16: Women

This chapter describes the broad array of behavioral issues for women using a developmental framework. We discuss expected behavioral issues occurring as part of the normal life cycle, as well as problematic ones requiring medical surveillance or intervention.

The task of adolescence is to find one’s own beliefs, moving from childhood to adulthood physically and in relationships (see Chapter 13). Several events can occur during this time that will require the sensitive attention of the primary care physician, but numerous studies have demonstrated that confidentiality must be maintained for the physician to be trusted and helpful to an adolescent.

Approach to the Gynecologic Examination

Some women fear a pelvic examination, especially when they are undergoing it for the first time. Little research has been done on what strategies are best in performing a pelvic examination, but several techniques have been found to be helpful in clinical practice.

Before performing the examination, clinicians should make the patient as comfortable as possible when taking a history by asking open-ended questions, demonstrating empathetic communication skills such as eye contact and nonjudgmental reactions, and not making assumptions about sexual activity and orientation. In addition, they should ask if the patient has had a previous pelvic examination. When taking a complete sexual history, they should inquire about prior sexual abuse or challenges with past examinations.

It is useful for the clinician to describe exactly what is being done before and during the examination. Both female and male clinicians should consider offering to have a chaperone present to reassure the patient about the professional content of the examination. Other techniques include appropriate draping; using a warm, lubricated speculum; using the narrowest speculum that will allow adequate visualization of the cervix; being as gentle as possible; and encouraging the patient to use relaxation techniques including deep breathing and mental imagery, techniques which are especially useful for young women and those who have experienced sexual abuse. In addition, elevating the head will facilitate eye contact and may make it easier for some women to relax. In situations where a patient has significant anxiety, an anxiolytic medication prior to the examination may be useful.

Research has shown that the experience of the first pelvic examination influences attitudes about subsequent examinations; therefore, it is important to make the first pelvic examination as positive an experience as possible. In a study describing women’s experiences of the first pelvic examination, a negative evaluation of the examination was associated with pain, embarrassment, having insufficient knowledge about the examination and what the clinician was doing, and not knowing that they could stop at any time. Taking time to provide knowledge and encourage realistic expectations of the examination may help shape attitudes about subsequent examinations.

If a gynecologic examination is being carried out on an adolescent in the context of reproductive health care or to screen for sexually transmitted infections, it is important to be aware of the legal requirements of confidentiality in the United States, which vary by state and are listed on the Guttmacher Institute website (http://www.guttmacher.org). Adolescents should be encouraged to involve their parents or guardians in medical decisions, and providers should be aware of mandatory reporting laws in the case of nonconsensual sexual activity, sex with an older adult, or other abuse.

Chronic Pelvic Pain and Vulvodynia

A condition that can affect women starting in teen or early adult years is chronic pelvic pain (CPP), which is commonly defined as noncyclical pain of at least 6 months duration that occurs in the pelvis, abdominal wall, lower back, or buttocks, and is serious enough to cause disability or require medical care. Chronic pelvic pain affects up to 15% of women and accounts for 20% of the hysterectomies performed in the United States. Up to 40% of women with CPP have other diagnoses, that may be the cause and/or effects of the CPP, such as depression, anxiety, sexual dysfunction, substance abuse, and other pain syndromes, requiring in-depth investigation into all contributing factors. A history of sexual or physical abuse, including intimate partner violence, has been identified in over 50% of CPP patients, and therefore must be included in the history (see Chapter 38). This evaluation often requires many visits, as well as providing patient education such as that provided by the International Pelvic Pain Society (http://www.pelvicpain.org/resources/handpform.aspx).

A definitive diagnosis is not made for the majority (61%) of CPP patients, but for those with diagnoses, they are more commonly of urologic or gastrointestinal than gynecologic origin. The four most common diagnoses are irritable bowel syndrome (IBS), interstitial cystitis, endometriosis, and adhesions; in these cases or other specific diagnoses, treatment is targeted at the underlying pathology. However, when no source is found, a multidisciplinary approach addressing dietary, social, environmental, and psychological factors, as well as standard medication therapy, is ideal. A recent Cochrane review supports counseling, a multidisciplinary approach to treatment, the use of injectable gonadotropin-releasing hormone (GnRH) agonist or oral medroxyprogesterone acetate, and lysis of adhesions for patients with no underlying source. Cyclic pain, although not commonly included in the definition of CPP, can be a significant problem and can be treated with similar approaches. Specifically, the levonorgestrel intrauterine device has been shown to be as effective as GnRH agonist for cyclic pain, which may also be responsive to combined hormonal contraceptives. Trigger point injections of the abdominal wall can help myofascial sources. Finally, oral analgesics may be used based on studies of benefit with other sources of pain, and some evidence supports the use of gabapentin with or without amitriptyline.

Vulvodynia is vulvar discomfort occurring in the absence of visible lesions, usually described as burning–diffuse, constant, and unprovoked, and less commonly, localized and provoked. Comorbidities associated with vulvar pain are low back pain, IBS, migraine, and fibromyalgia. Approaches to the patient with vulvar pain may include a variety of nonpharmacological modalities: education about vulvar care, addressing sexual and psychological issues, and pelvic floor physical therapy. Topical anesthetics such as xylocaine have been shown to improve pain. Tricyclic antidepressants and gabapentin have been used, although there have been few controlled trials. Topical estrogen may be helpful in women who also have vulvar atrophy. For the primary care provider, recommendations include counseling the patient about the disorder, giving emotional support, and facilitating appropriate subspecialist involvement.

Issues around Food and Eating Disorders

Eating disorders are common and challenging in young women, and the primary care physician plays an important role in their detection (see Chapter 23). The primary care physician also manages the medical complications, determines the need for hospitalization, and coordinates care. In addition, for patients with milder forms of disordered eating who may not be seeing a mental health specialist regularly, the primary care physician may have responsibility for ongoing care, including exacerbations that may mandate coordination with mental health and/or nutritional support. Although the diagnostic criteria for anorexia nervosa and bulimia nervosa are clearly defined, women may also have disordered eating that does not meet the criteria for anorexia nervosa or bulimia nervosa, but is nonetheless abnormal. In addition, two groups at particularly high risk for eating disorders include female athletes and women with diabetes.

Binge eating consists of episodes of eating a large amount of food in a discreet period of time with a sense of lack of control. The binges must have at least three of the following criteria: (1) eating much more rapidly than normal; (2) eating until uncomfortably full; (3) eating large amounts of food when not feeling physically hungry; (4) eating alone because of embarrassment; and (5) feeling disgusted, depressed, or very guilty after overeating. The episodes must occur at least twice a week for 6 months, and must not be associated with any compensatory behaviors (e.g., purging or fasting). The estimated population prevalence is 3.5% in women. Binge eating has been strongly associated with obesity; in weight control programs, an estimated 15–50% of individuals have binge eating disorder. Although many obese patients report binge eating, not all have binge eating disorder. As expected, obesity-related complications are likely to exist, and binge eating disorder may be more common in weight-cycling patients. Several studies have evaluated treatment options for binge eating disorder. The primary recommended treatment is psychotherapy, in particular cognitive behavioral therapy (CBT). Pharmacotherapy may also be beneficial but less so than psychotherapy. Medications that have been shown to be useful in reducing binge episodes include the selective serotonin reuptake inhibitors (SSRIs) and antiepileptics (topiramate).

Screening for Eating Disorders

Because many women will not seek care for an eating disorder, the clinician must remain alert for clues, such as amenorrhea, concern about weight loss by a family member, abdominal bloating, and cold intolerance. Questions that are useful in ascertaining eating habits include: “Are you trying to lose weight?” “What did you eat yesterday?” and “Do you ever binge eat (eat more than you want) or use laxatives, diuretics, purging, or diet pills?” One screening tool, the SCOFF questionnaire, may prove to be useful in screening for eating disorders. The questions included the following: (1) Do you make yourself Sick because you feel uncomfortably full? (2) Do you worry you have lost Control over how much you eat? (3) Have you recently lost more than One stone (fourteen pounds) in a 3-month period? (4) Do you believe yourself to be Fat when others say you are too thin? (5) Would you say Food dominates your life? A “yes” answer to any question is worth 1 point and a score of 2 is highly predictive of anorexia nervosa or bulimia nervosa. The Eating Disorder Screen for Primary Care (ESP) has also been proposed as a screening tool. The questions include: (1) Are you satisfied with your eating patterns? (no is abnormal); (2) Do you ever eat in secret? (yes is abnormal); (3) Does your weight affect the way you feel about yourself? (yes is abnormal); (4) Have any members of your family suffered with an eating disorder? (yes is abnormal); (5) Do you currently suffer with or have you ever suffered in the past with an eating disorder? (yes is abnormal). Both of these scales need to be evaluated in broader populations.

Clinicians should remain alert for the possibility of binge eating disorder in obese patients. Questions such as, “Do you ever binge eat?” “Do you often eat alone?” and “Do you ever feel guilty or depressed after overeating?” may be useful in detecting this disorder.

Treatment of Eating Disorders: A Framework

The first step is assessment of the patient’s safety, knowledge, and attitudes toward her condition by a primary care provider. She may then agree to work with one member of the treatment team, for example, a nutritionist. Similarly, counseling for developmental or family issues, or treatment for depression, may be acceptable to the patient. Family counseling may be helpful in limiting pressure from the family, as pressure may be less likely to result in changed behavior than to generate resistance from the patient. A counselor trained in treating adolescents may be able to help the patient navigate peer issues involved in the behavior. Whether or not referral to a nutritionist or psychologist is accepted, periodic medical visits to follow the presenting symptom(s)–for example, amenorrhea, low heart rate, or loss of weight–allow the primary care clinician to monitor the severity of symptoms (particularly cardiac status or other indications for hospitalization) while gently informing a patient of the medical risks of her condition. Evidence of associated medical risks, such as osteopenia, dental erosion in the case of bulimia, or concerns about fertility (particularly when the patient has low weight or is estrogen-deficient) may encourage a patient to acknowledge the diagnosis and begin full treatment. Danger signs such as bradycardia and electrolyte disturbances may mandate involuntary hospitalization.

In summary, the primary care practitioner should be equipped to detect an eating disorder, and then must work as a member of a multidisciplinary team, including a mental health professional and a nutritionist, to support weight gain as appropriate, modification of eating habits, and appropriate psychological and/or medical therapies.

In this phase of life, individuals begin to accept financial and emotional self-responsibility, to differentiate from the family of origin, and to develop intimate relationships with peers.

Healthy Behaviors and Health Care Maintenance

Safety in relation to sexuality, substance use, contraception, motor vehicles, and preventive care are ultimately the patient’s responsibility, but the physician can play an important role in establishing lifelong healthy habits and collaboration in this realm. The physician who uses gender-neutral and nonjudgmental styles of history-taking and is alert to patient cues will be more likely to be told about challenges for the patient that may have long-term modifiable consequences such as gender-identity issues, substance abuse, unsafe sex, intimate partner violence, eating disorders, and depression. Engaging with patients in partnership works best, allowing them to identify pros and cons of their choices, and supporting their ability to make changes if needed. Autonomous motivation to change and patient belief in ability to make a change are positively associated with successful changes in behavior and maintenance of those changes.

Role of Culture

Identity also includes a patient’s self-definition of her cultural role within the context of her family of origin, and this can impact her health and illness behavior (see Chapter 15). If, for example, she feels great pressure to succeed as an engineer, but prefers to be an artist, this dissonance can cause stress-related symptoms that bring her to the health care system. Somatoform behavior and medically unexplained symptoms (MUS) are common across all cultures and may be reinforced in preference to the expression of emotions in some families, masking a mental health disorder.

For women, unique issues regarding culture can relate to appearance and behavior as well. Some women may feel pressure from the dominant culture regarding slender body weight, but conflict may arise if their internal or family value system and/or sex partner is concordant with a larger body habitus. Other women could be encouraged verbally and through their cultural customs to be subservient to men, though this can be manifested to varying degrees, and may or may not result in conflict. Social support may be lacking as immigrant women become more acculturated in the United States. Also, immigrants engaged in a cultural transition process may experience criticism from older relatives as they assimilate to the prevailing culture and from younger relatives or friends if they maintain connection with the culture of origin. Traditional cultures may promote respect for elders and traditional gender roles, often a family-strengthening behavior, but reinforce secrecy around family violence and abuse. It is important for physicians to remember that family violence may include intimate partner violence, violence from extended family, and honor crimes (violence toward a woman whose behavior is interpreted as shaming the family). These issues may affect women of all ages uniquely, in their traditional role in the family, and physicians should be alert for clues that problems are occurring and when warranted use direct inquiry or screening.

Pregnancy and Infertility: Psychosocial Issues

Unintended Pregnancy

Almost half of the 6.7 million pregnancies in the United States each year (3.2 million) are unintended, and more than half of these unintended pregnancies are continued. Given these statistics and the risks of neural tube defects, it is appropriate for providers to advise all women of childbearing age who are not using effective contraception to take a daily multivitamin. Unintended birth is more common in women aged 18–24 years and in lower income women, and is associated with worse maternal and neonatal outcomes than intended birth. These include late presentation to prenatal care, smoking and drinking during pregnancy, premature birth, negative pediatric mental health effects, and not breast-feeding. Nearly 40% of unintended pregnancies end in abortion; at current rates, 30% of women will have an abortion in their lifetime.

Several factors contribute to unintended pregnancy, most importantly not using effective contraception at all or consistently. Fifty-four percent of women undergoing abortion report that they had used a contraceptive, most commonly the pill or condoms, during the month they became pregnant. Forty-six percent had not used contraception, and of these women many reported concerns about contraceptives, a quarter had had unexpected sex, and 1% had had forced sex. Contraceptive nonuse was more common among black, Hispanic, poor, and uneducated women.

To help women prevent unintended pregnancy it is imperative that clinicians counsel reproductive-aged, heterosexual women who are not trying to become pregnant about contraception. They should include the highest efficacy reversible methods such as intrauterine contraception and implants in the discussion, address patient’s concerns about methods, and help women choose the best method for them. Although oral contraceptives are the most commonly prescribed reversible contraceptives, they have a high failure rate of up to 8%, and require women to fill a regular prescription and take it daily. One recent study found that women, on average, do not take five pills each month, which likely contributes to its high failure rate. In contrast, the long-acting reversible methods have much lower failure rates of less than 1%.

Pregnancy Options Counseling and Referral: Professional Responsibility

Clinicians should provide objective, nonjudgmental pregnancy options counseling to women with newly diagnosed pregnancies. This includes asking women whether the pregnancy was intended and is desired; educating them about the options of pregnancy continuation, including adoption, and pregnancy termination; offering supportive counseling if they are undecided; and providing appropriate referrals. At times this can be challenging for individual clinicians who have strong feelings about the woman’s preference. For some, they may feel morally opposed to and uncomfortable referring a woman for abortion. For others, they may feel that her desire to continue the pregnancy is not wise due to factors such as her age, resources, relationship status, or potential interference with her educational or career goals. These feelings may interfere with one’s ability to provide unbiased counseling and referral for patients. This raises the issue of conscientious refusal and whether clinicians can opt out of such counseling.

The vast majority of U.S. states allow health care providers to decline direct participation in abortion services; 10 states permit clinicians to refuse to provide contraception for patients, and 6 permit pharmacists to refuse to dispense contraceptives. However, ethicists and medical organizations, such as the American Congress of Obstetricians and Gynecologists (ACOG), argue that it is the clinician’s responsibility to provide a timely referral when they do not, due to conscience, provide the services the patient requests. Studies show that in practice most physicians support these guidelines. To provide women adequate counseling and referral, it may be helpful for clinicians and office staff to clarify their values about pregnancy options through facilitated discussion of different scenarios and to decide on a policy about counseling and referral.

Abortion

Many well-designed studies have demonstrated that abortion is not associated with poor mental health outcomes. However, unintended pregnancy can be stressful for patients and requires significant psychosocial support, regardless of decision about pregnancy outcome. Women with unintended pregnancy are more likely to have a history of depression than women with intended pregnancy, and these women are at higher risk of a depressive episode at the time of or after an abortion. Thus, it is important to screen women with unintended pregnancy, regardless of their plans for the pregnancy, for depression. Also, whereas most women experience great relief after abortion, a few seek support as they grieve the loss of the pregnancy and may be referred to counseling services (http://yourbackline.org/).

When a woman seeks an abortion it is important to refer her as early as possible, because although abortion is extremely safe, its morbidity increases as women enter and proceed through the second trimester (although it is still lower than term birth). Women who have had an abortion are at increased risk of having a repeat, unintended pregnancy and therefore require extra support for choosing and using contraception effectively. Also, studies have found that two modifiable factors, intimate partner violence and substance use, increase a woman’s risk of abortion and therefore warrant screening and subsequent referral.

Infertility

Psychosocial stress is common in individuals struggling with infertility, increases as treatment becomes more complex, and makes discontinuation of treatment more likely. Although studies of baseline stress and conception rates with fertility treatments are mixed, a recent large meta-analysis found no relationship between baseline stress and pregnancy rates. The prevalence of psychiatric disorders also appears to be higher in infertility. Risk factors include past psychiatric illness, particularly discontinuation of medication due to anticipated pregnancy; longer duration of infertility; and history of pregnancy loss. Therefore, it is important to screen these patients for psychiatric illness, especially for anxiety and depression, as well as for the effects of infertility on various aspects of their lives and their stress levels.

Many studies have been conducted on the effect of psychosocial support–including counseling, support groups, and training in relaxation techniques and stress management–on pregnancy rates. Some studies have shown increased birth rates in patients participating in these services. A meta-analysis found an increased relative risk of pregnancy in patients participating in support groups compared with controls. Thus, it is important to screen patients seeking to become fertile for psychiatric illness and treat appropriately, and to recommend participation in a support group or similar social intervention.

Premenstrual Syndrome and Premenstrual Dysphoric Disorder

Premenstrual syndrome (PMS) is characterized by cyclic occurrences of a variety of symptoms prior to and resolving within a few days of the onset of menses. As many as 150 symptoms have been attributed to PMS, but the most common are fatigue, irritability, bloating, anxiety or tension, breast tenderness, mood lability, depression, and food cravings. Whereas up to 80% of women describe at least one PMS symptom, the more severe form, premenstrual dysphoric disorder (PMDD), occurs in only 3–8% of women and impairs daily living. Five symptoms characterize PMDD: (1) sadness, hopelessness, or being self-critical; (2) tension or anxiety; (3) labile mood interspersed with frequent tearfulness; (4) persistent irritability or anger; and (5) increased relational conflicts. Additional emotional and physical symptoms may also be present, and other psychiatric illnesses must be ruled out.

Because of varied symptoms and overlap with other conditions, a prospective daily symptom scale–demonstrating onset of symptoms around the time of ovulation and cessation of symptoms after the menses–is critical for diagnosis. Several calendars have been validated, including the Calendar of Premenstrual Experiences (COPE), in which women document symptoms daily on a 4-point Likert scale for 10 physical and 12 behavioral symptoms. A total score of less than 40 during days 3–9 of the cycle combined with a score greater than 42 during the last 7 days of the cycle is an effective screening tool for PMDD.

Treatment for PMS is approached in a stepwise fashion, first with behavioral changes and progressing to pharmacotherapy. Encouraging the patient to exercise regularly, limit salt and caffeine intake, and keep a regular sleep schedule may be beneficial. Calcium and vitamin D supplementation are associated with a lower incidence of PMS symptoms. The prospective daily symptom scale may be therapeutic as well as diagnostic by allowing the patient to be proactive in anticipating, managing, and avoiding symptoms. Since stress has been shown to increase symptoms, relaxation exercises and counseling may be effective.

Most patients with PMDD require pharmacological therapy for significant improvement. The SSRIs are considered first-line therapy and have been proven to be effective in multiple studies, for both behavioral and physical symptoms. Fluoxetine is FDA-approved for this indication at doses between 20 mg and 60 mg, with lower doses equally effective and better tolerated. Other effective SSRIs are sertraline, paroxetine, and citalopram, and all can be administered continuously throughout the month, intermittently from ovulation to the onset of menstruation, or semi-intermittently with increased doses in the late luteal phase. The benzodiazepine alprazolam can be used in the luteal phase to reduce symptoms, but with less effect than SSRIs. Patients who do not respond to SSRIs or anxiolytics can try agents to suppress ovulation; options include continuous oral contraception or contraceptive rings (the patch cannot be used continuously due to increasing weekly levels of ethinyl estradiol). One pill formulation with drospirenone improves PMS when prescribed traditionally, with a hormone-free interval, but only in comparison with placebo and only in the short term compared with other pill formulations (by 2 years symptoms are equivalent to the effects of other pills). Also, GnRH analogues, which require add-back estrogen therapy if used for more than 6 months, can treat symptoms. Other treatments showing some benefit are vitamin B6 supplementation and spironolactone.

Depression in Pregnancy

Women with a history of major depression are at highest risk of depression in pregnancy. Other risk factors include discontinuing or decreasing antidepressant medications. In the absence of suicidal or homicidal ideation, nonpharmacological treatments are advised. Psychotherapy for depression has been shown to be equally effective when compared to antidepressant medications (see Chapter 25). Often the focus of psychotherapy in this setting is on the transition to motherhood and the acquisition of the requisite skills.

The decision about prescription of psychotropic medications is complex: The risk of medication exposure to the fetus must be balanced against the risk of untreated depression for the mother, other children in the home and, ultimately, the infant. Decisions about medication include factors such as the severity of the depression, the number of prior depressive episodes, and a woman’s history of response to medications. All the evidence comes from observational studies.

Overall, experts recommend sertraline as the preferred drug for treatment of depression in pregnant women.

Postpartum Depression

During the postpartum period, women can experience mood changes, including postpartum blues, postpartum depression, panic disorder, and postpartum psychosis. Transient postpartum blues are common, occur within a few days of delivery in 40–80% of women, include mood swings, irritability, sadness and crying spells, and resolve within 2 weeks. Postpartum depression has been estimated to occur in 5–9% of women. The clinical diagnostic criteria are feeling depressed or hopeless most of the day almost daily for at least two consecutive weeks, with onset usually within 1 month but up to within a year of birth. The biggest risk factor for postpartum depression is a personal history of depression. Other risk factors include lack of social support, history of miscarriage or other pregnancy loss, not breast-feeding, pregestational or gestational diabetes, and family psychiatric history. Some of the symptoms of postpartum depression such as fatigue, sleeping problems, and decreased sexual drive are common symptoms of the immediate postpartum period, making the disorder more difficult to detect. Feeling overwhelmed or guilty, being unable to care for or bond with the baby, or not sleeping even when the baby is sleeping, should all alert the clinician to the possibility of the diagnosis.

The Edinburgh Postnatal Depression Scale has been validated and used in multiple settings to screen for postpartum depression. Clinicians should ask about mood, appetite, sleep, and being overwhelmed during postpartum visits. A woman who expresses thoughts about harming herself or the baby should receive immediate evaluation by a mental health professional. When evaluating a woman for possible postpartum depression, thyroid disorders should be ruled out, as both hypothyroidism and hyperthyroidism are more common in the postpartum period.

Women with mild to moderate symptoms should be initially treated with nonpharmacological measures including sleep hygiene, education, psychotherapy, CBT, or family therapy.

There are no randomized controlled trials of pharmacotherapy for postpartum depression, so recommendations are based upon observational studies and extrapolation from the general population. Antidepressant drugs are generally initiated in the same fashion as in the usual treatment of major depression, using a medication previously effective whenever possible. The SSRIs are the drug of first choice, given their safety profile and relative low risk of side effects, with the evidence slightly favoring sertraline and paroxetine. Although there is limited evidence about antidepressant use in breast-feeding women, there are only few reports of adverse effects. The benefits of depression treatment and of breast-feeding are generally felt to outweigh the risks of the medications.

Irritable Bowel Syndrome

Young adult women may present to their physicians with IBS, as it is the most common gastrointestinal disorder seen in primary care. It is characterized by chronic abdominal pain and altered bowel habits in the absence of an organic cause. IBS is estimated to occur in 1–20% of the population with a female predominance of 1.5:1. Only about 15% seek medical care for their condition, yet the volume of patients is large and the burden to society in health care costs and missed work is significant.

The pathophysiology of IBS remains unknown. It is thought to be a disorder of gastrointestinal motility, dysregulation of the nervous system, increased visceral sensitivity, and possibly bacterial overgrowth. Psychosocial stressors have been shown to precipitate and exacerbate symptoms but are not thought to be a cause of the underlying condition. Women who have a history of physical or sexual abuse are more likely than controls to suffer from IBS and other functional bowel disease. Patients with a history of abuse have poorer health outcomes as manifested by an increase in pain, physician visits, and surgical procedures than patients without an abuse history. Although women seeking treatment for IBS are more likely to suffer from depression, anxiety, panic disorder, somatization, or other mental illness, those who do not seek treatment have the same incidence of these problems as the general population. Hence, it is unclear whether psychiatric stressors exacerbate the disease or contribute to the underlying etiology, perhaps varying in different individuals. Other conditions related to IBS include sleep disturbance, depression, and fibromyalgia. Interestingly, health-related quality of life appears to be more related to extraintestinal symptoms rather than traditionally elicited gastrointestinal symptoms in patients with IBS.

Effective treatment for IBS involves an integrated behavioral and pharmacological stepwise approach individualized to the patient’s main symptom. Treatment for mild disease can involve only education, bulking laxatives, and antispasmodics. Both the SSRIs and the tricyclic antidepressants (TCAs) are effective for symptom relief in some patients but the TCAs can exacerbate constipation. Loperamide is helpful for treatment of diarrhea, but does not relieve other symptoms. Rifamaxin, a nonabsorbable antibiotic given for a short course, has been shown to relieve some symptoms of IBS. Newer treatments include alosetron, a 5-hydroxytryptamine-4 (5-HT-4) antagonist, which was removed from the market because of serious complications, but is now again available for limited use. Cognitive behavioral therapy (CBT) has been shown to be helpful in several studies. Dynamic psychotherapy and hypnotherapy have also been shown to be useful in reducing IBS symptoms, although results are somewhat mixed and effects were of short term in some studies. In the largest trial testing CBT in women, CBT was significantly more effective than education alone. Certain subgroups of IBS sufferers may be especially responsive to CBT. Simple educational interventions designed to help patients learn more about their bodies and IBS can be helpful in reducing anxiety and improving health-related quality of life. However–similar to other disorders overlapping with a history of childhood or adult abuse, sexual trauma, psychiatric comorbidities, or somatization disorder–sensitive communication strategies and avoidance of unneeded interventions are crucial.

Women with children negotiate a myriad of changes in themselves, their children, their families of origin, and their committed relationships. In the childbearing years, depending on their own relationship situation, women need to integrate the child into a diversity of potential relationship environments: same- or opposite-sex partner, marriage, cohabition, monogamous or nonmonogamous. Relationships are mapped upon changes in the woman’s emotional and physical self, career, and the rest of the family on all sides. This often requires profound multitasking. As children age, the parent(s) must accommodate varying tasks in the children’s lives, helping them with their transitions, even as the parents, sometimes paradoxically, make their own transitions. Women, with and without children, are the most likely ones to care for aging parents, parents-in-law, and other older relatives. Expected physiologic changes or unexpected illness further impact women in these years. It is imperative that primary care providers anticipate these developmental processes and incorporate them into their approach to these patients.

Menopause: Managing Symptoms

Personal, cultural, and family attitudes can have a large effect on the emotional and functional impact of menopausal symptoms. A biopsychosocial approach, which includes inquiring about the impact of these developmental processes and ascertaining whether symptoms can be managed without medication, is crucial. Since publication of the results of the Women’s Health Initiative, which showed increased risk of breast cancer and cardiovascular disease associated with use of estrogen/progestin, many women and their physicians are reluctant to use hormone therapy (HT) for treatment of menopausal symptoms. However, estrogen can be very helpful for the treatment of hot flashes and vaginal dryness and in the prevention of osteoporosis. Use of systemic estrogen, and progesterone if the women has a uterus, is an option that some women may choose if symptoms are severe or if other therapies are not successful. The primary care provider can help female patients sort through the multitude of options, including assessing the risks and benefits of HT, and make their own best decisions. Comorbidities such as family history of breast cancer, use of cigarettes, and personal or family history of thromboembolic disease may impact this decision.

The average age of menopause in the United States is 51 years. More than 50% of postmenopausal women experience “hot flashes,” a manifestation of vasomotor instability associated with the abrupt withdrawal of estrogen. Hot flashes, also known as hot flushes, are sensations of feeling warm, frequently associated with perspiration, palpitations, and anxiety. When they occur at night, they can be manifested by night sweats, frequent awakening, and consequently, sleep disturbance and chronic insomnia. A recent meta-analysis showed that the average duration of menopausal symptoms is 4 years, so any potential treatment options must be considered within the context of this symptom duration.

Another important menopausal symptom is urogenital atrophy. The loss of estrogen causes thinning of the vaginal epithelium and may lead to vaginal irritation, dyspareunia, and increased risk of vaginal infections. When the urethra is affected, urinary frequency, incontinence, and bladder irritation or infection can also occur.

Treatment of Vasomotor Instability

Symptoms such as hot flashes and changes in sexual function can have a profound effect on a woman’s mood and quality of life. Many women with mild vasomotor symptoms will try nonpharmacological interventions, such as lifestyle changes, relaxation, and exercise, but the evidence for these therapies is limited. Obesity, however, is a risk factor for hot flashes, hence weight loss may help reduce hot flash severity.

Determining the efficacy of pharmacological treatments for vasomotor instability is challenging, as about 30% of women will respond to placebo (Table 16-1). However, estrogen has been shown to be the most effective in reducing the frequency of hot flashes, associated with an 80% reduction in hot flash frequency.

Nonestrogen therapies that have been used for vasomotor symptoms include the selective serotinin reuptake inhibitors (SSRIs), the serotonin norepinephrine reuptake inhibitors (SNRIs), high-dose progestins, clonidine, gabapentin, and several complementary therapies. Several trials have evaluated antidepressants (SSRIs and SNRIs) in the treatment of postmenopausal hot flashes. Drugs that have been found to be effective include venlafaxine and desvenlafaxine (SNRIs) and paroxetine and escitalopram (SSRIs), and are generally associated with about a 60% reduction in hot flash frequency. High-dose progestins (megestrol acetate or Megace) have been associated with about a 50–60% reduction in hot flashes, although prolonged therapy can be associated with weight gain. Clonidine has been associated with about a 40% reduction in hot flashes. Gabapentin has also been associated with a reduction in hot flash frequency of about 30–45%.

Several complementary and alternative therapies have been used for treating hot flashes, although the trials are often small, short in duration, lack a placebo arm, and use variable doses. Isoflavones are contained in soy products and red clover, and have been frequently used for the treatment of menopausal symptoms; however, studies have not shown any benefit. Several herbal remedies have been promoted for hot flash reduction. Black cohosh, wild yams, progesterone cream, ginseng, dong quai, and evening primrose oil have all been used but do not have proven efficacy.

Many women go through menopause without medications, using behavioral strategies such as exercise, hydration, wearing layered loosely fitting clothes, and short daytime naps to compensate for hot flash-interrupted sleep. It is important for primary care providers to establish a collaborative relationship with patients, allowing them to discuss issues that may compound menopausal symptoms. Normalizing these sometimes stressful transitions may help a woman to accept a trial of watchful waiting or even psychotherapy to address the stress of these changes. Discussion of menopausal symptoms may not necessarily be a request for medications, but should trigger discussions about the variety of available management strategies.

Treatment of Urogenital Atrophy

The mainstays of treatment for urogenital atrophy are currently vaginal moisturizers and topical vaginal estrogen in either cream or ring form. Vaginal therapy can be safely used in most women, although there is some controversy about use in women with estrogen-dependent tumors. Regular use of vaginal moisturizers and use of lubricants during intercourse can be beneficial to relieve symptoms but do not treat the underlying genital atrophy.

Maintaining Sexual Function

It is important for physicians to inquire about sexual function; a national study of 1749 women and 1410 men aged 18–59 years found a prevalence of sexual dysfunction of 43% for women (see Chapter 32). Sexual function in women is both emotional and physical. As some women age, they experience a liberation from the responsibilities of young children, relationship struggles, and financial concerns that allows them to enjoy sex more than they ever have. This may also be due, in part, to a relative rise in testosterone, as estrogen levels decrease, that improves sexual function in some women. Others experience physiologic changes described above that diminish sexual function, such as urogenital atrophy or sleeplessness from hot flashes. Expectations may be different between male and female partners, especially if the male is able to treat erectile dysfunction medically. Besides lubrication, women can be advised to try a slower pace of sexual activity, as it is normal for reaction time to diminish with age in both genders. If estrogen is used to treat vasomotor symptoms of menopause, the relative drop in testosterone can diminish sexual drive or function in some women, and that subgroup of patients may benefit from the addition of small amounts of testosterone. A primary care physician may defer prescription of these medications to a gynecologist or endocrinologist, but should be familiar with the physiology and be able to make recommendations accordingly.

Women in their later years are achieving the tasks of shifting generational roles and changes in couple and family functioning. Challenges may include loss of spouse, family members, and friends, along with physiologic aging and financial concerns. Opportunities exist, however, for life review and integration, along with time for new friendships and activities. Additionally, a woman may enjoy being appreciated for her wisdom, without many of the burdensome responsibilities of younger years. A primary care provider should be prepared to assist in these challenges and supportive of the opportunities (see Chapter 14).

Osteoporosis and Falls

Both osteoporosis and falls are more common in older women than in men. More than half of all women will develop osteoporosis by the age of 80 years. Fractures are 2.2 times higher in women over the age of 65 years than they are in men. Women appear to recover more slowly from these injuries, which may contribute to increased medical costs for falls in women. Hence, prevention of falls is an important issue for older women and has several behavioral components. Interventions shown to reduce falls include muscle strengthening and balance retraining, multidisciplinary health and environmental risk factor screening and intervention programs, group exercise with tai chi, home hazard assessment, withdrawal of psychotropic medications, and vitamin D supplementation.

Fear of falling can significantly impact an older woman’s life by inhibiting activities, leading to a loss of independence. In one survey, 80% of women answered that they would rather be dead than experience the loss of independence and quality of life that results from a bad hip fracture and subsequent admission to a nursing home. Clinicians caring for older women should address this fear and consider interventions not only to reduce osteoporosis risk but also to reduce risk and fear of falling. Some of the same activities that reduce incidence of falls can reduce fear of falling; these include tai chi and strength training.

Urinary Incontinence

Up to 50% of elderly women report some urinary incontinence. Daily incontinence occurs in about one-fifth of community-dwelling women aged 85 years or older. More than half of the women with urinary incontinence do not tell their health care provider about their situation and just try to live with it. The psychological morbidity from this “hidden” problem can be high. Problems may include social withdrawal, depression, and sexual dysfunction. The clinician can uncover these problems with thorough history and physical examination to assess for volume overload, constipation, musculoskeletal limitations, bladder integrity, and vaginal atrophy. Specialist referral should be considered in those with abdominal or pelvic pain, hematuria, fistula, pelvic mass or prolapse, complex neurologic conditions, and those who fail conservative management.

Several behavioral treatments are helpful in urinary incontinence. For stress, urge, and mixed incontinence, avoiding overfilling of the bladder and regular muscle contraction (Kegel) exercises are beneficial. In urge and mixed incontinence, bladder retraining in cognitively intact women along with biofeedback is effective. In cognitively impaired women, prompted voiding by a caregiver can further reduce incontinent episodes. Smoking, caffeine, alcohol cessation, and weight loss are of benefit. Anticholinergics, antispasmodics, or combinations are the most commonly used and effective pharmacological options in conjunction with behavioral treatments for urge and mixed incontinence. Topical estrogen is another potentially helpful option. If these conservative measures are not effective, specialist referral is indicated.

Cognitive Dysfunction

Cognitive dysfunction, including mild cognitive impairment and dementia, are major issues facing older women, with an estimated annual incidence for Alzheimer dementia of 0.6% for people over the age of 65 years and 8.4% of those over the age of 85 years. Women appear to be at higher risk of developing dementia and, because of women’s longer life span, there are many more older women suffering from dementia than men. Prevention of dementia would be optimal in reducing the burden of this disease, and many of the prevention strategies involve behavioral approaches (see Chapter 30). Risk factors for dementia include hyperlipidemia, diabetes, hypertension, smoking, low levels of physical activity, low levels of mental activity, and poor social network. Older women should be encouraged to adopt a “brain-healthy” diet, which includes a decrease in overall fat and an increase in foods high in monounsaturated fats and antioxidants (fruits, vegetables, nuts, and cold-water fish). They should also maintain a healthy weight, get regular physical activity, participate in social activities, and exercise the mind (learn new things, read, play games, crossword puzzles, etc).

It has been hypothesized that HT after menopause would help decrease the risk of cognitive dysfunction and dementia. Several prospective population cohort studies found fewer declines in cognitive function in women taking HT. Earlier small clinical trials have shown some cognitive improvement in women taking HT, but the Women’s Health Initiative actually showed an increase in cognitive decline in some groups taking HT, both estrogen-alone and estrogen–progestin groups. As this study started several years after menopause for most of the participants, no conclusions regarding early postmenopausal therapy can be made. Using current evidence, HT should not be prescribed for the sole purpose of preserving cognition.

There are a number of behavioral issues in the primary care of the woman patient, and these should be integrated into preventive care and management of medical issues from a biopsychosocial perspective. Although the developmental stages women experience include challenges, there are also opportunities for fulfillment both for the patients and those who care for them.

We acknowledge Sangita Devaskar for her assistance with manuscript preparation.