Southern Illinois University School of Medicine

Aspects Magazine Volume 36 No. 3 - Southern Illinois University School of Medicine Office of Public Affairs

Women's Health

Written and Illustrated by Rebecca Budde

• Venus Williams dropped out of the U.S. Open in 2011, stating a recent diagnosis of the autoimmune disease, Sjogren’s syndrome. • In the summer of 2012, Rosie O’Donnell encouraged her fans to know the signs of a heart attack after she almost died from a heart attack. • Ashley Judd publicized her long-term battle with depression in her 2011 autobiography, All That Is Bitter & Sweet.

Womens Health Image

Despite these high-profile women publicly acknowledging their plights, the understanding about their conditions and how these affect the female body remains somewhat ambiguous.

Here are some facts that may surprise non-medical professionals, but not SIU physicians.

When supporters of the American Heart Association don their red shirts in honor of "Go Red for Women," it’s not because heart disease chooses women over men; it’s the leading cause of death for both. The tricky part is that the symptoms of a heart attack may present differently in females, go unnoticed and therefore cause an untimely death.

The classic presentation of acute coronary syndrome is exercise-induced pain that gets better with rest. "Women with acute coronary syndrome can present in atypical ways," says Gabor Matos, M.D., assistant professor of internal medicine specializing in cardiology. According to Dr. Matos, women may have generalized fatigue, shortness of breath, tightness in the throat, back pain or arm pain, whereas men are more likely to have chest pain, left arm pain or profuse sweating. Almost two-thirds of women who die of coronary heart disease have no previous symptoms, according to the CDC, and sometimes women with heart disease mistake their symptoms for other health issues.

The typical textbook victim of a heart attack is a white, overweight male. Though setting aside the cheeseburger for a healthier, low-fat meal can benefit many Americans, obesity or extra weight aren’t the only risks factors for cardiovascular disease. "Smoking is the predominant risk factor," Dr. Matos says. The CDC reports that almost half of Americans have at least one of the three main risk factors: tobacco use, high LDL cholesterol or high blood pressure. Family history of heart disease and lifestyle choices such as inactivity or alcohol consumption also contribute to unhealthy hearts.

Preventative measures are the same for both men and women: calorie restriction, exercise, avoidance of exposure to first- and second-hand smoke, not using drugs that are toxic to the heart, namely, cocaine. And it’s never too early to start teaching children to be heart-healthy. "Parents should pay attention to their children’s activity level, body weight, obesity, and indoctrinate and enforce a non-smoking policy."

Women are more likely to contract a sexually transmitted disease (STD) but less likely to have or notice symptoms.

The physical, social and emotional repercussions of unprotected sex often weigh more heavily on females. For many young women, unprotected sexual activity can lead to life-long issues caused by STDs.

"Most of the female reproductive tract is internal and connected in such a way that, under the right conditions, pathogens can easily ascend into the uterus and fallopian tubes and perinatal cavity," says Katherine Hild-Mosley, M.D., assistant professor of obstetrics and gynecology. Once a woman is infected with an STD, symptoms may be hard to detect. "Many women with an STD may have abnormal vaginal discharge or aches and pains that they mistakenly attribute to their normal menstrual cycle," Dr. Hild-Mosley says.

Unchecked and untreated, these pathogens can wreak havoc in the female reproductive system, including scarring in the reproductive tract, increased risk of ectopic pregnancy, cancer and even permanent infertility. Women infected with certain STDs who become pregnant may have significant risks during pregnancy and delivery, including passing the infection on to the baby. Many SIU gynecologists staff an STD clinic at the Sangamon County Health Department to help screen and educate young women and men on the dangers of STDs. Physicians discuss topics such as the importance of screenings, HPV vaccinations, contraception and risky sexual behaviors.

"Chlamydia is probably the most commonly reported STD in this area," Dr. Hild-Mosley says. "Screening for chlamydia and gonorrhea is routine for sexually active women who are 25 years old and younger."

Cervical cancer is almost always the result of the human papillomavirus (HPV), a sexually transmitted virus. The National Cancer institute reported 12,200 new cases of cervical cancer and 4,210 cervical cancer deaths in 2010. Once an annual screening, the American College of Obstetricians and Gynecologists now recommends that women with a history of normal Pap tests wait 3-5 years between Pap tests. The College also recommends co-testing women age 30 and older with the Pap test and the HPV test once every five years. "It’s a huge change, but improvements in the Pap test and our greater understanding of cervical cancer and its precursors make it a safe option," Dr. Hild-Mosley says. "If we are concerned about a patient, she’s had an abnormal Pap in the past or is otherwise high risk, we want to screen more frequently to be sure the abnormal cells are not persistent or progressing to more severe forms of dysplasia or invasive cancer."

In addition to STD screenings and education, SIU physicians encourage girls to get the HPV vaccine. "The HPV vaccine cuts the risk for warts and cervical cancer dramatically," says Casey Younkin, M.D., associate professor of obstetrics and gynecology. The CDC reports that in the past 40 years, cervical cancer rates and deaths from cervical cancer have decreased significantly, most likely due to reliable screenings and the vaccinations.

78%: The number of women affected with autoimmune disease

Autoimmune diseases are the third most common category of disease in the United States after cancer and heart disease, according to the Centers for Disease Control and Prevention (CDC). And, due to reasons not fully understood, women bear the effects of these diseases far more frequently than men. Diseases such as lupus, rheumatoid arthritis, Sjögren’s syndrome and autoimmune hepatitis often leave patients feeling physically and emotionally exhausted. They can affect multiple sites in the body, including the endocrine system, connective tissue, gastrointestinal tract, heart, skin and kidneys.

Symptoms of autoimmune diseases can evolve with time, causing patients to see several specialists over several years, says Anna Tumyan, M.D., assistant professor of internal medicine specializing in rheumatology. "It can be very frustrating because the patient continues to have symptoms, but doesn’t have a specific diagnosis," she says.

Women of childbearing years tend to be affected more often than women of other age categories. Pregnant women with rheumatoid arthritis or multiple sclerosis may experience the relief of some symptoms. However, pregnancy can lead to the worsening of symptoms in patients with lupus, Sjögren’s syndrome or Grave’s disease.

The good news: "Autoimmune diseases really aren’t common," Dr. Tumyan says. Only 5-8% of the population is affected. When a woman complains of fatigue or aches and pains, Dr. Tumyan believes that the situation isn’t an immediate cause for alarm. "Analysis should begin with the primary care physician," she says. "Baseline work-ups can easily be done in order to rule out or determine other causes." Sometimes an easily treatable issue, such as vitamin D deficiency or hypothyroidism, can cause pain and fatigue.

43%: The number of American women who experience sexual dysfunction

The miracles of Viagra® are no secret to the American public as commercials for the drug abound on TV and in magazines. The popularity of the drug seems to have made people more comfortable discussing and accepting the topic of male sexual dysfunction. Is a similar option available to help women?

"The sexual response cycle for men is pretty straight-forward; for women, it’s a little more complicated," says Dr. Hild-Mosley. "With female sexual dysfunction (FSD), we most commonly think of hypoactive sexual disorder, pain and arousal or orgasm problems. Each scenario warrants different treatments, and we don’t have a ‘one pill treats all issues’ for females," Dr. Hild-Mosley says. Medications, illness, stress, partner performance and religious beliefs can all contribute to the many presentations of FSD.

The Journal of Urology (March 2000) suggested a working definition of FSD that includes both physiological and psychological symptoms in conjunction with a source of distress. Dr. Hild-Mosley says that some of her patients say they are not sexually active with their partner, and they are comfortable with this. "Post-menopausal women, for example, may have problems with dryness and painful intercourse, but usually their partners are older too, so the couple just adjusts their relationship. They find other ways to support one another."

Balancing an active family and work schedule usually is the culprit for added stress and fatigue for middle-aged women. "This stress is definitely going to affect desire," Dr. Hild-Mosley says. "The partners are younger; they both are probably more interested in a robust sexual life, which means they are probably more motivated to seek treatment."

Viagra® can help women, too, particularly those who have symptoms induced by anti-depressants, according to Dr. Hild-Mosley. When depression, relationship or other psychological issues cause FSD, counseling also can be helpful. "If one of the partners is having a sexual problem, it’s easy for the other partner to feel rejected or take it personally," Dr. Hild-Mosley says. She says that it’s important to discover the root of the dysfunction to avoid future health problems.

Those with physiological symptoms of FSD can find help in a variety of forms. Women can alleviate some of these symptoms with moisturizers, lubricants or estrogen therapy. Physical therapy can help those who suffer from pain during intercourse.

The physicians in the SIU Department of Obstetrics and Gynecology routinely address FSD with their patients, and they are taking a multi-disciplinary approach to help patients by collaborating with the Division of Urology. "Men will go to the urologist for treatment of erectile dysfunction, and the urologist will later find out that things really aren’t better because the woman has sexual dysfunction as well," says Dr. Hild-Mosley. "We try to incorporate conversations about sexual dysfunction into every annual exam, well-woman visit and post-partum appointment. As our knowledge of FSD’s causes and treatments have increased, we are all more comfortable discussing it."

When toddlers­ forego the bottle and then decide that milk just isn’t their drink of choice, many mothers worry that their children will lack the calcium and vitamin D needed to build healthy bones. And they are right to be concerned.

Though milk isn’t the sole source, calcium and vitamin D are critical in childhood for developing future bone mass. "When girls are in that age range of about 9 to 13, they’re developing that extra bone mass and bone strength that they’re going to have for the rest of their lives," says Sheref Unal, M.D., assistant professor of pediatrics. "So it’s very important that they eat balanced diets and try to have good, healthy lifestyles."

Proper diet and weight-bearing exercise are essential for building strong bones even after the teen years because women tend to have smaller, thinner bones than men. By the time a woman reaches her 30s, her bone density will plateau. Although estrogen protects bone, a woman’s estrogen production decreases after menopause, causing a higher likelihood of fractures in older women.

A bone density scan, also known to some as a DXA scan (dual-energy x-ray absorptiometry), shows the amount of bone in the hip, spine or other bones and is used to diagnose osteoporosis in women age 50 and over. A second scan is done one to two years after the first, and the physician compares results to determine if bone density has decreased. Since some medications such as steroids may also cause bone loss, physicians may order a DXA scan for those who are on long-term treatments using these medications.

"By 65 every woman should have had a bone density scan, sooner if she has the risk factors associated with osteoporosis and is post-menopausal," says Casey Younkin, M.D., associate professor of obstetrics and gynecology. The risk factors include being underweight, smoking, having a family history of osteoporosis and taking steroids. Caucasian women are also at a higher risk.

Women are 70% more likely than men to experience depression.

The use of antidepressants among Americans, the majority of them women, has increased almost 400% in the last 25 yearsA woman sits on the couch wearing her bathrobe, a box of tissue beside her, a bag of chips in her lap and glass of wine in her hand. Her hair is an unattractive, tousled mess. She seems oblivious to her surroundings as she swipes the tears from her face. This image is the view of depression typically found in movies, but may be close to reality for many women. Once a deep, dark secret, depression is coming into the light as scientists learn more about its effect on women.

Studies show that the cause for depression is multi-faceted; hormonal, genetic, biological, chemical, environmental, psychological and social factors all play a role, according to Karen Broquet, M.D., associate dean for graduate medical education and professor of psychiatry. The concentration on females at the age of puberty predominantly points to the strong relation between mood and hormones. "We don’t understand all the factors that lead to depression, but we do know that hormones play a large part," Dr. Broquet says. "If you look at the rates in boys and girls, it’s close to equal until puberty. Then the rates of depression rise significantly in women until the post-menopausal years."

Pop culture continually pokes fun at the differences between the male and female brain. It’s true: women’s brains are different from men’s when it comes to emotions. "There may be core changes in the brains of men and women that correspond to depression," Dr. Broquet says. A PET scan study showed distinctive differences in the brain activity of men and women. "When asked to think about sad things, women’s brains became more active, they lit up profusely, whereas the men’s brains had much less activity on a sad stimulus." Similarly, there is a study that shows that women produce serotonin, a chemical in the brain connected to mood, at a much lower rate than men.

While differences can be seen in the brain, women also find that depression presents different symptoms for them: fatigue, appetite changes and sleep disturbances are more commonly reported by women, according to the Society for Women's Health Research. Those who are already experiencing similar symptoms due to chronic stress or chronic illnesses such a migraine headaches, fibromyalgia or autoimmune disorders are more likely to develop depression, according to Dr. Broquet. And, women who have depression symptoms coexisting with chronic conditions often have poorer long-term outcomes, according to the NIH.

Depression is not a one-type-fits-all diagnosis. Several types of depression can be found in both men and women, including major and minor depressive disorder, dysthymic disorder, psychotic depression and seasonal affective disorder. Also more prevalent in women, eating disorders such as anorexia nervosa and bulimia nervosa often coexist with depression.

Women with a history of a depressive illness are also on the high-risk list for developing postpartum depression (PPD). "For many women having a baby is a totally joyous occasion, but it’s a highly stressful time," Dr. Broquet says. "Everything changes: the body, sleep cycles, relationships. And, of course, the hormones are going haywire." Fortunately, obstetricians/gynecologists, primary care physicians and pediatricians screen new mothers for PPD and are alert to the signs of the illness when new mothers come in for annual exams, well-care or follow-up visits.

Women do tend to seek treatment more frequently than men, and even those with severe depression can improve with treatment. Primary care physicians are on the front line of identifying those who may need treatment for depression. SIU’s Family and Community Medicine’s Federally Qualified Health Center in Springfield provides support for those with mental health disorders. "This puts the direct treatment and teaching for family medicine residents on site," Dr. Broquet says. "Residents are exposed to various effective treatments of depression, including medication and multiple forms of psychotherapy."

Bone health breakthroughs: SIU’s bone health clinic

"I was seeing all these post-menopausal women who had fractures that weren’t being addressed," Dr. Casey Younkin says. "A woman who breaks a hip and leaves the hospital with no follow-up care has a higher likelihood of breaking the other hip. Only a small percentage of those who need treatment are being treated." Dr. Younkin

Dr. Younkin discusses the importance of taking vitamin D with Pieretta Patterson.

Khaled Saleh, M.D., professor and chair of the division of orthopaedics, treats the fractures of many of these women. He and Dr. Younkin realized the need for SIU to create a multi-disciplinary bone health clinic to treat and educate those with osteoporosis, a service unique to the SIU service area. The clinic is staffed by SIU obstetricians/gynecologists, rheumatologists, orthopaedists and endocrinologists who provide primary and secondary fracture prevention, as well as bone fragility treatment, care and education to at-risk patients in the central and southern Illinois area.

Pieretta Patterson, 65, of Springfield doesn’t seem to fit most of the risk categories for bad bones. She’s a healthy African-American with no family history of osteoporosis. However, Dr. Saleh performed a knee replacement on her right knee in February 2013. In May, Patterson had a bone density scan to be sure that her bones were strong enough to support her artificial joint. "It’s important for her to have a bone density scan because the artificial joint relies on the surrounding bone to hold it in place," says Dr. Younkin. "Often the artificial joint can get loose, especially if the bone is deteriorating around it."

Patterson will continue to follow up with the physicians in the bone health clinic to be sure she maintains strong, healthy bones.

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The mission of SIU School of Medicine is to assist the citizens of central and southern Illinois in meeting their health-care needs through education, patient care, research and service to the community.


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