Primary Care of Women

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[edit] Primary Care of Women

Janet B. Henrich

Over the past decade, women's health has emerged as a rapidly expanding field of scientific inquiry and knowledge with important implications for clinical practice and for the education and training of physicians. The increasing scientific information about the influence of gender differences on health and disease has expanded our concept of women's health beyond the traditional focus on reproductive organs and their function. Women's health can be viewed broadly as the study of the effect of sex and gender on health and disease that occurs across the spectrum of the biologic, behavioral, and social sciences. This broader interdisciplinary perspective of women's health has created an area of new knowledge and scholarship that is distinct from or more detailed than the knowledge base of existing disciplines. It has provided a new model to study the interactions among biologic mechanisms and psychosocial and environmental factors, as well as their influence on human growth and development and on women's response to health challenges. The clinical application of this information to women across all age groups highlights the interdisciplinary nature of this field.

[edit] BASIC PRINCIPLES

The concept of women's health requires a reassessment of the importance of gender differences on health and disease. Complex interactions exist among sex hormones, normal and abnormal physiology, and the physical and emotional well-being of women. As early as the embryonic period, there are structural differences between female and male brains. Many of these differences are programmed during fetal life by hormones. During the reproductive years the influence of sex hormones on sexual development and reproductive function differentiates a category of health issues that are unique to women. As women age and sex hormones decrease during the menopause, women's risk factors for disease change dramatically and become more similar to men's risks. Although women develop the diseases that affect men, biologic mechanisms and psychosocial factors influence the course of disease differently in women.

Until recently, most of the information used to make clinical decisions in women was based on studies conducted primarily in men. Women were excluded from research on diseases that are important to both sexes because of misconceptions about women's health, legal and ethical issues, and cultural biases. Because women, on average, live longer than men and are affected by major diseases at a later age, it was often perceived incorrectly that women were healthier than men. In fact, throughout life, women experience poorer health than men, especially in the advanced years. The lack of information concerning women had important implications. Information based primarily on studies done in men was often applied inappropriately to women or resulted in different standards of care.

Efforts to increase our knowledge about women's health issues require an integrated approach that acknowledges the diversity among women and considers the social factors that influence their lives. One of the important social trends over the past 50 years has been the increasing participation of women in the work force. Since World War II the number of women who work has more than doubled and now exceeds 80%. The full effects of multiple roles, work stress, and new environmental exposures on women's health and reproductive status are largely unknown but are certain to have important health and social ramifications. Paralleling the growing numbers of women in the work force is the increasing number of single-parent families headed by women, especially minority women. Many of these families live in poverty. Increasing evidence indicates that socioeconomic factors are major indicators of health and that, for some health outcomes, poverty and lack of education are more important determinants of health than ethnicity. However, important ethnic and racial differences remain in women's susceptibility and response to certain diseases that cannot be explained completely by socioeconomic status. For example, mortality rates for coronary heart disease, stroke, and breast cancer are higher in black than in white women, whereas death rates from lung cancer are higher in white women.

The increasing diversity of the population will affect health trends in the United States and the health status of women specifically. Regardless of their minority group, ethnic minority women have a lower life expectancy than white women and experience greater health problems. These differences are most pronounced in areas related to reproductive issues and childbearing, the occurrence and course of chronic disease, the incidence and outcome of cancer, and acts of interpersonal violence. Along with changes in society, human immunodeficiency virus (HIV) infection and homelessness have recently become additional special health concerns of minority women.

One of the most important factors underlying the current interest in women's health is the increasing number of women entering the health professions, especially medicine. Since the early 1900s the proportion of women represented in the physician population increased threefold, from 6% to 17%. According to projections, this proportion will increase to 30% early in this century. Already, women represent more than 40% of entering medical students and 50% of minority graduates from medical schools. Although significant barriers remain to their attaining equal professional and academic status, the potential for women to influence the structure of their profession, the delivery of health care, and the direction of medical research is considerable.

[edit] MORBIDITY AND MORTALITY

At the turn of the twentieth century the average life span of women in the United States was 48 years, compared with 46 years in men. Life expectancy is now 79 years for women and 73 years for men. Because of the gender gap in life expectancy, women currently constitute almost two thirds of the population over age 65 and three fourths of the population over age 85. The fastest growing age group in the United States is the population aged 85 years and older. As a result, it is estimated that women outnumber men by 2:1 in the age groups over 65 and 3:1 in the population over 85. The reasons for the dramatic increase in overall life expectancy are thought to be related to the control of infectious diseases and progress in the treatment of chronic diseases such as diabetes and cardiovascular disease. The reasons for the disparity in life expectancy between women and men are less well established but are thought to be primarily biologic.

Table 34-1 shows the leading causes of death in women of all ages and races. Despite a dramatic decline in mortality rates for heart disease in both sexes over the past two decades, cardiovascular disease remains the leading cause of death for women and accounts for one third of all deaths in women. Heart disease occurs about 10 years later in women than in men. This delayed onset is thought to result primarily from the protective effect of estrogens in premenopausal women and accounts for 90% of heart disease mortality in women occurring after the menopause. Significant racial and ethnic differences are associated with mortality among women. Black women are more likely to die from heart disease than white women up to age 75; thereafter, death rates are higher in white women. In contrast, Hispanic and Native American women have significantly lower rates of death from heart disease. Evidence suggests that heart disease, once it develops, is more serious in women than in men, resulting in higher mortality rates. In addition to biologic factors, the poorer survival of women may result from the older age and increased prevalence of comorbid conditions in women at diagnosis, as well as less well-defined social factors that influence the diagnosis and treatment of heart disease in women.

Table 34-1 Age-adjusted Mortality Rates From Leading Causes of Death in U.S. Females, 1995

Cancer is the second leading cause of death in women and is the most common cause of premature death. The mortality rate for all cancers combined in women has changed little during the last part of the twentieth century. Major advances in the diagnosis and treatment of cervical and uterine cancers in women have been offset by increased mortality rates for lung and breast cancer. Although breast cancer is still the most common cancer diagnosed in women, lung cancer is now the leading cause of cancer deaths. Unfortunately, most of these deaths can be attributed to cigarette smoking. Whereas deaths from lung cancer in men have begun to decline because of a decrease in male cigarette use, death rates for women increased between 1990 and 1995 and probably will continue to rise.

Breast cancer is the second leading cause of cancer deaths in women. Although the incidence of breast cancer has risen over the past decade, mortality rates have remained relatively stable. This disparity is thought to be caused partly by the widespread use of screening mammography and the detection of earlier-stage cancers that have a more favorable prognosis. Significant age and racial differences are associated with breast cancer mortality. Declining mortality rates in younger women have been offset by an increase in older women. Although breast cancer incidence rates are 12% lower in black than in white women, mortality rates are 15% higher in black women. Reasons for racial differences in breast cancer incidence and mortality are unclear but may be related to socioeconomic and biologic factors as well as certain health behaviors, such as participation in screening mammography. Although breast cancer screening with mammography and clinical breast examination decrease mortality from breast cancer in women over age 50 by approximately 30%, less than 50% of American women 50 years and older receive regular screening, and this figure is considerably lower in poor, minority, and elderly women.

Although stroke-related deaths have declined by almost 60% in the United States over the past 25 years, deaths from stroke (cerebrovascular disease) still account for approximately 6% of all deaths in women and rank third as a cause of mortality. Striking racial differences exist in stroke mortality: death rates in black women are almost twice those for white women. Most stroke deaths in women result from thromboembolic disease and occur in older women. However, subarachnoid hemorrhage, the least common form of stroke, is more common in women than in men and contributes to stroke mortality, particularly in younger women.

Death rates from chronic pulmonary diseases have increased steadily for both women and men during the past 25 years, but with a greater increase in women. Because this increase has been linked to patterns in cigarette smoking, death rates in women for pulmonary disease, as well as for lung cancer, will probably continue to rise. Death rates from pneumonia and influenza closely parallel pulmonary-related deaths and vary over time based on the epidemiology of these acute illnesses.

Diabetes has consistently ranked as a leading cause of death in women. Moreover, the reported death rate from diabetes most likely underestimates the impact of this disease on mortality because of its strong association with other life-threatening medical conditions, such as cardiovascular disease, stroke, and kidney failure. It is estimated that diabetes affects one in six women over age 45; however, prevalence rates are higher in black, Hispanic, and Native American women. Separate from disease-related death rates, diabetes is a significant cause of morbidity and, in women of childbearing age, has important adverse effects on pregnancy outcome, resulting in an increased risk of fetal and perinatal mortality as well as congenital malformations.

Although HIV infection is not one of the 10 leading causes of death in women overall, it is responsible for the largest percent increase in death rates of all the major causes of mortality. HIV-related mortality rates are nine times higher for black than for white women. As a result, HIV infection ranks third in leading causes of death in black women ages 15 to 24 and first in the age group 25 to 44 and, in some geographic areas, has become the number-one cause of death. As the epidemiology of this epidemic changes, with heterosexual transmission accounting for an increasing proportion of HIV infection in women, these rates are expected to continue to rise.

Mortality rates alone do not provide a complete picture of women's health status. Although women live longer than men, overall measures of health status are worse in women (Table 34-2). Based on estimates from the National Health Interview Survey (NHIS), more women than men report symptoms or seek care for acute medical conditions, such as respiratory and digestive disorders, and are more disabled by these self-limited illnesses, as measured by number of bed days or days lost from work. In addition, several chronic conditions occur more frequently in women and cause significant disability, such as arthritis, thyroid disease, migraine, bladder disorders, gastritis, colitis, and chronic constipation. Data from other sources show that affective disorders, especially major depressive episodes, and the anxiety disorders are significantly more prevalent in women. Most importantly, women have a lower perception of their health status than men. According to estimates from the NHIS, only 36% of women describe their health as excellent, compared with 41% of men.

Table 34-2 Selected Age-adjusted Indicators of Health Status and Medical Care Utilization, 1991

[edit] LIFE SPAN GROUPS

Many of the important health issues in women have their onset or greatest impact at certain ages and are intricately linked with women's psychosocial and sexual development. To develop a more integrated concept of women's health, it is instructive to look at the important health issues in women within the major life span groups. Several governmental and institutional sources were used to compile this information. Of these, the themes developed by the Report of the National Institutes of Health: Opportunities for Research on Women's Health, known as the Hunt Valley Report, form the basis of this section.

[edit] Birth to Young Adulthood

As young women reach puberty, health issues are related primarily to developmental changes involving physical and sexual growth and changing relationships within and outside the family. Central to the psychosocial development of young women is the process of gender identification and orientation and the development of self-esteem. Intentional and unintentional injuries, including increasingly frequent acts of physical and sexual violence, are the primary cause of death and disability in young women and account for half of all deaths in this age group. A small proportion of girls develop a chronic disease or disability. Most of these conditions are related to autoimmune disorders, such as lupus erythematosus, juvenile rheumatoid arthritis, and thyroid disease. Because of hormonal influences, many of these conditions first occur or are exacerbated during puberty.

[edit] Ages 15 to 44 Years

During young adulthood, mortality rates in women are relatively low, and deaths from injury predominate. As women progress through this age group, cancers of the breast and reproductive tract emerge as the leading cause of death, followed by unintentional injury and heart disease. Among the unintentional and intentional injuries in this age group, motor vehicle accidents, homicide, and suicide account for three fourths of all injury deaths. The death rate from motor vehicle accidents is highest in women ages 15 to 24; more than half these deaths are alcohol related. A major tragedy in the United States is the rapidly increasing death rate from homicide and suicide in young women. Black women, similar to black men, are most likely to be homicide victims, and firearms are used in more than half these deaths. Because 30% of murders in women are perpetrated by a family member or acquaintance, the contribution of ongoing family violence to these fatal events is probably substantial.

The most dramatic trend in this age group has been the emergence and rapid rise of HIV infection as a major cause of death. Poor and minority women have experienced the greatest increase in death rates from this disease. The biologic and social aspects of HIV infection are difficult to separate; however, evidence suggests that HIV infection in women may have a different presentation and clinical course and worse prognosis than in men. The consequences of this disease for gynecologic care and reproductive counseling in women are unique. Because of the potential interrelationship among HIV disease, human papillomavirus infection, and cervical neoplasia, as well as recent questions about the accuracy of the Papanicolaou (Pap) test in women with HIV disease, the Centers for Disease Control and Prevention (CDC) recommends that HIV-infected women have a Pap smear annually. As a result of HIV transmission during pregnancy, HIV infection is the fourth leading cause of death among black children. The social consequences of this disease are enormous and result in loss of productive life, disruption of family structure, and premature death. The challenge to primary care physicians to help control the transmission of HIV infection is an essential part of national prevention efforts.

An important role of physicians in the care of young women is to recognize and reduce risk taking and other unhealthy behaviors. Health habits become established during early adulthood. Unhealthy behaviors not only place women at risk for life-threatening events but also have important implications for the development of illness later in life. For example, early or unprotected sexual activity increases women's risk for sexually transmitted diseases. Not only are these diseases transmitted more easily from men to women, but women are disproportionately affected because of infectious complications that can lead to disorders of reproductive function, such as pelvic inflammatory disease, ectopic pregnancy, and infertility. Unfortunately, efforts at risk reduction, particularly in the use of harmful substances, are hampered by industry and market forces and other social factors that influence women's lives. For example, the adverse effects of cigarette smoking on lung cancer and other respiratory diseases, heart disease, osteoporosis, and reproductive function are well documented, but women become established smokers at an earlier age and have longer lifetime smoking histories than men. The effect of recent advertising restrictions on women's tobacco use is as yet unclear. Social values and cultural pressures have also contributed to the increasing prevalence of dieting and eating disorders. Using strict criteria, an estimated 5% of adolescent girls and young women have bulimia or anorexia. These disorders are often refractory to treatment and can be life threatening.

This life span group delineates women's reproductive years. In addition to traditional childbearing and family responsibilities, women are increasingly assuming new roles. The effect of multiple and often conflicting roles on women's mental and physical health remains to be determined but is closely linked to reproductive freedom and health. Thus physicians need to understand the safety, effectiveness, and acceptability of current methods of contraception in culturally diverse women. Because of an increased understanding of many other common disorders of reproductive function, primary care physicians can no longer view these disorders as exclusively gynecologic problems. The association of polycystic ovary disease with insulin resistance and the hyperandrogenic state and the contribution of nonreproductive causes to chronic pelvic pain highlight the general medical nature of these disorders.

Autoimmunity links many medical disorders with highest prevalence in women ages 15 to 44. Most of the autoimmune diseases are more common in women than in men and cause greater morbidity. Many are influenced by changes in estrogen levels, particularly during pregnancy. Among the collagen vascular diseases, rheumatoid arthritis, systemic lupus erythematosus, and scleroderma have prevalence rates that are three to nine times higher in women. Many autoimmune-related endocrinopathies, such as Hashimoto's thyroiditis and Graves' disease, have a female/male ratio as high as 15:1. Other autoimmune diseases that are more prevalent in women are type 1 diabetes mellitus, idiopathic adrenal failure, multiple sclerosis, and myasthenia gravis. Less well recognized is the role of autoimmunity in recurrent pregnancy loss and infertility in women.

Among the mental disorders, depressive illnesses are twice as common in women as men. An estimated 6% of women will experience a major depressive episode sometime during their lifetime, and twice that many will have chronic low-grade symptoms of depression. The greater risk of depression in women increases from childhood to adolescence and extends throughout life; however, the genetic, biologic, and environmental contributions to this gender effect are not fully understood. Women are also three times as likely as men to be diagnosed with an anxiety disorder, including agoraphobia, simple phobia, and panic disorder, as well as with somatization disorders. In addition, many women experience mood, cognitive, or behavioral changes associated with cyclic changes in hormone levels during the menstrual cycle or with marked changes in levels during the postpartum period or at the menopause.

A major cause of psychosocial morbidity in women is sexual and physical abuse. It is reported that 20% of adult women, 15% of college-age women, and 12% of adolescent girls have experienced sexual abuse and assault, and one of eight women in an ongoing relationship with a man has been assaulted by her partner. Pregnancy is a particularly high risk factor for assault. Unfortunately, due to lack of knowledge and training and misconceptions about domestic violence, physicians often fail to recognize or address symptoms of abuse. Adequate screening tools are especially crucial in the emergency department, where up to 30% of abused women may seek care. To ensure widespread detection of abuse, screening should become a regular part of the medical history in any setting.

[edit] Ages 45 to 64 Years

Death rates for women in this age group have declined by 30% in the past 25 years. Previously the leading cause of death was heart disease; however, cancer is now ranked number one, with lung cancer emerging as the leading cause of cancer deaths. These shifts in rates reflect primarily the decline in mortality from heart disease in both sexes attributed to lifestyle changes, such as better control of hypertension and lower blood cholesterol levels.

Many of the important chronic conditions in women first appear between ages 45 and 64, with the prevalence of some increasing greatly during this period. Significant racial and ethnic differences are associated with the prevalence of many of these conditions. The prevalence of obesity especially is disproportionately high in minority women; 52% of black and 50% of Hispanic women are overweight, compared with 33% of white women. Because obesity is a major risk factor for diabetes, heart disease, stroke, gallbladder disease, and some cancers and may be a factor in osteoarthritis, weight control in women is an important public health issue.

The emergence of many of these conditions is inextricably linked to the menopause and the marked decline in estrogen levels that occur during this age period. Decreased estrogen levels contribute to the development or progression of many disorders central to the aging process in women, such as heart disease, osteoporosis and cancer. Since hormonal replacement therapy (HRT) decreases the risk of developing some of these disorders, a woman's decision to use HRT should consider the beneficial effects of HRT on menopausal symptoms, osteoporosis, and cardiovascular disease, as well as the reported risks associated with HRT, specifically an increased risk of uterine and breast cancer.

Although the menopause encompasses many of the physiologic changes that define this period, women also experience major transitions in social roles and life circumstances that profoundly affect their physical and mental health. Children leave home, many women become widowed or divorced, parenting roles change as women care for aging parents, and disabilities increase, making it difficult for some women to function within and outside the home. Not surprisingly, 3% of women will experience a major depressive episode during this period. An understanding of these life events is essential to the comprehensive care of mature women.

[edit] Ages 65 Years and Older

Cardiovascular disease is the leading cause of death in older women, followed by cancer and cerebrovascular disease (stroke). Mortality rates for all three disorders rise steeply after age 65 and begin to approach the rates for men. Chronic pulmonary disease and pneumonia continue to cause high death rates because of the increase and severity of infections associated with an age-related decline in immune function. Injury is the sixth leading cause of death in older women; most of these deaths are related to falls.

After age 65, many other chronic illnesses, such as hypertension, diabetes, the arthritides, most digestive disorders, and thyroid disease, are more common in women than men of the same age and cause significant morbidity. As women's longevity increases, they bear the burden of illnesses that are seen primarily in very old persons. Of these, the neurologic degenerative diseases, such as dementia, sleep disorders, and neurosensory and movement disorders, are particularly common in women. Unfortunately, the added years of life in women are often spent in a frail or dependent state and often result in institutionalization. Currently, women residing in nursing homes outnumber men by 3:1. In particular, urinary incontinence and osteoporosis put women at high risk for institutionalization. Prevalence rates of urinary incontinence are twice as high in women as in men and affect up to one half of community-dwelling women. Osteoporosis is associated with deformity and pain secondary to vertebral fractures; however, hip fracture, usually the result of a fall, is the most serious consequence of osteoporosis in older women. According to the National Osteoporosis Foundation, one half of older women with a hip fracture will never walk independently, one third will never live independently, and one fifth will die within a year of the fracture.

The social and psychologic changes that women experience as they age add to the burden of illness. Social isolation increases with the death of loved ones, loss of financial stability, and increasing physical disabilities. In addition to an increasing incidence of dementia with age, mental health problems become more prevalent or serious. The role of the primary care physician is to recognize and help reduce the impact of these accumulated conditions on women's ability to function and on their quality of life.

[edit] EDUCATION AND TRAINING

Academic medical institutions are increasingly aware of the importance of women's health. Questions remain, however, concerning the domain of women's health, and the best way to train physicians, and which discipline(s) should be primarily responsible for curriculum development, clinical care, and training in this area.

Data from the National Ambulatory Medical Care Survey (NAMCS) provide insight into the complex nature of women's health care. Family practitioners provide most nonobstetric care to women ages 15 and older (57%), and internists and gynecologists provide decreasing amounts of the remaining services (25% and 18%, respectively). As women age, the proportion of care delivered by gynecologists decreases, whereas care provided by internists increases. Gynecologists provide few services to women over 65. Family practitioners and internists deliver services for both acute and chronic nongynecologic disorders, whereas gynecologists provide little of this care. In contrast, gynecologists provide more than half of general medical examinations and two thirds of routine gynecologic services.

Considerable overlap exists between the practice parameters of family practice and general internal medicine and those of obstetrics and gynecology. In addition, many physicians in medical subspecialties provide some generalist care to women outside their subspecialty focus. Female patients seek care from one or a range of these providers over their lifetime, and the patterns of care vary depending on the age and the social, economic, and health status of each woman. Where women fall in this health care matrix determines to a large extent the type and comprehensiveness of care received.

These findings have important implications for the health care of women. The lack of uniform standards of care, especially regarding preventive services, and the splintering of routine care among disciplines may result in poorly coordinated and incomplete care. The multiprovider approach fostered by this system does not necessarily mean improved services to women and is antithetic to the concept of primary care. Faced with overlapping but often inadequate services, women must increasingly take responsibility for directing and monitoring their health care.

In response to these findings, the Council on Graduate Medical Education recommends that all physicians, regardless of their educational level and specialty interest, be educated in the fundamentals of women's health and demonstrate competence in providing care to women. To implement these recommendations, women's health must have a form and a structure, a source of funding, and a recognized place in the medical community. Many of these objectives can be achieved by the establishment of collaborative interdisciplinary centers or programs in women's health within academic health centers. The U.S. Department of Health and Human Services, through the Public Health Service Office on Women's Health, funded six such vanguard centers in 1996, six in 1997, and an additional six in 1998. These centers are designed to facilitate the development of innovative clinical models, integrated curricula, and interdisciplinary research in women's health and to foster the development of women faculty.

Some disciplines are also expanding residency training to address new national residency training requirements in women's comprehensive health care. In internal medicine, training programs must now include women's health topics as part of their core curricula; some offer additional clinical experience through multidisciplinary women's health centers. A few programs have developed separate residency tracks within sections of general internal medicine that focus on women's health. At the fellowship level, scattered programs in women's health exist as separate tracks in general medicine fellowship programs.

[edit] Recommendations for Core Curriculum

As a foundation for addressing women's health conditions, physicians must understand basic female physiology and reproductive biology. In addition, they need to appreciate the complex interaction between the environment and the biology and psychosocial development of women. Among the conditions not specific to women, physicians must be aware of those aspects of disease that are different in women or have important gender implications. The ability to apply this information requires that physicians adopt attitudes and behavior that are culturally and gender sensitive. Women's relationship to the medical system is also changing and requires physicians to understand women's patterns of health seeking and forms of communication and interaction, as well as to appreciate gender differences in clinical decision making.

To assist academic medical institutions in implementing curricular changes, the Public Health Service Office on Women's Health, in collaboration with the National Institutes of Health Office of Research on Women's Health and the Health Resources and Services Administration, published a report in 1996 that provides the rationale for the development of a women's health curriculum and outlines the educational philosophy, scope, and content of a core curriculum. The report's recommendations are designed to augment and enhance rather than duplicate or replace existing curricula in the traditional disciplines. Although the report is directed at undergraduate medical education, its concepts and content can be applied broadly across the educational spectrum and may be helpful in modifying and updating residency training in the traditional medical disciplines.

[edit] ADDITIONAL READINGS

• RN Anderson, KD Kochanek, SL Murphy: Report of final mortality statistics, 1995. Mon Vital Stat Rep 1997; 45 (11, suppl 2):
• Council on Graduate Medical Education: Fifth report: women and medicine, Pub No HRSA-P-DM-91-1, 1995, US Department of Health and Human Services.
• National Institutes of Health: Opportunities for research on women's health, NIH Pub No 92-3457, 1992, US Department of Health and Human Services, Public Health Service, National Institutes of Health.
• PA Wingo, LA Ries, HM Rosenberg,et al.: Cancer incidence and mortality, 1973-1995: a report card for the U.S.. Cancer 1998; 82:1197.
• Women's Health in the medical curriculum: report of a survey and recommendations, 1996, US Department of Health and Human Services, Health Resources and Services Administration, National Institutes of Health.