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Women’s health: Understanding the primary care physician’s role


Female patients present unique health challenges including pregnancy, heart disease, diabetes and breast cancer.

In many ways, women are ideal patients. After all, they’re more likely than men to have a primary care doctor and to comply with preventive care recommendations. But there’s a catch: The stress of juggling work and family roles may cause some women to skip or delay annual physical exams, mammograms and other screening tests, according to a recent study of 9,000 women published in the Archives of Internal Medicine.

“Many women are motivated to make healthful changes, but they feel constrained by too many pressures-work, kids and aging parents,” says Emily Oken, MD, MPH, a physician at the Fish Center for Women’s Health at Brigham and Women’s Hospital and an associate professor in the department of population medicine at Harvard Medical School and Harvard Pilgrim HealthCare Institute. “The challenge is to get them to say it’s okay to put themselves first.”

That’s just one of several difficulties associated with caring for women. With ever-shifting screening guidelines for cancer and chronic illnesses and high rates of unintended pregnancies, diabetes and obesity, women face many health problems. As a result, it’s becoming increasingly important to take a few extra minutes with patients. “I think women know more about their finances than their heath,” says Jo Marie Munnich, MD, associate clinical professor of family medicine at the University of California-San Francisco (UCSF) Medical Center and a physician at the UCSF Women’s Health Center.

Coping with depression and stress

In the Archives of Internal Medicine study, more than 13% of women reported experiencing signs of psychological distress, such as feeling nervous, hopeless, restless, fidgety or depressed. And nearly one-third of those women were more likely to delay getting healthcare than their male counterparts. Clearly, stress is widespread.

RELATED: 3 reasons why integrating behavioral health services may benefit your primary care practice

“I see three women a day who cry,” says Munnich. “They are so overwhelmed [by work and family obligations].” Many put their family’s needs ahead of their own. So “doctors need to link the importance of a woman staying healthy to her ability to take good care of family members,” says Molly Cooke, M.D. FACP, immediate past president of the American College of Physicians and a professor of medicine at UCSF.

That’s why, for example, pregnancy is a great time to help women quit smoking. “When you make the point about the dangers of secondhand smoke for the baby, it’s powerfully motivating,” says Cooke. To ensure that women don’t miss check-ups and screenings, many doctors encourage patients to include their doctor’s appointment in their calendar just as they would a business meeting.

Next: Planning pregnancies


Depression is also common among women; it affects about 12% of those age 40 to 59, according to the Centers for Disease Control and Prevention (CDC). Women are 70%  more likely than men to experience depression during their lifetime, according to the National Institute of Mental Health.

Despite the condition’s prevalence, patients are unlikely to tell you about their mood-and bringing up the subject can be tricky. To find out about a patient’s emotional wellbeing, some practices routinely screen for depression in their new patient questionnaire, which incorporates the PHQ-4 screening tool (see box). If the result is positive, a medical assistant gives the patient a more detailed questionnaire. Other physicians ask their patients in person during the first visit. Questions such as, “How is your mood? Are you feeling depressed or down?” can be a good conversation starter. But keep in mind, some patients won’t give you the answers right away.

“I try to make sure my patients feel comfortable talking with me,” says Oken. “And I pay attention to symptoms like difficulty sleeping or pain, which can signal depression.”

Planning pregnancies

About half of pregnancies aren’t planned, according to a recent study published in the American Journal of Public Health. So it’s crucial to ask patients if they’re using birth control. If they’re not, consider asking, “Would you be okay with getting ­pregnant?”

“Many 40-year-olds think they can’t get pregnant, but I tell them I’ve seen so-called ‘menopause babies,’” says Kisha Davis, MD, MPH, a family physician in Gaithersburg, Maryland and a board member of the American Academy of Family Physicians. Making matters worse, the risk of miscarriage is far higher among women in their 40s. The upshot? It’s a good idea to recommend birth control for all women under 50 who have not reached menopause, says Munnich. Patients should know birth control doesn’t have to be a pill; many older patients can benefit from the low-maintenance IUD or an etonogestrel implant like Nexplanon.

Some doctors are less concerned about unplanned pregnancies and more about whether a woman is healthy enough to become pregnant in the first place.

“I worry about patients who have health conditions that aren’t well managed, like weight and diabetes,” says Oken. “I tell them that a woman’s health can have an impact on the baby. For instance, we know if someone has diabetes before pregnancy, the baby is more likely to be born with birth defects and may experience complications during delivery.”

So it pays to talk to patients about their plans to become pregnant-and ensure that they are doing everything they can to manage any chronic illnesses.

Next: Setting the record straight about screenings


Setting the record straight about screenings

It’s no wonder patients are confused about screenings, given the recent controversy about mammograms.

“During an office visit, I bring up the fact that the recommendations are confusing, so patients shouldn’t feel badly,” Cooke says. “I spend a few minutes explaining how screening tests work. That helps people understand why the recommendations change. If I say, ‘Do this because I tell you to, the patient is likely to come back and say, What’s the deal?’” Another approach is to use patient handouts, which can explain the tests.

Here’s how to manage some of the most common screening challenges:


Patients have many misconceptions surrounding breast cancer screening. For example, some women who have no family history of breast cancer assume they’re at low risk and don’t need to be screened. Others think a doctor can feel a lump-or they will feel ill if they have cancer-so they don’t need a mammogram.

“It’s important to take the time to figure out where a patient is coming from,” says Munnich. “I can’t assume someone is anxious about having a mammogram when they’re actually skeptical.”

Another observation Munnich has made: “I’ve noticed there’s a drop-off in women getting mammograms between the ages of 50 and 70,” she says. “Yet that’s when they need it most. Some women are getting mammograms in their 40s and are ‘burning out’ by the time they hit 50.”

She tells patients that although they may know someone who’s had breast cancer in their 40s, the incidence is much higher in the 50s, 60s and 70s.


Many women shy away from the test, but they will often agree to a fecal occult blood test (FOBT).

“I’ve noticed a huge difference in colorectal screening when patients are offered the FOBT,” says Munnich. Over time, many people will tire of the FOBT and will go for the colonoscopy. One of the main reasons people want to avoid a colonoscopy is the prep. Fortunately, a patient handout can ease patients’ fears. “My colonoscopy handout explains how to do the prep so patients aren’t so miserable,” says Munnich. “They can be finished by 8 p.m. the night before the test.”


Women can get the bone densitometry (DXA) scan before 65, but would have to pay for the procedure themselves. “Many women are very disappointed to learn that they can’t get the DXA scan until age 65 years,” says Munnich. “They may be worried because their mothers have osteoporosis.” But getting plenty of weight-bearing exercise and taking calcium and vitamin D supplements can help protect against the condition.

Pap smear

“Once women understand that we know what causes cervical cancer (the human papilloma virus)-and that it takes a certain amount of time to develop-it’s easy to convince patients they don’t need this every year,” says Davis.

Still, patients often get confused about the difference between a Pap smear and a pelvic exam (they often assume they had the smear if they received a pelvic exam).

Next: The latest on key screening tests for women


Next: Preventing heart disease


Preventing heart disease

Women may be worried about breast cancer, but heart disease is what they really need to fear. Women’s lifetime risk is nearly 40% by age 50, according to a recent study   of cardiovascular disease in women published in Epidemiology. In addition, many have risk factors such as diabetes, high blood pressure, high cholesterol and obesity. About one-third of white women are obese; the numbers are even higher among African-American and women of Mexican descent. About 11% of women have Type 2 diabetes, and even more have prediabetes.

Although more women are exercising regularly and fewer women are smoking, there’s plenty of room for improvement. But helping patients make lasting lifestyle changes is a challenge.

“There are women with prediabetes who aren’t taking it seriously-either because they don’t have any symptoms or are doing worse on the medication,” says Oken.

Mentioning a relative who has the problem might help remind patients of the seriousness of the disease. As far as diet is concerned, some doctors recommend that women have their own shelf or cabinet at home stocked with healthy foods they like. They might also consider cooking meals on Sundays and putting them in containers for the week.

Exercise is also key. Even if time is scarce, patients might be able to set aside an hour for a walk or bike ride over the weekend.

“We ask patients what their goals are and how ready they are to make changes,” says Davis. “We recommend that they start simple-cut back on soda and bread, for instance. Small changes tend to be more lasting.” In some practices, nurses follow up with patients to check on their progress. Patient handouts can offer tips on healthful eating and exercise.

There are different ways to help patients make lifestyle changes, and some work better than others. “Exorting someone to do something they already know-like get more exercise-sets up an oppositional relationship,” says Cooke.

“Using an approach called motivational interviewing gets the patient and doctor on the same side of the issue.” This involves helping people identify ways their lives would be improved by altering their behavior. It involves assessing their readiness for change and giving people the confidence to take the necessary steps. For more information, go to

The key to helping women take charge of their health is, of course, to develop a good rapport with them.

“Women are worried about their health, and they often apologize for it,” says Munnich. “I tell patients I know they’re worried about their health and money. I say, I’m like your financial consultant. When I use that analogy, people really get it. It’s a collaborative approach to health care, and it empowers women to open up to me about their fears.”

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Jennifer N. Lee, MD, FAAFP
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© National Institute for Occupational Safety and Health