Advancing Research on Chronic Conditions in Women (2024)

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10 An Agenda to Advance Research on Chronic Conditions in Women The evidence presented in previous chapters highlights significant gaps in knowledge needed to unravel and understand the biological, structural, and social factors that influence the development and trajectory of chronic conditions in women across the life course. These gaps hinder efforts to improve the health of women through diagnosis, treatment, prevention, and management of these chronic conditions and reduce disparities. Chapter 2 highlighted the significant progress achieved in the realm of basic science to elucidate critical distinctions in chromosomal sex and gonadal hormone differences for certain chronic conditions. However, further investigation is warranted to deepen that understanding. The chapter also described how women’s multiple social identities intersect with experiences shaped by structural and social determinants of health and that influence health behaviors and the onset, characteristics of, and progression of chronic conditions. The health care system also plays a role in the disparities and inequities women with chronic conditions experience. The disenfranchisement women feel when clinicians dismiss or minimize symptoms can lead to misdiagnosis, missed diagnosis, and poorer health outcomes when they defer care or are denied appropriate care. Chapter 3 provided methodological considerations for understanding the impact of chronic conditions in women, and Chapter 4 provided a high-level description of the impact resulting from the chronic conditions on which the committee focused as an illustration. Together, these chapters point to the inconsistent inclusion or reporting of data on the impact of conditions that are female-specific and gynecologic or that predominantly impact or affect women differently in national surveillance and other population-based databases. Data are also lacking on the differences in the impact of chronic conditions by age, gender, race, and ethnicity. Regarding the female-specific and gynecologic conditions that Chapter 5 reviewed, the research base is limited for many, so the understanding of etiology, prevention, diagnosis, and treatment is incomplete despite the substantial negative effects on women’s well-being. Chapter 6 noted that advances made in understanding chronic conditions that are predominant in women or that affect women differently has largely been shaped by research focused on men, with conclusions often applied to women. For some conditions, this can result in inappropriate diagnosing and treatment of these conditions in women. PREPUBLICATION COPY: UNCORRECTED PROOFS 

2 ADVANCING RESEARCH ON CHRONIC CONDITIONS IN WOMEN Chapter 7 examined in more detail the structural and social determinants of health in the context of specific chronic condition in women. It highlighted the role these factors play in modifying the risk of chronic conditions and their consequences and pointed to the limitations in data on how these factors shape the health of different groups of women. Evidence provided in Chapter 8 highlighted the fact that many women will experience multiple chronic conditions at a time, but studies often focus on a single condition, creating substantial gaps in knowledge about how best to diagnose and care for women with multiple chronic conditions. Chapter 9 discussed the challenges of translating basic science research to improve care and identified approaches for better translation and the need to engage patients and communities designing clinical, health services, and population-based research as opportunities to improve relevance, acceptability, and centering of women’s needs. The committee highlighted a number of research gaps throughout the report. In developing its recommendations, the committee sought to give priority to research gaps that were more crosscutting rather than condition specific. A RESEARCH AGENDA FOR THE FUTURE The committee identified key research gaps that the National Institutes of Health (NIH) and other relevant research agencies should support to advance the understanding of chronic conditions in women. Based on the committee’s conclusions, the following area of research are recommended to help fill these gaps. The Impact of Chronic Conditions in Women Several challenges exist in quantifying and measuring the impact of chronic conditions in women (Chapters 3 and 4). It is difficult to measure because these conditions can be difficult to diagnose, have wide variability in diagnostic approaches, have an unknown etiology, or have high diagnostic misclassification resulting from their association with multimorbidity and similarities to other symptoms and conditions. The result of a lack of accurate reporting of the impact these conditions cause has resulted in wide prevalence ranges based on national surveillance data, data sources, and research studies. Quality of life in women living chronic conditions has also been challenging to measure. Economic impact, specifically direct and indirect costs, is another measure of impact with little knowledge about how it affects women. Chronic conditions in women contribute to substantial health care costs, such as from diagnosis, surgery, and number of procedures required. Chronic conditions have a significant effect on a woman’s productivity at work and home. These findings are based on limited data, much from studies of single conditions. Conclusion 1: Based on a paucity of data, chronic conditions continue to significantly have an impact on women. Limited data hinders an in-depth understanding of the burden that chronic conditions have on women. Many chronic conditions are understudied, and measurement and diagnostic challenges leads to underreporting and inaccurate findings. Recommendation 1.1: NIH and other relevant research agencies should support research to improve estimates of the impact of chronic conditions in women. Specifically, research is needed to more accurately: PREPUBLICATION COPY: UNCORRECTED PROOFS 

AN AGENDA TO ADVANCE RESEARCH ON CHRONIC CONDITIONS IN WOMEN 3 1.1a. Diagnose and reduce misclassification of female-specific and gynecologic conditions (e.g., endometriosis, vulvodynia). 1.1b. Diagnose chronic conditions that predominantly impact or affect women differently (e.g., chronic pain, myalgic encephalomyelitis/chronic fatigue syndrome, and autoimmune diseases). 1.1c. Characterize differences in chronic condition presentation by gender, race and ethnicity, and the various structural and social determinants that these women experience or are affected by. 1.1d. Assess the economic impact of chronic conditions in women (both direct and indirect costs) and quality of life. Many of the surveillance systems for chronic conditions noted in this report (National Health and Nutrition Examination Survey, National Health Interview Survey, and Behavioral Risk Factor Surveillance System), do not capture or track female-specific and gynecologic conditions. Assessing the impact of chronic conditions in data sources, especially for those not captured in national surveillance, claims data, or population-based studies, is challenging because of limited sample sizes and incomplete representation of all affected populations and subpopulations. Even when national databases or studies report on chronic conditions, many do not report prevalence by age group, gender identity, race, ethnicity, or sexual orientation. This impedes understanding of the variation among groups and leads to inaccurate and inadequate reporting. Furthermore, national surveillance data and population-based studies have not disaggregated data in their analyses by gender, race, ethnicity, or sexual orientation. Black and African American, Hispanic/Latina, American Indian and Alaska Native, Asian American, and Native Hawaiian and Pacific Islander women represent heterogenous groups. Studies of impact lack the ability to consider the differences in condition/disease presentation among these groups and subgroups. Conclusion 1.2: Comprehensive and accurate disease surveillance systems and population-based studies play an important role in providing data on chronic conditions and disease risk factors, as well as on disparities in the incidence and prevalence of conditions and their distribution by race, ethnicity, gender, age, and social determinants of health. Current data systems fail to collect data on a number of female-specific and gynecologic conditions or publish disaggregated data on chronic conditions that predominantly impact or affect women differently. Recommendation 1.2: To improve data collection on female-specific and gynecologic chronic conditions and those that predominantly impact or affect women differently, NIH and other relevant research agencies should support national surveillance and population-based studies to expand data collection activities to include female-specific and gynecologic conditions and female-predominant conditions not currently included. 1.2a. Results from data collected on female-specific and gynecologic conditions and chronic conditions that predominantly impact or affect women differently should be provided and disaggregated by gender, race and ethnicity, sexual orientation, and other social factors. PREPUBLICATION COPY: UNCORRECTED PROOFS 

4 ADVANCING RESEARCH ON CHRONIC CONDITIONS IN WOMEN Understanding the Biology and Pathophysiology of Chronic Conditions in Women Understanding the biological mechanisms that contribute to chronic conditions is important for developing approaches to diagnose, treat, and prevent female-specific and gynecologic conditions and conditions that predominantly impact or affect women differently. Research is progressing in areas such as how sex differences, including chromosome and hormonal effects, influence the development of chronic conditions in women. Gonadal hormone effects are well studied in terms of how estrogens affect chronic conditions in women, however are still not well-known, and the interaction of sex chromosomes and gonadal hormones on phenotypical expression of chronic conditions is not well understood. Additionally, the role of other hormones in the development of chronic conditions in women need to be further identified, for example, how changes in hormones can affect the onset of certain chronic conditions. More knowledge about the role sex differences play in chronic condition etiology is essential for understanding the targets for which to develop novel therapies and treatments. Conclusion 2: Some progress has been made in understanding the pathophysiology and biologic mechanisms of chronic conditions in women, but further progress is needed to better support prevention, diagnosis, and treatment of these conditions. Recommendation 2.1: To further elucidate the pathophysiology and biologic mechanisms underlying chronic conditions that predominantly affect or impact women differently, NIH and other relevant research agencies should support research to understand the independent and interacting roles of gonadal hormones and sex chromosome genes causing sex differences and chronic conditions affecting women more than men. The understanding of the etiology of several female-specific and gynecologic conditions and conditions that predominantly impact or affect women differently is incomplete, although gynecologic and pain-related chronic conditions share similar common inflammatory and autoimmune etiologic pathways. Research has shown that inflammation and the immune system are major mechanistic drivers of a wide range of chronic conditions, and many conditions share similar inflammatory pathways. However, those pathways are not well understood in the context of the environment that women live in. Recommendation 2.2: To develop a better understanding how inflammatory and immune system pathways affect the development of chronic conditions in women, NIH and other relevant research agencies should support research to: 2.2a. Understand the basic etiology of female-specific and gynecologic chronic conditions (e.g., dysmenorrhea, uterine fibroids, nonmenstrual chronic pelvic pain, and pelvic floor disorders). 2.2b. Elucidate the role inflammation and immune system pathways and environmental exposures play in the etiology of chronic conditions in women. 2.2c. Elucidate how epigenetic alterations change gene expression as a consequence of exposures (e.g., diet, stress, environmental) to alter cellular function and contribute to the etiology of chronic conditions in women. PREPUBLICATION COPY: UNCORRECTED PROOFS 

AN AGENDA TO ADVANCE RESEARCH ON CHRONIC CONDITIONS IN WOMEN 5 2.2d. Understand the etiological mechanisms of chronic conditions that include pain as a component of the condition’s presentation (e.g., chronic pain, migraines, myalgic encephalomyelitis/chronic fatigue syndrome, and fibromyalgia). Research on genetic variations in chronic conditions in women can further the understanding of their genetic underpinnings. Research has not yet discovered the genetic drivers of varied experiences of chronic conditions, but that would inform novel treatment targets. Recommendation 2.3: To identify the genetic drivers of chronic conditions in women, NIH and other relevant research agencies should support research to better understand the genetic drivers of subtypes and symptom heterogeneity of female- specific and gynecologic conditions (for example, genome-wide association studies of endometriosis and chronic pelvic pain) and ensure that databases used in such studies are diverse given the observation of subpopulation differences. Animal models and preclinical studies can provide valuable insights into the biological mechanisms and potential novel therapeutics and treatments for chronic conditions in women. Recommendation 2.4: To address the lack of suitable animal models and other preclinical systems for exploring the biological mechanisms underlying chronic conditions in women, NIH and other relevant research agencies should support research to: 2.4a. Develop or improve experimental animal models to gain better insights into biological and physiological processes that lead to female-specific and gynecologic conditions such as disruptions in menstruation, endometriosis, chronic pelvic pain, and infertility. 2.4b. Develop in vitro models, cell systems, organoid systems, and fluidic models (system on a chip) to better understand the pathobiology of chronic conditions. 2.4c. Utilize systems biological analysis (“omics,” etc.) to understand the interactions of genomes, transcriptomes, proteomes, and epigenomes contributing to chronic conditions. 2.4d. Improve understanding of how sex hormones, sex chromosome genes, and their epigenetic regulators affect the etiology and progression of chronic conditions. 2.4e. Improve understanding of the molecular mechanisms/consequences of prolonged inflammation and the prenatal and maternal environments which alter cellular function and affect chronic conditions. PREPUBLICATION COPY: UNCORRECTED PROOFS 

6 ADVANCING RESEARCH ON CHRONIC CONDITIONS IN WOMEN Female-Specific Factors in the Development of Chronic Conditions Reproductive milestones are key factors influencing the development of chronic conditions in women. Most studies have established associations related to cardiometabolic conditions and some other conditions. Deviations in reproductive milestones such as early menarche, shorter reproductive window, including early menopause, and hormonal fluctuations, play a role in conditions such as endometriosis, depression, cardiovascular disease, stroke, and human immunodeficiency virus (HIV) but are less understood for other chronic conditions. The number of children delivered and breastfeeding have been associated with chronic conditions such as cardiometabolic conditions and endometriosis, so further investigation is warranted. Adverse pregnancy outcomes (e.g., gestational diabetes) can affect chronic conditions; research should further explore how they affect developing chronic conditions later in life. Evidence suggests that migraines and other chronic conditions during pregnancy are detrimental to women’s well-being across the life course. Studies on the influence of exogenous hormones, such as oral contraceptives, on the development of chronic conditions in women have produced conflicting findings. Conclusion 3: Reproductive milestones (menarche, pregnancy, menopause) impose dramatic changes in a women’s body and functioning and can influence the risk of developing certain chronic conditions across the life course. Recommendation 3.1: To better understand the exact mechanisms hormonal fluctuations play in the development of chronic conditions in women, NIH and other relevant research agencies should support research to: 3.1a. Elucidate the importance of age of menarche in the development of chronic conditions. 3.1b. Understand the role of menstrual cycle regularity/irregularity, length, and menstrual cycle phases in the development of chronic conditions over the life course. 3.1c. Understand how the length of the reproductive window (fertile years), parity, and breastfeeding influence the development of chronic conditions in women. 3.1d. Understand the link between adverse pregnancy outcomes such as gestational diabetes and hypertensive disorders of pregnancy and the development of chronic conditions later in life. 3.1e. Examine the role of migraines during pregnancy and their link to negative pregnancy outcomes. 3.1f. Explore the effect of exogenous hormones in the development of chronic conditions. 3.1g. Understand the effects of premature menopause (<40 years) and early menopause (40–44 years), both spontaneous and iatrogenic (surgery, chemotherapy, or radiotherapy), on the risk of chronic conditions.3.1h: Better understand and characterize reproductive milestones in racial and PREPUBLICATION COPY: UNCORRECTED PROOFS 

AN AGENDA TO ADVANCE RESEARCH ON CHRONIC CONDITIONS IN WOMEN 7 ethnic groups of women as well as lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA+) women. The decline and change of hormone levels during menopause and perimenopause have significant effects, such as the symptoms experienced by many women. Despite progress in understanding such symptoms, the exact biological pathways have not been clearly delineated. Research has identified the reduction in estrogens during postmenopause to be an important contributor to developing specific chronic conditions, most notably osteoporosis, cardiovascular disease and stroke. However, its influence on others, such as musculoskeletal conditions, including sarcopenia, is less understood. One important challenge to research is how best to evaluate menopause given the heterogeneity of symptoms experienced and reliance on symptom reporting and hormone level tests, which can fluctuate. Despite advancements in treatment options for menopausal symptoms, such as hormone therapy and nonhormonal medications, not all women can benefit from them. Recommendation 3.2 To develop new and better approaches for addressing the symptoms that affect women during perimenopause, menopause, and postmenopause, NIH and other relevant research agencies should support further research that aims to: 3.2a. Understand the biological mechanisms underlying the timing and the manifestation of menopausal symptoms, including vasomotor symptoms. 3.2b. Improve methods of evaluating and diagnosing perimenopause and menopause. 3.2c. Investigate and evaluate the effectiveness of a range of management and treatment options for treating menopausal symptoms, including pharmacological and nonpharmacological therapies, and preventing future chronic conditions. 3.2d. Examine the relationship between menopause and the risk of developing or exacerbating chronic conditions. Special attention should be given to musculoskeletal conditions that lead to frailty in women. 3.2e. Investigate preventive measures for mitigating the effect of menopause on chronic conditions. Disparities and Life Experiences Disparities in chronic conditions in women with various social identities regarding gender, race, ethnicity, sexual orientation, and gender identity are pronounced yet still understudied. The research primarily examines differences by social group identity and not how structural factors, such as discrimination, racism, sexism, ageism, and homophobia, and social determinants of health (e.g., economic stability, social isolation) intersect to contribute to disparities. The influence of structural and social determinants of health in the context of gender roles and cultural norms is poorly understood. PREPUBLICATION COPY: UNCORRECTED PROOFS 

8 ADVANCING RESEARCH ON CHRONIC CONDITIONS IN WOMEN Conclusion 4: Structural and social determinants of health influence the development, progression, and management of chronic conditions in women. Recommendation 4: To better understand how the structural and social determinants of health affect outcomes in women from various social identities, NIH and other relevant research agencies should support research to understand how multiple social identities (race and ethnicity, cultural norms, gender identity, sexual orientation) interact with structural and social determinants of health to influence chronic conditions in women across the life course. Multiple social identities (race and ethnicity, cultural norms, gender identity, sexual orientation) interact with structural and social determinants of health to influence chronic conditions in women across the life course. Women who experience adverse childhood experiences, sexual and physical trauma, and interpersonal violence are at higher risk; these are impartially influenced by societal gender roles and expectations. Exposures to early life experiences and traumatic events across the life course shape the outcomes associated with chronic conditions, but these factors are not well incorporated in studies. In addition, adverse childhood experiences, sexual and physical trauma, and interpersonal violence have been associated with female-specific and gynecologic conditions, such as vulvodynia and menopausal symptoms, and other chronic conditions, including depression, substance use disorder, chronic pain, fibromyalgia, migraine, and Alzheimer’s disease. Conclusion 5: Early-life experiences and societal gender expectations may expose women to traumatic events throughout their lives that can adversely affect their health. Recommendation 5: Data regarding the link between life experiences and chronic conditions in women are not robust, and thus NIH and other relevant research agencies should support research to explore the role of traumatic experiences as risk factors in the development of chronic conditions throughout the life course. Health-promoting lifestyle behaviors, such as physical activity and dietary behaviors, are associated with a decreased risk of chronic conditions. Evidence shows that structural and social determinants of health, such as the built and neighborhood environment, contribute to inequities in ability to engage in health-promoting lifestyle behaviors, especially in racially and ethnically minoritized women, and play a role in developing chronic conditions, but data on the link between lifestyle behaviors and chronic conditions in women are limited and not robust. Conclusion 6: Lifestyle behaviors can decrease the risk of developing chronic conditions and chronic conditions can minimize the ability to engage in positive lifestyle behaviors. Lifestyle behaviors across the life course are not well studied in women. Recommendation 6: To improve the understanding of the role of lifestyle behaviors on the development of chronic conditions in women, NIH and other relevant research agencies should support research to: 6a. Investigate how health-promoting lifestyle behaviors influence chronic conditions in women and how the presence and effects of chronic conditions themselves can affect these behaviors. PREPUBLICATION COPY: UNCORRECTED PROOFS 

AN AGENDA TO ADVANCE RESEARCH ON CHRONIC CONDITIONS IN WOMEN 9 6b. Understand how structural and social determinants of health interact with various lifestyle behaviors to influence prevention, development, and course of chronic conditions in women. Diagnosis and Treatment Women may exhibit differences in preclinical and clinical presentation of female-specific and -dominant chronic conditions. The lack of distinction in sex and gender differences in condition/disease presentation has contributed to significant morbidity and mortality from many chronic conditions. Strong evidence shows that diagnostic tools lag behind for female gynecological conditions and chronic overlapping pain conditions and phenotyping that distinguishes heterogeneity in symptoms. In addition, sex-specific biomarkers are lacking for certain chronic conditions, which hinders the ability to accurately diagnose them. Conclusion 7: Women may present differently than men for many chronic conditions which can lead to misdiagnosis or underdiagnosis. Diagnostic tools tailored to sex-specific differences are essential for accurately capturing how conditions manifest in women. Recommendation 7: To improve early and accurate detection and diagnosis of chronic conditions in women, NIH and other relevant research agencies should support research to: 7a. Develop sex and gender-specific diagnostic tools for conditions in which there are clear differences in the clinical presentation of diseases in women such as cardiovascular disease (e.g., No obstructive coronary artery disease, spontaneous coronary artery dissection). 7b. Develop diagnostic tools that can more accurately distinguish between chronic conditions that share similar symptoms (e.g., chronic pain, fibromyalgia, myalgic encephalomyelitis/chronic fatigue syndrome). 7c. Explore a multilevel approach to the diagnosis of chronic conditions in women that includes identifying biological markers, developing diagnostic tools that capture variation in symptom manifestation and incorporate the lived experience, and engaging with health systems. Multiple Chronic Conditions Multiple chronic conditions have a significant impact on women, with evident gender differences in its presentation of clusters of chronic conditions. Chapters 5 and 6 mention multiple chronic conditions elucidated in studying individual female-specific and gynecologic and those that predominantly impact or affect women differently that has furthered the understanding of multiple chronic conditions. However, research has actively prioritized the study of single diseases and single-disease models. This has limited the understanding of the etiology, prevention, diagnosis, and treatment and care for women with multiple chronic conditions and the field of multiple chronic conditions as a whole. Conclusion 8: Women tend to develop multiple chronic conditions over the life course. Animal and preclinical research has identified the role of aging and inflammation related PREPUBLICATION COPY: UNCORRECTED PROOFS 

10 ADVANCING RESEARCH ON CHRONIC CONDITIONS IN WOMEN mechanisms in the development of chronic conditions. In clinical research, studies of multiple chronic conditions have been hampered by a lack of standardized definitions and diagnostic approaches resulting in challenges in prevention and treatment. Recommendation 8.1: To understand the cellular processes that have been postulated to be possible targets that could play a role in preventing or ameliorating multiple chronic conditions in women, NIH and other relevant research agencies should support research to: 8.1a. Understand the biological mechanisms involved in the development of multiple chronic conditions in women, including aging-related mechanisms and inflammation. 8.1b. Further investigate the role of cellular senescence in the development of multiple chronic conditions and how reversal or prevention of senescence, through the use of senolytic therapies, can potentially delay the development of age-related chronic conditions (e.g., cognitive decline, musculoskeletal loss). 8.1c. Develop animal models that examine the co-occurrence of specific chronic condition groups. No standardized clinical definition of or diagnostic criteria exist for multiple chronic conditions, leading to differences in measurement. Tools often exclude female-specific and gynecologic conditions, leading to underreporting of multiple chronic conditions and an incomplete understanding of it in women. Recommendation 8.2 To improve the diagnosis of multiple chronic conditions in women, NIH and other relevant research agencies should support research to: 8.2a. Develop new measurement tools for multiple chronic conditions that include female-specific and gynecologic conditions to more fully understand the impact in women. 8.2b. Review and validate diagnostic or measurement tools for multiple chronic conditions to aid in the development of a standardized definition. Recommendation 8.3: Since research approaches that use single-disease models hinder the ability to understand pathophysiology, treatment, prevention, and management of multiple chronic conditions in women, NIH and other relevant agencies should support: 8.3a. The development of research approaches that appropriately study multiple chronic conditions in women. 8.3b Research that ensures the representation of women with multiple chronic conditions in research designs. PREPUBLICATION COPY: UNCORRECTED PROOFS 

AN AGENDA TO ADVANCE RESEARCH ON CHRONIC CONDITIONS IN WOMEN 11 Clinical guidelines are typically designed to manage single conditions. Evidence-based clinical guidelines are lacking for treating and managing the complex interactions between conditions. Interactions of specific treatments, such as polypharmacy, can contribute to developing or exacerbating of other chronic conditions. The design of treatment and management approaches should be informed by the experiences of women living with multiple chronic conditions. Recommendation 8.4: To improve the treatment and care of women with multiple chronic conditions, NIH and other relevant agencies should support research to: 8.4a. Develop evidence-based treatment and management guidelines for women with multiple chronic conditions. 8.4b. Examine negative effects of polypharmacy that can contribute to developing other chronic conditions. 8.4c. Design tools that incorporate measures of daily functioning and quality of life to improve the assessment of the impact of multiple chronic conditions in women. 8.4d. Design and test integrated and longitudinal models of care for women with multiple chronic conditions. Inequities and Women-Centered Research Inequities in care for women can stem from gender biases resulting in discrimination and stigma in clinical care settings. Structural sexism also can significantly influence health policies, including access to care and research funding. These factors affect health care access and quality and result in dismissing symptoms, which leads to underdiagnosis, misdiagnosis, and differential outcomes in treating and managing chronic conditions. For example, women’s experiences of symptoms such as pain are often underestimated compared to men, so women are less likely to receive proper treatment. Stigma and discrimination toward conditions such as HIV and substance use disorder lead to women being reluctant to seek care and preventive services. Incorporating patient-centered outcomes and the patient’s voice and lived experience can center research on women and can enhance the quality of care for women. Conclusion 9: A health equity lens is important for improving health care access, care, and outcomes including patient-centered outcomes in women. Recommendation 9: To address inequities that continue to exist for women in the health care setting, NIH and other relevant research agencies should provide research support to: 9a. Elucidate gender differences in access and use of health care services, taking into consideration the effects of structural sexism on health policies, inequities in health resource distribution, and social determinants of health. PREPUBLICATION COPY: UNCORRECTED PROOFS 

12 ADVANCING RESEARCH ON CHRONIC CONDITIONS IN WOMEN 9b. Develop methods for assessing discrimination (e.g., sexism, racism, ageism, and homophobia) encountered by women when accessing health care services for chronic conditions. 9c. Assess and validate diagnostic tools for appropriate use in diverse racial and ethnic groups. Despite progress regarding the inclusion and representation of women in various fields of research, the evidence on chronic conditions points to a lack of including women from difference racial and ethnic, gender identity, and sexual orientation backgrounds. A lack of strategies that involve women and their communities in research has led to not understanding outcomes for and the unique health needs of these women. Conclusion 10: Women-centric research strategies can help ensure that research activities address the unique health needs of women leading to more effective and equitable health outcomes. Recommendation 10: NIH and relevant funding agencies should support research that is women-centric. Studies should account for sex and gender and include a diversity of women in the research process. Researchers should: 10a. Recruit women from different racial, ethnic, gender identity, age, and sexual orientation backgrounds and underserved rural populations to better define the full spectrum of preclinical and clinical disease presentation. 10b. Involve women with multiple chronic conditions, including their communities, in the design, implementation, and dissemination of research findings. 10c. Use novel techniques for engaging and incorporating women who have yet to seek care due to obstacles in accessing health care services or because their conditions are in a preclinical stage. 10d. Use community-based research approaches (e.g., community engagement and community-based participatory research) to improve relevance, acceptability, and centering of women’s needs and outcomes. 10e. Account for sex and gender in studies where appropriate and standardize measures for capturing these variables accurately. The committee’s research agenda aims to bridge gaps in the scientific understanding of the etiology of chronic conditions and the interface of biological and social factors that influence the trajectory of these conditions. Ultimately, research outcomes would lead to greater diagnostic rigor, better data on the impact of these conditions, and more effective therapeutic interventions and woman-centered care. PREPUBLICATION COPY: UNCORRECTED PROOFS