Not for Women Only

Too often, women's health problems are ignored, dismissed or misdiagnosed. As patients and providers, how can we be sure women get the care they need?

WOODLAND HILLS, CALIFORNIA

Heart attacks. A man’s problem, right?

Wrong.

"Heart disease is the number one killer of women," says Kathy Davis, a registered nurse practitioner and member of United Nurses Associations of California (UNAC), an affiliate of the National Union Hospital and Health Care Employees/AFSCME Local 1199. More than 250,000 women die from heart attacks and strokes each year in this country. An American woman’s chance of developing breast cancer is one in eight; her chance of dying of heart disease is one in two.

Heart disease is just one of several health issues of particular concern to women — including domestic violence and depression — that are often overlooked or misdiagnosed by health care providers. Awareness of women’s unique health needs has grown in the past 10 years, thanks in large part to the patients, health care professionals and legislators who have fought for changes in medical research, teaching and care.

However, too many women are still suffering — and dying — needlessly due to health care providers who remain unaware of differences between men and women when it comes to risk factors, diagnoses and treatment. And too often, providers dismiss women’s symptoms as anxiety or imagination. As patients and caregivers, what can we do to ensure that women receive the best and most appropriate care?

FEMALE HEART. Women’s symptoms of heart disease often differ from men’s, reports Davis’s co-worker Cheryl Dial, also a registered nurse practitioner and UNAC/AFSCME member. Dial says, "Women may not have the heavy or crushing pain in the middle of the chest [typical of men’s heart attacks]. They could. But it might be more subtle."

In women, heart disease usually comes after menopause, about 10 years later than it does in men. It may present itself as indigestion, heartburn, shortness of breath, extreme fatigue, pain in the jaw, discomfort or pressure in the chest, or nausea.

Yet a 1996 Gallup poll showed that two-thirds of primary-care physicians thought women’s symptoms were the same as those of men. Though Davis notes that awareness of women’s heart disease has increased since then, women are still more likely to ignore their bodies’ signals and so are their doctors. The result: Women are twice as likely as men to die from a heart attack.

SHORT END. Why are women getting the short end of the health care stick?

Until recently, research on heart disease and other illnesses was done on men and the results applied, unchanged, to women. Medical training often didn’t cover the ways in which risks, symptoms, and treatments might differ between the sexes.

Moreover, although information and training are improving, American culture — including the health care system — often dismisses women as irrational. In fact, a recent study shows that women are three times more likely than men to have their symptoms of heart disease misdiagnosed as anxiety.

Such misdiagnoses are not restricted to heart disease. Medical providers may also miss the signs of domestic violence, or dismiss complaints as over-reaction.

INTIMATE ATTACK. "Women are 10 times as likely as men to be attacked by a partner or person known to them," says Davis. The numbers add up fast: Over 4 million women are battered by a husband or boyfriend each year, according to the Family Violence Prevention Fund.

Too often, however, health care providers aren’t trained to recognize or to handle domestic violence. Dial says, "You have to keep your eyes and your ears open and your sixth sense alert." Beyond the obvious signs of abuse, symptoms may also include anxiety, fatigue, sexually transmitted diseases, abdominal pain and headaches.

Both Davis and Dial stress the importance of listening and of asking direct questions, like "Has anyone physically or verbally injured you?" or "Is there anything else you wanted to talk about?" Dial explains, "If it’s the right time for them, they will open up. [If not,] they will feel safe to come back and see you at another time."

For further information on domestic violence and what individuals and unions can do to combat it, see the "Not For Women Only" columns in the January/February 1997 and September/ October 1997 Public Employee.

DEEP BLUES. Although depression occurs twice as often in women than in men, health care providers often aren’t trained to recognize or handle it. Davis notes that one in three women may become clinically depressed sometime in her life.

Even so, according to Dial, "Depression often goes unrecognized and untreated. If women do see a provider, they don’t usually walk in and say, ‘I’m depressed.’"

Clinical depression isn’t sadness at a loss or a short period of melancholy; it’s a depressed mood accompanied by four or more symptoms lasting at least two weeks. Symptoms may include change in appetite or weight, insomnia or oversleeping, fatigue, feelings of worthlessness or guilt, poor concentration, and loss of interest in sex. Depression may also manifest itself in repeated visits to a health care provider.

Again, as with domestic violence, both nurse practitioners rely on listening and on asking questions to help them diagnose this common and treatable illness.

PROVIDING EDUCATION. What should women be looking for in their providers? And how can providers offer the best care for their female patients?

Both Dial and Davis stress the importance of providers’ educating and building relationships with their patients. They believe one of the most important things a provider can do is to encourage patients to adopt a healthy lifestyle.

Dial advises providers to be aware of the differences between men’s and women’s health. She says, "Give women their options, and let them know what’s going on with their bodies at different phases of their lives, what’s normal and what might require investigation."

Davis likes to see her patients at least once a year, and she encourages all women to visit their health care providers regularly.

She acknowledges that building provider-patient relationships is challenging in the age of managed care. "When you’re given 15 minutes for a complete physical, a pap smear and to deal with the fact that your patient’s mother just died, it can be crazy."

CRITICAL CONSUMERS. But health care isn’t a one-way street. As consumers, what can women do to improve their own care?

Davis says, "Women need to take some responsibility for their own health care. I tell my patients to be critical consumers. To read what’s out there, write down questions and bring them in or call me."

Dial says the most important thing a woman can do is "make good choices for her health by not smoking, keeping her weight under control, eating a healthy low-fat diet, making a commitment to a regular exercise routine, and not drinking an excessive amount of alcohol."

Finally, says Davis, "Establish a relationship with a health care provider you feel you have a good rapport with, someone you can trust."

"We have a lot to do with our health," says Dial. "It’s not really in the hands of someone else. The majority of our health depends upon what we do outside of the doctor’s or nurse’s office."

By Alison S. Lebwohl

Resources

Cheryl Dial and Kathy Davis recommend the following on women’s health:

The Harvard Guide to Women’s Health, 1995 from Harvard University Press, provides reliable information on any medical topic, in a straightforward format with accessible language.

The New Our Bodies, Ourselves, 1992 from Touchstone, covers women’s health from a woman’s point of view and includes chapters on subjects like sexuality and aging.

Female Solution, 1998 from MidAge Health, is a guide to women’s bodies, with information on traditional and alternative medicine, co-written by UNAC/AFSCME member and OB/GYN Registered Nurse Practitioner Judith Norris.

Common periodicals, like Reader’s Digest, Good Housekeeping and Redbook often have helpful health-related articles.

Community classes may be available on stress reduction, nutrition, quitting smoking or other useful, health-related topics. Try your HMO, benefits office, Employee Assistance Program, or the American Heart Association, American Lung Association, local hospital and local YMCA/YWCA.

The National Domestic Violence Hotline offers local referrals and confidential counseling, (800) 799-7233. TDD: (800) 787-3224.

AFSCME’s Women’s Rights Department offers numerous free materials on issues affecting women’s health, including: domestic violence; women and alcohol; osteoporosis; breast cancer; family and medical leave. E-mail AFSCME's Women's Rights Department or call (202) 429-5090.

Tips for Wellness

Davis and Dial recommend that women do the following. Most of their specific recommendations are based on information from the American Medical Association.

• Exercise regularly. Start slowly and work up to 30 minutes of brisk walking four to five times a week.
• If you smoke, quit. Women’s health journal Self notes, "Smoking makes a man get a heart attack seven years earlier than usual, but a woman 19 years earlier than usual."
• Eat well and keep your weight under control. Both women recommend a total fat intake of less than 30 percent of all calories consumed.
• Have your cholesterol level checked.
• Have your blood pressure checked at least once a year.
• Limit your alcohol intake to one drink a day, or less.
• Do monthly self breast exams, and schedule a yearly breast exam with a health care professional.