Principles of Ambulatory Medicine, 7th Edition

Chapter 99

Approach to Women's Health

Patricia A. Thomas

Women's health is currently conceptualized as a holistic, multidisciplinary approach to the health care of women throughout the life span and, as such, is much evolved from its narrow origins in the biomedical approach to reproductive health (1). On a global scale, women's health embodies a variety of social and economic concerns that affect the lives of girls and women worldwide. Many forces converged to promote the development of this field, but perhaps the most compelling for clinicians was the evidence that previous models failed to deliver quality health care to a substantial proportion of women.

The Council on Graduate Medical Education's 1995 Report on the Status of Women made several observations about the need for new clinical competencies in women's health (2). First, women have important health needs throughout their life spans, not just during the reproductive years. More than men, the health status of women appears to be impacted by a complex interplay of psychologic, social, and economic factors. For example, women living in states with low scores on women's political and economic indicators are more likely to report poor health (3). Women traditionally earn less than men and are twice as likely to be uninsured. Women report higher rates of depression and chronic illness across all ages, and higher rates of physical disability (Fig. 99.1). Women who become disabled are more likely to have lower employment status and income than men (4). Since women live longer than men, attention to prevention of chronic illness and disability is especially important. Second, demographic shifts, including changes in family structure and aging of the population, which currently affect health trends, relate especially to women's health. As the population ages, a greater percentage of older adults are women. Minority women, whose numbers will increase as the population becomes more diverse, have poorer health outcomes by several measures. The number of single-parent households headed by women, who traditionally have a greater chance of living in poverty, is increasing. A third observation is that inadequate health insurance and fragmented delivery of primary care services have led to poorly coordinated care for many routine and comprehensive health concerns of women. Although community surveys indicate improving trends in cervical and breast cancer screening, colon cancer screening and counseling issues are still underutilized (Fig. 99.2). For women patients more than men, rates of screening seem to relate to characteristics of the physician-patient relationship (5). For a number of chronic illnesses, there appears to be a bias in the provision of care that women receive, compared with men. Men are more likely to undergo noninvasive investigations for coronary artery disease, to undergo renal transplantation, and to receive antiretroviral therapy for human immunodeficiency virus infection (6). The reasons for these gender inequalities are not entirely clear and call for further re-search.

Although women receive more health services than men, women are less satisfied with their care and are more likely to change caregivers because of dissatisfaction with care (7). This may relate to the traditionally fragmented health care received, since women frequently see more than one clinician for routine care (8). Dissatisfaction has also been traced to gender differences in communication and lack of a sense of partnership with one's physician. In one report, women's overall satisfaction with care was more dependent than men's on informational content, continuity, and multidisciplinarity (9). The rising number of women in medical careers, as well as the lay women's health movement, have advanced the standard toward a woman-centered approach to communication and shared decision-making.

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What constitutes effective clinical practice of women's health? In 2001, an interdisciplinary group published core competencies in women's health for medical students, which can be used as a starting point (10). Focus groups of women patients have described the ideal health care experience as holistic, incorporating not only reproductive health, but also attention to psychologic health, social functioning, sexual health, family, and other relationships (11). Women patients want their physicians to offer not only traditional pharmacotherapy, but also lifestyle interventions, alternative medicines, counseling, and education.

The field is still evolving, but a common approach is to consider prevention, risk assessment, and illness by stages of life. Many of the diseases that must be considered in the care of women are common to both men and women. Often the prevalence is higher in women (e.g., eating disorders, autoimmune disease), or the clinical presentation is different in women (e.g., coronary artery disease). A recurrent theme in women's health is that female patients may fail to respond to narrow biomedical approaches to illness, perhaps because of sex-specific biologic and gender-specific psychosocial factors. Throughout this textbook, authors have attempted to highlight these differences in their discussions, and readers are encouraged to use those chapters referred to here for more in-depth discussion of these topics.

A Life Span Approach to Women's Health

Most clinicians understand well that health and illness are the result not only of physiologic changes but also of social, cultural, and economic changes in the patient's life. In the field of women's health, newer competencies call for the clinician to possess the knowledge and attitudes necessary to integrate biologic and psychosocial factors in the provision of comprehensive care of women. The following discussion provides some examples of how this integration could be applied over life stages.

Adolescence

Clinicians who care for adult women often care for adolescents. In addition to issues of puberty and sexual differentiation, issues of gender identity and body image become manifest in these years (Chapter 6). Major causes of death in this age group are trauma and suicide. Many chronic adult diseases, such as autoimmune disease, first manifest at puberty. Eating disorders are becoming increasingly prevalent in this age group. The foundation of counseling for health risk behaviors begins in these years. Adolescent women are as likely as men to smoke, drink, and use other drugs, but suffer increased health risks as a result of these behaviors. They are twice as likely to be sexually abused than men (12).

Young Adulthood: Age 18 to 29 Years

In early adulthood, women may be juggling career, social relationships, and family life. Although this age group has the best equity with men's wages, 25% of women in this age group report no health insurance and 30% no usual source of health care (13). Many of the health concerns of women during these years, often referred to as the reproductive years, relate to reproduction, menstrual disorders, and contraception (see Chapters 100, 101, and 102). Counseling issues include avoidance of unintended pregnancy and sexually transmitted diseases (STDs), weight management, and smoking cessation (see Chapter 4). Risk behaviors remain important. As with men, significant mortality and morbidity during these years is related to violence and injury; domestic violence is especially prevalent in this age group (seeChapter 28) (14).

Adult Women: Ages 30 to 44 Years

Economically, women often lose wage equity with men just as family burdens increase; women in this age group earn 75% of men's wages. In the United States, 52% of married women contribute half or more of their household income; 61% of mothers with children under the age of 3 were in the workforce in 2002. Forty-one percent of women head their own households, and 28% of these have dependent children (15). Single mothers living in poverty often must make choices between health care and other commodities. Among low-income single mothers, for instance, childcare consumes almost 20% of the household income. Reproductive and lifestyle counseling issues remain important for this age group. By the close of this period, cancer of the breast and reproductive tract have assumed importance as leading causes of death (see Chapters 104 and 105). Screening and risk assessment for cancer as well as screening for sexually transmitted diseases should be incorporated into routine health care visits.

Midlife: Age 45 to 64 Years

Persons of this age group are sometimes referred to as the sandwich generation, and women during these years often function both as mother to teenage children and daughter to aging parents. More than 60% work outside the home. Transitional issues at this time of life are often accompanied by depression (see Chapter 24). Sixty percent of women in this age group report one or more chronic conditions, such as diabetes, hypertension, and arthritis. Prevalence of cardiovascular disease rises sharply, and cardiovascular risk assessment assumes importance (see Chapter 62). Cancer screening continues to be important,

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and colorectal cancer screening is added at age 50 years. Menopausal health concerns are also important, beginning with perimenopausal symptoms and culminating with decisions regarding hormone therapy (see Chapter 106).

Late Life: Age 65 Years and Older

At the age of 65 years, the average U.S. woman has 21 years of life ahead. More women than men will assume caregiver roles to sick spouses and, unfortunately, caregivers are more likely to be in poor health themselves and experience difficulty accessing health care (16). In 2002, 41% of women older than 65 years of age lived alone, compared with 18% of men, accounting for the importance of social isolation in this group (17). The frequency of severe depression is 18% to 22% for women in this age group. After life-long lower wages compared with men, the retirement years for women are also often years of economic deprivation. Older women have a higher poverty rate than older men (12.4% versus 7.7% in 2002) (18). Osteoporosis occurs earlier in women (see Chapter 103), and the socially disabling problem of urinary incontinence is more frequent (see Chapter 54). Other health concerns parallel those of men during this phase of life (see Chapter 12).

A Systems Approach to Women's Health

Another approach to meeting the complex needs of women has been the development of interdisciplinary women's health centers. These centers are designed to promote coordinated clinical care in one geographic location and to facilitate the comprehensive delivery of that care, which is implied by the suggested quality measures listed in Table 99.1. Disciplines that are frequently represented in such centers include physicians, nurses, nurse practitioners, mental health professionals, physician assistants, health educators, and alternative health care practitioners. Access to care, ease of referral, increased communication, and coordination of care among clinicians can be facilitated with such an integrated center. Many centers are hospital sponsored. Reviews of the experience of these centers note that preventive services are delivered at higher rates and women report higher patient satisfaction (19,20). In addition, the U.S. Department of Health and Human Services has funded National Centers of Excellence in Women's Health in 18 academic medical centers. These Centers of Excellence deliver services to a more diverse population and serve not only as models of integrated clinical care but also as research and training centers (21).

The growth of women's health centers, coupled with the founding of the Office of Research on Women's Health at the National Institutes of Health (NIH) and expanded funding of research initiatives, promises to continue the development of knowledge that will inform clinicians and patients about the delivery of health services to women in the decades ahead.

Specific References

For annotated General References and resources related to this chapter, visit http://www.hopkinsbayview.org/PAMreferences.

1. Hoffman E, Magrane D, Donoghue GD. Changing perspectives on sex and gender in medical education. Acad Med 2000;75:1051.
2. Council on Graduate Medical Education. Fifth report: women and medicine. Washington, DC: US Department of Health and Human Services, 1995.
3. Jun HJ. A multilevel analysis of women's status and self-rated health in the United States. J Am Med Womens Assoc 2004;59(3):172–80.
4. Randolph DS. Predicting the effect of disability on employment status and income. Work 2004;23(3):257–66.
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10. Cain J, Donoghue G, Magrane D, et al., eds. Women's health core competencies for medical students. Washington, DC: Association of Professors of Gynecology and Obstetrics, 2001.

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11. Anderson RT, Barbara AM, Weisman C, et. al. A qualitative analysis of women's satisfaction with primary care from a panel of focus groups in the National Centers of Excellence in Women's Health. J Women's Health 2001;10(7):637–647.
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14. Tjaden P, Thoennes N. Prevalence, incidence and consequences of violence against women: findings from the National Violence Against Women Survey. National Institute of Justice, Centers for Disease Control and Prevention. Washington, DC: US Government Printing Office, November 1998.
15. U.S. Department of Labor, Womens Bureau. Available at: http://www.dol.gov/dol/wb.
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17. Federal Interagency Forum on Aging-Related Statistics. Older Americans 2000: key indicators of well-being. National Institute of Aging, National Center for Health Statistics. Washington, DC: US Government Printing Office, August 2000. Available at:http://www.agingstats.gov. Accessed February 15, 2002.
18. Current Population Reports. Poverty in the United States: 2002. Publication no. P60-229 Washington, DC: US Bureau of the Census, September 2003.
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20. Anderson RT, Weiseman CS, Scholle SH, et al. Evaluation of the quality of care in the Clinical Care Centers of the National Centers of Excellence in Women's Health. Women's Health Issues 2002;12(6):309–325.
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