Women’s Health: Beyond the Bikini

Health is complex. Women are complex. Women’s health is complex. So why does “women’s health” so often refer to reproductive issues alone?

The American Heart Association and the American College of Obsetricians and Gynecologists did something smart. They looked at the past few decades of progress in women’s cardiovascular health and asked “why are women still under-informed about their risk of heart disease. . . and why are we still not better at lowering risk?”

Those of us who practice primary care day-in, day-out could probably tell you a lot of reasons: competing priorities, limited time, siloed care— leaving a void for a big-picture assessment of health and health risks. This is a problem for all kind of patients and providers, but it’s particularly acute in women’s health, where issues of reproductive health often take center stage (especially in younger women). A well-woman visit is an opportunity for more than pap smears and birth control! This might be in a primary care practice or a gynecologist’s office (where many young women get their only care). What are we telling women when they come for a well woman visit, and what are they telling us? Are we communicating well, or are we checking boxes on the EHR and making sure we get reimbursed fully? I had a well woman visit myself this year, and I heard a lot about pap tests and nothing about blood pressure or depression.  This is not unusual, but it’s not good.

There’s mounting evidence about sex (biological and physicological) and gender (sociocultural) influences on cardiovascular health and disease. Cardiovascular disease was first identified, studied, and treated in men. Our entire paradigm of the disease is based on men. Yet women’s disease is different, women’s response to disease is different, and the healthcare system’s treatment of women is different. Still, we too often fail to appreciate how these differences matter, and that undermines our efforts as health professionals to address risk.

The million dollar question: How do we identify, communicate, and mitigate women’s cardiovascular risk effectively?

One approach? Treat women’s health as a holistic issue rather than just focusing on the parts covered by a bikini.

We’ve done incredible work with understanding risks for breast and cervical cancer and initiating screenings and treatments that reduce risk and reduce mortality. Women get it! This is a triumph for women’s health, but we need to face the fact that it’s heart disease, not breast cancer, that is the number one killer of U.S. women. We need to talk about this with our patients. We have mounting data about the role of autoimmune disease, pregnancy events, psychosocial factors, and hormonal shifts over the life course in cardiovascular risk. But many primary care providers don’t include such sex-specific factors in routine screening— they’re not part of the standard risk assessment tools. (aside: the more data we generate, the more we can improve our tools.  Who are we enrolling in studies? Are we gathering the right information about them? Are we playing the long game well? I’ll get into this more another day, so stay tuned.)

As the recent AHA/ACOG statement suggests: “All well-woman visits, including the postpartum follow-up visit, should be considered an opportunity to focus on lifestyle choices that optimize cardiac health, including weight management, smoking cessation, physical activity assessment, nutritional counseling, and stress reduction.” These topics are germane to cardiovascular health, but also to mental health, fitness, reproductive health, and overall wellness. We don’t have time not to talk about this. If you’re a provider, how can you integrate more holistic risk assessment and counseling into routine care? What do your patients think?

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