WOMEN’S HEALTH CARE
| GENDER-SPECIFIC MEDICINE: VENUS vs MARS —Christine M. Stabler, MD, Deputy Director, Family Practice Residency
Program, Lancaster General Hospital, Lancaster, PA
|
| Institute of Health report (1994): entitled Women and Health; found 2 forms of sex-based bias in older clinical studies;
1) male bias, ie, since observers and researchers male, they spoke and drew conclusions from man’s perspective; 2) male
norm, assumption that everyone acts like men and index case male; Nurses Health Study and Framingham study—first
studies to note significant sex-based differences between men and women
|
| Central nervous system (CNS) differences: female brain contains more intercellular connections (therefore, women
twice as likely to recover ability to speak after stroke affecting Broca’s cortex); male brains larger and have larger neurons;
dopamine—male and female neurons take up significantly different amounts of dopamine; women more likely to develop
dystonic reactions to tranquilizers, probably due to differences in dopamine uptake; pain—data suggest women have lower
threshold for pain and lower pain tolerance; women tend to be undertreated for pain; evidence that some analgesics work differently
in men and women; opioids (eg, pentazocine, nalbuphine) seem to work better in women than in men; mood
disorders—major depression and dysthymia twice as common in women (possibly because men produce ≈52% more serotonin
than women); schizophrenia and bipolar disorder—have same prevalence but present differently in men and
women; have different age of onset and response to treatment; autism, learning disorders, and attention-deficit
disorders—more prevalent in men
|
| Cancer and exposures: women have 20% to 70% greater risk of developing lung cancer from same amount of tobacco
smoke; lung cancers not diagnosed as early in women as in men, possibly because tumors in women tend to be smaller
and more peripheral (therefore, usually more advanced when symptoms develop); estrogen and progesterone may protect
against pancreatic cancer (incidence slightly lower in women)
|
| Gastrointestinal system: women more likely to develop gallbladder disease due to differences in bile composition; sex
differences also seen in prevalence of inflammatory and irritable bowel disorders
|
| Women and AIDS: HIV more aggressive early on in women and causes more damage earlier to T cells, even though circulating
viral load (VL) may be lower at presentation; therefore, medical treatment should begin earlier in HIV-positive
women, ie, protocols should use different VL and CD4 cell count levels for starting treatment in women
|
| Diabetes: type 2 diabetes more prevalent in women, especially after 65 yr of age; encourage older women to be more
physically active and to take steps to prevent diabetes and comorbidities (eg, diet, exercise, tight glycemic control)
|
| Musculoskeletal issues: women much more likely to develop osteoporosis and osteoarthritis (OA) and to injure anterior
cruciate ligament in sports-related accidents; women >40 yr of age more likely to develop pain due to OA at base of thumb
because articular surfaces disparate in size (bones same size in men)
|
| Bone metabolism: research suggests women reach peak bone mass in mid 20s, whereas bone mass continues to increase
for ≈6 more years in men; women can lose up to 10% of bone mass during first year after menopause
|
 | Bone architecture: men’s bones much more dense during buildup to peak bone mass, eg, cancellous bone in vertebrae
more dense in men; physicians should—focus early on helping women maintain bone mass, including calcium supplementation
and weight-bearing exercise; intervene in women undergoing precipitous decline in bone mass at menopause
|
| Cardiovascular system: shape, size, and pacing and conducting system of heart different in women; women have higher
resting pulses; certain drugs for treating heart conditions riskier in women (eg, women more likely to develop torsades
de pointes when given ibutilide); ion channels and nitric oxide synthesis different in women’s hearts; coronary arteries
smaller and more tortuous in women, so they may be more likely to have ischemic disease; symptoms—prevalence of
palpitations higher in women, especially during perimenopausal period (may be related to estrogen deficiency); women
vulnerable to premenstrual tachycardia and palpitations when estrogen levels drop; production of follicle-stimulating
hormone (FSH) may produce estrogen spikes, leading to quiescent times, after which palpitations recur
|
| Treadmill stress testing: sensitivity and specificity not as good in women as in men; women require more functional testing
(eg, stress echocardiography)
|
| Heart disease: number 1 killer in American women (accounts for 58% of female deaths); prevalence higher in women of
color; traditional substernal chest pain may be absent in women; heart disease typically presents 10 yr later in women
than in men; in women, shortness of breath, fatigue, and nausea more likely to be anginal equivalents and precede coronary
events than typical chest pain seen in men; physicians should consider premorbid coronary artery disease in
women with vague complaints, eg, fatigue; one study found that women more likely to be treated later than men and to
receive suboptimal therapy
|
| Women’s Health Study: concluded that low-dose aspirin probably not beneficial for preventing cardiovascular disease in
women, but helpful in preventing strokes, especially in women >65 yr of age; recommended that aspirin therapy be delayed
until women express risk factors or have evidence of existing cardiovascular disease (not primary prevention
strategy in women); also concluded that antioxidants not beneficial, except possibly in women >65 yr of age
|
| Drugs and metabolism: men and women metabolize drugs differently (cytochrome P450 system “not wired the same
way”); levels of certain enzymes in liver and blood differ significantly in women, eg, concentration of alcohol dehydrogenase
lower in women, so they are likely to become drunk at lower doses of alcohol; female stomach typically empties
more slowly than male, and progesterone slows gastric emptying
|
| Weight issues: when women lose weight, leptin (promotes satiety and helps suppress appetite) drops precipitously, so
women much more likely to regain weight than men
|
| Migraines: more common in women, starting at onset of puberty; prevalence increases to ≈40 yr of age, then begins to decrease
as perimenopause begins; because estrogen modulates release of certain neurotransmitters, eg, serotonin, women
may perceive more pain during migraine
|
| Urogenital issues: women much more likely to develop incontinence, probably due to anatomic changes; female urethra
shorter, so even small changes in angle between urethra and bladder may lead to incontinence; interstitial cystitis largely
female problem
|
| Immunologic differences: estrogen stimulates humoral and cell-mediated immunity (testosterone does not); estrogen
and testosterone have same effect on immune-modulating tissues; women have higher circulating levels of immunoglobulins,
but activity lower just before ovulation; women mount more vigorous response to infection, resulting in
more sequelae, eg, viral meningitis
|
| Autoimmune disorders: hormones alone do not explain higher prevalence in women; postmenopausal hormone therapy
and use of oral contraceptives (OCs) do not have impact on most autoimmune disorders; prolactin implicated in normal
immune activity, and some autoimmune diseases may be mediated by use of bromocriptine (suppresses prolactin)
|
| Comments: pregnant women more susceptible to malaria; chronic fatigue syndrome twice as common in women; IgE
levels in women significantly decreased at menopause; IgE increased by exogenous hormones; IgE may be estrogen-dependent
|
| Asthma: in children <12 yr of age, prevalence higher in males; from puberty on, prevalence higher in females; women 20
to 50 yr of age >3 times as likely to be hospitalized with asthma; 46% of female admissions for asthma occur during
premenstrual period
|
| ABNORMAL UTERINE BLEEDING (AUB)—Raymond R. Walker, MD, MBA, Associate Professor of Family Medicine,
University of Tennessee College of Medicine, Memphis
|
| Dysfunctional uterine bleeding (DUB): diagnosis of exclusion, after other causes for AUB ruled out; no clear etiology;
can be ovulatory or anovulatory; anovulatory bleeding usually at beginning (menarche) or near end (perimenopause) of menstrual
history
|
| Definition of abnormal menstrual bleeding: >7 days of bleeding; exceeding >80 mL (normal menstrual flow 30 to
35 mL); comments—difficult to quantify discharge; 66% of women with blood loss >80 mL develop iron deficiency
anemia
|
| Subjective criteria for AUB: use of super or maxi pads (especially 2) at all times; having leakage problems, even when
using 2 tampons or tampon and pad together; changing pads every 30 min to 2 hr; soiling of clothing despite use of tampons
and pads; inability to make it to bathroom in time to change pad; point—inquire whether pad just has spot or
soaked; other things to check for—hypotension, light-headedness, or dizziness; positive tilt test (sitting or standing) indicates
significant blood loss; tachycardia; shortness of breath; low exercise tolerance; inability to keep up with others;
diagnosis of anemia on complete blood count (CBC); sudden development of problems in perimenopausal period
|
| Differential diagnosis: pregnancy (including ectopic pregnancy); uterine myoma; fibroids; adenomyosis; inflammation
or infection; endometriosis; endometrial or cervical polyps; pelvic inflammatory disease (PID); vaginitis or cervicitis;
polycystic ovary syndrome (PCOS) associated with obesity, hirsutism, acanthosis nigricans, and type 2 diabetes; anorexia
nervosa; hormonal imbalance due to excessive physical activity; endometrial carcinoma or endometrial hyperplasia
|
| Systemic causes: thrombocytopenia; von Willebrand’s disease; leukemia; hypothyroidism; pituitary tumor; adrenal tumor;
lupus erythematosus; history of hepatitis B or C; excessive alcohol intake; drug abuse; prostitution
|
| Iatrogenic causes: hormone therapy (eg, OCs, conjugated estrogens [Premarin], medroxyprogesterone [Provera]); tranquilizers;
tricyclic antidepressants; warfarin (Coumadin); dietary changes (eg, patient who stops eating vegetables and
other foods rich in vitamin K); switching generic brands of warfarin; long-term corticosteroid use; contraceptive devices
or injections or changes in OC; intrauterine devices (IUDs; IUD in place may irritate uterine lining or lead to infection);
comment—stopping or starting medication sometimes easiest way to control problem
|
| Diagnostic work-up: ask about pelvic pain, weight gain or loss; look for signs of liver dysfunction or coagulation problems
(eg, easy bruising, jaundice); check for signs and symptoms of PCOS; ask about postcoital bleeding; look for cervicitis and
vaginitis; look for galactorrhea and other signs of pituitary tumor (including double or blurred vision); ask about headaches
|
| Physical examination findings: thyromegaly suggests thyroid disease; uterine enlargement may suggest pregnancy,
PID, tubo-ovarian abscess (TOA), or fibroids; pelvic fullness or mass suggests PCOS, ovarian tumor, or ectopic pregnancy;
uterine tenderness may suggest infection or irritated or perforated uterus if IUD in place; presence of jaundice
suggests cirrhosis or other hepatic problem; check for easy bruising
|
| Tests: pregnancy test; thyroid function tests (including thyroid-stimulating hormone [TSH]); CBC (examine red blood cell
[RBC] indices); platelet count; assess shape of platelets; iron studies; ultrasonography (US) of pelvic region to look for
ectopic pregnancy, PCOS, ovarian tumors, fibroids, condition of endometrial stripe; coagulation studies; check midcycle
progesterone level; endometrial biopsy; hysteroscopy or sonohysteroscopy; dilation and curettage (D and C)
|
| Treatment options: nonsteroidal anti-inflammatory drugs (NSAIDs) help with pain and cramping; OCs (use with caution
in patient with fibroids [may increase size]); progestins (if DUB ovulatory, can break cycle by causing sloughing of
uterine lining); gonadotropin-releasing hormone (GnRH) analogues (can block ovulation; danazol sometimes used); antifibrinolytic
drugs (if other measures fail to stop significant bleeding); estrogen or progestin drip in hospital prior to hysterectomy;
high-dose OCs for anovulatory bleeding (4 pills for 4 days, 3 pills for 3 days, 2 pills for 3 days, then 1 pill
daily); surgery—indicated when everything else fails; can perform abdominal, vaginal, or laparoscopically-assisted vaginal
hysterectomy; other options—endometrial ablation; uterine artery embolization (less invasive)
|
| PRECONCEPTION SCREENING AND CARE —Stephen Ratcliffe, MD, Program Director, Lancaster General Hospital,
Lancaster, PA
|
| Case of Shauna: 22 yr of age; had premature babies at 15 and 17 yr of age; presents with history of irregular periods, body
mass index (BMI; calculated as weight (kg)/[height (m)]2 ) of 32, of mild hirsutism, and concerns about potential pregnancy;
smokes 1 pack daily; has positive family history for diabetes, maternal aunt with cystic fibrosis (CF), and one of her
children has mild neural tube defect; taking valproic acid for epilepsy
|
| What to do: first rule out pregnancy, then address other issues, including family planning (birth spacing important), diet
and exercise, adverse health behaviors (eg, smoking, alcohol use, drugs), update immunizations; advise patient to avoid
teratogens during pregnancy (eg, alcohol, angiotensin-converting enzyme [ACE] inhibitors and angiotensin II receptor
blockers [ARBs] during first trimester, valproic acid associated with up to 15% incidence of neural tube defects); if
Shauna desires pregnancy, switch her from valproic acid to another agent; other things to address—smoking, weight
loss; sexually transmitted disease (STD) prevention; CF
|
| Cystic fibrosis: offer CF screening before conception for women with positive family history who are of Northern European
descent or are Ashkenazi Jews or Zuni or Pueblo Indians; test misses CF gene 20% of time in Northern Europeans,
but only 3% of time in Ashkenazi Jews; can screen mother or father or both (if either parent has negative test, chance for
CF much lower)
|
| Polycystic ovary syndrome: diagnosed in Shauna; weight loss key to management; other modalities include use of metformin
(1 g bid helps woman regain normal menses)
|
| Diabetes: patient’s hemoglobin A1c 10.5% at 12 wk into pregnancy; patient underwent high-level US to check for congenital
heart defect in fetus
|
Educational Objectives
| The goal of this program is to educate the listener about various medical problems that occur in women. After hearing and
assimilating this program, the clinician will be better able to:
|
| 1. List some of the major anatomic, central nervous system (CNS), metabolic, cardiovascular, urogenital, and immunologic
differences between men and woman.
|
| 2. Discuss why adult women experience more migraines, bouts of asthma, and episodes of incontinence.
|
| 3. Work up and provide care for women with abnormal uterine bleeding.
|
| 4. Review the various causes of abnormal uterine bleeding.
|
| 5. Offer preconception screening and care for women of childbearing age.
|
Discussed On This Program
Aspirin (acetylsalicylic acid; ASA) [several trade names]
Bromocriptine mesylate [Parlodel, Parlodel Snap Tabs]
Danazol [Danocrine]
Estrogens, conjugated [Premarin, Premarin Intravenous]
Ibutilide fumarate [Corvert]
Medroxyprogesterone acetate [Amen, Curretab, Cycrin, Depo–Provera, Depo-subQ Provera, Hematrol, Provera]
Metformin HCl [Fortamet, Glucophage, Glucophage XR, Riomet]
Nalbuphine HCl [Nubain]
Pentazocine [Talwin]
Valproic acid [Depacon, Depakene, Depakote, Depakote ER]
Warfarin sodium [Coumadin]
Suggested Reading
Albers JR et al: Abnormal uterine bleeding. Am Fam Physician 69:1915, 2004; Albrecht SA et al: Smoking cessation
counseling for pregnant women who smoke: scientific basis for practice for AWHONN’s SUCCESS project. J Obstet Gynecol
Neonatal Nurs 33:298, 2004; Apgar BS: Dysmenorrhea and dysfunctional uterine bleeding. Prim Care 24:161,
1997; Argulian E et al: Gender differences in short-term cardiovascular outcomes after percutaneous coronary intervention.
Am J Cardiol 98:48, 2006; Beaumont H et al: Danazol for heavy menstrual bleeding. Cochrane Database Syst
Rev (1):CD000400; Bedinghaus J et al: Coronary artery disease prevention: what’s different for women? Am Fam Physician
63:1393, 2001; Canavan TP, Doshi NR: Cervical cancer. Am Fam Physician 61:1369, 2000; Cohen AW: Prenatal
care, screening, and complications. Curr Opin Obstet Gynecol 3:759, 1991; Crawford PO: Best practice
guidelines for the management of women with epilepsy. Epilepsia 46(Suppl 9):117, 2005; Czlonkowska A et al: Gender
differences in neurological disease; role of estrogens and cytokines. Endocrine 29:243, 2006; de Weerd S et al: Preconception
care: preliminary estimates of costs and effects of smoking cessation and folic acid supplementation. J Reprod
Med 49:338, 2004; Elit L: Endometrial cancer: prevention, detection, management and follow up. Can Fam Physician
46:887, 2000; Fang J, Alderman MH: Gender differences of revascularization in patients with acute myocardial infarction.
Am J Cardiol 97:1722, 2006; Farrar D: Preconception care and diabetes. Pract Midwife 8:14, 2005; French L:
Dysmenorrhea. Am Fam Physician 71:285, 2005; Gold LD, Krumholz MH: Gender differences in treatment of heart
failure and acute myocardial infarction: a question of quality of epidemiology. Cardiol Rev 14:180, 2006; Hunter MH,
Sterrett J: Polycystic ovary syndrome: it’s not infertility. Am Fam Physician 612:1079, 2000; James A et al: Testing
for von Willebrand disease in women with menorrhagia: systemic review. Obstet Gynecol 104:381, 2004; Kim C et al:
Preconception care in managing care: the translating research into action for diabetes study. Am J Obstet Gynecol 192:227,
2005; Lozeau AM, Potter B: Diagnosis and management of ectopic pregnancy. Am Fam Physician 72:1707, 2005;
Malm H: Prescription of hazardous drugs during pregnancy. Drug Safety 27:899, 2004; McGurgan P, O’Donovan P:
Endometrial ablation. Curr Opin Obstet Gynecol 15:327, 2003; Oriel KA, Schrager S: Abnormal uterine bleeding. Am
Fam Physician 60:1371, 1999; Proverbio AM et al: Gender differences in hemispheric asymmetry for face processing.
BMC Neurosci 8:44, 2006; Shwayder JM: Pathophysiology of abnormal uterine bleeding. Obstet Gynecol Clin North
Am 27:219, 2000; Sia J et al: HIV infection and zidovudine use in childbearing women. Pediatrics 114:707, 2004;
Turok DK et al: Management of gestational diabetes mellitus. Am Fam Physician 68:1767, 2003; Uebing A et al:
Pregnancy and congential heart disease. BMJ 332:401, 2006; Weiss HD: Selecting medications for the treatment of urinary
incontinence. Am Fam Physician 71:315, 2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial relationship
with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported
nothing to disclose.
Dr. Stabler was recorded March 29, 2006, and Dr. Ratcliffe, March 28, 2006, at the annual Spring Family Practice
Review, sponsored by the Temple University School of Medicine and held in Lancaster, PA. Dr. Walker spoke March
2, 2006, at the annual Review Course for the Family Physician, sponsored by the University of Tennessee College of
Medicine, Memphis. The Audio-Digest Foundation thanks the speakers and the sponsors for making this program
possible.
|
