Women are not just small men

Throughout her years studying in Groningen in the 1970s, Angela Maas championed the cause of women’s rights. These days, she works hard to ensure that cardiology is more tailored towards women. Her latest book Hart voor vrouwen was published in May, and she will take up a position as a UN representative in 2020.

Text by Kirsten Otten

Angela Maas (1956) studied Medicine in Groningen from 1974 until 1981, before training as a cardiologist in the St. Antonius Hospital in Nieuwegein. In 2006, Maas defended her PhD thesis about calcium deposits seen in blood vessels on mammograms at Radboud University Medical Center. Last year saw the publication of her third book, entitled Hart voor vrouwen – an informative book about heart problems in women. Although principally aimed at women, the book is also a useful read for partners, GPs and cardiologists.

As the daughter of a GP with a home practice, Angela Maas saw patients coming and going from an early age: ‘I became fascinated by the phenomenon of the ‘patient’ and knew that one day, I would become a doctor.’ Unlike most of her classmates at the grammar school in Utrecht, Maas decided to go and study in Groningen in 1974: ‘I’d heard it was one big party there.’

And was it?

‘You bet! But after a couple of nights in Albertus, I became a regular in certain bars and ‘fem-soc’ discussion groups. It was the height of the second wave of feminism, and I was into the feminist/socialist movement. These particular support groups were fighting for the position of housewives. We were often asked: ‘Does anyone actually know a housewife?’ We all put our hands up because all of our mothers were housewives… gender issues got me going even in those days.’

Do any of the lectures from that period stick in your memory?

I have very fond memories of the embryologist A.G. de Wilde. He was able to show us exactly how organs develop from an ovum and a sperm cell by drawing a few sketches. We didn’t have videos back then, but his drawings were just as good for us students!

What made you choose cardiology?

‘I first encountered cardiology during a junior doctor rotation with Prof. Evert (Everhardus) van der Wall. An inspirational man who could teach by the patient’s bedside and even managed to get the shy students involved. I fell for the specialism straight away but thought that it would be too difficult for me.’

‘Women were never really encouraged to choose cardiology: most of the programmes only accepted a limited number of women. Cardiology was a ‘man’s world’, consisting of men contemplating ‘men’s problems’, such as heart attacks and hardening of the arteries. These male patients were hard at work all day and when they came home, their wives expected too much of them… that’s what we were taught! Women with heart problems were largely considered to be hysterical or strange.’

And yet you still chose cardiology.

‘I’m a swift and decisive person. More and more people – including cardiologists who I met while training in Curaçao – said how much this specialism suited me. And I liked the idea of choosing a ‘men’s’ subject. A year after graduating in Groningen, I started my training as a cardiologist in the St. Antonius Hospital in Nieuwegein.’

How did you come to focus on the female heart?

While I was training, I learned that women often presented with ‘strange symptoms’, which could not be explained. I continued to see this when I started work in 1988: the results of women’s ECGs, cardiac catheterization and exercise tolerance tests were often inconclusive. Patients obviously wanted to know what was wrong with them. ‘You don’t know, do you?’ they’d say. They were right and that was so frustrating.’

‘In 1991, cardiovascular disease in women gradually found its way onto the scientific agenda. It became clear that you shouldn’t use the same standards for women as you do for men. Women are not just small men. Their hearts are certainly smaller, but due to their hormones, their hearts work differently and their coronary arteries age differently from those of men. These differences cause abnormal symptoms.’

Can you give a few examples of these differences?

‘Men’s coronary arteries tend to become blocked at a relatively young age. This can usually be treated quite easily with an angioplasty or a bypass. But women’s arteries narrow later in life under the influence of varying factors, including the menopause, high blood pressure during pregnancy, diabetes... And narrowing of the arteries in women is trickier to spot during an exercise-ECG.’

You have special cardiology surgery hours for women in the Radboud University Medical Center. Is this something you would recommend to other hospitals?

‘Absolutely. As well as the physical differences, there are also differences in the way that men and women approach their symptoms – gender-specific care is often much more efficient, making it cheaper too. Women tend to endure their symptoms for longer than men, sometimes with serious consequences. Men take more of a business-like approach in explaining their symptoms, whereas women are often more emotional and tend to put their symptoms down to stress. This sometimes wrong-foots the doctors examining them.’

But stress can cause heart problems, as you say in your book Hart voor Vrouwen.

‘Definitely. Middle-aged women seem to be particularly susceptible to heart attacks in which stress plays a role. Stress over-activates the hormonal system of the adrenal glands. This increases inflammation activity in the body, causing spasms in the blood vessels. These spasms can lead to a type II heart attack.’

You are a busy woman yourself. Are you under a lot of stress?

‘If I didn’t feel any stress, I’d never get up off the sofa. Low-level stress keeps you on your toes. But I’ve had to learn to make choices. Our priorities changes in every phase of our lives: caring for children, having a career, taking care of your health. And this means that you sometimes have to stop doing certain things for a while. So I’ve decided not to invite people for dinner at my home any more: I enjoy going to other people’s homes if they invite me, but entertaining others myself causes me more stress than pleasure.’

Do you still manage to visit Groningen?

‘I gave the Aletta Jacobs lecture in March; a real honour. I always love being in the city and the UG is currently doing all it can to get more women into top academic positions. The appointment of Cisca Wijmenga as Rector Magnificus is obviously a prime example. And I felt particularly proud when I read that Adriaan van Voors, who recently published an article in The Lancet about medication for women with heart failure, comes from Groningen!’