycardia syndrome) is the clearest example. Rapid heart rate on standing, dizziness, fatigue, brain fog, anxiety, autonomic instability. Sometimes the hands mottle. Sometimes there are panic attacks at night. The presentation crosses every organ system line. Ask a cardiologist: “That’s an autonomic problem.” Ask a neurologist: “That’s a cardiovascular problem.” Ask a gastroenterologist about the GI component: refer out. No specialty wants to claim it, so patients get passed around or turned away, usually after years of being told their symptoms don’t add up to anything real.

I had a colleague, an old-school clinician who trained very clinically, who was seeing a young woman in the marching band. She stood at attention, got overheated, passed out. Had anxiety. He looked at her pulse and her fluid status and intuited that something was off with her volume. He gave her fludrocortisone to help her hold onto intravascular fluid, and all of a sudden she was able to get through high school and go to college.

He was an outlier. Most physicians seeing that same young woman would have seen anxiety. A teenage girl who faints. The specialty structure had no home for what was actually happening, so the explanation defaulted to the one that’s always available.

That’s the Article 2 mechanism again. When the biological explanation can’t be classified, the patient gets reclassified. It’s not specific to any single condition. It runs wherever medicine encounters a presentation that crosses the lines its structure is built around.

PCOS & Endometriosis

PCOS and endometriosis follow the same logic. The mechanisms are known. PCOS involves hormonal and metabolic dysfunction with significant inflammatory underpinning; endometriosis involves misplaced endometrial tissue driving systemic inflammation. Neither is well served by telling the patient to lose weight, manage her stress, and exercise more. But that’s frequently what happens, because the surface presentation offers an easier story than the actual one.

As Dr. Jenski put it: “the hormonal and inflammatory drivers get ignored because there’s an easy redirect: ‘It’s her fault. If she just took better care of herself…’” That’s just avoidance dressed up as a diagnosis.

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The Compounding Effect

Six patterns. One population. And the thing about patterns is that they don’t arrive one at a time.

A woman who gets the POTS misclassification in her thirties, the missed heart diagnosis in her forties, the withheld hormones through perimenopause, and the Lyme referral carousel in her fifties hasn’t experienced six separate failures. She’s experienced one sustained failure across decades. Each instance adds to the last. The diagnostic delay compounds. The internalized doubt compounds. And something else compounds too, something that doesn’t show up in any chart.

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Trust Your Gut. Here’s Why.

Women are more intuitive than the system gives them credit for. I know that requires some care to say, but the neuroscience is starting to back it up.

You have as many neurons in your GI tract as in your spinal cord. The gut-brain axis is not a metaphor. There’s emerging literature suggesting that the initial sense you get before conscious thought, that feeling that something is off before you can articulate why, is a real signal. Experts who’ve handled enough material develop the ability to know something is wrong before they can explain why. Women, because of their unique physiology and the way they’re trained from early life to read interpersonal and bodily cues, tend to have a more developed version of this.

The system routinely dismisses it:
Your labs are normal.
You seem anxious.
Come back when something shows up on a test.

And by gaslighting those patients, you make them question their own hunches. They start to believe that the feeling isn’t real. The intuition that was their best clinical tool gets suppressed by the authority of a system that wasn’t paying attention. Gradually, through years of being told what they feel isn’t there.

Educate it. Study, learn, percolate, give yourself some time. Don’t make rash decisions on a hunch, but don’t dismiss it. Do not dismiss it.

That’s what becoming a medical feminist means to me. Not anger at the system, but clarity about its limits. And a willingness to work inside those limits in a way that actually serves the people sitting across from me.

Functional medicine, as I describe it to patients, is the specialty between the silos. You’ve got your cardiology, your rheumatology, your endocrinology. We need all those people. But there’s a space between them, and that’s where we fit in. A space that looks at the whole body, across all the organ systems, without defaulting to the explanation that’s simply easiest to defend.

Listen to yourself. Listen to your body. No one knows you better than you. And never give up on yourself.