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MD Consult: Books: Goldman: Cecil Medicine: Section XIX – Women’s Health

Goldman: Cecil Medicine, 23rd ed.

Copyright © 2007 Saunders, An Imprint of Elsevier

Section XIX – Women’s Health

Chapter 254 – APPROACH TO WOMEN’S HEALTH

Janet B. Henrich

Women’s health has emerged as a rapidly expanding field of scientific inquiry and knowledge with important implications for clinical practice and for the education and training of physicians. Women’s health can be viewed broadly as the study of the effect of sex and gender on health and disease that occurs across the spectrum of the biologic, behavioral, and social sciences. Increasing scientific information about the influence of sex and gender differences on health and disease has expanded our concept of women’s health beyond the traditional focus on reproductive organs and their function. This broader interdisciplinary perspective has created a new area of knowledge and scholarship that is distinct from or more detailed than the knowledge base of existing disciplines. It has provided a new model to study the interactions between biologic mechanisms and psychosocial and environmental factors and their influence on human growth and development and response to health challenges. The clinical application of this information to women across all age groups highlights the interdisciplinary nature of this field.

BASIC PRINCIPLES UNDERLYING WOMEN’S HEALTH

The importance of the effect of sex and gender differences on health and disease is outlined in the Institute of Medicine Report Exploring the Biological Contributions to Human Health: Does Sex Matter? Complex interactions exist among sex hormones, normal and abnormal physiologic processes, and the physical and emotional well-being of women. As early as the embryonic period, there are structural differences between female and male brains. Many of these differences are programmed during fetal life by hormones. During the reproductive years, the influence of sex hormones on sexual development and reproductive function differentiates a category of health issues that are unique to women. As women age and sex hormones decrease during the menopause, women’s risk factors for disease change dramatically and become more similar to men’s. Although women develop the diseases that affect men, biologic mechanisms and psychosocial factors influence the course of disease differently in women.

Until recently, most of the information used to make clinical decisions in women was based on studies conducted primarily in men. Women were excluded from research on diseases that are important to both sexes because of misconceptions about women’s health, legal and ethical issues, and cultural biases. Because women, on average, live longer than men and are affected by major diseases at a later age, it was often perceived incorrectly that women were healthier than men. In fact, throughout life, women experience poorer health than men do, especially in the advanced years. The lack of information concerning women had important implications. Information based primarily on studies done in men was often applied inappropriately to women or resulted in different standards of care. To rectify this gap in knowledge, the National Institutes of Health implemented a policy in 1994 that requires the inclusion of women and minorities in all human research studies funded by the National Institutes of Health. Substantial progress has been made in this area. Recent efforts have focused on ensuring that adequate numbers of women are included and that findings related to sex and gender differences are reported.

Efforts to increase our knowledge about women’s health issues require an integrated approach that acknowledges the diversity among women and considers the social factors that influence their lives. One of the important social trends during the past 50 years is the increasing participation of women in the work force. Currently, it is estimated that 59% of women aged 16 years or older are in the work force, including 71% of women with children younger than 18 years, and 60% of working women are employed full-time throughout the year. The full effects of multiple roles, work stress, and new environmental exposures on women’s health and reproductive status are largely unknown but are certain to have important health and social ramifications. Paralleling the growing numbers of women in the work force is the increasing number of single-parent families headed by women, especially minority women. Many of these families live in poverty. Increasing evidence indicates that socioeconomic factors are major indicators of health and that for some health outcomes, poverty and lack of education are more important determinants of health than ethnicity is. However, important ethnic and racial differences remain in women’s susceptibility and response to certain diseases that cannot be explained wholly by socioeconomic status. For example, mortality rates for coronary heart disease, stroke, and breast cancer are higher in black than in white women, whereas death rates from lung cancer are higher in white women.

The increasing diversity of the population will affect health trends in the United States and the health status of women specifically. Regardless of their racial or ethnic designation, minority group women have a lower life expectancy than white women do and experience greater health problems. These differences are most pronounced in areas related to reproductive issues and childbearing, the occurrence and course of chronic disease, the incidence and outcome of cancer, and acts of interpersonal violence. Along with changes in our society, human immunodeficiency virus (HIV) infection is an additional special health concern of minority group women.

One of the most important factors underlying the current interest in women’s health is the increasing number of women entering the health professions, especially the discipline of medicine. During the last century, the proportion of women represented in the population of physicians increased four-fold, from 6% in the early 1900s to 24% in 2000. Contributing to this growing population, the proportion of women graduates from medical schools increased from 6% in 1960 to 43% in 2001. Currently, women constitute 49% of entering medical school students. Although significant barriers remain to their attaining equal professional and academic status, the potential for women to influence the structure of their profession, the delivery of health care, and the direction of medical research is considerable.

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