This chapter describes the broad array of behavioral issues for women using a developmental framework. We discuss expected behavioral issues occurring as part of the normal life cycle, as well as problematic ones requiring medical surveillance or intervention.

The task of adolescence is to find one’s own beliefs, moving from childhood to adulthood physically and in relationships (see Chapter 13). Several events can occur during this time that will require the sensitive attention of the primary care physician, but numerous studies have demonstrated that confidentiality must be maintained for the physician to be trusted and helpful to an adolescent.

Approach to the Gynecologic Examination

Some women fear a pelvic examination, especially when they are undergoing it for the first time. Little research has been done on what strategies are best in performing a pelvic examination, but several techniques have been found to be helpful in clinical practice.

Before performing the examination, clinicians should make the patient as comfortable as possible when taking a history by asking open-ended questions, demonstrating empathetic communication skills such as eye contact and nonjudgmental reactions, and not making assumptions about sexual activity and orientation. In addition, they should ask if the patient has had a previous pelvic examination. When taking a complete sexual history, they should inquire about prior sexual abuse or challenges with past examinations.

It is useful for the clinician to describe exactly what is being done before and during the examination. Both female and male clinicians should consider offering to have a chaperone present to reassure the patient about the professional content of the examination. Other techniques include appropriate draping; using a warm, lubricated speculum; using the narrowest speculum that will allow adequate visualization of the cervix; being as gentle as possible; and encouraging the patient to use relaxation techniques including deep breathing and mental imagery, techniques which are especially useful for young women and those who have experienced sexual abuse. In addition, elevating the head will facilitate eye contact and may make it easier for some women to relax. In situations where a patient has significant anxiety, an anxiolytic medication prior to the examination may be useful.

Research has shown that the experience of the first pelvic examination influences attitudes about subsequent examinations; therefore, it is important to make the first pelvic examination as positive an experience as possible. In a study describing women’s experiences of the first pelvic examination, a negative evaluation of the examination was associated with pain, embarrassment, having insufficient knowledge about the examination and what the clinician was doing, and not knowing that they could stop at any time. Taking time to provide knowledge and encourage realistic expectations of the examination may help shape attitudes about subsequent examinations.

If a gynecologic examination is being carried out on an adolescent in the context of reproductive health care or to screen for sexually transmitted infections, it is important to be aware of the legal requirements of confidentiality in the United States, which vary by state and are listed on the Guttmacher Institute website (). Adolescents should be encouraged to involve their parents or guardians in medical decisions, and providers should be aware of mandatory reporting laws in the case of nonconsensual sexual activity, sex with an older adult, or other abuse.

Chronic Pelvic Pain and Vulvodynia

A condition that can affect women starting in teen or early adult years is chronic pelvic pain (CPP), which is commonly defined as noncyclical pain of at least 6 months duration that occurs in the pelvis, abdominal wall, lower back, or buttocks, and is serious enough to cause disability or require medical care. Chronic pelvic pain affects up to 15% of women and accounts for 20% of the hysterectomies performed in the United States. Up to 40% of women with CPP have other diagnoses, that may be the cause and/or effects of the CPP, such as depression, anxiety, sexual dysfunction, substance abuse, and other pain syndromes, requiring in-depth investigation into all contributing factors. A history of sexual or physical abuse, including intimate partner violence, has been identified in over 50% of CPP patients, and therefore must be included in the history (see Chapter 38). This evaluation often requires many visits, as well as providing patient education such as that provided by the International Pelvic Pain Society (http://www.pelvicpain.org/resources/handpform.aspx).

A definitive diagnosis is not made for the majority (61%) of CPP patients, but for those with diagnoses, they are more commonly of urologic or gastrointestinal than gynecologic origin. The four most common diagnoses are irritable bowel syndrome (IBS), interstitial cystitis, endometriosis, and adhesions; in these cases or other specific diagnoses, treatment is targeted at the underlying pathology. However, when no source is found, a multidisciplinary approach addressing dietary, social, environmental, and psychological factors, as well as standard medication therapy, is ideal. A recent Cochrane review supports counseling, a multidisciplinary approach to treatment, the use of injectable gonadotropin-releasing hormone (GnRH) agonist or oral medroxyprogesterone acetate, and lysis of adhesions for patients with no underlying source. Cyclic pain, although not commonly included in the definition of CPP, can be a significant problem and can be treated with similar approaches. Specifically, the levonorgestrel intrauterine device has been shown to be as effective as GnRH agonist for cyclic pain, which may also be responsive to combined hormonal contraceptives. Trigger point injections of the abdominal wall can help myofascial sources. Finally, oral analgesics may be used based on studies of benefit with other sources of pain, and some evidence supports the use of gabapentin with or without amitriptyline.

Vulvodynia is vulvar discomfort occurring in the absence of visible lesions, usually described as burning–diffuse, constant, and unprovoked, and less commonly, localized and provoked. Comorbidities associated with vulvar pain are low back pain, IBS, migraine, and fibromyalgia. Approaches to the patient with vulvar pain may include a variety of nonpharmacological modalities: education about vulvar care, addressing sexual and psychological issues, and pelvic floor physical therapy. Topical anesthetics such as xylocaine have been shown to improve pain. Tricyclic antidepressants and gabapentin have been used, although there have been few controlled trials. Topical estrogen may be helpful in women who also have vulvar atrophy. For the primary care provider, recommendations include counseling the patient about the disorder, giving emotional support, and facilitating appropriate subspecialist involvement.

Issues around Food and Eating Disorders

Eating disorders are common and challenging in young women, and the primary care physician plays an important role in their detection (see Chapter 23). The primary care physician also manages the medical complications, determines the need for hospitalization, and coordinates care. In addition, for patients with milder forms of disordered eating who may not be seeing a mental health specialist regularly, the primary care physician may have responsibility for ongoing care, including exacerbations that may mandate coordination with mental health and/or nutritional support. Although the diagnostic criteria for anorexia nervosa and bulimia nervosa are clearly defined, women may also have disordered eating that does not meet the criteria for anorexia nervosa or bulimia nervosa, but is nonetheless abnormal. In addition, two groups at particularly high risk for eating disorders include female athletes and women with diabetes.

Binge eating consists of episodes of eating a large amount of food in a discreet period of time with a sense of lack of control. The binges must have at least three of the following criteria: (1) eating much more rapidly than normal; (2) eating until uncomfortably full; (3) eating large amounts of food when not feeling physically hungry; (4) eating alone because of embarrassment; and (5) feeling disgusted, depressed, or very guilty after overeating. The episodes must occur at least twice a week for 6 months, and must not be associated with any compensatory behaviors (e.g., purging or fasting). The estimated population prevalence is 3.5% in women. Binge eating has been strongly associated with obesity; in weight control programs, an estimated 15–50% of individuals have binge eating disorder. Although many obese patients report binge eating, not all have binge eating disorder. As expected, obesity-related complications are likely to exist, and binge eating disorder may be more common in weight-cycling patients. Several studies have evaluated treatment options for binge eating disorder. The primary recommended treatment is psychotherapy, in particular cognitive behavioral therapy (CBT). Pharmacotherapy may also be beneficial but less so than psychotherapy. Medications that have been shown to be useful in reducing binge episodes include the selective serotonin reuptake inhibitors (SSRIs) and antiepileptics (topiramate).

Screening for Eating Disorders

Because many women will not seek care for an eating disorder, the clinician must remain alert for clues, such as amenorrhea, concern about weight loss by a family member, abdominal bloating, and cold intolerance. Questions that are useful in ascertaining eating habits include: “Are you trying to lose weight?” “What did you eat yesterday?” and “Do you ever binge eat (eat more than you want) or use laxatives, diuretics, purging, or diet pills?” One screening tool, the SCOFF questionnaire, may prove to be useful in screening for eating disorders. The questions included the following: (1) Do you make yourself Sick because you feel uncomfortably full? (2) Do you worry you have lost Control over how much you eat? (3) Have you recently lost more than One stone (fourteen pounds) in a 3-month period? (4) Do you believe yourself to be Fat when others say you are too thin? (5) Would you say Food dominates your life? A “yes” answer to any question is worth 1 point and a score of 2 is highly predictive of anorexia nervosa or bulimia nervosa. The Eating Disorder Screen for Primary Care (ESP) has also been proposed as a screening tool. The questions include: (1) Are you satisfied with your eating patterns? (no is abnormal); (2) Do you ever eat in secret? (yes is abnormal); (3) Does your weight affect the way you feel about yourself? (yes is abnormal); (4) Have any members of your family suffered with an eating disorder? (yes is abnormal); (5) Do you currently suffer with or have you ever suffered in the past with an eating disorder? (yes is abnormal). Both of these scales need to be evaluated in broader populations.

Clinicians should remain alert for the possibility of binge eating disorder in obese patients. Questions such as, “Do you ever binge eat?” “Do you often eat alone?” and “Do you ever feel guilty or depressed after overeating?” may be useful in detecting this disorder.

Treatment of Eating Disorders: A Framework

The first step is assessment of the patient’s safety, knowledge, and attitudes toward her condition by a primary care provider. She may then agree to work with one member of the treatment team, for example, a nutritionist. Similarly, counseling for developmental or family issues, or treatment for depression, may be acceptable to the patient. Family counseling may be helpful in limiting pressure from the family, as pressure may be less likely to result in changed behavior than to generate resistance from the patient. A counselor trained in treating adolescents may be able to help the patient navigate peer issues involved in the behavior. Whether or not referral to a nutritionist or psychologist is accepted, periodic medical visits to follow the presenting symptom(s)–for example, amenorrhea, low heart rate, or loss of weight–allow the primary care clinician to monitor the severity of symptoms (particularly cardiac status or other indications for hospitalization) while gently informing a patient of the medical risks of her condition. Evidence of associated medical risks, such as osteopenia, dental erosion in the case of bulimia, or concerns about fertility (particularly when the patient has low weight or is estrogen-deficient) may encourage a patient to acknowledge the diagnosis and begin full treatment. Danger signs such as bradycardia and electrolyte disturbances may mandate involuntary hospitalization.

In summary, the primary care practitioner should be equipped to detect an eating disorder, and then must work as a member of a multidisciplinary team, including a mental health professional and a nutritionist, to support weight gain as appropriate, modification of eating habits, and appropriate psychological and/or medical therapies.

In this phase of life, individuals begin to accept financial and emotional self-responsibility, to differentiate from the family of origin, and to develop intimate relationships with peers.

Healthy Behaviors and Health Care Maintenance

Safety in relation to sexuality, substance use, contraception, motor vehicles, and preventive care are ultimately the patient’s responsibility, but the physician can play an important role in establishing lifelong healthy habits and collaboration in this realm. The physician who uses gender-neutral and nonjudgmental styles of history-taking and is alert to patient cues will be more likely to be told about challenges for the patient that may have long-term modifiable consequences such as gender-identity issues, substance abuse, unsafe sex, intimate partner violence, eating disorders, and depression. Engaging with patients in partnership works best, allowing them to identify pros and cons of their choices, and supporting their ability to make changes if needed. Autonomous motivation to change and patient belief in ability to make a change are positively associated with successful changes in behavior and maintenance of those changes.

Role of Culture

Identity also includes a patient’s self-definition of her cultural role within the context of her family of origin, and this can impact her health and illness behavior (see Chapter 15). If, for example, she feels great pressure to succeed as an engineer, but prefers to be an artist, this dissonance can cause stress-related symptoms that bring her to the health care system. Somatoform behavior and medically unexplained symptoms (MUS) are common across all cultures and may be reinforced in preference to the expression of emotions in some families, masking a mental health disorder.

For women, unique issues regarding culture can relate to appearance and behavior as well. Some women may feel pressure from the dominant culture regarding slender body weight, but conflict may arise if their internal or family value system and/or sex partner is concordant with a larger body habitus. Other women could be encouraged verbally and through their cultural customs to be subservient to men, though this can be manifested to varying degrees, and may or may not result in conflict. Social support may be lacking as immigrant women become more acculturated in the United States. Also, immigrants engaged in a cultural transition process may experience criticism from older relatives as they assimilate to the prevailing culture and from younger relatives or friends if they maintain connection with the culture of origin. Traditional cultures may promote respect for elders and traditional gender roles, often a family-strengthening behavior, but reinforce secrecy around family violence and abuse. It is important for physicians to remember that family violence may include intimate partner violence, violence from extended family, and honor crimes (violence toward a woman whose behavior is interpreted as shaming the family). These issues may affect women of all ages uniquely, in their traditional role in the family, and physicians should be alert for clues that problems are occurring and when warranted use direct inquiry or screening.

Pregnancy and Infertility: Psychosocial Issues

Unintended Pregnancy

Almost half of the 6.7 million pregnancies in the United States each year (3.2 million) are unintended, and more than half of these unintended pregnancies are continued. Given these statistics and the risks of neural tube defects, it is appropriate for providers to advise all women of childbearing age who are not using effective contraception to take a daily multivitamin. Unintended birth is more common in women aged 18–24 years and in lower income women, and is associated with worse maternal and neonatal outcomes than intended birth. These include late presentation to prenatal care, smoking and drinking during pregnancy, premature birth, negative pediatric mental health effects, and not breast-feeding. Nearly 40% of unintended pregnancies end in abortion; at current rates, 30% of women will have an abortion in their lifetime.