COMMENTARY

Notes for National Women's Health Week and Check-Up Day, May 14-20, 2006

Ursula Snyder, PhD

Disclosures

May 01, 2006

National Women's Health Week and National Women's Check-Up Day are fast approaching: May 14, Mother's Day, kicks off National Women's Health Week, and May 15 marks National Women's Check-Up Day, which is a nationwide effort coordinated by the US Department of Health and Human Services. This effort is meant to encourage women to consider their own health by scheduling a yearly appointment with their healthcare provider and calls attention to the importance of preventive care and screenings for heart disease, diabetes, cancer, sexually transmitted infections (STIs), and other conditions.

The basic components of a typical well-woman check-up -- depending on the patient's age -- may include a pelvic exam (with Pap smear and STI testing), a clinical breast exam, mammogram, lipid profiles, blood sugar estimation, hemogram, and urine test. Other components may include renal profile, liver function tests, thyroid function tests, chest x-ray, whole abdomen ultrasound, osteoporosis screening, colorectal cancer screening, immunizations, and an eye examination. Smoking cessation, nutrition, exercise and mental health counseling, and contraception/family planning may also be included. The well-woman check-up is also an occasion for the patient to update her provider with her general life and work/school situation and family health history; her health history over the past year, and any current medications, herbs, or supplements she may be using.

Women of all ages should be screened for violence. (See Medscape's CME/CE program, Improving Screening of Women for Violence - Basic Guidelines for Healthcare Providers). Every day 4 women die in the United States as a result of domestic violence. In addition, 2 to 4 million women are battered each year, with at least 170,000 of these violent incidents being serious enough to require clinical care. Approximately 132,000 women annually report that they have been victims of rape or attempted rape, although it has been estimated that 2 to 6 times that many women are raped, but do not report it. Every year, 1.2 million women are forcibly raped by their current or former male partners.[1] The 2004 Kaiser Women's Health Survey[2] suggests the vast majority of providers are still not screening their female patients for history of domestic or dating violence.

Currently, 62 million women in the United States are in their childbearing years.[3] Thus, it may be appropriate to discuss contraception, emergency contraception, and preconception care[4,5] during the well-woman check-up. "Ask every woman" of reproductive age whether she intends to become pregnant in the next year may become the new mantra of preconception care, according to Dr. Peter Bernstein, a Medscape board member and maternal-fetal medicine specialist.[4] He writes:

Primary care providers need to understand that most of the care that they provide to fertile women is a part of preconception care -- not something extra that they are being asked to do. They need to reframe some of their thinking and counseling to recognize that the patient they are caring for might be pregnant the next time she presents for care. Seen in this light, counseling a patient about smoking cessation or choosing a medication for the management of hypertension takes on a different significance. [4]

More information about how primary care providers can incorporate preconception care into their practice can be found on the March of Dimes Web site at https://www.marchofdimes.com/professionals/681_4182.asp. An educational curriculum on the topic is also available.

Although an infertility evaluation would not be appropriate for a well-woman check-up, it is quite likely that some patients will present with apparent infertility and want to talk about it. The CME/CE program, Infertility: Evaluation and Treatment, may be useful as a basic review.

Discussion of sexual problems with clinicians is becoming more common and may arise during the well-woman check-up. Addressing women's sexual problems requires an approach that brings to bear the relevance of the psychosocial, sociocultural, and socioeconomic contexts of human sexuality and sexual problems as well as an understanding of the physiologic and biological aspects.[6,7] (See the interactive CME/CE program, The "New View" Approach to Women's Sexual Problems.)

As part of a well-woman check-up, sexually active women may be screened for HIV and other STIs. Nearly 30% of the estimated 40,000 new HIV infections each year in the United States occur in women.[8] Sexually active women younger than 26 years of age and pregnant women of all ages should be screened for Chlamydia trachomatis.[9]

For the midlife woman, in addition to the usual screenings, it may be appropriate to consider eating disorders. (See the interactive CME/CE program, Eating Disorders and Body Image Distress in Women at Midlife.) As the author Dr. Margo Maine notes:

"when eating disorders or body image conflicts are mentioned, the face we imagine is one of youth. It may be a preteen, an adolescent, or a young adult woman, but seldom do we visualize the face of an aging woman... [Yet] comparable levels of dieting and disordered eating are found across the spectrum of young and elderly women." [10]

A thorough well-woman check-up could take considerable time. A novel approach to address certain components of a well-woman check-up that one might consider is a group visit. In a recent issue of the column, "Field Notes in Obstetrics and Fetal Medicine," board member Dr. Bernstein reviews highlights from a conference, "The Power of Connection: Group Health Care for the 21st Century."[11] The speakers at this conference showed that providers who moved to the group model of care found that it has allowed them to spend more time with their patients and to enjoy improved communication; this model was also conducive to increased patient compliance and patient satisfaction.

As important as it is to encourage women to actively manage their health, it is also important not to unnecessarily medicalize aspects of ordinary life (eg, menopause, sexual problems)[6,12,13,14] or normal emotional responses to stressors[12,13,15] or to frame risk factors as diseases (eg, osteoporosis, high blood pressure, high cholesterol).[12,13] Increasing disease awareness without disease mongering is harder than ever and, according to Ray Moynihan and colleagues, "poses a global challenge to those interested in public health."[12,13,14] Moreover, it is crucial to consider the specific social and economic conditions in which an individual lives her life, because they will play a significant role in her health and her probability of developing illness and disease (Table).[16]

Here are some information and statistics to consider as you gear up for National Women's Health Week and Check-Up Day.

  • At 140 million, women constitute more than half the total population of the United States; nearly 30% of women belong to racial/ethnic minorities.[17]

  • Poverty disproportionately affects women. Nearly 13 million women live in households with incomes below the federal poverty level. Poor or near poor women are more likely than high-income women to report fair or poor overall health and limitations of activity; they are also more likely to report having anxiety or depression, arthritis, asthma, diabetes, hypertension, obesity, and osteoporosis.[17]

  • Heart disease is the leading cause of death for all racial and ethnic groups in the United States. More women than men die of heart disease -- about half a million women annually.[17] Heart disease-associated mortality is about two thirds higher among black women than among white women; heart disease-associated mortality is lower among Hispanic, American Indian, and Asian/Pacific Islander women compared with white women.[18]

  • Cancer is the second leading cause of death of women in the United States. In 2005, breast cancer, lung cancer, and colon cancer were the 3 most common cancers in women. White women have the highest cancer incidence rates; however, black women have the highest cancer death rates. American Indian/Alaska Native women have the lowest cancer incidence rates and the third highest cancer death rates.[19]

  • Although breast cancer survival overall has increased in recent years, black women still tend to have more advanced disease upon diagnosis and higher mortality compared with white women.[17] Results of a large prospective study suggest that varying mammography-screening intervals may account for some of that difference.[20]

  • Poor, near poor, and middle-income women have lower rates of both Pap tests and mammography than high-income women. Women with lower levels of education than high school and those who are high school graduates have lower rates of both services than women with at least some college education.[17]

  • The incidence of cervical cancer -- a 100% preventable cancer -- is more than 5 times greater among Vietnamese women in the United States than among white women.[21]

  • Stroke is the third leading cause of death of women. In 2003, females accounted for 61% of stroke deaths. The 2003 death rates per 100,000 population for stroke were 50.5 for white women and 69.1 for black women.[22]

  • Diabetes is the fifth leading cause of death of women in the United States. In 2005, 9.7 million; 8.8% of all women aged 20 years or older had diabetes.[23] The prevalence of diabetes is 70% higher among blacks and nearly 100% higher among Hispanics than among whites. The prevalence of diabetes among American Indians and Alaska Natives is more than twice that of the total population.[21]

  • HIV/AIDS was the leading cause of death for black women aged 25 to 34 in 2002. Survival after an AIDS diagnosis is lower among blacks than among other racial groups. Black women account for 67% of the estimated new AIDS diagnoses among women in 2004; Latinas accounted for 15%.[8]

  • Black women are 4 times more likely to die of pregnancy-related complications than are white women, and American Indian and Alaska Native women are nearly twice as likely to die from these complications.[21]

  • Black women receive poorer-quality care than whites for 53% of measures studied and have worse access to care for 29%. Hispanic women receive poorer-quality care than non-Hispanic whites for 60% of measures and have poorer access for 87%. For services unique to women, blacks and Hispanics both receive poorer-quality care for 75% of measures.[17]

  • Data from the 2004 Kaiser Women's Health Survey based on a nationally representative sample of 2766 women aged 18 and older highlight risks for the poor and the uninsured (see footnote) and indicate that clinicians need to do a better job with counseling:[2]

    • 8 in 10 women in the United States report excellent, very good, or good health. Nearly 1 in 5 women are in fair or poor health; the proportion increases with age, to nearly one third of women 65 and older.

    • 95% of elderly women have a regular provider, compared with 75% of women 18 to 44 years of age and 90% of women aged 45 to 64 years. As women age, they are less likely to visit an Ob/Gyn regularly.

    • Nearly 1 in 6 nonelderly women is uninsured. Women who are Latina, low-income, single, and young are particularly at risk for being uninsured.

    • Uninsured women are the least likely to have had a provider visit in the past year (67%), compared with women with either private (90%) or public insurance (Medicaid, 88%; Medicare, 93%)

    • Compared with women with insurance, uninsured women consistently report lower rates of screening tests for breast cancer, cervical cancer, high blood pressure, high cholesterol, and osteoporosis.

    • One quarter of nonelderly women delay or don't get needed medical care because they cannot afford it. Cost-related problems appear to have worsened since 2001. Many women cannot afford prescription drugs. They may not fill prescriptions or they may resort to skipping doses and splitting medicines.

    • Despite growing attention to the role of early intervention and healthy behaviors in health promotion and disease prevention, many clinicians fail to incorporate counseling during patient visits.

      • Only 55% of women say they discussed diet, exercise, and nutrition with a clinician during the past 3 years.

      • < 50% had conversations about specific behaviors, eg, calcium intake (43%), smoking (33%), or alcohol use (20%).

      • 31% of women aged 18 to 44 talked with a clinician about their sexual history, STDs (28%), HIV/AIDS (31%), emergency contraception (14%), or domestic or dating violence (12%).

    • Almost 1 in 4 women (23%) on Medicaid said they were turned away from a physician because the clinician was not accepting new patients, compared with 18% for uninsured and 13% privately insured women.

  • There is a "startling lack of data on women with disabilities," according to the US Department of Health and Human Services. In a national study of women with physical disabilities, the following findings were reported:[24]

    • 31% of the women with physical disabilities in the study were refused care by a physician because of their disability.

    • Women with physical disabilities had considerable difficulty finding physicians who were knowledgeable about their disability to help them manage their pregnancy.

    • More women with physical disabilities reported chronic urinary tract infections, heart disease, depression, and osteoporosis at younger ages than the comparison group of able-bodied women. The report acknowledges that these conditions are not entirely preventable, but suggests that rates could be reduced by informing women with disabilities about their increased risk as appropriate and offering suggestions about what they could do to reduce their risk or delay the onset of conditions and diseases associated with aging.

    • There was a much higher rate of use of public health clinics, specialists, and emergency departments among women with disabilities compared with women without disabilities.

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