Women’s health across the lifespan
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 lifespan groups.8
Birth to Young Adulthood
As girls reach puberty, the health issues that emerge 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 an increasing frequency of acts of physical and sexual violence, are the primary cause of death and disability in young women. Chronic disease or disability develops in a small proportion of girls. Most of these conditions (e.g., lupus erythematosus, juvenile rheumatoid arthritis, and thyroid disease) have an autoimmune component. Because of hormonal influences, many of these conditions first occur or are exacerbated during puberty.
15 to 44 Years
The second lifespan group stretches from ages 15 to 44. 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. Of the unintentional and intentional injuries, motor vehicle accidents, homicide, and suicide account for three fourths of all injury-related deaths.6 Death rates from homicide and suicide have shown a downward trend in young women. Nevertheless, black women, like black men, are more likely than members of other races to be homicide victims, and firearms are used in more than half of those deaths. Intimate partners play a substantial role in violence against women; one third of murders of women are perpetrated by an intimate partner.9
The most dramatic trend in this age group, beginning in the 1980s and peaking in the mid-1990s, was the emergence and rapid rise of HIV infection as a major cause of death. Although overall AIDS incidence and death rates have decreased yearly since 1996, the rate of decline has been smaller in women. The consequences of this disease for gynecologic care and reproductive counseling for women are unique. Because HIV can be transmitted during pregnancy and more than 40% of pregnancies are unintended, routine medical care should include discussions about effective contraceptive methods, the effects of pregnancy on HIV infection and treatment, and the potential for perinatal transmission of HIV. Treatment strategies for women who may become or who are pregnant should take into consideration regimens that maximally suppress maternal viral load and reduce transmission to the fetus while minimizing toxicity. A three-part regimen of zidovudine (AZT) reduces the risk of perinatal transmission by 70% and is effective even in women with advanced disease.10 United States Public Health Service recommendations for antiretroviral chemoprophylaxis to reduce perinatal HIV transmission are evolving rapidly and take into consideration the now standard use of more aggressive combination drug therapies to treat HIV, as well as the clinical status and antiviral drug history of the woman. Zidovudine should be part of the antepartum drug regimen in all pregnant HIV-infected women, if feasible. Treatment guidelines are updated periodically and are available on the Internet (http://AIDSinfo.nih.gov).
An important role of clinicians in the care of young women is to recognize and reduce risk-taking and other unhealthy behaviors. For example, early or unprotected sexual activity increases women’s risk for sexually transmitted diseases (STDs). 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 and subsequent ec-topic pregnancy or 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 pregnancy are well documented, yet 20% of women continue to smoke and 18% of teenage mothers smoke during pregnancy.6
Social and cultural factors have also contributed to the increasing prevalence of dieting and eating disorders. It is estimated that up to 4% of young women suffer from anorexia nervosa or bulimia, and an additional 5% have less specific eating disorders that are characterized by aberrant eating patterns and weight-management habits.11 These statistics most likely underestimate the prevalence of eating disorders in young women. According to findings from the 2003 Youth Risk Behavior Surveillance System developed by the Centers for Disease Control and Prevention, during the month before the survey, 56% of adolescent women had attempted dieting, 18% had gone more than 24 hours without eating, 11% had taken diet aids without professional advice, and 8% had induced vomiting or taken laxatives for weight control.12
The female lifespan group of 15 to 44 years of age delineates the reproductive years. In addition to having the traditional childbearing and family responsibilities, women are increasingly assuming new, additional roles. The effect of multiple and often conflicting roles on women’s mental and physical health remains to be determined, but it is almost certainly closely linked to reproductive freedom and health. Thus, clinicians need to understand the safety and effectiveness of current methods of contraception, including extended oral contraception and emergency contraception, as well as the acceptability of these methods to women of various cultures.13-15
Many common disorders of reproductive function are not exclusively gynecologic problems. For example, polycystic ovary syndrome is associated with insulin resistance and an increased risk of diabetes and cardiovascular disease16 [see 16:V Polycystic Ovary Syndrome].
Autoimmunity is a common theme in many of the medical disorders that have the highest prevalence in women 15 to 44 years of age. Most of the autoimmune diseases occur more often, as well as cause greater morbidity, in women than in men. Many of these diseases are influenced by changes in estrogen levels, particularly during pregnancy. The prevalence rates of collagen vascular diseases such as rheumatoid arthritis, systemic lupus erythematosus, and scleroderma are three to nine times higher in women than in men. Many autoimmune-related endocrinop-athies, such as Hashimoto thyroiditis and Graves disease, have a female-to-male ratio as high as 10:1. 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 in men. Each year, an estimated 6.5% of women experience a major depressive episode, and twice that many have chronic low-grade depression. The increased risk of depression in women begins at puberty and declines after the menopause. In addition, many women experience mood, cognitive, or behavioral changes associated with cyclic changes in hormone levels during the menstrual cycle or with the marked changes in hormone levels that occur during the postpartum period and the menopausal transition. The genetic, biologic, and environmental contributions to women’s susceptibility to depression are not fully understood; however, hormonal factors are thought to play a major role. Women are also twice as likely as men to be diagnosed with an anxiety disorder, including panic disorder, posttraumatic stress disorder, generalized anxiety disorder, agoraphobia, and simple phobia.7
A major cause of psychosocial morbidity in women is physical and sexual abuse. According to the National Violence Against Women Survey conducted by the National Institute of Justice and the Centers for Disease Control and Prevention in 1998, 52% of women have been physically assaulted at some time during their life, and 18% have experienced a rape.17 Young women are at particular risk for rape; of those women who have been raped, more than half were younger than 18 years when rape first occurred.17
Physical and sexual assault of women is primarily a problem of partner violence. Three fourths of women who experience physical or sexual abuse after 18 years of age are assaulted by a current or former spouse or a male intimate. Unfortunately, clinicians often fail to recognize or address symptoms of abuse, whether because of inadequate knowledge of physical and sexual violence, misconceptions about it, or inadequate training in its management. Adequate screening tools are especially crucial in the emergency department, where up to one third of women who have been assaulted seek care.
45 to 64 Years
Death rates for women 45 to 64 years of age have declined by 30% in the past 25 years. Previously, the leading cause of death in this age group was heart disease; however, cancer is now ranked number one. This shift in mortality reflects primarily a decline in death rates for heart disease—a decline that has been observed in both sexes and that is attributed to changes in lifestyle, better control of hypertension, and lower blood cholesterol levels.
Many of the important chronic conditions in women first appear in this age group; some of them, such as heart disease, osteoporosis, and cancer, are inextricably linked to the menopause and the associated marked decline in estrogen levels. Hormone replacement is the most effective therapy for vasomotor and vaginal symptoms associated with the menopause; in addition, hormone therapy (HT) decreases bone loss and the risk of osteo-porotic fractures and colon cancer. However, because of the adverse effects of HT shown in the Women’s Health Initiative Trial (i.e., an increased incidence of breast cancer, heart disease, stroke, dementia, and urinary problems),18-24 HT should not be used as preventive therapy in postmenopausal women [see 16:XI Menopause].
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 are called upon to care for aging parents; and disabilities increase, making it difficult for some women to function within and outside the home. An understanding of these life events is essential to the comprehensive care of mature women.
65 Years and Older
Heart disease is the leading cause of death in women 65 years of age and older, followed by cancer and stroke. Mortality for all three disorders rises steeply after 65 years of age and begins to approach the rates for men.
As the longevity of women increases, they bear the burden of illnesses that are seen primarily in the very old. 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.
The social and psychological changes that women experience as they age add to the burden of illness. Social isolation increases because of 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 primary care clinicians is to recognize and help reduce the impact of these accumulated conditions on women’s ability to function and on their quality of life.
Clinical Evaluation of Women
History
Most elements of the medical history are similar for women and men. Those that are unique to women or are different in women are discussed here.
The goal of the dietary, exercise, and weight history in women is to identify patterns that may indicate an eating disorder or weight-management problem [see 13:IX The Eating Disorders]. An assessment of calcium and vitamin D intake is important for bone health at all ages—including the teenage years and 20s, when peak bone mass is built—as is questioning about folic acid supplementation in women of childbearing age to help prevent development of fetal neural tube defects in early pregnancy.
The menstrual and reproductive history, including past and current forms of contraception and hormone use, is important in evaluating current problems and in assessing risk for future conditions. The focus of the sexual history varies depending on age, with an emphasis on STD and pregnancy risk assessment in young women, the identification of medical conditions that may adversely affect fertility and pregnancy outcome in women who are considering pregnancy [see 16:IX Medical Complications in Pregnancy], and conditions that may interfere with healthy sexual function in older women. Symptoms of urinary incontinence and pelvic floor dysfunction should be sought specifically [see 16:XII Urinary Incontinence and the Overactive Bladder]. The need for Papanicolaou (Pap) smear screening— and, at an appropriate age, screening mammography—should be ascertained.
Screening questions for depression and interpersonal violence are appropriate in women of all ages and socioeconomic class because of the high prevalence of these conditions in women.
Primary clinicians are in a unique position to identify patients at risk for inherited cancer syndromes. Careful questioning about a family history of breast, ovarian, and related cancers can identify women at high risk for the breast cancer susceptibility genes BRCA1 and BRCA2 who may benefit from genetic testing and subsequent preventive measures if they test positive for a mutation [see 3:VIII Genetic Diagnosis and Counseling].
When obtaining the medication history, clinicians need to be aware of important sex differences in the effects of certain classes of medications that may put women at increased risk for adverse drug reactions.25,26 For example, because women have longer baseline QT intervals than men, the use of drugs that further prolong the QT interval, such as certain antibiotics, antihistamines, antiarrhythmics, and antipsychotics, may put women at increased risk for torsade de pointes, a potentially lethal ventricular arrhythmia.27,28 The University of Arizona maintains an online registry of drugs that prolong the QT interval or induce torsade de pointes (http://www.arizonacert.org/medical-pros/ drug-lists/drug-lists.htm). Also, women with depressed left ventricular function who use digoxin for heart failure are at greater risk of death than men with a similar diagnosis.29 This risk is attributed partly to higher serum digoxin levels in women. Because of this potential harm, clinicians are advised to weigh carefully the risks versus benefits of digoxin therapy in women with heart failure.
The hepatic cytochrome P-450 family of enzymes is involved in the metabolism of endogenous and exogenous steroids and many other drugs. Anticonvulsants can lead to oral contraceptive (OC) failure by inducing the cytochrome P-450 enzyme system to metabolize estrogen more rapidly. A similar mechanism has been attributed to antibiotics, leading to drug warnings about the risk of pregnancy when antibiotics are prescribed to women on OCs. Because the evidence supporting drug interactions between antibiotics and OCs is weak,31 the Council on Scientific Affairs of the American Medical Association convened a panel to review the data and provide recommendations. The panel concluded that rifampin, acting primarily as an inducer of the cytochrome P-450 3A4 isoenzyme, is the only antibiotic tested that significantly reduces plasma concentrations of OC-de-rived estrogens and increases OC failure rates.32 However, women using several other commonly prescribed antibiotics have wide variations in OC-derived hormone levels; some women have elevated follicle-stimulating hormone levels or breakthrough bleeding, suggesting that ovulation may occur. On the basis of these findings, the panel concluded that even though the risk of OC failure with these antibiotics is very small, some women may be at risk, particularly those using low-dose or very low dose OCs. The panel recommended nonhormonal contraceptive methods for women who are concomitantly using OCs and rifampin, as well as for women who are taking other antibiotics and are concerned about a small risk of pregnancy, have had previous contraceptive failure, or develop breakthrough bleeding.
Because women are generally smaller and have more body fat than men, there is an increased risk of bleeding in women who are on anticoagulants if doses are not carefully adjusted for body size. Women also have an enhanced response to certain fat-soluble drugs, such as antipsychotics.25 High body weight by itself can influence drug efficacy in women. For example, women who weigh 70.5 kg or more are at increased risk for contraceptive failure on OCs—particularly with low-dose and very low dose OCs.33 This effect is attributed to lower circulating drug levels as a result of higher metabolic rates in women with a large body habitus, increased absorption of OCs by fat cells in women with high fat levels, or both.
Physical examination
Most primary clinicians include the breast and pelvic examinations as part of the routine physical examination in women. Skill in these examinations requires an appreciation of the spectrum of normal findings in women of different age groups and the ability to recognize pathology. Clinicians who wish to increase their skills in performing the breast and pelvic examination can attend workshops or training sessions in one of several teaching associate programs affiliated with academic medical centers or can study teaching modules developed by the American College of Physicians and other professional organizations.
Laboratory tests
Routine Blood Tests
Body structure and hormones, particularly estrogen, affect routine blood test results in women. Serum creatinine and cre-atine kinase (CK) levels are generally lower in women than in men because women have less muscle mass. The MB fraction of CK (CK-MB) is specific for cardiac tissue and is used as a marker for cardiac injury. CK-MB reference limits for diagnosing acute coronary syndromes are lower in women than in men because women generally have smaller hearts. There is also a small contribution to CK-MB from skeletal muscle, leading to higher levels in men.34 Premenopausal women have lower serum uric acid levels than men because estrogen increases renal urate excretion.
Alkaline phosphatase levels increase gradually with aging in both women and men and can reach levels that are 50% higher than those reported in young adults. The source of the increase in postmenopausal women is bone; the liver is the source in older men.
Estrogen and the serum estrogen receptor modulators tamox-ifen and raloxifene increase thyroid-binding globulin levels in women, resulting in an increase in total thyroxine (T4) and tri-iodothyronine (T3) concentrations but not in the free concentrations of thyroid hormones; thus, thyroid function remains normal.
Women have lower ferritin levels than men as a result of iron losses during menses, pregnancy, and lactation, and a high proportion of women have absent iron stores, resulting in lower red blood cell (RBC) measures (e.g., hemoglobin concentration, hematocrit, and RBC count). Because anemia is defined as RBC values more than two standard deviations below the mean, normal ranges for women are lower than they are for men; however, these differences diminish with age, because RBC measures decline in both women and men as part of normal aging.
Breast Cancer Screening
Primary care clinicians need to be familiar with the risks and benefits of screening mammography and of newer breast cancer screening technologies offered to high-risk women, including breast magenetic resonance imaging35-38 [see 12:VIIBreast Cancer]. Many clinicians do a clinical breast examination (CBE) before ordering a screening mammogram to help prevent the possibility of a biased exam if the mammography report is normal. A mass found on CBE should be investigated further even if it is not identified by mammography39 [see 16:XIV Approach to the Patient with a Breast Mass].
Osteoporosis Screening
Clinicians should be knowledgeable about the indications for bone densitometry and should be able to interpret a woman’s fracture risk on the basis of her bone mass and other factors that influence the risk of hip and other fractures [see 3:VI Diseases of Calcium Metabolism and Metabolic Bone Disease].
Cardiovascular Disease Testing
Noninvasive tests for CHD generally have lower diagnostic accuracy in women than in men. Consequently, clinicians should be familiar with the sensitivity and specificity of exercise testing and of newer imaging techniques whose accuracy is lower in women [see 16:XX Cardiovascular Disease in Women].
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* Upper age limits should be individualized for each patient. For cardiovascular disease, when indicated by risk assessment.
Tobacco cessation, drug and alcohol use, sexually transmitted diseases and HIV, nutrition, physical activity, sun exposure, oral health, injury prevention, and polypharmacy.
Figure 1 United States Preventive Services Task Force guidelines for preventive primary care in women.42 These recommendations are conservative and represent the minimum level of preventive services that should be offered.
Cervical Cancer Screening
Cervical cancer screening requires proficiency in obtaining the traditional Pap smear or in using liquid-based cytology or other new cervical cancer screening technologies. Knowledge of the Bethesda system for reporting results of cervical cytology is essential to interpreting Pap test results and in managing patients with atypical cells, including DNA testing for high-risk types of human papillomavirus (HPV).
Vaginitis and Sexually Transmitted Disease Testing
Because STDs are often asymptomatic in women, screening is vital for preventing their spread, as well as their progression to pelvic inflammatory disease. Nonculture technologies have become the preferred method for diagnosing Chlamydia infections and gonorrhea in women and in identifying the cause of genital ulcers [see 7:XXII Vaginitis and Sexually Transmitted Diseases]. Clinicians need to be familiar with the use of these tests and the proper way to collect specimens. None of these newer technologies, however, replace the simple saline wet mount as a valuable tool for establishing the cause of a vaginal discharge.
Primary Prevention Guidelines in Nonpregnant Women
Many of the conditions that cause the greatest morbidity and mortality in women can be prevented or delayed by the early recognition and treatment of risk factors and the identification of individuals who might benefit the most from early intervention. The United States Preventive Services Task Force (USPSTF) publishes primary preventive guidelines that can assist clinicians in providing care to women [see Figure 1].42 These guidelines are available online (http://www.ahrq.gov/clinic/uspstfix.htm). The recommendations are conservative and represent the minimum level of preventive services that should be offered.
The USPSTF recommends that all women have periodic measurement of blood pressure, height, and weight, as well as undergo screening for obesity and depression. Cervical cancer screening with Pap smears is recommended in sexually active women. Although other policy-making organizations offer different guidelines about when to start or stop Pap smear screening and the optimal screening interval in low-risk women, the USPSTF recommends initiating screening 3 years after sexual activity begins or at age 21, whichever occurs first, and screening low-risk women at least every 3 years after two or three annual normal Pap smears. Routine screening is not recommended for low-risk women after age 65 if they have had adequate recent screening or for women who have had a total hysterectomy for benign conditions.
Newer screening methods using liquid-based cytology offer advantages over conventional Pap smears, such as the option of reflex HPV testing, but are more expensive. Until more information is available from trials assessing the role of HPV testing in cervical cancer screening, the USPSTF holds that the evidence is insufficient to recommend the use of this new technology over the routine Pap smear. Sexually active women younger than 25 years should be screened routinely for Chlamydia; screening for Chlamydia, gonorrhea, syphilis, and HIV should be done in any woman with risk factors for these diseases.
The USPSTF recommends that breast cancer screening with mammography, with or without clinical breast exam, be done every 1 to 2 years starting at age 40, although women 50 to 65 years of age and those at increased risk for breast cancer benefit the most [see CE:V Adult Preventive Health Care]. Clinicians should discuss the risks and benefits of breast cancer chemopro-phylaxis with women who are at high risk for breast cancer. Routine screening for ovarian cancer is not recommended.
According to the USPSTF, women should receive cholesterol screening every 5 years starting at age 45; women with risk factors for cardiovascular disease, such as hypertension or hyper-lipidemia, should be screened further for diabetes. As with men, colorectal screening is recommended beginning at age 50. Routine screening for osteoporosis in women is recommended starting at age 65. Many younger women, however, have conditions that put them at increased risk for osteoporotic fractures; in these women, screening is recommended to be started at age 60. Periodic vision and hearing screening is recommended for both women and men after age 65.
On the basis of findings from studies that were conducted primarily in men, the USPSTF currently recommends that clinicians discuss the use of aspirin for the primary prevention of CHD with postmenopausal women and with younger women with risk factors for CHD. However, results from the first randomized trial that assessed the risks and benefits of aspirin as chemopre-vention for CHD in women found a beneficial effect only in women 65 years of age and older.43 In younger women, aspirin reduced the risk of thromboembolic stroke but had little effect on CHD, findings opposite to those described in men. As in men, the use of aspirin in older women was associated with an increased risk of hemorrhagic stroke and major gastrointestinal hemorrhage. Until more information is available about aspirin’s effects in women, discussions about its use should be individualized for each patient.
The USPSTF recommends counseling women of childbearing age about folic acid supplementation to reduce the risk of neural tube defects and recommends counseling women of all ages about adequate calcium and vitamin D intake. All women should be counseled about tobacco and other substance use, strategies to decrease the transmission of STDs, effective methods of contraception, a healthy diet and increased physical activity, and injury prevention. In older women, counseling should focus on prevention of falls and the potential dangers of multiple medication use.
