Women's HealthWomen's Health

Twenty Common Problems in Women's Health Care is not competing to muscle aside the more comprehensive textbooks on primary women's health care, ie, Primary Care of Women by Carson et al (Mosby, 1995), Primary Care of Women by Lemke et al (Appleton & Lange, 1995), and The Medical Care of Women by Carr et al (Saunders, 1995). Rather, editorial collaborators Smith, a physician, and Shimp, a pharmacist, have chosen 20 topics "based on data obtained from the National Ambulatory Medical Care Survey and the National Center for Health Statistics and published papers about why women visit their health care providers and the problems they bring to these encounters. In addition, we sought advice from colleagues, friends, patients, and family members about the concerns of today's women."

Perhaps this less ponderous assignment has allowed the authors to climb more easily out of the box labeled "women's health care = gynecology + psychiatry + internal medicine." Smith and Shimp have attempted, and in some aspects have achieved, a more cohesive, integrative, and truly interdisciplinary model of women's health than we have had in a textbook thus far. (By my rough estimate, the distribution of pages is: "truly interdisciplinary," 60; internal medicine, 150; psychiatry, 180; and gynecology, 220. Although, as usual, the pelvis is at the head of the list, this still is a more equitable distribution than in most texts on women's health.)

In the more traditional tomes, clusters of chapters are titled (yawn . . . ) "Medical Disease in Women," "Diseases of the Gynecologic Organs," and "Psychiatric and Behavioral Disorders." For any thoughtful women's health physician, reading such a table of contents is equivalent to 0.25 mg of triazolam washed down with 16 oz of valerian tea, or has the effect of the phrase "May I have the first slide please?" after the lights have been dimmed. In contrast, 20 Common Problems' " suprabox" perspective is evident in the much more intriguing titles of several of its five parts. Part 1, "Preventive Care/Health Maintenance," covers family planning, prenatal care, menopause, and health maintenance examinations. Part 2, "Womanhood, Choices and Challenges," discusses sexuality, obesity, and eating disorders. Part 3, "Women in Trouble," reviews sexual assault, domestic violence, sexual harassment, substance abuse, and depression and anxiety, and includes a very innovative chapter, "Relational Problems." (At last, the research of Carol Gilligan, Jean Baker-Miller, and other feminist psychologists and psychiatrists has reached physicians!) Smith and Shimp state that they have added this chapter based on the frequent comment that "the most common health care problem for women is men." Part 4, "Gynecologic Concerns," reviews miscarriage, breast disorders, urinary incontinence, vulvar and vaginal disease, menstrual disorders, and sexually transmitted infections. And part 5, "Other Common Health Concerns," reaches into the closet of internal medicine and pulls out osteoporosis, hypertension and heart disease, and gastrointestinal and gallbladder diseases. (I would have chosen headaches and thyroid diseases rather than the abdominal problems.)

In addition to the generally up-to-date clinical information, the book also covers practical aspects of patient care in contemporary settings. For example, chapter 1, "The Women's Health Maintenance Examination," reviews screening guidelines but also discusses techniques to promote good health behaviors and reviews common problems in the delivery of preventive services in a managed care environment. Chapter 8, "Substance Abuse," has an extended section on substance abuse counseling (not a forte of most physicians), including "stages of change," "brief office interventions," and "motivational counseling techniques" that can be applied to alcohol abuse, cigarette smoking, and illicit and/or polysubstance abuse.

As with the three textbooks mentioned earlier, 20 Common Problems outlines the arduous terrain that a women's health physician must cover during visits that are pressured to be briefer (to increase "productivity"). The cognitive skills that are required to travel these territories are still drastically undervalued both within medicine and within the reimbursement structure. In 20 Common Problems, a partial list of the mandates to primary care providers includes:

A job description of this multifaceted primary care physician is both inspiring and overwhelming. (Note: In response to the need for physicians with the interdisciplinary skills needed for contemporary women's health care, the American College of Women's Health Physicians [ACWHP] has created a residency curriculum for interdisciplinary training of residents in the new primary care specialty of women's health. ACWHP's model residency is scheduled to begin July, 2001, in Santa Fe, New Mexico.)

Of special use to medical students and residents who are learning interviewing skills and to practicing physicians who are branching into areas of women's health beyond their residency training (new species like the gyneternist and the interchiatrist) are techniques for screening for many diseases and conditions, eg, the TWEAK screening questionnaire for alcohol abuse, questions to use in obtaining a comprehensive sexual history, screening questions for elderly abuse or neglect, and planning individual approaches to treatment of obesity through information from patient interviews.

Despite these strong suits, there are several notable deficiencies. First, the preface states, "this book is unique in that it is based on the current best evidence and provides detailed diagnostic and management options, including prescription and non-prescription drugs and alternatives/complementary approaches." However, the alternative therapies information is spotty. Some chapters do have research-based information on alternative therapy. For example, chapter 11, "Vulvar and Vaginal Disease," discusses studies on the use of Lactobacillus crispatus in treatment of recurrent bacterial vaginosis and the use of yogurt to decrease recurrences of vaginal candidiasis. However, most other chapters are weaker on the alternative-therapies promise of the preface. For example, in chapter 13, "Menstrual Disorders," the "Alternative Therapies" section for dysmenorrhea reviews calcium channel blockers, β-adrenergic agonists, and transcutaneous electrical nerve stimulation (TENS) units. This chapter does have a table "Herbal Medicinals Approved for Menstrual Disorders per the German Commission E," but none of the herbs are discussed in the text, and the two paragraphs on "Herbal Therapies for Menstrual Disorders" spends most of its space warning of the dangers of herb-drug interactions and of problems with quality control in herbal manufacturing, rather than reviewing evidence-based research. "The Women's Health Maintenance Examination" chapter gives the misinformation that "acupuncture [has] not been subjected to placebo-controlled trials but has been incorporated into mainstream medicine as an adjunct to smoking cessation and managing painful conditions." Examination of the medical literature should precede the writing of such statements in textbooks.

Perhaps the weakest exploration of complementary therapies is in the "Depression and Anxiety" chapter, which reports on St John's wort that "experience in this country is still limited, however, and there is a general sense that hypericum is useful primarily in depressions of mild intensity." Actually, not only is it easy to access medical journals from other countries, but a recent meta-analysis evaluated 23 randomized trials (20 were double blind) of St John's wort in a total of 1757 outpatients with mild to moderate depression. Improvement in depressive symptoms (on a standardized scale) was observed in all groups.¹ At least eight treatment-controlled trials have shown that clinical improvement in patients receiving St John's wort and patients receiving tricyclic antidepressants does not differ significantly.²

Second, I am concerned that a textbook published in 2000 is not more hesitant in claiming cardiovascular benefits for hormone replacement therapy. The "Menopause" chapter states "a number of epidemiological studies have demonstrated a cardioprotective effect of estrogen. The cardiovascular benefits of estrogen include a decreased rate of CHD [coronary heart disease], decreased death rate . . . and a decrease in all cause mortality." The authors acknowledge that the Heart and Estrogen/Progestin Replacement Study (HERS) trial indicates that hormone replacement therapy (HRT) for women with CHD "may be associated with cardiovascular risk as well as cardiovascular benefit." Yet, despite the HERS trial and despite well-known criticism of the earlier epidemiological studies of HRT and prevention of CHD, the authors regularly associate HRT with the word "cardioprotective" and still strongly encourage most women to consider long-term hormone therapy. Clinicians and medical researchers at the leading edge of women's health have many more questions about the benefits of HRT than are described in this textbook.³

In summary, 20 Common Problems in Women's Health Care is a valuable contribution to the resources in women's health. The innovative organization of several central problems in women's primary care is refreshing and worthwhile. This book is another signpost on the road to a truly interdisciplinary textbook in women's health. For those of you in medical school and residency interested in women's health, use this textbook to get started, and go on to write that visionary textbook!

Dr Strong's little book is an interesting essay on the care of pregnant women prior to labor in the United States. He has written it to give patients and policy makers a realistic view of what prenatal care can and cannot accomplish.

According to the book, the evidence supports that prenatal care decreases maternal and infant mortality but has little or no effect on low birth weight and prematurity. Unfortunately, with best intentions, it has been oversold to the American public as a cure-all for the problems of low birth weight and prematurity. Dispelling this overly optimistic view of prenatal care is one of the major goals of the book, and it is well achieved.

Strong makes a good case for patients asking informed questions about prenatal care. Unfortunately, he discards case reports and case control studies as evidence that should be considered suspect. In this, the book does a disservice to the reader by ignoring the fact that case control studies, when well done, can give estimates of treatment efficacy similar to randomized control trials.^{1 - 2} And, it was an astute case report that identified the congenital rubella syndrome.

Based on reasonable evidence, the book advocates sweeping changes in the organization of prenatal services to American women. These changes include prenatal care by certified nurse midwives for the majority of patients (those who are low risk) and collaborative involvement with physicians whose sole practice is the care of non–low-risk patients and obstetrical problems. This revised prenatal care should emphasize that pregnancy is a normal event and not a disease. There would be fewer but longer visits for the low-risk individual, which would emphasize communication and education in healthful behaviors that would benefit the pregnancy. The reorganization would involve splitting the specialty of obstetrics from gynecology. Prenatal care, the author argues, should be regionalized, have redundancies of services removed, and incorporate practice guidelines utilizing evidence-based medicine. Strong discusses the real obstacles to achieving such change but does not give the reader a sense of how long it might take.

Having discussed the evidence that prenatal care cannot fix the problem of prematurity and low birth weight in the United States, the book goes on to explore the reason why. Strong provides reasonable evidence that the answer lies in part with the parents and their environment. The book explores the role of unhealthy behavior on the part of the mother, physical abuse, unwanted pregnancy, and chaotic social situations as causes for prematurity and low birth weight. How can these be solved by more technology and medical intervention? The reasonable answer provided by Dr Strong is that they cannot.

Expecting Trouble: The Myth of Prenatal Care in America makes the reader look at the limitations of medical intervention and opens the discussion on the patient's and society's contributions to good pregnancy outcome. How do we make people more responsible? How do we achieve a revolution in the delivery of care to pregnant women? How do we allow every woman to conceive only those pregnancies that she wants? All are good questions raised by this book, but not answered. This is a book to read for the questions it asks.

Uniqueness is always intriguing. In this book, Steven Peitzman recounts the history of a one-of-a-kind place, the Women's Medical College of Pennsylvania. This story is rich with meaning for today; as we encourage young girls to explore science and consider career possibilities, it can be shocking to realize exactly how hard women of previous decades struggled to break into the medical profession. Over the years, the Women's Medical College (WMC) gave hundreds of determined women the education and support they needed to become doctors, opportunity otherwise out of reach for many.

One hundred and fifty years ago, when virtually all US medical schools barred female students, a few male Quaker physicians and reformers of Philadelphia set out to organize training for women. Ann Preston, member of the first graduating class in 1851 (comprising eight women), wrote that "the joy of exploring a new field of knowledge, the rest from accustomed pursuits and cares, the stimulus of competition, the novelty of a new kind of life, are all mine. . . . " Preston went on to become professor of physiology at WMC and then dean, presiding over the school's post-Civil War enrollment expansion, curriculum reform, and facility development.

The notion that decent women would attempt the strenuous and indelicate work of medicine still appalled critics, and the Philadelphia County Medical Society prohibited members from working with female doctors. Preston defended WMC as representing "the advancing civilization of the age, as the inevitable result of that progressive spirit which is unfolding human capabilities in many directions. . . . [O]n behalf of a little band of true-hearted young women who are just entering the profession, we must protest . . . the injustice which places difficulties in our way, not because we are ignorant or pretentious or incompetent . . . but because we are women." In 1869, male medical students hissed, jeered, and (according to some reports) threw spitballs and stones at WMC students who dared attend Pennsylvania Hospital clinical lectures. Fortunately, Quaker women had established the Woman's Hospital of Philadelphia back in 1861, giving WMC students a secure chance to gain clinical experience and observe female physicians treating (even operating on) local women and children.

Peitzman describes 1880 to 1910 as a golden age when WMC anticipated most other medical schools in requiring a four-year curriculum, including substantial laboratory work and study in new specialties such as bacteriology. Serving in WMC's maternity outpatient service, students ventured into poor immigrant neighborhoods to deliver babies, acquiring hands-on knowledge and increased self-confidence. Graduates spread across the country, setting up private practices and charity clinics, while more than 200 worked as medical missionaries in China, India, and elsewhere.

Nevertheless, with the 1910 publication of the Flexner report, it became apparent that WMC did not fit the American Medical Association's desired model of medical education. The institution had too few full-time faculty, conducted too little research, and was not connected to either a university or teaching hospital. Correcting such deficiencies would involve enormous expenditures, and WMC already faced severe deficits. The nation's other all-female medical schools in New York City, Baltimore, and Chicago had already closed. Johns Hopkins, Michigan, and other major institutions had made medical study coeducational, but WMC's local backers and alumnae pledged enough money to preserve one place run by and for women. At a time when few other medical schools or hospitals had female doctors on staff, graduates wanted new generations to have the opportunity to watch women role models lead classes, run a medical school, and perform lifesaving operations.

Through the 1920s and 1930s, administrative disputes caused internal discord at WMC, while the Depression kept the small school at the brink of financial disaster. AMA inspectors still attacked the school's perceived weaknesses. Yet WMC not only remained open, but managed to build a large new campus and to recruit prominent professors who initiated serious research. International students, Jewish women, Asians, and African-Americans found that they were welcome at WMC when other medical schools closed the doors.

The postwar transformation of medicine affected WMC most dramatically. Competition for federal research grants put the school under pressure to hire star research scientists, most of them male. WMC gained strength but sacrificed much of its unique feminist character. In 1964, for the first time in a century, WMC hired its first permanent male dean. Five years later, institutional malaise and a fear that civil rights legislation would cut off funding to single-sex institutions led decision makers to make a fundamental alteration in the school's nature—admitting men. Peitzman's final chapters contain a valuable account of the forces affecting the newly coed institution through the 1970s, 1980s, and 1990s. The renamed Medical College of Pennsylvania managed to balance academic research growth and high-tech care with a focus on educational quality in an atmosphere of camaraderie—until smallness and economic crisis drove it into affiliation with Allegheny Health Systems and subsequent chaos.

Peitzman provides compelling explanations for why WMC survived as a unique institution for so many years against such difficult odds. This book offers a powerful historical perspective on the gendered nature of US medical education.

Today it is challenging to say something both comprehensive and fresh about the perils and promises of medical genetics. Mary Briody Mahowald's Genes, Women, Equality rises to this challenge. In considering a broad range of issues, Mahowald grounds her argument in the tenets of feminist standpoint theory and advocates a feminist egalitarian approach to judging the ethics of various genetic interventions and addressing the inequities likely to result from their use.

Focusing on justice and equity is itself a refreshing approach in areas—genetics and bioethics—in which threats to autonomy are often considered the primary concern. Yet what often feels most refreshing is not Mahowald's theoretical approach, and what may prove most satisfying is not necessarily her overarching argument for gender justice. Instead, this readable volume offers fresh insights on particular issues, and Mahowald skillfully makes connections and draws on literature that others tend to overlook.

One example is Mahowald's survey of current ethical debate about genetic interventions among advocates for the interests of those living with disabilities, a debate to which Mahowald has been a prominent contributor. With respect to assisted reproduction, cloning, sex selection, genetic enhancement—areas that implicate concepts of family and parenting—Mahowald does not merely employ the usual genetic, social, and legal understandings of family. She frequently focuses on the ethical and psychological relevance of choice or lack thereof (eg, with respect to an adopted child, stepchildren, or one's domestic partner) in exploring the meaning of "family ties." Drawing on her own empirical research, her chapter on the parental desire for biological connection to children considers both genetic and gestational ties and presents data about the different possibilities and priorities of men and women in this regard.

This chapter also highlights a central feature of Mahowald's argument: men and women are, and will be, differently affected by genetic interventions by virtue of differences of both biology and social situation. In at least two senses, genetics gives rise to inequalities. Genes, in combination with gestational environment, are responsible for biological differences between men and women. Moreover, in existing social environments, men and women experience inequalities of power. Genetic interventions, at least in many cases, will have different and relevantly unequal effects on men and women. The results of prenatal testing for a chromosomal anomaly, for example, might equally devastate or reassure both prospective mothers and fathers; however, the needle of amniocentesis enters only the woman's body, and she must consent to or refuse its use. Throughout, Mahowald persuasively documents these differential effects. Readers may be less persuaded by her reasons for addressing these differences.

Despite devoting a chapter to the conceptual foundation and ethical motivation for feminist standpoint theory, apparently Mahowald does not make sufficiently clear why the perspectives of marginalized groups—including, and here represented by, women—should be privileged in constructing public policy and adjudicating conflicting rights and interests related to genetics. At least some readers remain unconvinced that (and uncertain about why) the views and interests of women, racial and ethnic minorities, disabled people, or economically disadvantaged people should be privileged, or given greater weight, than men, the powerful, the advantaged.¹ Failing to understand the epistemic reason for giving special attention to the perspectives of women, readers may worry that Mahowald either is blind to the effects of genetics on men or wants to engage in some form of reverse discrimination that downplays those effects as a sort of compensatory justice for the less powerful or, worse, a sort of revenge against the more powerful. This is a misreading of Mahowald's argument and the feminism she advocates.

The fundamental reason to privilege the views and interests of the disadvantaged is not to compensate them for their previous under privileging or even primarily to erode the privileges of the advantaged. The reason to give weight to the standpoints of marginalized people, Mahowald argues, is that they have an epistemically privileged perspective on the issues at hand. They can see ethically relevant things that those in dominant positions cannot. At a conceptual level, those in dominant positions are in a position to create our conception of, for example, "the normal" and more practically are in a position to design our physical environment to accommodate normally able people and to exclude those less able. Mahowald's argument is not that effects on and perspectives of the advantaged should be disregarded, but that the standpoints of the disadvantaged must be included for the sake of accuracy in assessing what "is." Moreover, in determining what ought to be, the standpoints of the disadvantaged should be given greater weight when they are likely to bear the greater physical, psychological, social, and economic burdens of innovation. This is the reason that Mahowald takes such pains to argue that women and other disadvantaged groups will be disproportionately affected by genetic innovation. Those who remain unpersuaded on this point will nevertheless gain a richer perspective on the issues Mahowald illuminates.