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Women's Health

Broadening scope

Author: Amanda Lyons

Attitudes and realities are continuing to evolve and women’s connections with healthcare – including with those who deliver it – are more important than ever.

 

Feelings of connectedness matter to people, personal connection perhaps most of all. Whether face-to-face, via a screen or even through written correspondence for those who still appreciate some of the old ways, most want to be part of others’ lives, and have others be part of theirs.

This is especially true in healthcare, where the ability to make a genuine bond with a clinician allows patients and doctors to forge a relationship in which information is easily exchanged, no matter how sensitive or potentially uncomfortable.

For women in Australia, the best opportunity to establish such a connection is with their GP.

‘Women present fairly regularly to their GPs in Australia, either for routine things such as a Pap smear or because they need renewals of contraception,’ Dr Meredith Frearson, a GP with an interest in women’s health, told Good Practice. ‘Therefore, they make connections with a GP.

‘Those connections may also mean that GPs have an opportunity to find a range of health problems, as well as being a professional confidant for women to discuss their concerns.’

Prof Danielle Mazza, Chair of General Practice at Monash University and author of the textbook, Women’s health in general practice, is confident this is indeed the case.

‘We’ve got wonderful opportunities in Australia for general practice to assist women to achieve their best health outcomes and maximum potentials,’ she told Good Practice.

‘We are trusted health professionals and women’s health is part of the bread and butter of general practice.’

That ‘bread and butter’ general practice, however, is not necessarily what it was even as recently as the beginning of the century. Doctors’ and patients’ approaches to women’s health are continuing to grow according to changes in lifestyle, parenting practices, working lives, sexuality, gender identification, and other important areas.

 

Sexual and reproductive health

While all patients are unique, issues of sexual and reproductive health are common threads running through the lives of most women.

‘This is a large component of our work with women, because it is really relevant for most of a woman’s life stages,’ Dr Lara Roeske, Chair of the RACGP’s Sexual Health Medicine Specific Interests network, told Good Practice. ‘It is a dimension to the lives of women and shouldn’t be ignored.’

Sexual and reproductive health is also an area of healthcare that has undergone great change over the past few decades as the social landscape has shifted.

‘Women these days are pursuing studies, relationships and travel, and often aren’t “settling down” until well into their 30s, so the opportunity for unwanted pregnancy and STIs [sexually-transmissible infections] can actually cover a 20-year period,’ Dr Roeske said.

‘This means a role for GPs is to be very proactive around preventing unwanted pregnancies; so providing good contraceptive counselling and screening for STIs.’

These developments have also led to a changing profile in terms of contraceptive options, with a potentially expanding role for GPs.

‘There’s been a real interest in the use of IUDs [intrauterine devices] by women in their 20s, not just reserved as a contraceptive option for older women or women who have had children,’ Dr Roeske said.

‘There are few options currently for women to have an IUD inserted. Family Planning Australia provides an excellent service, but there’s a waiting time involved and when you’re talking about good contraception you don’t want women waiting too long. The other way is to go privately and see a gynaecologist, and that can be quite cost-prohibitive.

‘However, there are already a number of GPs around Australia who provide a quality service in the general practice setting, and they’re championing this as a proposition for general practice, something that can be offered to women as another safe, high-quality alternative.’

It is also important for GPs to remember there is another side of the coin to fertility management – helping to facilitate pregnancies. As women continue to have children at later stages of life, healthcare professionals have an enhanced role in helping to ensure potential mothers are as healthy as possible during all possible stages of the pregnancy journey.

‘GPs can help women achieve their reproductive life goals by knowing what they are and providing contraception, abortion, and preconception or inter-conception care as required,’ Prof Mazza said.

‘The aim should be to not only reduce unplanned pregnancies, but also to help women achieve the pregnancies that they want.’

Prof Mazza emphasised that different aspects of sexual and reproductive health are closely related throughout a woman’s life, although they may not always be treated that way.

‘We tend to segregate all of the issues – contraception, abortion, preconception care, inter-conception care,’ she said. ‘GPs undertake of all these roles, but not necessarily in a simplified, integrated way.

‘It’s important to understand that the provision of effective contraception impacts on rates of unplanned pregnancy and the capacity of women to adequately plan future pregnancies and achieve their reproductive life goals.

‘I think it’s important for general practice, which is the major provider of these services for women in Australia, to come to grips with its responsibilities around all of these areas and integrate them into practice in a meaningful way so those connections are made and the best health outcomes are achieved.’

According to Prof Mazza, examples of these responsibilities include the availability of medical abortion, which brings this procedure into the realm of day-to-day general practice, and helping women and their partners plan their families in a time when people are tending to experience first pregnancy in their 30s rather than their 20s.

‘It’s about improving the health literacy of women with regards to their own fertility. Helping them to understand it,’ she said.

GPs can also play a vital role in improving health literacy by educating patients on developments in best procedures in sexual and reproductive health practices, such as the upcoming changes to the National Cervical Screening Program.

‘I’m explaining to women that the new test is more sensitive and specific, and that we’re likely to even further improve the success we’ve already built on with the Pap smear program,’ Dr Frearson said. ‘I’m having a conversation to try and help spread the word out into the community.’

 

Illness and disease don’t discriminate

In the same way men’s health is more than ‘prostate cancer and sports injuries’,1 women’s health is far broader than people tend to assume, and includes a number of health issues that can potentially fly under the radar. For example, while it is widely accepted that men can often be at risk of cardiovascular disease (CVD), it is not always considered that women share a high risk, particularly as they age.

‘Women have a different profile in terms of when they develop CVD. That’s impacted by oestrogen and menopause,’ Prof Mazza said.

‘There are generally low rates of CVD before menopause, but after menopause there is a very rapid increase in prevalence that actually surpasses men.

‘So being aware of those kinds of issues and not stereotyping conditions like ischaemic heart disease and CVD as “male” conditions is important.’

Patients themselves are often unaware of this risk, instead focusing on other, more well-known diseases.

‘There’s been a few trials asking [female] patients what their biggest fears are, and breast cancer will often come at top of that list,’ Dr Frearson said. ‘But when we look at the sheer impact of CVD for women, it becomes the biggest health issue for them at menopause and later.’

CVD is not the only health problem that may escape consideration in consultations with female patients.

‘Bowel cancer is an incredibly common cancer in women,’ Dr Roeske said. ‘Women are at increased risk of stroke and tend to experience stroke earlier than men. I’ve had some personal journeys with early onset dementia in women, and alcohol intake at all stages of women’s lives is a very important issue.

‘The safe levels for alcohol consumption are a lot lower for women than men, based on their body shape, size and fat distribution. A lot of women aren’t across what is safe and acceptable for them; it’s a lot lower than many of our female patients actually think.’

This indicates that part of the changing relationship between doctors and their female patients needs to include an acknowledgement of these wider health issues. Dr Frearson believes GPs can build on their existing relationships with women by using regular visits for sexual and reproductive concerns to conduct other checks.

‘It’s an ideal opportunity for us to say, “Well, let’s do a check-up together, let’s check your blood pressure and cholesterol and look at your family history and talk about diet and exercise”,’ she said. ‘That’s one of the real benefits of being a GP, that you have the opportunity to look at all those interrelating factors.’

 

Dark shadows

Women are not only more likely to visit the GP than men, but also more likely to present with depression and other issues of mental health.2

While the causes of depression are generally considered to be a complex interplay of factors, including biological and social,3 the statistics do raise implications about gendered social perceptions of mental health, in which so-called ‘emotional problems’ are ascribed to women, making men less likely to disclose.2

‘I think women present more readily to healthcare professionals with mental health issues because it’s more “acceptable” for them to do so, and also because of their awareness that so many others are dependent on them for care and support,’ Prof Mazza said. 

Prof Mazza highlighted further gendered circumstances in many female patients’ lives that can have an impact on their mental health.

‘The sexualisation of young girls, issues related to the development of eating disorders, discrimination against women. These are all ongoing issues that affect women’s health and limit them in many ways,’ she said.

Depression can also be a sign of family or intimate-partner violence, a key aspect of mental health that GPs can be crucial in unearthing.

‘[There is an] association between experiencing violence and mental health manifestations; the issue of women who come in with many somatic and unexplained symptoms that are often related to a history of violence,’ Prof Mazza said.

Women’s more regular consults with a trusted GP for routine yet intimate matters can be helpful when approaching sensitive issues.

‘If you’re providing good care around sexual and reproductive health, you’re privy to intimate details,’ Dr Roeske said. ‘There’s often an increased confidence and trust in that relationship for women to disclose a whole raft of issues.

‘It can present an opportunity to unmask depression or assess the mental state and lead into those issues of partner abuse or violence.’

According to Prof Mazza, GPs are often key players when a woman decides to seek help for issues of violence.

‘GPs are very trusted,’ Prof Mazza said. ‘Often, women turn to GPs for assistance [with family violence] before disclosing or telling anybody else about it.’

There are many examples of small but effective strategies GPs can undertake to indicate that the consultation room is a safe place to disclose information about such a personal and sensitive issue.

‘For example, sitting just under my computer monitor [in my consult room], I have a domestic violence safety card from our local services, just like I have a “Breast feeding welcome here” sign and a Lifeline card,’ Dr Frearson said. ‘It just is a way of trying to communicate that these are things I’m happy to talk about.’

Dr Roeske believes it is also important for practices to have training and strategies in place for handling the issue when it occurs.

‘As a GP you need to think about your priorities around safety for women experiencing abuse and violence, having a look at how you are resourced in the provision of safety and healing for these women,’ she said. ‘That is a whole-practice approach: there needs to be some clarified systems and referral pathways for the GP to use.’

 

References

  1. Lyons A. Opening up: While cultural stereotypes of masculinity are changing, challenges to accessing healthcare remain for GPs and their male patients. Good Practice. June 2017: 6.
  2. The World Health Organization. Gender and women’s mental health. Geneva, Switzerland: WHO. Available at www.who.int/mental_health/prevention/genderwomen/en/ [Accessed June 30 2017].
  3. Australian Bureau of Statistics. Mental and behavioural conditions. Canberra: ABS, 2015. Available at www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/4364.0.55.001~2014-15~Main%20Features~Mental%20and%20behavioural%20conditions~32 [Accessed 30 June 2017].