It is well known that women not only tend to acquire rheumatic and musculoskeletal diseases (RMDs) more frequently than men but also often face disparities in the diagnosis and management of these conditions. But why do these disparities persist in the rheumatologist’s office and beyond, and what are some ways that rheumatologists can help to mitigate them?

“The main issue is gender bias,” Loreto Carmona, MD, PhD, a rheumatologist and epidemiologist with the Instituto de Salud Musculoesquelética, Madrid, Spain, told Medscape Medical News. She is the first author of a viewpoint article published in Annals of the Rheumatic Diseases that “highlights significant sex- and gender-based disparities, where women are disproportionately affected by prevalence, diagnosis, treatment, and occupational risk factors.”

Carmona said that “The problem persists because bias is often invisible; many doctors do not realize they are treating women differently…. Historically, medical research and diagnostic rules were based on how diseases look in men. Also, there is a social and medical tendency to normalize women’s pain, seeing it as ‘expected’ or less urgent. Another factor is the lack of data on how hormones (like estrogen) and life stages (like menopause) affect these diseases. Furthermore, women often have less access to advanced therapies when the diagnosis comes late, which makes their long-term health outcomes worse.”

The viewpoint article by Carmona and colleagues noted that osteoarthritis affects 18% of women vs 9.6% of men aged older than 60 years, rheumatoid arthritis (RA) has three times greater incidence in women, and systemic lupus erythematosus (SLE) rates are considerably higher in women compared to men (8.82 vs 1.53 per 100,000 person-years). In addition, the authors cited data showing that women with axial spondyloarthritis face an average diagnostic delay of 8 years, compared with 6 years for men, and are more likely to be misdiagnosed.

Many Factors Contribute to Disparities

According to Medha Barbhaiya, MD, MPH, a rheumatologist and clinical researcher with the Barbara Volcker Center for Women and Rheumatic Diseases at Hospital for Special Surgery, New York City, said the reasons behind these disparities can be multifactorial from a clinical perspective.

“Certain manifestations of systemic rheumatic diseases like fatigue, joint pain or rashes, cognitive issues, and intermittent swelling can be quite nonspecific,” Barbhaiya told Medscape Medical News. “Thus, women can experience diagnostic delays, particularly when laboratory testing is negative or indeterminate or there’s not a clear-cut diagnosis. Additionally, the symptoms may at times be attributed to other things, like stress or anxiety.”

“I think that historically women have been less believed when they go to doctors to talk about their symptoms,” Megan Clowse, MD, MPH, professor of medicine, ob/gyn, and population health sciences and chief of the Division of Rheumatology and Immunology at Duke University School of Medicine, Durham, North Carolina, told Medscape Medical News. This can be an issue, Clowse pointed out “because most of our rheumatic diseases are more common in women, and that sort of can lead to some delay in patients being taken seriously by their providers and really heard about their symptoms, particularly pain symptoms.”

Long wait times for appointments are another key issue. A 2024 Canadian study published in Musculoskeletal Care found that long wait times hit a spike during the pandemic years but still persisted as of 2024. After adjusting for triage level, age, and geographic location, women waited significantly longer in the peri-COVID period than men (10.2 days; 95% CI, 7.1-13.3) but in the post‐COVID period still waited an average of 7.5 days longer (95% CI, 4.0-11.1).

“Unfortunately, while there was a small improvement, we found that women were still waiting longer for appointments post-COVID,” said the study’s first author Steven Katz, MD, professor of medicine and chair in the Division of Rheumatology at Queen’s University, Kingston, Ontario, Canada. “Because we suspect the causes of delay are multifactorial and beyond our triage system on its own, it suggests a broader societal effort is needed to resolve these issues, as it is unlikely unique to just rheumatology referrals.”

One potential underlying cause may be caregiving burdens. According to the Family Caregiver Alliance, 66% of caregivers are women. These responsibilities can interfere with the caregiver’s ability to make appointments as soon as noncaregivers. Further, one 2023 paper published in Arthritis Care & Research revealed an elevated risk for incident RA and SLE among postmenopausal women who experienced various stressors, including caregiving 3 or more days per week (hazard ratio [HR], 1.31; 95% CI, 0.89-1.92; P for trend = .2115).

“Studies have demonstrated that the risk of specific autoimmune rheumatic diseases is increased in women who are postmenopausal and experiencing psychosocial stress,” Elizabeth Volkmann, MD, MS, associate professor of medicine, director of the University of California-Los Angeles (UCLA) Scleroderma Program, and co-director of the UCLA Connective Tissue Disease-Related Interstitial Lung Disease Program in the Division of Rheumatology, Department of Medicine at the Ronald Reagan UCLA Medical Center, Los Angeles, told Medscape Medical News. “Caregiving burdens can affect access to timely care, as caregivers may not be able to schedule and keep appointments with specialists due to the competing demands of their caregiving role, which can in turn lead to diagnostic delays.”

One Example: Tracking Reproductive Health Concerns

Questions and concerns that women with RMDs may have about pregnancy and reproductive health may also go unaddressed at rheumatology visits, but these can be addressed with concerted effort, experts said.

“Certainly, some of the reproductive health needs of our younger patients with rheumatic disease are frequently overlooked in the rheumatology clinic and not really understood outside of the rheumatology clinic,” Clowse said. “And so our patients do end up with substandard care sometimes if their reproductive health care needs aren’t really addressed by their rheumatologist.”

Clowse recently helped to lead a study, published in Arthritis Care & Research, that attempted to raise documentation rates around patients’ contraceptive methods and interest in pregnancy. After developing a learning collaborative encompassing five clinical sites, the researchers found that medical assistants and malleable electronic health record (EHR) systems can significantly improve documentation of contraception and pregnancy interest.

The community-based sites in the collective implemented custom, flagged EHR fields and largely assigned documentation to medical assistants at check-in, while the academic sites relied on provider documentation in notes.

Investigators found that the intervention improved documentation substantially, particularly in the three community practices. Site A increased contraception documentation from 0% to 66.4% and pregnancy intention documentation from 0% to 63.1%; site B from 39.0% to 64.8% and 0% to 72.0%, respectively. At site C, the lead physician and an advanced practice provider improved substantially (contraception from 19.7% to 79.4%; pregnancy intention from 0% to 88.9%). The two academic sites saw more modest changes.

While EHRs may have been overlooked for this purpose in the past by some rheumatology practices, the study demonstrated the technology’s potential for making a tangible difference, learning collaborative member and study co-author Richard Jones, MD, PhD, a rheumatologist with the Clinic for Rheumatic Diseases in Northport, Alabama, and a member of the clinical faculty at the Tuscaloosa, Alabama, campus of The University of Alabama at Birmingham Marnix E. Heersink School of Medicine, told Medscape Medical News.

“There has been recognition for some time that accurately tracking reproductive health issues by rheumatologists in [EHRs] has been lacking,” Jones said. “This study confirms yet again the reality of that deficiency in both private and academic practices but also proposes remedies for this deficiency. The group came up with the interventions, mostly by asking the correct questions at patient visits and documenting those answers.”

Simple Actions to Optimize Care

According to experts, rheumatology practices can take relatively simple steps to improve care for female patients.

“I think in general, improving care for women with systemic rheumatic disease requires not just improving our ability to manage and prevent disease complications,” Barbhaiya said, “but really also requires listening to women, taking their symptoms seriously, recognizing potential biases, and incorporating factors relevant to reproductive and other women’s health issues into their rheumatology care. It is also extremely important to understand any barriers to health that exist in their daily lives.”

To help address caregiving burdens and their impact on health and timely care, Volkmann said rheumatologists could ask whether patients serve as caregivers or have other relevant stressors in their lives.

“Rheumatologists do not routinely ask patients whether they serve as a caregiver,” she said. “Having a greater understanding of this important issue could help rheumatologists care for patients and make accommodations where necessary. For example, the caregiver may have a greater ability to attend telehealth visit vs an in-person visit.”

With a broader lens, rheumatology practices can assess their own performance to identify areas for optimization.

“Rheumatology practices can take several steps,” Carmona said. “First, they can check their own data by analyzing results for men and women separately to identify gaps in diagnostic times in their clinic. Then, train staff at the primary care level on gender bias and the importance of active listening to female patients expressing pain and debunking myths. Ideally, address menopause and reproductive health in rheumatology research, and update diagnostic criteria to include how diseases present in women.”

Clowse disclosed receiving consulting fees from AstraZeneca, Bristol Myers Squibb, GlaxoSmithKline, and UCB, as well as being on the advisory boards of MotherToBaby and RheumNow. Barbhaiya, Carmona, Jones, Katz, and Volkmann had no relevant disclosures.

Scott Harris has been covering rheumatology for more than a decade. He lives near Washington, DC.