Further Thoughts on Women's Health

Sunshine in Lynch Park

     I started my June post remarking how surprising it felt that yet another month was over and that I was already in another rotation, and I could repeat those exact same thoughts now as July ends. Even though graduation next May still seems years away, the days have flown by ever since I started my clinical rotations. Since my last post I've completed my time in women's health, and I'm already done with two weeks in primary care. Leaving women's health was even more difficult than leaving my psych rotation, so before I move into full general medicine mode, I have some reflections from my time there. 

This has nothing to do with WH, I'm just
proud of my first batch of cold brew
that I made with my coffee sock.

     The first is that you learn to get over awkwardness in women's health. I'd say you get over it quickly, but that's not 100% true. There were still days toward the end of the rotation when it felt odd to ask a woman about her bathroom habits or if she had any discharge, not to mention all the times I said, "you're going to feel me touching you" or "do you have any irritation in the vagina?" Asking about a woman's sexual habits was pretty awkward at the beginning as well, especially if you started realizing those women were the same ages as some of your female relatives. That being said, my classmate and I needed to get over the awkwardness quickly. All these questions weren't asked just for kicks and giggles. They were necessary to get to the bottom of a diagnosis, determine if treatment was working, and figure out how a patient's issues were affecting their life. Plus, I quickly realized that the answers were not ones I could just guess or assume, especially when it came to sexual activity. A 50-year-old might look at me as if it was was crazy to imagine she might still be interested in sex, whereas a 79-year-old might answer "yes" so emphatically that it would seem crazy that I could think a woman might ever lose interest. There were a few women who asked why I needed to know, and at the beginning I might have wondered myself, but it was amazing how asking such simple questions could lead to important diagnostic information. I think of the women who'd given up sex because it had become painful or uncomfortable, but who had never mentioned it to a clinician because they were too embarrassed or because they thought nothing could be done, and then how elated they were when we could tell them that there was in fact a treatment for their interstitial cystitis, or vaginal atrophy, or pelvic organ prolapse, or whatever their particular problem was. It was pretty rewarding to be able to give someone back a part of their life. 

     The second reflection is a bit of a long one. It began with how we joked frequently during my rotation that being a woman sucks. Sometimes it was the playful joking of saying that women go through the awfulness of periods just so we can go through the agonizing pain of childbirth, or that once you hit menopause everything starts falling out (at least one kind of prolapse was found in 14-34% of women in the WHI study, and some studies think this is closer to 50%). At times though it was a rather dark sort of joking, especially when you looked at statistics. For example, 1 in 8 U.S. women will develop breast cancer in their lifetime. That sucks. Cancer of reproductive organs in general has the potential to be more deadly for women than for men because the reproductive organs of men are more easily examined, whereas the reproductive organs of females are primarily hidden inside the body. To often this means that symptoms of a cancer are not detected until the cancer has progressed and spread, a primary reason why ovarian cancer is the fifth leading cause of cancer death in women, even though only 1-3% of women will ever get ovarian cancer. Looking at younger females, 1 in 15 sexually active young women (ages 14-19) will have chlamydia at some point. This is can be quite tragic since chlamydia is most commonly asymptomatic in females (possibly as few as 5% have symptoms) so it's not treated, but left untreated chlamydia can lead to pelvic inflammatory disease (PID) in at least 10-15% of women. PID in turn can have drastic effects on a women's fertility: 1 in 8 women with a history of PID will have a hard time becoming pregnant, and the rates of infertility increase dramatically with each incidence of PID. For any woman who does become pregnant, she then faces the possible heartbreak of a miscarriage. Depending on which study you look at, miscarriages happen in 31% to 70% of pregnancies, though most of these occur early in a pregnancy, often before the woman even knows she's pregnant. Still, 15-20% of confirmed pregnancies end in a miscarriage, a rate much higher than many people realize, which can lead many women who miscarry to believe that the miscarriage was their fault or that they must suffer alone because they think no one else knows their pain. 

     The hardest statistics to look at are the ones where a woman's suffering is not related to purely medical causes, but to what other people do to her. For example, there's the disturbing statistic that the rate of abuse of women INCREASES during pregnancy. In the UK it's estimated that 30% of domestic abuses begins when a woman becomes pregnant, and in the US almost 1 in 6 pregnant women have been abused by their partner. The fact is that I need to be more concerned about screening pregnant patients for abuse than for preeclampsia or gestational diabetes because the rate of abuse for pregnant women is higher than the rate of both those conditions combined. That's absurd. Even if a woman is not abused during pregnancy, chances are she has already been abused in her life because studies show that 1 in 4 women in the US were sexually abused as children. While I may not have statistics for it, there also seems to be an alarming number of women being sterilized against their will. I saw 3 such patients over the course of 4 weeks. Three! That's a lot in such a short time frame. These weren't old women either; all three had been sterilized by force or without their knowledge within the last 5-20 years, so this is a current problem. While all 3 were from countries other than the U.S., this is not solely a foreign problem. California didn't pass a ban on forced sterilization of prisoners until last September, and that only after an investigation had revealed over 140 females patients were coercively sterilized between 2006 and 2010, at least 39 of those without legal consent. This doesn't just suck; it's horrifying. 

Shout-out to the woman who first introduced me to the
beauty and strength of being a woman: my mom

     I could leave this post right here. I could end with the conclusion that women have horrible lives due to their own anatomy and the injustices of society. I could do that, but I won't, mostly because I disagree with that as a universal statement, and also because that's just not the conclusion I got from my rotation in women's health. Over and over again I was presented with the sheer strength of women. Sometimes it was the forceful strength of the woman in labor, pushing with all her might. Sometimes it was the quiet strength of the woman who'd suffered in silence, simply plugging away with her life despite lasting discomfort. Sometimes it was the plucky strength of the older woman who'd wink while reminding me and my classmate that "it's a terrible thing to grow old." Sometimes it was the resilient strength of the woman who'd faced injustice after injustice and hadn't let it break her. I've never really used the term "girl power" (at least not seriously), but there was something about working with women every day that grew in you the feeling of sisterhood and camaraderie. Yes, sometimes my patients convinced me that women were completely crazy (especially during my first week), but they also convinced me that I could work in women's health and really enjoy it, even the parts that aren't all pregnancy and babies (though there is something simply magical about locating a fetal heartbeat on your own for the first time... and every time after). Is women's health where I'll end up? I don't know yet, but I'm so very grateful that I was able to spend 5 weeks there.
     And now as I close, some last few bullet point thoughts*:

1. KEGELS! No matter your age, women, you should be doing these. They might not be the most effective treatment once a problem like prolapse develops, but starting them early might help prevent some problems from developing in the first place.
2. Uteruses are overrated. They're good for growing babies but after that they're more of a nuisance.
3. If you are menopausal or postmenopausal, a local estrogen (either a ring or a cream) is something you might want to talk to your gynecologist about. 
4. Coconut oil has a surprising number of uses. 
5. If you're being abused, or you think someone you know might be, do not keep quiet. There are always ways out and always ways to help. Obviously this post was focused on women, but this point applies to anyone, male or female. Oh, and while we're at it, instead of just helping someone who is being abused, let's work on creating the kind of society where abuse is neither tolerated nor encouraged.
6. Don't rule out a male gynecologist. My preceptor was a man and he was one of the best doctors I've ever seen. My classmate and I both talked about how we want to be clinicians like him one day, and you could tell his patients loved him. Sure, some women admitted being nervous about seeing a male gynecologist, but it was well worth it for such excellent care.
7. On a similar note to the last point: Ladies, be nice to the male students. It's always going to be awkward to have a student in the room for these kind of examinations (and a few patients did turn away me and my female classmate), and it can seem even worse if the student is some young, attractive fellow, but if your clinician asks if you mind having a student in the room, please consider saying yes. The practical experience is invaluable and many of my male classmates have left their women's health rotations frustrated because no patients would let them see them. Just think about it.

Turtles know the proper way to enjoy sunshine.

     If you've made it all the way to the end of the post, congrats! It was a bit longer than my usual posts, and somewhat lacking in photos or catchy songs (I was unable to find a song that adequately conveyed the idea of "if you're a girl there's a good chance you'll face societal injustice, multiple forms of abuse, the pain of your own body working against you, and when you' go through menopause everything will go to pot and/or fall out, but it's ok because girls are awe-inspiring and amazing," so if anyone knows of one, let me know), but I had a lot to say after this rotation. Who knows what I'll have to say after my time in primary care. For now though, it's back to the books to review all the intricacies of diabetes, coronary artery disease, hypothyroidism, and basically everything else in medicine. Hopefully I'll emerge from my study cave to get at least a little vitamin D this weekend. :)

*I'm not a licensed or certified PA yet, so any medical advice is simply a suggestion. Talk to your own healthcare provider further if you have questions.

PSA: CPR (20/30)

     Two summers ago I did a short PSA on drowning because many people don't know how to recognize the signs, which are often subtle (not the thrashing and yelling that Hollywood teaches us to expect). Today I present another PSA on a topic that has the potential to save even more lives: CPR. 

     First, I have some quick background info. CPR is used to treat cardiac arrest (also called sudden cardiac arrest or SCA). While a heart attack can lead to SCA, the two are not the same. In a heart attack, a blockage in the heart's blood vessels deprives areas of the heart of oxygen, which causes the affected cells to die, resulting in pain. The heart will usually continue to beat though. In a SCA it's the electricity of the heart that is affected. The normal electrical systems of the heart that control heart rate and rhythm stop working, and thus the heart stops beating completely, often without warning. There are many possible causes of SCA, everything from coronary artery disease to inherited heart defects (e.g. hypertrophic cardiomyopathy, valve diseases, Brugada syndrome) to stress to drowning to simply being hit in the chest by a baseball at the exact moment that the heart's electrical system is vulnerable (i.e. commotio cordis). If a heart attack is left untreated, it can also lead to a SCA once enough cells die or enough scar tissue forms. Because it is the electrical system of the heart that is failing, victims of SCAs require immediate defibrillation to "jump start" (so to speak) the heart and get it to beat properly again. If the heart is not beating, oxygen is not being delivered to the rest of the body, including the brain, and permanent brain damage can occur within 4 minutes, and death typically follows by 8 or 10 minutes. This is especially concerning because, as their name implies, SCAs often happen without any warning (the first sign is typically when a victim loses consciousness) and 88% occur while a victim is at home, away from the immediate help of emergency services.

     About right now you might be asking how all this affects you. If you're not a healthcare professional, you might never be trained in how to use a defibrillator, which is what a person suffering from an SCA most needs. However, anyone can be trained to perform cardiopulmonary resuscitation (CPR). While CPR typically does not cure an SCA, it buys valuable time. By keeping the heart pumping, CPR ensures that oxygen is still delivered to the rest of the body and thus staves off the death of other cells until defibrillation can be performed and the heart can resume pumping on its own. According to the American Heart Association (AHA), CPR can double or triple a victim's chance of survival, but in the US it is performed in only 32% of cases. So what can you do?

     The simplest answer is to take a CPR class. The AHA and Red Cross regularly offer classes in Basic Life Support (BLS), which includes training in the performance of CPR and the use of a defibrillator, and often includes training in the Heimlich maneuver as well. Classes do not cost much, last a couple hours, and are offered in different versions for laypersons and healthcare professionals. If you don't have the time or money for that, at least learn the basic steps. They've been simplified over the years to encourage more people to learn them and they're rather easy now. As depicted in the graphic to the right, the first step is check a person for responsiveness. You can yell at them or rub their sternum with your knuckles, and then check for breathing. If they don't respond at all and/or they're not breathing, move to the next step. If you're by yourself, call 9-1-1. If someone else is with you have them make the call and send them to find an automatic external defibrillator (AED) as well. Next, begin CPR. The AHA currently recommends that laypeople do what they call "compressions only" CPR, which means that you don't have to stop to give the victim breaths. You simply need to "push hard, push fast" in the center of the victim's chest. Ideally you're pushing at a rate of 100 bpm, and you're allowing for full recoil of the chest, but the fact of the matter is that poorly performed CPR is still going to be better than no CPR at all. Even if you are incredibly nervous (and that's normal), it's far better to start compressions than to sit around wringing your hands waiting for EMS to arrive. If you're scared of hurting the victim the fact is that they are already dead (at least in a cardiopulmonary sense), and your attempts to provide CPR can only help. The bottom line: just try.  Still nervous? Here's a 90-second video explaining how to perform CPR, complete with cheesiness and the Bee Gees. 

    Lastly, I'll conclude this PSA with some encouraging news about CPR from Sweden. Almost one third of Sweden's population of 9.6 million is trained in CPR. That fact in and of itself is pretty amazing and worth celebrating, but the Swedes continue to go above and beyond to find ways to help their citizens survive a cardiac arrest. In The New England Journal of Medicine published June 11, 2015 Swedish researchers published two articles back-to-back that explored the effects of early CPR (before EMS services arrived) and on how to dispatch laypersons to the scene of an out-of-hospital cardiac arrest. The first study showed that when CPR was initiated before EMS services arrived, a victim's chances of surviving increased from 4.0% to 10.5%, a significant increase. The second study looked at the use of a new app for people trained in CPR. When a call is made that someone has just suffered a cardiac arrest, the app will notify any users within 500 m of the incident and dispatch them to perform CPR until EMS arrives. This study found that the app resulted in bystander-initiated CPR in 62% of the incidents, as opposed to 46% in the control group (still better than the US average of 32%) when the app was not used. Already some cities and counties across the US are trying to create their own similar apps. Who knows? In a few years or a decade, maybe bystander-initiated CPR will occur in 75% or 80% of cardiac arrest cases, and maybe we can bring the survival rate higher than the dismal 4% or 10.5%.