Unique Perspectives on Caring for Pregnant/Reproductive Age Women Struggling with Addiction and Mental Illness

I am a current fourth year medical student at Drexel University College of Medicine rotating at The Caring Together Program -- a clinic that provides both mental health and addiction services to women, many of which have been recently incarcerated. Caring for this unique population has introduced me to a number of patient circumstances that I could not have previously even imagined I would encounter. As a student aspiring to go into the field of Obstetrics and Gynecology, I am particularly drawn to patients at this clinic who are pregnant, hoping to become pregnant, or are in the postpartum period.

At Caring Together, we follow the American Committee of Obstetricians and Gynecologists (ACOG) Committee Opinion number 511 recommendation of obtaining a complete reproductive history from all patients upon intake to our clinic. This has shown to be of great importance for women struggling with mental illness and addiction, as we find many of our patients experience significant mood swings and irritability in a cyclic pattern prior to their menstrual period. This also helps us assess the risk of unintentional pregnancy in women, which is of great importance as we prescribe many psychiatric medications that are labeled as pregnancy category D (positive evidence of risk) or X (contraindicated in pregnancy). These categorizations indicate that they carry a significant risk of adverse perinatal and postnatal outcomes if used during pregnancy. 

According to the American Family Physicians (AAFP), each year an estimated 500,000 pregnancies in the United States involve women who have or who will develop psychiatric illness during the pregnancy. The use of previously mentioned category D and X psychotropic medications in these women is a concern. However, it is not always advisable to abruptly discontinue these medications in women who become pregnant, and decisions to do so are made on a case-by-case basis. This issue is particularly worrisome in those with a history of suicide attempts, significant mania, or psychosis, especially if they have been stable on a particular medication for some time. Discontinuation of the medication can result in significant psychiatric morbidity, leading to poor adherence to prenatal care and ultimately worse outcomes for the mother and her child. For all of these reasons, we not only attempt to make medication decisions prior to conception but also assist in providing birth control for our reproductive age women receiving psychiatric care.

In addition to making decisions regarding prescription medication, we also screen for illicit drug use in all of our patients with a thorough history as well as frequent urine drug screens. Given the potential adverse fetal and maternal effects of drug use, ACOG recommends screening all pregnant women for drug use at their first prenatal visit. The NIDA Screen is a quick and effective way to begin the conversation about substance use with pregnant patients.

Danielle Schenker   DUCOM 2020

The Rising Rates of COPD in Women

As I reflected on my pulmonology elective at its conclusion, I noticed something peculiar: during my four weeks, with anywhere between 2 to 6 hours of ambulatory pulmonology patient exposure per day, a large chunk of the COPD patients were women. I remembered a handful of male patients with severe disease, but overwhelmingly the patients were female. I thought there could be any number of reasons for this; perhaps women were more likely than men to follow up with their outpatient pulmonologists, or they were healthier than their male counterparts and were able to stay out of the hospital. My inquisitive mind sent me on a search of the literature, and I was surprised with what I found. There has been a striking rise in COPD rates in the female population.

COPD, or chronic obstructive pulmonary disease, is a long-term destructive lung process most commonly associated with smoking. Traditionally thought of as a disease for older white men due to the prominence of tobacco smoking in this population, recent evidence has shown alarmingly increasing rates of COPD diagnoses in women. The etiology appears to be similar in women as it is in men, with tobacco smoking the main culprit. Smoking rates increased in the mid-1920s with specific targeting of women and began to decline in the 1960s with the Surgeon General’s report on the consequences of smoking. Nonetheless, TV and newspaper advertisements targeting women in the 1970s described cigarettes as liberating and slimming. These advertisements have resulted in increasing cases of new COPD diagnoses in women that were once targeted. When comparing the percentage of male to female smokers over the last century, it appears that the highest percentage of male smokers (>55%) was in the mid-1950s. Compared to men, roughly 35% of women smoked during this time. Both genders experienced a decrease in smoking over the next several decades, but this decline was less pronounced in women; by the 2010s, both men and women had roughly the same percentage of smokers in their respective populations (20-30%).

Women experience more lung damage than men from the toxins in cigarette smoke and other environmental irritants. There are several biological explanations for this, including smaller airway diameter and altered nicotine breakdown via estrogen. Women also have increasing environmental exposures, via secondhand smoke and outdoor or workplace pollutants, and subsequent increased susceptibility. Despite greater susceptibility to chronic lung damage, women oftentimes do not get properly diagnosed. They are less likely than men to get spirometry testing, the gold standard for COPD diagnosis, when they present to their primary care provider with respiratory complaints.

Most concerning perhaps is the fact that COPD exacerbations are more common in women than in men, contributing to overall decreased lung function and, eventually, death. The number of women dying from COPD related lung decline exceeds that of men.

With overall worsened quality of life compared to men, women living with COPD require special recognition and attention from providers. We need to be better at diagnosing the disease in women, with prompt delivery of spirometry to those presenting with typical (and atypical) respiratory complaints. Providers need to be aggressive to prevent exacerbations and preserve lung function as much as possible. Treatment needs to be holistic, addressing all components of the illness- including anxiety and depression that oftentimes cause detrimental effects to quality of life. There should be increased awareness and motivation to address this health disparity, and with the trend in research and advocacy I believe we are moving in the right direction.

Mehnaz Ali Khan   DUCOM 2020