© 2002,Lippincott Williams & Wilkins. Inc.

The Social Structure, Stress, and Women's Health
KRISTI WILLIAMS, PhD, * and LIANNE M. KURINA, PhDt *The Ohio State University, Columbus, Ohio, and [University of Chicago, Chicago. Illinois

Of all the social determinants of health, gender is one of the most significant. Research spanning multiple disciplines indicates that women have higher rates of psychological distress, depression, and physical morbidity than men. 1,2 According to the social stress model.':" group differences in mental and physical health partly reflect socially structured variations in exposure and vulnerability to stress. Thus, understanding the socioenvironmental factors that influence the number and types of stressors to which women are exposed is essential to understanding women's health risks. The structural context in which women live has changed significantly over the past 30 years. Gender roles, family roles, and family structure have undergone dramatic shifts, many of which have been particularly relevant to women, These changes have imCorrespondence: Kristi Williams, Department a/Sociology, The Ohio State University, 42 Bricker Hail, 190 N. Oval Hall, Columbus, OH 43210. E-mail: klw@mail.sociology.ohio-state.edu. Funding/or this work was provided by NIHIN1A grant 2 T32AG00243 to K. Williams (NIA Specialized Training: Demography and Economics 0/ Aging) and Alfred P. Sloan Foundation, Center on Parents, Children and Work grant 2000-6- I 4 /0 L. M. Kurina.

portant implications for the types of stressors women face and, ultimately, for their health and well-being. This chapter reviews recent research and theory on the impact of three key demographic patterns on the number and types of stressors to which women are exposed and the consequences of these stressors for their physical and mental health, These three factors that have significantly increased stress in women are: (1) women's increased workforce participation, (2) the rise in divorce and single parenthood, and (3) the aging of the population. We also provide an overview of the psychosocial factors that influence women's vulnerability to stress, discuss the biologic pathways through which socioenvironmental stressors affect women's health and well-being, and explore disease outcomes of the stress process that are especially relevant to women, We conclude with a discussion of the ways in which interdisciplinary collaborations between sociologists, psychologists, and biomedical researchers can enhance our understanding of the processes through which stressors in the social environment affect women's health.




The Stress Model of Illness
Stress refers to a state of emotional or physiological arousal that occurs when demands from the environment (ie, stressors) tax the individual's adaptive capacity.Y The psychological and emotional changes evoked during the stress process can, over time, undermine mental and physical health. Stress has been shown to influence health through both biologic and behavioral mechanisms. Biologically, stress is associated with cardiovascular responses; 7 neuroendocrine changes, including catecholamine activity and increased cholesterol levels.f-" and impaired immune functioning."? Stress can also lead to negative health behaviors such as substance and alcohol abuse, smoking, and a lack of exercise. II Psychological and sociological research on the stress process indicates that exposure to stressors does not always lead to a stress reaction." In many ways, stress is in the eye of the beholder. Whether exposure to stressful life circumstances undermines health and well-being depends on how the stressor is perceived (eg, as threatening or benign), the salience of the stressor to the individual, and the strategies and resources available to the individual to respond to and cope with socioenvironmental challenges." Thus, vulnerability to stress is distinct from exposure to stress. A number of social and personal resources are thought to influence an individual's vulnerability to stress. Among these, social support has received the greatest attention. The advice, emotional support, and caring provided by interpersonal relationships not only helps individuals cope with stress but also reduces the probability that particular challenges will be perceived as unmanageable. 12, 13 Personal control or mastery, "the belief that one's own intentions and behaviors can impose control over one's environment.v'" influences vulnerability to stress through a similar process. 15 In addition, the salience of a socioenviron-

termines her vulnerability to stress. Research indicates that stressors that are related to social roles that are central to an individual's identity are more likely to undermine her mental and physical health. 16 Although some research indicates that, compared with men, women are exposed to more chronic strains 17-1 9 and are more vulnerable to the negative conse~uences of the stressors that they encounter, 1 other studies find no gender differences in exposure or vulnerability to stress.20-23 Clearly, both men and women experience stress, and the stress process is an important determinant of the health of all individuals, regardless of gender. However, because men and women have different social roles and structural positions, the types of stressors that they encounter and the resources available to cope with and adjust to these strains often differ considerabl y.

Much of the early biomedical research on the links between stress and health focused exclusively on men. This approach was due in part to attempts to understand men's greater risk of mortality from cardiovascular disease and other chronic health problems. This focus, however, left the impression that stress is an important risk factor for men only. The identification of the "Type A personality" and its greater prevalence among men/" buttressed this view. Because the gender distribution of morbidity has undergone significant shifts in the past several decades, there has been growing recognition of the need to more fully understand the link between stress and women's health. Indeed, some of the greatest changes in the gender distribution of chronic health problems are observed for conditions that are closely tied to stressful life circumstances. For example, despite a general decrease in the incidence of cardiovascular disease among men, it has actually increased

Gender, Social Stress, and Health

and (3) the aging of the population. in dis- Women and Paid Work Women's paid labor force participation has increased dramatically in the past two decades. and family structure have undergone dramatic shifts. A central tenet of the sociological stress model is that stressful experiences "don't spring out of a vacuum but typically can be traced back to surrounding social structures and people's locations within them.P Moreover. and psycholo~ical distress than their male counterparts. women do not have a monopoly on occupational stress. family roles. the differing structural contexts in which men and women live have important implications for the types of stressors they encounter. Although these changes have had many positive consequences. Sociological research on stress focuses on global mental and physical health outcomes of the stress process. however. including self-assessed health and psychological well-beinz or deoression. although women have longer life expectancies than men. the way they perceive or appraise potential stressors. depression. only 38% worked outside of the home. up from approximately 51% in 1978_28 The increase in the labor force participation of married women with children has been even more dramatic.:' -·39In a recent review ofwomen's occupational health. Thus. that a full understanding of the impact of stress on women's lives necessitates an understanding of the specific disease outcomes that result from the socioenvironmental stressors that women encounter and also requires knowledge of the biologic mechanisms through which these effects are produced. We therefore conclude with a review of emerging research on a potential mechanism through which stress may uniquely affect women's health (impaired ovarian function and diminished estrogen levels) and consider evidence establishing links between this mechanism and women's risk of heart disease and osteoporosis.. In 1978. is particularly relevant to an understanding of the unique stressors encountered by women. but by 1990 this figure had risen to 58%_29 These trends are not due exclusively to an increase in part-time employment: approximately three quarters of all em~loyed women work full-time. men's jobs are often challenging and demanding as well. We strongly contend. many of which have been particularly relevant to women.. Today approximately 69% of women between the ages of 25 and 64 work in the paid labor force.women. and the resources available to cope with environmental challenges. year-round. What is clear. Social change can.26 Sociologists have long been attuned to the importance of stress in women's lives." Of course. is that oaid emolovment is associ- . the resources available to women to manage these stressors. therefore. with its emphasis on structural and environmental stressors. Messing"" suggests that "stress is identified as the women's [occupational] health problem. Women and Stress in the 21st Century The structural context in which women live has changed significantly over the past 30 years. and ultimately their mental and physical health.30-34 employed women report more stress. cussing the consequences of recent demographic shifts on women's exposure and vulnerability to stress. this advantage has steadily declined over the past 10 years.27 According to this model. We next review the impact of three key demographic shifts on women's exposure and vulnerability to socioenvironmental stressors: (1) women's increased workforce participation. the health outcomes we examine are limited to these global measures of health and well-being. they also influence the types of stressors women face.i Although most research indicates that paid employment benefits a woman's mental and physical health. Gender roles. however. impinge on all phases of the stress process. The sociological stress model. (2) the rise in divorce and single parenthood.

associated with greater vulnerability to stress. at greater risk of experiencing this type of stress. the characteristics of the jobs that women tend to occupy have been shown to undermine personal control. Despite the dramatic increase in women's labor force participation. a process that is itself associated with psychological distress and poorer health. often requires the sublimation of one's own needs to the needs of others. general population studies indicate that these factors are positively associated with job strain and psychological distress. while family stressors should be more salient to wornen. employment in specific occupations and industries remains highly segregated by sex. Gender role theory suggests that stressors associated with the work role should be more salient to men than to women. Roxburgh?" speculates that employed women's vulnerability to workplace stressors is amplified by exposure to additional stressors associated with housework and childcare. research on gender and personal relationships suggests that women are more vulnerable to the negative effects of interpersonal stressors.46 Although there is a paucity of research on the effects of these job characteristics on women per se.48. nursing. women may also be especially vulnerable to the stressors that they encounter in this domain.49and lower personal control is. customer service). teaching. First. as identity theory suggests. the yearly earnings of women employed full-time in the paid labor force are approximately 71 % of men's.ated with a different set of demands and challenges for men and women. suggests that women are actually more psychologically vulnerable than men to the negative effects of job demands and high levels of routinization at work. 50 Providing care.t" and the gender gap in earnings places women. men and women tend to be employed in different sectors of the economy. stressors that occur in roles that are highly salient to one's identity more strongly undermine health. the strains associated with balancing the demands of work and family fall disproportionately on women. whether in the context of interpersonal relationships or paid labor. social work. women are concentrated in jobs that involve the provision of Sex Segregation of the Labor Force care to others (eg. the impact of financial strain on mental and physical health is well established.:" Women are also concentrated in service sector jobs that are characterized by low levels of autonomy and high levels of routinization.39 Although the reasons for this pattern deserve further investigation. We explore this possibility in more depth in the following section. the types of stressors to which they are exposed differ considerably. women's work roles appear to provide fewer psychosocial rewards (eg.P:"? Compared with men's. There are two primary reasons for this. On average." This could mean that in addition to being exposed to more demands associated with providing care to others. in tum. The available evidence. 54women should be less vulnerable to the negative effects of work-related stressors than men. however.43.41 Because men and women tend to work in different sectors of the economy.45. Second.42 For example. Very little research has examined whether women have heightened vulnerability to work-related stressors.l" If. especially unmarried women. The substantial increase in women's labor force participation has not been accompanied by parallel decreases in their work within the home. 50-52 Moreover.!" In addition. personal fulfillment and recognition from others). and these gender differences appear to partly explain women's poorer self-assessed health status/" Moreover. Estimates indicate that emnloved married women perform apnroxi- The "Second Shift" and WorkIFamily Strain .

The proportion of children born to single mothers increased from 18. The implications of this research for women's health are far-reaching' According to the allostatic load model." some evidence indicates that the challenges associated with balancing the roles of worker and wife/parent undermine women's mental and physical health. when they are also exposed to family demands. this gap is closed when the division oflabor in the home is equal. Divorce and Single Parenthood Patterns of marriage and parenthood have also undergone significant shifts in the past 30 years.. Although the "feminization of poverty" is rooted in a number of social structural factors.4% in 1980 to 33.59 Although studies of the health consequences of women's multiple roles have not produced a consistent pattern of findings. and psychologic resourcesresulting in poorer health. 4 sustained stress reactions have particularly detrimental consequences for biologic systems in the body and.32.56 The result is that many employed women face a "second shift" when they return home from the workplace.7 hours per week engaged in paid work and housework. 58 Theories of role strain "propose that women's multiple roles result in role overload or role conflict. poverty and financial strain are arguably the most pervasive of all stressors that disproportionately affect women in the United States. reflect their exposure to stressors in multiple domains that result in sustained stress reactions and an increased allostatic load.V Furthermore.2% in 2000. Between 1975 and 1990. ultimately.55. For example. HEALTH CONSEQUENCES Although very little is known about the physical health consequences of women's "second shift. the stress of household labor and maintenance is greater among women than men.67 A consequence of these trends is that an increasing number of women are raising children on their own. the percentage of ever-married women who had divorced by midlife increased from 20% to 32% for white women and from 29% to 45% for black women. women have higher levels of norepinephrine than men after returning home in the evening.62 Further. energy. On average. women's higher rates of morbidity may. during the workday. for the risk of disease and illness" Thus. a compound secreted by the sympathetic adrenal medullary system during a stress response. divorce and nonmarital childbearing are two of the quickest routes to poverty for women.61. the best evidence indicates that women's family roles and work roles interact to affect their psychological well-being.38 This discrepancy is amplified among those with children: women perform more than 75% of all childcare tasks.mately twice the amount of housework as men-what amounts to about two thirds of all household chores. such as low levels of control." These findings suggest that among emnloved individuals with similar levels of work stress. EXPOSURE TO POVERTY AND FINANCIAL STRAIN A lack of economic resources is one of the most significant stressors associated with divorce and single parenthood for women. Indeed. 57 Employed married women spend an average of 64. research on men and women in management positions finds that although men and women have similar levels of epinephrine. a situation that exposes them to a range of chronic strains that can ultimately affect their health and well-being. Rosenfield't'' reports that although employed women report more distress and depression than employed men.. divorce is associated with a 27% decline in available . women's mental health is most negatively affected by exposure to job stressors. in part." The rise in the divorce rate has been accompanied by an increase in nonmarital childbearing. which contribute to increased stress and excessive demands on time.

74 PARENTING STRAINS chosocial resources that help them manage these challenges. The available evidence indicates that balancing the demands of work and family is particularly challenging for single mothers. including residential crime and frequent residential mobility.69 Even more striking is the fact that approximately 46% of single mothers live below the poverty line." As noted. Doherty?" found that the transition to divorce is associated with declines in personal control. Avison 77 found that single mothers are more likely than their married counterparts to be exposed to caregiving and work strain. divorce and single parenthood are associated with poverty for many women. future research should attempt to describe the unique parenting-related stressors to which single mothers are exposed and identify the psy- Divorce and single parenthood not only increase women's exposure to stress. very little is known about the specific stressors that single mothers encounter in their daily lives.f" Other studies have found that compared with married women. parenting minor children is often stressful. 71.income for women and a 37% decline among women with children. a pattern that researchers attribute to divorce-related stressors.68. This evidence indicates that poor women are particularly reactive to the socioenvironmental challenges that they encounter. who typically assume sole responsibility for providing emotional support and care to children. The social networks of poor women tend to be smaller and less supportive than those of more advantaged women. and the effects of poverty on morbidity and mortality are well established. HEALTH CONSEQUENCES Despite the pervasive stressors engendered by divorce and single parenthood.76 The stressors encountered by average parents are exacerbated for single and divorced custodial mothers. very little is known about their direct health consequences for women.75. VULNERABILITY TO STRESS Regardless of women's marital. employment. 73. divorced women have higher levels of cholesterol. poverty and financial strain. Given the prevalence of single parenthood in the United States. However." . although chronic stressors themselves. but can also enhance the well-being of their children. because most research has focused on the effects of single parenthood on children's well-being. Recent estimates indicate that half of single mothers have a court order for child support. but only 25% receive the mandated amount. Understanding the stress process among single mothers can not only help to improve women's health. or socioeconomic status. For example. Mothers report greater levels of psychological distress and lower levels of well-being compared with those who do not have children. Poor women also have lower levels of personal control. Research on socioeconomic differentials in personal and social resources supports this possibility. expose individuals to a number of secondary stressors. disadvantaged women would continue to have lower psychological wellbeing. For example.7o Single mothers often have sole responsibility for providing financial support to children. but also the poverty that they engender may increase women's vulnerability to additional stressors. For example. goals that are often incompatible given the high cost of childcare. Moreover. 72 Divorced and never-married mothers who live in poverty encounter additional stressors associated with providing care and financial support to children. 78 Divorce itself may also increase vulnerability to secondary stressors such as financial strain. Turner and Noh78 found that even if poor women and more advantaged women were exposed to similar levels of stress. Some research confirms that separated and divorced mothers report more stress and generally poorer health than their married counterparts.

l" These trends have important implications for the types of stressors that women encounter throughout their lives.2% of the population. WIDOWHOOD Women's longer life expectancy. population will be over age 65. In fact. Between 1960 and 2000.88 some research suggests that women's physical health may be more negatively affected than men's. the strains of residential relocation (eg.?' The financial strain associated with widowhood is largely responsible for the poorer mental health of widowed compared with married women. control for factors that characterize divorce and that may amplify its negative effects on health. and Health Divorce per se and the stressors that it engenders do not appear to undermine women's health more than men's. especially. the older population is expected to explode in the next 40 years as baby boomers reach retirement age. 1105 owhood and advanced age accrue disproportionately to women. a role that itself engenders multiple stressors.S. Recent projections indicate that by 2040. financial strain is perhaps the greatest stressor faced by widowed women.f" Although there is little consensus on gender differences in the negative effects of widowhood. Controlling for socioeconomic status and/or the presence of children in the household may result in an underestimation of the negative effects of divorce for women because it is these factors that shape the challenges that divorced women face. but midlife and younger women are also increasingly likely to provide care to an aging parent. and loneliness associated with The age structure of the u. Estimates indicate that widowhood is associated with an 18% reduction in women's living standards.s.85 Because of their greater life expectancy.85 The most dramatic sex difference is seen among the oldest-old: approximately 72% of those over age 85 are women. 87Widowhood also exposes women to a number of secondary stressors.87.86. but this figure had risen to 12. adults over 65 represented only 9.87 Although most evidence indicates that widowhood is worse for men's mental health than for women. After the strain of bereavement. Population Aging . there was a 65% increase in the proportion of the population aged 65 and older. approximately one third of elderly women live near or below the poverty line. It is likely that divorce leads to the most negative health consequences for socioeconomically disadvantaged women with children.8% by 2000. more than 20% of the U. particularly among women. to be near a caregiving child or family member) or institutionalization. compared with 74% of men. including the loss of social support provided by the marital relationship. women substantially outnumber men at all ages over 65. means that women are much more likely than men to be widowed in late life. researchers generally recognize that the primary structural and psychosocial mechanisms responsible for the negative effect of widowhood on health likely differ for men and women.85 The death of a spouse is a stressful life event that is associated with increases in psychological distress and declines in self-assessed health. however. More research is needed to determine whether socioeconomic status and.f''' As a result. research indicates that divorce is associated with poorer health outcomes and greater mortality risk for men compared with women.8s Only 40% of women over the age of 65 live with a spouse. custody of a minor child moderates the effect of divorce on women's health. In 1960. Stress. Moreover. combined with the tendency of women to marry somewhat older men.Social Structure. population has changed dramatically in the past 40 years.82-84 Most studies on which this conclusion is based.

a significantly greater proportion of women compared with men reF:0rt having two or more chronic conditions.92 Among those over age 80. A recent report by the U. the proportion of adults requiring care due to illness or disability increases dramatically. socioenvironmental stressors appear to more strongly undermine the psychological well-being of functionally disabled individuals. however." Providing care to an ill or disabled family .97 Although these close personal relationships no doubt protect women's health. Moreover. Although the causes for increased vulnerability to stress in late life are not well understood. For. and estimates suggest that it will triple again in the coming 60 years. In addition to exploring these issues.S. 1 . Because the health problems experienced by women tend to be less immediately lifethreatening than men's. Mirowsky" found that although women tend to be more depressed than men at all ages." Moreover. results in a decline in socially supportive networks that might otherwise buffer individuals from the negative effects of stress exposure. For example. In general. 3 A recent report issued by the U. Moreover." VULNERABILITY LIFE TO STRESS IN LATE Research on gender and life course differences in depression suggests that exposure and/or vulnerability to late-life stressors is particularly freat for women.l" perhaps because of their reduced autonomy. "there is no historical precedent for the experience of most middle-aged and youngold persons having living parents. Age-related changes and late-life stressors may increase vulnerability to additional stress. Bureau of the Census'" indicates that 34% of elderly women need assistance with everyday activities compared with only 22% of men. stressor for women in late life. women spend a greater amount of time during late life coping with the strains of chronic illness and functional limitations. Ensel and Lin95 found that stressful life events such as the death of significant others are more strongly associated with physical health problems of older compared with younger adults. they can also involve strains associated with providing emotional support and practical assistance. functionally dependent women are more likely to live alone than their male counterparts. PROVIDING CARE TO AGING PARENTS As the population ages. they likely include the decline in autonomy and personal control that accompanies health problems and functional limitations. the role of exposure and vulnerability to late-life stressors in precipitating or exacerbating the health problems and functional limitations of older women deserves much more investigation. the number of persons aged 85 and over compared with those aged 50 to 64 years. Moreover. some evidence indicates that women are particularly vulnerable to the negative effects of stressful life events experienced by friends and relatives.s3 Very little is known about the potentially stress-provoking aspects of women's close relationships in later life or the impact of demands and strains in this domain on women's health and well-being. The parent-support ratio has tripled in the past 40 years.1106 WILLIAMS AND KURINA HEALTH PROBLEMS AND FUNCTIONAL DECLINE IN LATE LIFE Regardless of their marital status. the gender gap increases significantly with age.S. future research should seek to identify the factors responsible for life course variations in vulnerability to stress and determine whether these processes differ for men and women. example. Census Bureau'" states." The result of this demographic shift is a dramatic increase in what is commonly described as the parent-support ratio. older women tend to have more close relationships outside of marriage than men. women are especially likely to experience poor health and chronic disease in later life.

and therefore less appreciated. Caregivers report more psychological distress and greater physical and p. a constriction of the blood vessels. 104.102 In addition to providing more frequent care to aging parents than their male counterparts. who. however. Research indicates that women's psychological distress in midlife is strongly related to the challenges of balancing roles of parent. does stress produce adverse effects on the body? What are the biologic pathways through which stress affects health. PHYSIOLOGICAL STRESS RESPONSES TO Pathways from Stress to Illness There are two distinct physiological pathways. 100 In addition to the primary stressors directly associated with caregiving. resulting in the "fight or flight" response: increased blood sugar levels. in midlife. perhaps because the provision of care by a daughter is more expected. The aging of the population. and care provider to an aging parent. we focus on the relationship between stress and ovarian dysfunction and consider how suppression of reproductive hormones may be related to common and disabling conditions among women. an increase in heart rate (together increasing blood pressure). and a diversion of blood from nonessential organs to the heart. exactly. which has the effect of reinforcing and prolonging the fight or flight response. directed by the sympathetic nervous system (SNS) and the hypothalamus respectively. The SNS acts quickly and generates a brief. and might some of these pathways differ for men and women? In this section. combined with trends toward later childbearing. but how. has resulted in what some have called the "sandwich generation"-baby boomers. Regardless of the existence of other roles. strong physiological response to a perceived threat.107 Concurrently. Stress stimulates the hypothalamus to manufacture and release corticotropin releasing factor (CRF). which causes the pituitary gland to release . women are more likely than their male counterparts to miss work or quit their jobs due to responsibilities of providing care to a parent. and Health deavor and one that is overwhelmingly undertaken by women. we review the primary physiological responses to stress and discuss some of the potential diseaserelated effects of these responses that are particularly relevant to women. find themselves simultaneously raising children and providing care to aging parents. 100 The result is that among those who provide care to an aging parent. In contrast. women's caregiving responsibilities tend to be more demanding and often include daily care and household maintenance. and skeletal muscles.Social Structure. brain. the hypothalamus activates a slower-acting but much longer-lasting stress response through the hypothalamuspituitary-adrenal (HPA) axis. and caregiver. worker.s_xchiatric symptoms than 1107 The relationship between stress and ill health is commonly accepted.l'" Moreover.l'" Moreover. women report more stress than men. worker. some evidence suggests that female caregivers receive less socioemotional support from the care recipient than their male counterparts. the SNS stimulates the adrenal medulla to release catecholamines (epinephrine and norepinephrine) into the bloodstream. that are activated in response to stress. it is clear that the strains of caregiving undermine health and well-being. Specifically. Short-term stressors mobilize the SNS. including osteoporosis and heart disease. Stress.99-101 Estimates indicate that over 50% of women will provide care to an aging parent at some point in their lives.105 situation that may lead to finana cial strain associated with reduced work hours or unemployment. than the provision of care by a son. providing care to an aging parent often exposes women to secondary stressors associated with balancing the roles of parent.

115 These gender differences. Although these findings are commonly interpreted as evidence that estrogen pro- . by affecting healthrelated behaviors. on average. acute stressors are associated with an upregulation of the immune system. I 13.l''" suggesting that differences in estrogen levels (which do not become pronounced until puberty) may be partly responsible for gender differences in stress reactions. including the hypothalamus-pituitary-thyroid (HPT) axis.64 Finally. I 12 and the ma~ority of these women go untreated. via persistent hypercortisolism. and indirectly.I07 In addition to its effects on the cardiovascular system. The physiological mechanisms activated by stress are presumably an adaptation to help people cope with the threat at hand. energy resources are mobilized. 108-1 11 Depression impacts physical well-being both directly. twice as common in women as it is in men: it is estimated that 12% of the women in the United States suffer from depression each year. DEPRESSION. too-frequent threats. and unnecessary functions are temporarily shut down. Realization of the pathway from stress to physical illness is strongly contingent upon the severity and/or persistence of the stress response. or a breakdown in the negative feedback system that normally regulates the stress response can generate problerns. which may be typical in chronically stressed individuals. thereby helping to sustain the rise in blood pressure necessary to promote efficient distribution of nutrients to the cells.1108 WILLIAMS AND KURINA adrenal cortex to produce and release corticosteroids (primarily cortisol) into the body. however. Depression is. A comprehensive meta-analysis of research on gender differences in stress responses indicates that among adults. in particular) mimic those of stress. in which lymphocytes are mobilized into the bloodstream. we mainly consider the first alternative: chronic or severe stress leading to persistent HPA activity. while women show greater heart rate reactivity. have been shown to depress immunologic function. The increase in cortisol levels after activation of the HPA axis promotes glucose formation from noncarbohydrate molecules and enhances epinephrine's vasoconstrictive effects. the HP A axis also interacts with and strongly influences the other neuroendocrine axes in the body. This process is not in and of itself pathologic. nonadaptation to repeated stressors of the same type. including the brain.P" Somewhat counterintuitively. the immune system. The best evidence suggests that the biologic pathways through which stress affects health may differ by gender. but prolonged increases in cortisol levels. effects of which we will consider in more detail below. the endocrine abnormalities common in major depression (hypercortisolism. indeed. 14 Given how common an exposure depression is (and stress that much more so!). the immune system is put on alert. and the hypothalamus-pituitary-gonadal (HPG) axis. and the cardiovascular system. cortisol also affects the immune system. health-damaging effects can also occur when the cortisol stress response is not sufficiently strong-a condition that promotes the secretion of inflammatory cytokines (normally suppressed by cortisol) and hence an enhanced inflammatory re~ Here. AND ILLNESS Stress is a strong risk factor for depression. men show greater blood pressure and urinary epinephrine reactions to laboratory-induced stressors. STRESS AND OVARIAN FUNCTION Persistently elevated levels of cortisol and catecholamine exposure have effects on multiple organ systems in the body. STRESS. we suggest that the etiological pathways to illness discussed below have important implications for women's health. responsible for the regulation of reproductive function. are not observed among prepubertal children. critical to normal metabolism.

Stress. including heart disease and osteoporosis. Although more extreme forms of hypogonadism are typically treated with estrogen supplementation. in the absence of other endocrine abnormalities. estrogen levels themselves may be affected by stress. women have a much lower risk of heart disease than men. Given emerging evidence of the links between stress exposure and estrogen levels. inhibiting ovarian function and decreasing levels of circulating estrogen. is associated with changes in important heart disease risk factors. subordinate females were characterized by hypercortisolemia. stress and depression are among the most important causes of functional hypothalamic hypogonadism.l " (2) increases in the likelihood of clotting.119 As shown in Figure 1. stress and persistent HPA activation can effectively shut down the HPG axis. impaired ovarian function. in tum. and women's health: potential etiologic pathways. There are several reasons to suspect that estrogen levels are related to the risk of heart disease among women.III. have been linked to specific health risks among women. I 23 and (3) increased storage of fat in the abdominal cavity. I 18. Thus. including: (I) acceleration of atherosclerosis as a result of frequent or sustained increases in blood pressure. emerging evidence indicates that among women. 118. such as increased serum Prolonged/acute stress -7 HPA activation -7 HPG inhibition -7 Ovarian dysfunction -7 Decreased estrogen levels Increased risk of heart disease I increased risk of osteoporosis FIG. 119 Such an effect has been observed in cynomolgus macaques. HEART DISEASE Research in a variety of animal models and in humans has established that stress and depression are significant risk factors for heart disease. Kaplan et al!18 showed that in comparison with dominant females. 125 but their risk increases steadily with age. In women. but there is growing interest in the relationship between endogenous estrogen levels and heart disease. estrogen. 124. The limited data that exist suggest that ovarian dysfunction may be quite common among premenopausal women'{' and that. First. in particular. a primate species with a complex social structure resulting in strong dominance hierarchies. .health consequences of stress exposure (particularly the risk of CHD).120. occult anovulation will generally go unnoticed and untreated (except in cases where women are trying to have children).121 ultiple etiological pathM ways have been proposed for these relationships. We consider these etiologic pathways in greater detail below. behavior dysfunction. researchers have begun to explore the role of ovarian function and estrogen in mediating the effects of stress on specific disease outcomes.1. Diminished estrogen levels. as discussed below. due to HPAinduced changes in platelet reactivity. Menopause. and low circulating levels of estrogen.123 Research on heart disease in women has been undertaken only in recent decades. ovarian dysfunction consists of a spectrum of conditions from amenorrhea to occult anovulation. impaired ovarian function resulting in diminished estrogen levels may itself be a unique pathway through which stress adversely affects women's health.

136 and are strongly associated with future morbidity and mortality. 138 Although findings have not been entirely consistent. 128 These findings suggest that estrogen may playa role in protecting young women against heart disease. the impact of other ovulatory disturbances on BMD was uncertain. ovarian function and atherosclerosis progression and their potential links to socioenvironmental stressors have not been studied prospectively in premenopausal women. although no relationship was observed between urinarr sex hormone excretions and CHD risk. To date. Although the relationship between stress and osteoporosis or fractures has not been studied directly. 133 IS extreme I common y among postmenopausal women in the United States. strongly supported by research with the cynomolgus macaques. I 17. as affected by short luteal phase. or oligomenorrhea. there is emerging evidence that depression is associated with decreased BMD and an increased risk of osteoporotic fracture in older women. gonadal dysgenesis. young women. history of premenstrual symptoms. Might diminished estrogen exposure before menopause predispose women to heart disease later in life? Several case-control studies suggest that this may be the case. 13 These findings. combined with emerging evidence of the effects of stress on estrogen levels. however. Early menopause (whether natural or surgical) is also associated with an increased risk of heart disease. OSTEOPOROSIS Osteoporosis. but this process was inhibited by exogenous estrogen. Irregular menstruation has been linked both to risk factors for cardiovascular disease like increased plasma fibrinogen concentrations and thickened or sclerotic arterial intima 129 and to risk of myocardial infarction. and premenopausal oophorectomy for BMD. 126 changes that are mitigated by estrogen supplementation in the form of hormone replacement therapy (HRT). via the same pathway described above for heart disease (see Fig. menstrual irregularities.137 suggesting a biologic mechanism for the observed relationship between estrogen deficiency and BMD. The pathway from stress or depression through ovarian dysfunction and diminished estrogen levels to heart disease is a plausible etiological pathway. suggest that impaired ovarian function may be a pathway through which stress affects heart disease risk among women. and vertebral osteoporosis or bone loss. 145-148 The high prevalence of depression and stress in women in the United States and the small changes in bone density associated with important increases in fracture rates together suzzest the oublic health imnortance of fur- . I 4 A review of the literature at the time of this discovery emphasized the importance of gynecologic disorders like amenorrhea. defined operationally as a significant reduction in bone mineral density (BMD) compared with that of average . however. subsequent studies have shown links between endogenous estrogen exposure. 127. 118 premenopausal subordinate females developed atherosclerosis at about the rate of male macaques (whereas atherosclerosis progression was very slight in dominant females).levels of low-density lipoprotein and decreased serum levels of high-density lipoprotein. 131 Results of a nested case-control study in the Netherlands suggested that anovulatory cycles were more frequent in women who later developed CHD. anovulatory cycles.139-144 The results of these studies suggest that less severe estrogen deficiencies could also operate to enhance the risk of osteoporosis and fracture later in life. seen both in postmenopausal women (not taking HRT) and in premeno~ausal women with ovulatory disturbances. 1).P" The presence of biologically active estrogen receptors in normal human osteoblast cells was demonstrated unequivocally in 1988.P" A smaller study showed that premenopausal women with CHD had significantly lower levels of plasma estradiol. 134 Hip and vertebral fractures are directly related to low BMD135.

but the mechanisms through which social support protects individuals were previously not well understood. divorce. it rarely links these mechanisms and outcomes back to the varying social environments of men and women. results from a complex interaction of biologic. In fact. and psychological factors. but they also attempt to explain individual or group differences in stress responses by examining the influence of the social environment on the walc that particular stressors are appraised. There is little doubt that the strains associated with balancing the demands of work and family and providing care to aging parents.151 shows great promise for understanding how socialpsychological factors influence biologic stress responses and. 146--149 Sociological research clearly indicates that the roles and statuses that women occupy structure the number and types of stressors to which they are exposed. ultimately. researchers in each discipline emphasize different aspects of this process and rarely combine their efforts. epidemiologists are interested in differences between the sexes in disease risk. depression. Psychoneuroimmunologists have made important contributions in this regard by establishing that social support has direct beneficial effects on immunocompetence and on cardiovascular and endocrine systems. The result is a somewhat fragmented view of the causes and health consequences of the stressors that women encounter in their daily lives. social. In contrast. which emphasizes the interaction of psychosocial processes with nervous. Making these links is essential to a complete understanding of the stress process as experienced by women. have important implications for women's health risks. psychologists. Although sociologists. The positive association of social support with mental and physical health is a central component of the sociological model of health and illness. many biomedical studies of the stress process focus exclusively on laboratoryinduced stressors. Not only do health psychologists recognize that social and psychological influences on group differences in health are mediated by biologic processes. but they generally do not have the theoretical framework or methodological tools to consider social context in sufficient detail to incorporate it into their causal disease models. and biologic dimensions of the stress process. they rarely investigate the effects of these stressors on specific disease outcomes. an approach that precludes a consideration of gender differences in biologic reactivity to stressors based upon their salience or relevance to one's identity. psychological. and biomedical researchers commonly agree that the health of all individuals.ther investigating the links between stress. Thus. endocrine. poverty. Although social scientists have made great contributions by identifying socially structured variations in exposure and emotional vulnerability to stress. An integration of these lines of research has great potential for the development of a more complete understanding of the processes underlying gender differences in specific disease risks. and single parenthood. including women. as well as the challenges associated with aging. emerging research in health psychology and psychoneuroendrocrinology indicates that the primary biologic pathways through which these stressorsaffect health differ for men and women.152 Psychoneuroimmunology has also been successful in identifying gender differences in the links hetween socioenvironmental . althnnch nhvsiolooical and enidemiolocical Avenues for Interdisciplinary Research research has greatly enhanced our understanding ofthe specific mechanisms through which stress affects health and has shed light on sex differences in health outcomes of the stress process. The field of health psychology has made great strides in integrating the sociological. Moreover. I 0 Psychoneuroimmunology. disease risks. and immune systems. and osteoporosis.

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