A Subspecialty for Half the World’s Population: Women’s Neurology

The emerging subspecialty of women’s neurology addresses a long-overdue gap in understanding how sex and gender impact neurological health. Despite women making up nearly half of the global population,¹ research has historically treated male physiology as the default, leaving critical aspects of women’s health underexplored, including in neurology. For example, sex hormones like estrogen and progesterone significantly influence brain regions like the hippocampus and prefrontal cortex, yet human studies often neglect the role of women’s reproductive health and hormone cycles.² In an article in The Guardian, Jennifer Garrison, PhD, of the Buck Institute for Research on Aging, commented, “[A] truly profound sex bias in biomedical research and in clinical research goes back for as long as we have had biomedical research. The male body has been biology’s baseline for the last 100 years and if you don’t study female bodies, then you’re never going to learn anything about them.”³ This omission has reduced our insights into conditions such as migraines, multiple sclerosis, and epilepsy, which often present differently in women. As Nina Miolane, PhD, of the University of California Santa Barbara, commented in an interview with NeurologyLive, “All together, studies on health factors specific to women constitute less than half of 1% of the brain imaging literature. These knowledge gaps are even more prominent for women of color, older women, and women with disabilities. This has impacted the lives of women in ways that we are just starting to understand.”⁴

"All together, studies on health factors specific to women constitute less than half of 1% of the brain imaging literature. These knowledge gaps are even more prominent for women of color, older women, and women with disabilities. This has impacted the lives of women in ways that we are just starting to understand."

In the past decade, however, progress has been made, including at the governmental level. In 2016, the National Institutes of Health (NIH) mandated sex as a biological variable in research. Their guidance document states, “[P]reclinical research studies continue to rely heavily on male animals and/or omit reporting of the sex of animal subjects; this is particularly problematic in those studies intended to inform understanding of diseases and conditions affecting both sexes. Just like randomization, blinding, sample size calculations, and other basic design elements, consideration of sex is a critical component of rigorous experimental design. Failure to account for sex as a biological variable may undermine the rigor, transparency and generalizability of research findings.”⁵ In 2021, the Canadian Institutes of Health Research endorsed a similar policy.⁶ The White House supported these efforts with a presidential memorandum in 2023 and an executive order in 2024 to support women’s health research in the federal budget.⁷

Thus, women’s neurology is pregnant with possibility and rapidly growing. Two recent developments already affecting the field are the 2024 release of the women’s neurology curriculum by the American Academy of Neurology (AAN) and the 2023 founding of the Ann S. Bowers Women’s Brain Health Initiative.

The AAN Women’s Neurology Curriculum for Residents

One of the challenges moving forward is whether researchers and doctors will be prepared to join and expand the field. In a 2000 survey in the United States, 33% of medical schools reported “an office or program with [a] women’s health curriculum oversight,” which had risen from 10% in 1994/1995.⁸ In 2008, a survey of US medical students “reported only brief to moderate coverage of women’s health and sex/gender-specific topics in curricula; sex/gender-specific information on common medical disorders received the least coverage, a pattern that has persisted for more than a decade.”⁸ In a very small survey in 2019, US neurology residency program directors reported that “28% of the programs had no lectures focused on the care of women with neurologic illness” and 56% of the directors admitted that their programs offered said inadequate training.⁹ “The defined barriers to incorporating such didactics were lack of time, lack of expertise, and/or a lack of educational materials.”¹⁰

“The most powerful work to be done is to connect….That’s what curriculum and education do. It’s one of the most powerful connectors and levelers of what we do,…to build on the momentum…and be the superconnector that this work inherently entails.”

The authors of the AAN women’s neurology curriculum created it to address many of the issues cited above. Three women representing the 3 North American schools that have a women’s neurology fellowship—Esther Bui, MD, FRCPC, from the University of Toronto, Janet F.R. Waters, MD, MBA, from the University of Pittsburgh, and Mary Angela O’Neal, MD, from Harvard University—led the development of what Bui calls “a 2-year overnight success.”¹⁰ As development of the curriculum continued, other clinicians were brought on to the project to cover different subspecialties. One of these clinicians was Riley Bove, MD, of the University of California San Francisco, a neurologist whose research focuses on gender, sex, and hormone and multiple sclerosis (MS). She commented, “[W]e had been approaching the AAN, even as far back as 2019, about doing these guidelines and had multiple emails with them, and things fell flat….It’s been a long road, and developing guidelines for the AAN is hard in general and not a linear process. Finally, the time has come; the field is ready for this.”¹⁰

Esther Bui, MD

(Credit: EstherBui.com)

The curriculum presents core competencies covering pathophysiology, clinical approach, diagnostic evaluations, and treatment stages for 5 subspecialties (headache, cerebrovascular diseases, demyelinating diseases, epilepsy, and neuromuscular diseases) according to 3 life stages (women of reproductive potential; pregnancy and postpartum health; aging and menopause). The document concludes with 2 future directions (future collaborations; emerging subspecialties).¹¹

Bui is excited about the significance of an AAN-approved and -distributed curriculum: “The most powerful work to be done is to connect….That’s what curriculum and education do. It’s one of the most powerful connectors and levelers of what we do,…to build on the momentum…and be the superconnector that this work inherently entails.”¹⁰ Bove added, “Another thing to point out is [that] Esther [Bui] and I may look at similar questions—preconception planning, pregnancy management, postpartum sexuality and gender—but the specific content of the expertise is very different for MS or NMO [neuromyelitis optica] vs epilepsy. When you’re thinking about curriculum development, you want to think about…the process in general. There’s a need for preconception planning. There’s a need for careful postpartum management….Even though we have the same kind of framework, the way that you populate that framework with knowledge is very different. One of the things I like [in the curriculum is the] tables that point out the things that you might want to think about,…and it differs according to the specific disease.”¹⁰

Riley Bove, MD

(Credit: SAGE Neurology)

Bui and Bove both recognize that of the challenges that remain, adoption is one of the most frustrating. “Leading-edge work…has a crest and a trough. As people like Riley [Bove] and other leaders in their subspecialties are pushing forward to understand the newest disease-modifying therapies, the other 99.9% are not even aware that fertility therapies are viable for patients with neurological disease.…That’s probably where the education work is, in the trough, and [Bove] is at the peak. [We need] to bring everyone along with us,” Bui said. She added, “We would love to engage program directors or education leaders across North America to help them do a quick assessment of their own programs. I’m more than happy to be the liaison for that.”¹¹ Bove was more pragmatic, saying, “We have been writing guidelines on MS and women’s health for decades. We have so many expert consensus opinions, multidisciplinary [efforts], etc. We lecture at every international conference, every national conference….We have so much information, [but] dissemination to general neurologists or people who don’t want to talk about women’s health is hard. One part is communication skills…but the other part is if they don’t want to go there, they’re just not going to know.”¹⁰

Both clinicians, however, remain optimistic about the curriculum as well as the field of women’s neurology. Bui acknowledged, “This is a blueprint, but it’s not the [final] architectural design.”¹⁰ She finds motivation in the work already done and [in] future directions, including work beyond gender as binary and the inclusion of the patient perspective: “That’s an exciting future direction: engaging and welcoming those who are interested in working in this world beyond the cisgender woman lens. It’s about sex and gender….[And there is the] patient voice, because without a story, [it is just] data. [Story is] one of the most transformative ways to transmit our data.”¹⁰ Bove defines success for the women’s neurology curriculum as “when any neurology trainee can articulate these concepts, not just the ones who are interested in the topic.”¹⁰ She also focuses on the increasing power of the patient’s voice: “There’s patient demand, and patients know that they can demand this expertise and that it’s available to them [elsewhere] if their neurologist won’t [provide] it. That’s another [point] that is critical here: not settling.”¹⁰

The Ann S. Bowers Women’s Brain Health Initiative

The Ann S. Bowers Women’s Brain Health Initiative (WBHI) represents a strong effort in neuroscience to leverage big data for advancing women’s health. Modeled after the impacts observed with big data in fields such as particle physics and genomics, the WBHI is based at the University of California Santa Barbara (UCSB), and is assembling a University of California-wide brain imaging consortium aimed at accelerating discovery.⁴ This ambitious collaboration includes the Brain Imaging Centers at UC Santa Barbara, UC Berkeley, UC Irvine, UCSF, UC Riverside, and UC San Diego, with planned expansion to UC Davis and other sites globally.

Nina Miolane, PhD

(Credit: X)

By integrating brain imaging data from multiple sites, WBHI has its sights set to create the largest, most comprehensive dataset focused on women’s brain health. The WBHI Data Coordination Core at Stanford facilitates automated data storage, processing, and sharing on OpenNeuro, a platform for sharing data, and the WBHI AI Core—a collaborative effort between UCSB and Cornell—develops cutting-edge AI tools to drive discoveries in women’s health. Recognizing that breakthroughs require sustained, cross-sector collaboration, the WBHI offers an innovative, scalable model for advancing brain health research among women.

“We at the Ann S. Bowers [WBHI] believe that when women’s brain health is made central, we all benefit. As the codirector of the AI core, one of the central pillars of my role is in engaging the larger AI/computer science community in the pursuit of women’s brain health. Historically speaking, the fields of AI and computer science are also imbalanced by sex, having more men than women researchers in this area,” Amy Kuceyeski, PhD, codirector of the Ann S. Bowers WBHI AI Core and a professor of radiology at Weill Cornell Medicine, told NeurologyLive.⁴ “We…aim to develop a wave of trainees that are well-versed and passionate about issues related to women’s brain health, and to engage the wider AI/CS community in the pursuit of understanding the mysteries of the female brain.”

Amy Kuceyeski, PhD

(Credit: X)

Ann S. Bowers, the namesake of the Ann S. Bowers WBHI, was a pioneering American business executive and philanthropist. She served as Intel Corporation’s first director of personnel and Apple’s first vice president of human resources, breaking new ground in Silicon Valley’s tech industry. In 1990, she established the Noyce Foundation, honoring her late husband, Robert N. Noyce, PhD, who served as the cofounder of Intel and inventor of the integrated circuit—a key innovation that catalyzed the personal computer revolution.

Throughout her career, Bowers was dedicated to advancing education, supporting strong leadership, and fostering innovation. A trusted advisor to Silicon Valley startups and longtime board member of Bay Area nonprofits, her influence extended beyond the tech world into philanthropy and community development. Bowers’ commitment to empowering leaders and investing in transformative initiatives has continued to inspire the work of the WBHI, advancing research that prioritizes women’s brain health.

"We at the Ann S. Bowers [WBHI] believe that when women’s brain health is made central, we all benefit. As the codirector of the AI core, one of the central pillars of my role is in engaging the larger AI/computer science community in the pursuit of women’s brain health."

“The Ann S. Bowers WBHI is driven by a simple idea: progress in neuroscience will flourish when the health of men and women are valued equally. Our goal is to generate the most diverse and comprehensive collection of data ever acquired for women’s brain health—to ask questions [about] women’s health that have been overlooked for too long,” Nina Miolane, PhD, codirector of the Ann S. Bowers WBHI AI Core and assistant professor of electrical and computer engineering at UCSB, told NeurologyLive.⁴ “First, we go broad. The WBHI creates a large-scale database of brain imaging and women’s health-related phenotypes by integrating data across UC Brain Imaging Centers.”

“Second, we get precise. In addition to collecting a snapshot of the brain on a massive number of people, what if we collect a massive amount of MRI data on individuals? Dense-sampling MRI studies that track individuals at high temporal frequencies or over extended periods of time are transforming what we know about the dynamic properties of the human brain,” Miolane said.⁴ “At the Bowers WBHI, we value deep collaborative research and gather experts from neuroscience [and] artificial intelligence to answer life changing questions.”

Conclusion

The future of women’s brain health as a subspecialty in neurology will likely be shaped by the evolving landscape of research funding and policy decisions, particularly with respect to the NIH. As the NIH remains the largest public funder of biomedical research globally, its approach to funding and prioritizing areas like women’s health will be essential. The proposed changes to streamline the NIH, reduce its size, and potentially shift funding mechanisms could have significant implications for research in this neurology subspecialty. Joel Zinberg, MD, JD, a senior fellow at the Competitive Enterprise Institute and director of the Public Health and American Well-Being Initiative at the Paragon Health Institute, highlighted in a statement the desire to “break down those silos” and make institutes “more cross-cutting,” which could offer both opportunities and challenges for subspecialties such as women’s neurology.¹²

At the same time, the concerns about potential political influences on the research process, as noted by Elias Zerhouni, MD, who ran the NIH from 2002 to 2008 under President George W. Bush, underscored the need for maintaining the independence and scientific integrity of the peer review process. “You want it to be above politics,” he emphasized in a statement, which is particularly important when it comes to ensuring that women’s brain health research remains focused on evidence-based outcomes and is not diverted by political agendas.¹² As the research and clinical community look ahead, the future of funding and support for women’s neurological health will depend on how these changes are navigated, with a continued focus on advancing scientific understanding and improving outcomes for women across all stages of life.

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