Resources for Reproductive Options Counseling

Here's an example of nuchal translucency on ultrasound

So here's some very useful links (or how to be ready to respond to 'Dr. Google'):
Genetics and Testing:
A very accessible article about preconceptual health issues A primer for those in (or interested in) primary care and genetics testing - Case examples include Tim (the father) who get's diagnosed with familial polyposis and you are asked what should you do with his son Jay...
A searchable genetic reference site
The Online Mendelian in Man (I think it's fine for Woman too!) site - here's the info at a glance about Down Syndrome
This one page fact sheet from the American Society for Reproductive Medicine succinctly puts together a lot of data and has a Reproductive facts webpage  in additional to useful patient education materials
An extensive listing of other web resources
Here's the CDC site Genomics weekly update

For those of you interested in Obstetrics - Drexel is underway to join the current listing of residency programs with a Family Planning Fellowship. Here's the national listing. If you are interested,  email Dr. Montgomery (Chair of Ob/Gyn) or Dr. Woodland (Residency Director) More info on reproductive options is available at ACOG

A May 2010 report discusses the new field of onco-fertility, an area focused on maintaining reproductive options in cancer patients.

Here's a useful description about fertility risks for men and women
Here's a link to questions you ask of women or men with multiple sclerosis who are considering starting a family

What We Do At WHEP

Universal Screening - Child Maltreatment and Intimate Partner Violence

Screen everyone. When it comes to violence and trauma - screen everyone. One of your classmates used the term 'exuberant' screening - be exuberant. Physicians err on the side of caution in screening when the outcome of missing the diagnosis has a significant impact. This is true for a quiet tender abdomen in a patient with a fever - thus we look for appendicitis so as to not miss a ruptured appy that will result in life long abdominal pain. It is equally true for child maltreatment and intimate partner violence. Screen everyone.
Universal screening is the best way to do this. Universal screening means telling everyone that we do this with everyone.  By creating your clinical habit to ask everyone, you eliminate the challenge of deciding the if, when and who of screening about unhealthy relationships, abusive situations or being abusive to others.
How do you actually ask? Whether of a child with suspicion injuries or upon a first visit with a woman or man consider stating "We ask everyone these questions so that we make sure that people who are being harmed know that we are here to help." "There is a lot of abuse out there and we are mandated reporters." To a child (age dependent) ' You're here because you are hurt - we need to check you head to toe to make sure everything's ok.'
Won't I offend? We (should) ask everyone about use of drugs and alcohol; sexual habits including safe sex; status of HIV screening as well as history of trauma. The concern about offending a patient needs to be on the back burner. If a patient states it isn't an issue to them - it may not be (or it may be that they do not yet feel safe enough with you to divulge this.) If you inform the patient that you need to ask everyone (it's your job!) - then if it isn't true for them, you move on. If parents of a child with a suspicious injury get evaluated because we do it universally as our pledge to keep children safe - those for whom it was unfounded will be unfounded. But for others, we will have kept a child safe. Universal screening means seeing past personal bias of who seems to be at risk (certain groups) versus who really is at risk (every economic class and ethnicity.) - everyone.
How and where do I do this in the medical history? Here's some options -
1) Under Health Promotion issues - Stress screening [e.g. (On a scale of 1 - super mellow to 10 - ready to jump out of my skin - How stressful is work? How stressful is home? When stress becomes 10 or higher - what do you do to take care of yourself?] Has there every been a time when something traumatic happened to you? when something bad happened? What was that? How are you doing now? Has there every been a time when someone forced you to have sex? When they hurt you (hit/kick/punched)? When they kept you away from friends or family?)
2)  Include IPV screening as a dedicated part of the history on health maintenance (including wearing seat belts; alcohol; self breast/testicular exams)  "There is a lot of relationship violence that we see (as well as the health effects from it.)" "Have you ever been in a violent or abusive relationship?"

"When you get upset - how do you handle it? Have you ever felt that you 'lost it' when you got angry? Does this worry or concern you? Do you wish you could deal with frustration better?"
3)Include in the surgical history (Have you ever broken anything and how? Ever hospitalized? What for?)
4)The sexual history - "When was your earliest sexual experience? Did anyone ever force themselves on you? etc."
5) A sleep history - "Do you have good quality sleep? Do you have nightmares or bad dreams?"
6)In the mental health history - "There is a lot of violence and trauma in our world and it influences how people live even after it happened. Was there ever a time when something bad happened to you? How did you handle that?"
There is also some information in the literature that people who present with problems such as chronic pain, GI disorders, functional gyn problems; sexual dysfunction; aversion to dentists/oral health; and chronic headaches should be screened.

Here's a listing of some of our wonderful local Drexel collaborators and experts 

DUCOM
At Women's Health Education Program
     Candace Robertson, MPH Healthy relationship education for teens and IPV health screening
     Ana Núñez, MD IPV health education screening; Philadelphia Ujima - culturally and health literacy    appropriate health outreach
      Jill Foster, MD  Ped/Adol HIV/AIDs Center; St Christopher's Hospital for Children; expertise in the intersection of intimate violence and adolescent sexual health, child maltreatment, sexual health and LGBT youth
      Ted Corbin, MD - ED Physician  Violence Intervention Program "Healing Hurt People"; expertise in outreach to young men with trauma
       Ralph Riviello, MD - ED Physician, Sexual Assault Treatment Center; expertise in helping victims of rape/assault
       Susan McCleer, MD, Psychiatry forensic psychiatry
School of Public Health violence prevention collaborators
  Sandy Bloom, MD - Creating sanctuary: toward the evolution of sane societies and more resources here
  John Rich, MD, MPH - Wrong Place; Wrong Time
DU collaborators
Julie Mostov, PhD International Violence and Women's Advocacy
Maria McColgan, MD, MEd, FAAP Child Protection Program, St Chris (Seminar Series speaker 2010!)


References regarding New Jersey maltreatment case

IPV and Curricular Opportunities to Learn About It Update on Intimate Partner Violence and Medical EducationThe Drexel University College of Medicine Women’s Health Education Program is a model for training medical students to screen for and respond to intimate partner violence.
Ana E. Nunez, MD, Candace J. Robertson, MPH, and Jill A. Foster, MD

One Path To Women's Health Scholar

In my first year, the Women’s Health lecture series piqued my interest as a chance to learn about the real-world issues in women’s health. As I continued attending the lectures, I realized I was getting more—I was learning a viewpoint on how to take a critical approach to my education and my career. I decided the Women’s Health Scholar’s program would be a valuable experience in helping me become a better clinician and a better researcher.


Volunteering at the HOP clinics had been my main form of community outreach, and I hoped to connect this experience with my Women’s Health interests. During my second year, two of my classmates developed the “Jump Into Reading” program at the Eliza Shirley clinic to encourage mothers to read with their children. For my community project, I helped secure book donations, facilitate reading space, and of course, I regularly attended the reading program to read with moms and kids.

During one of my lighter third year rotations, I emailed Drs. Núñez, and Kahng about a bulletin board idea. Since it was Lupus Awareness month, I wanted to put together images and clinical pearls to help students internalize the diverse pathology associated with Lupus. Since I was on an away rotation, I got feedback from the Women’s Health team via email, asked Winnie to print the slides for me, and I came back to Philly on a Saturday to hang the images on the Women’s Health bulletin board.

With most of the requirements complete, the 15-20 paper was still looming. Having recently abandoned my previous career choice of OB/Gyn in favor Pediatrics, I felt like I was a half-step behind my classmates who had always known they wanted to work with children. I considered abandoning the Women’s Health Scholar’s path, but upon reflection, I realized that completing a paper on a topic relevant to Pediatrics would allow me to develop an area of interest and feel more grounded.

As a third-year student, I had spent a day in the GROW clinic, where I was fascinated by the multidisciplinary approach to patient care, including extensive social and psychological support for parents. I contacted Dr. Kersten, the director, and he invited me to spend as much time as I wanted in clinic, introduced me to his team, and asked me to participate in data gathering for a research project on failure to thrive. Now that I am writing my paper, I am grateful that I pushed myself to reach out and pursue an interest I might have otherwise left alone.

The most valuable part of the Women’s Health Scholars experience for me has been that I have pushed myself to pursue interests, develop my own ideas, and expand my exposure to different issues in women’s health. I am certain that I will have a better-informed academic and clinical perspective upon leaving Drexel.

Blog submission Stephanie Doupnik, Class of 2011; Women's Health Pathway student

Photo credits Dunes, Namib Desert. S.Doupnik

Heart Health and Women

Cardiac disease is an excellent example of sex/ gender health disparities. Cardiac disease is not unique in women - it is the number one killer of men and women in the US. Women fear dying of breast cancer, but die most of heart disease. So, how is it a disparity? Since 1984, more women have died of heart disease as compared to men (even though it occurs in men and usually ten years earlier!)

DIFFERENT EMPHASIS ON RISK FACTORS - The heart story does not focus on different risk factors - rather different importance in risk factors. For example, the ten year - or 'female advantage' in heart disease is lost if a women is a Diabetic. It's lost if she's a smoker. It's also gone when menses stops (surgically or naturally.)
DIFFERENT WAYS IT CAN PRESENT - Heart related diseases can present differently in women. Yes, women can have the 'classic' findings of obstructive heart disease as men - exertional chest pressure that radiates down the arm and is relieved with rest. But they can have other findings that may be viewed as atypical - yet are typical for women: unexplained fast heart beat (tachycardia); nausea; unexplained fatigue; inability to do housework or typical tasks (esp seen in elderly women) and even more alarming, 1 in 4 women may not have any complaints at all! Thus, we need to screen EVERYONE for heart risk (high, medium and low) and evaluate appropriately.
DIFFERENT THRESHOLDS TO PREVENT AND TREAT - Although, heart health awareness are creating change, women still have lower rates of screening for lipids and heart health as compared to their male counterparts. A well known study created vignettes of 'classic' cardiac symptoms and changed the ethnicity (white versus black) and gender. The scripts were exactly the same. Physicians most likely recommended cardiac catheterization to men over women patients. Another 2007 study found that physicians still intervene less with women and heart disease.
SO WHAT SHOULD WE DO? - Collectively and personally, we all need to be more aware of heart health risk factors - for clinicians as well as for patients be they children, men or women. Getting into the risk assessment habit (high, medium, low and optimal) for everyone helps overcome the selective focus of missing half of the population.

A Sampling of Great Web Resources
 Our webpage (Women's Health Education Program)
 Women’s Health Initiative
 DHHS Office of Women’s Health
 Food information planning site Mypyramid.gov Want to know how many calories you eat? What's in the food that you love? Check this site out.
 Society for Women’s Health Research
 The Heart Truth: Resources for health professionals (videos of patients; patient cases and slides)
 NHBLI: National Heart Blood Lung Institute (great resources on heart health)
 Video on taking a heart health history and the role of gender and ethnicity in heart health risk
– Gender and Ethnic Medicine Cardiac Disease and Women

Reports
– IOM Report Sex Matters 2001 Evidence based report highlighting the difference that sex/gender makes in health.
– Heart Disease and Stroke Statistics-2010 Update, American Heart Association. A ton of great graphs and info here.
– HRSA Women's Databook - each years data book has useful health information on various topics.
Other
 -Sentinel article on heart health and women  Evidence-based guidelines for cardiovascular disease prevention in women L Mosca, LJ Appel, EJ Benjamin, K Berra, N … - Circulation, 2004
-CDC BMI Online Calculator

Intimate Partner Violence - More and Deadlier For Women

Violence against women is an enormous health issue in the United States. According to an FBI report in 2001, nearly a third of female homicide victims were killed by an intimate partner. Intimate partner violence, or IPV, is violence committed by a spouse, ex-spouse, or current or former boyfriend or girlfriend. IPV includes physical violence, sexual violence, threats of such acts, and emotional abuse. Although both genders are affected, the vast majority of this physical and psychological burden is borne by women.

In 2003, the CDC published a report on the costs of Intimate Partner Violence and estimated that 5.3 million IPV victimizations occured in adult women each year, 2 million of which were injuries and 550, 000 which required medical attention. The costs associated with IPV totalled over $4 billion for medical services and nearly $1 billion in lost work productivity and earnings. The health sequelae are well-established; IPV is linked to low self-esteem, eating disorders, depression, suicidal thoughts, and harmful health behaviors such as smoking, alcohol abuse, drug use, and risky sexual behavior.

So how well do physicians screen their patients for IPV? An ongoing 2010 multi-center Canadian study (Bhandari, et. al) looked at IPV screening attitudes and behavior amongst orthopaedic surgeons. 87% of orthopods believed that less than 1% of female patients in their care were victims of IPV. This was in stark contrast to prior data from fracture clinics that found one-third of women had been victims of IPV within the past year and 2.5% had presenting injuries directly resulting from IPV.

It also turns out that primary care physicians are slightly better at screening for IPV than orthopods, yet still fall far short of expectations. The American Academy of Family Physicians cites on their website a recent study that estimated that 10% of physicians routinely screen for domestic violence during new-patient visits. Where patients presented with physical injuries from abuse, only 79% of physicians asked patients direct questions about domestic violence. 17% of obstetrician-gynecologists routinely screen, compared with 10% of family physicians and 6% of internists.

Resources on Intimate Partner Violence:
National Domestic Violence Hotline  1-800-799-SAFE (7233), 1-800-787-3224 TTY, or
http://www.ndvh.org/
National Coalition Against Domestic Violence  http://www.ncadv.org/
National Sexual Violence Resource Center  http://www.nsvrc.org/
Family Violence Prevention Fund  http://www.endabuse.org/
When Closeness Goes Wrong - Podcast


 PRevalence of Abuse and Intimate Partner Violence Surgical Evaluation (P.R.A.I.S.E.): rationale and design of a multi-center cross-sectional study.BMC Musculoskelet Disord. 2010; 11: 77.Published online 2010 April 23.

Blog Submission by Olivia Wang, MS4; WH Pathway, Class of 2011