Assessing Women in General Practice

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Assessing Women in General Practice 


Pharmacists Patient Care Encounters with Female Patients
Core Patient Assessment Data/Information (Core Database)

Sexual Health Assessment and Interviewing Methods

When interviewing women patients, there are often topics that are considered “sensitive” and that are sometimes difficult for both patients and providers to have comfortable conversations. A good comprehensive resource for learning about sexual health assessment and interviewing methods can be found in “Sexual Medicine and Primary Care” by William L. Maurice, M.D. at:
http://www.kinseyinstitute.org/resources/maurice.html.

Interview methods are specifically addressed in Chapter 2 of the above reference at:
http://www.kinseyinstitute.org/resources/fulltext/maurice/pdf/SexualMedicine_CH02.pdf

Another, much briefer, resource is the CDC’s Guide to Taking a Sexual History, which can be found here:
http://www.cdc.gov/std/treatment/SexualHistory.pdf. However, it is more oriented toward STIs and offers little guidance about how to implement the suggested assessment questions.

Another brief written resource on sexual history taking/assessment that may be helpful is:
http://virtualmentor.ama‐assn.org/2005/10/medu1‐0510.html

 

General Assessment


1. Wellness
(Promotion of health and wellness; screening for potential fetal toxicity risk)

a. Diet
b. Exercise
c. Alcohol
d. Tobacco
e. Illicit drug use or other substances
f.
Self‐image
How do you feel about the way you look? Do you feel that you are underweight? Overweight? Just right? How much would you like to weigh?


2. Health Prevention

a. Patient‐provider relationship
Do you have a primary care provider?

b. Pap smear
Have you had a pap smear?

c. Breast Health
When was your last mammography?

d. Cancer risk
Do you have a personal history of cancer or a family history of hereditary cancers (i.e., breast, ovarian, endometrial and colon cancer)?

e. Personal safety
Do you feel safe at home? At school? In your work environment?

3. Medical and medication history

a. Medical conditions, including mental health
What medical conditions do you have?
Do you currently have or have you had in the past depression, anxiety, bipolar disorder, or schizophrenia? (Presentation and assessments may be different in adolescents as compared to adults and screening should be age specific)

b. Medications (prescription and over‐the‐counter)
What medications are you currently taking, including both prescription and over‐the¬counter medications?
Do you take multivitamins or other dietary supplements?

4. Reproductive history

a. Menstruation
When was your first menstrual cycle? Do you have regular menstrual cycles?

b. Pregnancy
Have you ever been pregnant in the past? Are you pregnant today?

5. Sexual health

a. Sexual activity
Are you currently sexually active?

If yes, do you have sex with men, women, or both?
If yes, do you practice safe sex?
If yes, do you desire contraception? (For patients of reproductive age)
If yes, do you have bleeding after sex?

b. Female sexual dysfunction
Do you have or have you ever had sexual dysfunction?

Desire/libido problems?
Arousal problems?
Orgasm problems?
Pain with intercourse?

6. Bone health

a. Assessment of calcium and vitamin D
How many servings of milk or other dairy foods (eg, yogurt or cheese) did you have yesterday? Are you taking calcium and vitamin D supplements? If so, how much and how often? How many servings of other calcium‐containing foods (eg, dark green, leafy vegetables, or calcium‐fortified orange juice or cereal) did you have yesterday?

b. Assessment of other identified risk factors for osteoporosis (exercise, cigarette smoking, excessive alcohol intake)

7. Urinary changes

a. Urinary tract infection screening
Do you have symptoms of dysuria (e.g., frequency of urination, pain or burning on urination, cloudy or bloody urine)?

If yes, how frequently?
If yes, were you treated?

Adolescents


1. Background

a. Age range of adolescence is not clearly specified, but can range from 10‐21 year of age, encompassing a variety of physical, social, and mental health changes. (10‐19 according to WHO http://www.who.int/topics/adolescent_health/en/, 11‐21 according to American Academy of Pediatrics Bright Futures)

b. Health care professionals should be aware of their local laws and public health regulations regarding confidential access to health care for minors and reporting requirements. Providers should also be aware of the cultural norms regarding youth/adult interactions.

c. No clinically significant pharmacokinetic differences between males and females have been documented in this age range.

2. Key Considerations for the Provider

a. Physical growth and development screening

i. Obesity and overweight
ii. Eating disorders
iii. Adequate intake of vitamin D, calcium folate, and iron
iv. Assess immunization status

1. Reference materials: Sample questions and anticipatory guidance can be found in AAP Bright Futures; Women’s Health Across the Lifespan; Immunizations: http://www.cdc.gov/vaccines/

b. Sexual health screening

i. Onset of menarche and sexual activity

1. Use of contraception 
2. STI prevention
3. STI and cervical cancer screening 
4.  STII guidelines: http://www.cdc.gov/std/treatment/

c. Violence and injury prevention screening

i. Use of illicit drugs, alcohol, tobacco (usually comorbid with mental health problems) 
ii. Reference materials: Sample questions and anticipatory guidance can be found in AAP Bright Futures

d. Mental Health and Emotional Wellbeing

i. Depression and anxiety—may not present with classis adult signs and symptoms
ii. Suicidal ideation
iii. Reference materials: Sample questions and anticipatory guidance can be found in AAP Bright Futures; Pharmacotherapy guidelines available in Women’s Health Across the Lifespan


Women in Reproductive Years: Non‐Pregnant


The definition of reproductive years depends on age of menarche, and includes adolescence. Providers should be aware of their local laws and regulations regarding confidential access to health care for minors and reporting requirements for providers. Providers should also be aware of the cultural norms regarding youth/adult interactions.

Questions to Ask:

1. How do you feel about the way you look? Do you feel that you are underweight? Overweight? Just right? How much would you like to weigh?

2. How many servings of milk or other dairy foods (eg, yogurt or cheese) did you have yesterday? Are you taking calcium and vitamin D supplements? If so, how much and how often? How many servings of other calcium‐containing foods (eg, dark green, leafy vegetables, or calcium‐fortified orange juice or cereal) did you have yesterday?

3. When was your first menstrual cycle?

4. Do you have a regular menstrual cycles?

5. Have you ever been pregnant in the past?

6. Are you sexually active?

a. If yes, do you desire contraception?
b. If yes, do you practice safe sex?
c. If yes, have you had a Pap smear or HPV test?
d. Do you take a multivitamin with folate?
e. Do you have sex with men, women, or both?

7. Do you feel safe at home? At school? In your work environment?

8. Do you currently have or have you had in the past depression, anxiety, bipolar disorder, or schizophrenia?

a. Mental health issues, especially depression, may present differently in adolescents as compared to adults and screening should be age specific.

9. Do you have a personal or family history of cancer?

10. Vaccine status using age appropriate vaccinations available at: http://www.cdc.gov/vaccines/

Additional Information on Assessment of Fertility and Reproductive Health:

The American Society for Reproductive Medicine (asrm.org) has an “e‐learning” program with modules that are geared primarily toward assessment and management of fertility and reproductive health issues, though there are some modules focused on menopause, precocious puberty, and some gynecologic conditions. Some of these issues may be of relevance. ASRM is unique in offering some ethics training modules for clinicians who are particularly interested in assisted reproduction. Here is the link: http://www.asrm.org/eLearn/Catalog/md/

 

Women in Reproductive Years: Pregnant

Questions to Ask:

1. Are You Pregnant?

2. Pregnancy dating

a. usually stated as starting on the first day of the LMP
b. may be stated as starting at the time of conception (day 14)

3. Are you seeing a healthcare provider for your pregnancy care?

4. Screen for any high risk medications during pregnancy

a. Differentiate risk by trimester

5. Has the management of your chronic condition(s) been addressed since you have become pregnant?

6. Are you having any problems with your pregnancy?

a. If so, what pharmacologic and non‐pharmacologic treatments have you been taking to manage the symptoms associated with your pregnancy?

7. Are you up to date on your current vaccinations?

8. If you want to discuss the safety of sex during pregnancy, please consult your physician.

 

Women in Reproductive Years: Breastfeeding

Many of the same questions asked during a patient history can be asked of a breastfeeding woman as of non‐nursing women but who are of a similar age. The following are questions that would be more specific for a breastfeeding/nursing woman.

1. What prescription medicines, nonprescription (OTC) medicines, natural products, vitamins and/or minerals, etc. are you currently taking, for how long and at what dose?

2. Are you taking any medicines/OTCs/natural product, etc. as mentioned above, what is the specific dosing schedule (exact times of the day, evening or night) for any medicine/OTC/natural product, etc.?

3. How does the dosing schedule of the particular medicine/OTC product/natural product, etc. compare to the infant’s typical breastfeeding schedule? For example, does the woman take the medicine, etc. immediately before or after she breastfeeds her infant?

4. Does your health care provider and/or the infant’s pediatrician know that the woman is taking the above mentioned medicines/OTCs/natural products, etc.?

5. Why are you taking each of the medicines/OTCs/natural products, etc.?

6. Are there other medicines/OTCs/natural products, etc. in the same therapeutic class(es) that would offer less risk to the nursing infant?

7. Have you noticed any symptoms in the infant since you started taking a particular medicine/OTC product/natural product, etc. (examples, appears more sleepy, has diarrhea, spitting up more, decreased feeding time, etc.)?

8. If the nursing women needs to take the above mentioned medicines/OTCs/natural products, etc., should any of their schedules be changed from the way the nursing woman is currently taking them?

9. Is a call to the nursing woman’s health care provider warranted? Is a call to the infant’s pediatrician needed? If so, please explain.


Peri‐and Post Menopausal Women


Perimenopause generally lasts from age 45 years to age 55 years and is a time of gradual change in hormone levels and menstrual cycles. Menopause is the absence of menstrual periods for at least one year.

Assessment Questions Pertaining to Both Peri‐and Post‐Menopausal Patients

1. Wellness

a. Diet?
b. Exercise?
c. Cigarette smoking?
d. Alcohol intake?

2. Sexual Health

a. Are you sexually active? If yes, the number of partners?
b. Symptoms of vaginal atrophy? Burning, itching, pain with intercourse?
c. Symptoms of female sexual dysfunction?

i. Desire/libido problems?
ii. Arousal problems?
iii. Orgasm problems?
iv. Pain with intercourse?

3. Urinary Changes

a. Occurrence of urinary incontinence? Urge vs overflow vs combination?
b. Increased occurrence of urinary tract infections?

4. Bone Health

a. Assessment of calcium and vitamin D intake
b. Check medication for potential drug interactions
c. Assessment of other identified risk factors for osteoporosis (exercise, cigarette smoking, excessive alcohol intake)
d. Ask about falls – determine if there is a need to assess the home for fall risk

5. Cardiovascular (CV) Health

a. Assessment for identified CV risk factors (high cholesterol, hypertension, smoking, diabetes, overweight/obesity, sedentary lifestyle)
b. Determine if woman knows signs and symptoms of myocardial infarction in woman (i.e. indigestion, dizziness)
c. Determine if woman knows signs and symptoms of stroke (i.e. dizziness, confusion).

6. Periodic Health Evaluations for Women Age 40‐64 Years (Make sure to review the most recent recommendations since they change over time)

a. Colorectal cancer screening beginning at age 50
b. Fasting glucose testing beginning at age 45
c. Lipid profile assessment
d. Mammography - Link to Recommendations
e. Papanicolaou test - Link to Recommendations
f. TSH every 5 years beginning at age 50


Assessment Questions Pertaining to Peri‐Menopausal Women

1. Menstrual Cycle Changes

a. Bleeding between periods?
b. Bleeding after sex?
c. Spotting at anytime in the menstrual cycle?
d. Bleeding that is heavier or lasts for more days than usual?

2. Sexual Health

a. Are you sexually active? Do you practice safe sex and/or use birth control?
b. How many sexual partners have you had? Do you understand the risk for sexually transmitted infections?

3. Vasomotor Symptoms (VMS)

a. Frequency of hot flashes?
b. Duration of hot flashes?
c. Patient’s level of acceptance relative to the above?
d. Patient’s self‐identified triggers for the VMS?

4. Sleep Disturbances

a. Insomnia?
b. Difficulty staying asleep?
c. Night sweats affecting sleep?

5. Hormone Therapy Considerations

a. Have you considered using birth control to assist in managing symptoms of perimenopause, for birth control, and to help regulate the menstrual cycle?
b. What do you know about the risks/benefits of hormone therapy?
c. Are you aware of the different types of regimens and the different dosage formulations?

6. Bone Health

a. Baseline DEXA scan

Assessment Questions Pertaining to Post‐Menopausal Women

1. Cardiovascular

a. Determine if woman knows signs and symptoms of myocardial infarction in woman (i.e. indigestion, dizziness).

i. Check to see if ankles are swollen or SOB
ii. Discuss risks and benefits of taking baby aspirin


b. Determine if woman knows signs and symptoms of stroke (i.e. dizziness, confusion).

i. Check to see if there is weakness on either side of the body.  

2. Bone Health

a. Date of last DEXA
b. Musculoskeletal complaints

3. Vision

a. Changes in Vision
b. Last ophthalmology exam

4. Cognitive function

a. Either mini‐mental status exam or ask the patient if she is having more problems with memory than others her age.
b. Depression/Anxiety

i. MMSE & Geriatric Depression Scale (GDS) if woman is being seen in clinic
ii. Use simple screening tool and make referral if need (community practice)


The North American Menopause Society (menopause.org) has some good CME content including short, free, case‐study based CME modules on assessment and management of menopausal symptoms (see http://www.menopause.org/for‐professionals/cme‐activities). These, of course, are more focused on specific problems and less on general interviewing strategies. NAMS has a patient site with information about sexual health, which may also be useful to clinicians who are trying to learn a “vocabulary” for discussing sexuality with patients: http://www.menopause.org/for‐women/‐em‐sexual‐health¬menopause‐em‐online

 

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