Women's health issues ppt (1).pptx

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1. WOMEN’S HEALTH ISSUES PRESENTED BY Hadiqa Inam Sidra Tassadaq Syed Zain Abbas Samra Ghaffar Muhammad Usman Syed Eice

2. GENDER AND HEALTH Health and illness vary according to social class, geographical location, time and gender. In terms of gender, much research shows that although women live longer than men, they are more likely to be diagnosed and treated for a wide range of health problems, from headaches and constipation to depression, obesity and diabetes. Such gender differences can be understood in terms of all the factors such as health beliefs and behaviour, symptom perception, help-seeking, coping, adherence to medication and behaviour change.

3. There are, however, a few health problems which are gender-specific. For example , while men suffer from baldness, impotence and prostate cancer, women get breast cancer, endometriosis and uterine cancer. They also suffer miscarriages, receive terminations of pregnancy and experience the menopause.

4. MISCARRIAGE Miscarriage is a common phenomenon occurring in 15–20 per cent of known pregnancies, with 80 per cent of these occurring within the first trimester. Miscarriage or ‘ spontaneous abortion ’ has been defined as the unintended end of a pregnancy before a foetus can survive outside the mother. Despite the frequency with which miscarriage occurs, it has only been in the last 10 to 15 years that research has begun to identify and explore the consequences of early pregnancy loss.

5. This section explores the psychological consequences of miscarriage in terms of the quantitative and qualitative research and then examines the impact of how miscarriage is managed in terms of women’s experiences of this event.

6. Quantitative research This research has tended to conceptualize women’s reactions to miscarriage in terms of : Grief Depression & anxiety Coping

7. Grief : One main area of research has conceptualized miscarriage as a loss event, assuming that after miscarriage women experience stages of grief parallel to that of the death of a loved one. The main symptoms identified are sadness, yearning for the lost child, a desire to talk to others about the loss and a search for meaningful explanations. Research has also highlighted grief reactions that are unique to the miscarriage experience. For example , women often perceive themselves as failures for not being able to have a healthy pregnancy.

8. Depression & Anxiety: Other research has focused on depression and anxiety following miscarriage. Present State Examination (PSE) was used to assess women four weeks post-miscarriage. They found that 48 per cent of the sample had sufficiently high scores on the scale, which is over four times higher than that in women in the general population. When analysed, these women were all classified as having depressive disorders. In another study , it was found that women who had miscarried had a significantly increased risk of developing a minor depressive disorder in the six months following their loss .

9. Coping : A small number of studies have considered the experience of miscarriage from a coping viewpoint. According to a study, they found that 86 per cent of the sample had established their own set of reasons as to why the miscarriage had occurred, ranging from medical explanations to feelings of punishment and judgement. While working in terms of self-enhancement, 50 per cent of the sample made downward social comparisons with women who had reproductive problems. By comparing themselves with women who were worse off than themselves, they were able to increase their own self-esteem.

10. Qualitative Research: In an early study, Hutti (1986) conducted in-depth interviews at two time points with two women. The results showed that although both women referred to a similar inventory of events, the significance that they attached to these events was different and dependent upon their previous experience. For example , one woman had a previous miscarriage and was described as taking more control over her medical treatment; she found her grief to be less severe than with her first miscarriage. In contrast, the woman who had experienced her first miscarriage represented the miscarriage as a ‘severe threat to her perception of herself as a childbearing woman.

11. Bansen and Stevens (1992) focused on 10 women who had experienced their first pregnancy loss of a wanted pregnancy. It was concluded that miscarriage was a ‘silent event’ which was not discussed within the wider community. The women were described as being unable to share their experiences and felt isolated as a result. When they did get the opportunity to talk about their loss, they realized how common miscarriage is and that was a source of comfort to them. Furthermore, it was also concluded that miscarriage constituted a major life event that changed the way in which women viewed their lives in the present and affected the way in which they planned for the future.

12. Treatment after miscarriage

13. With ultrasound, it's now much easier to determine whether an embryo has died or was never formed. Either finding means that a miscarriage will definitely occur. In this situation, you might have several choices:

14. Expectant Management Medical treatment Surgical treatment

15. Expectant management. If you have no signs of infection, you might choose to let the miscarriage progress naturally. Usually this happens within a couple of weeks of determining that the embryo has died. Unfortunately, it might take up to three or four weeks. This can be an emotionally difficult time. If expulsion doesn't happen on its own, medical or surgical treatment will be needed.

16. Medical treatment. If, after a diagnosis of certain pregnancy loss, you'd prefer to speed the process, medication can cause your body to expel the pregnancy tissue and placenta. The medication can be taken by mouth or by insertion in the vagina. Your health care provider might recommend inserting the medication vaginally to increase its effectiveness and minimize side effects such as nausea and diarrhea. For about 70 to 90 percent of women, this treatment works within 24 hours.

17. Surgical treatment. Another option is a minor surgical procedure called suction dilation and curettage (D&C). During this procedure, your health care provider dilates your cervix and removes tissue from the inside of your uterus. Complications are rare, but they might include damage to the connective tissue of your cervix or the uterine wall. Surgical treatment is needed if you have a miscarriage accompanied by heavy bleeding or signs of an infection.

18. Impact of Miscarriage: The results indicate that miscarriage can result in feelings of grief, anxiety and depression. In addition, women experience their miscarriage as a process, involving a series of stages which can result in women reassessing both their past and future experiences. medical management of miscarriage brings with it the risks associated with surgery, a more 'natural' approach can leave women feeling misinformed and unprepared.

19. Termination of Pregnancy An abortion (or termination) is the medical process of ending a pregnancy so it does not result in the birth of a baby. In 1967 the Abortion Act was passed in the UK and abortions were made legal. The Act was welcomed by many women who could subsequently gain access to a legal abortion on the grounds that it was considered to be less physically and mentally harmful than childbirth. Nowadays, abortions can be obtained through the National Health Service (NHS) and also through private for-profit services.

20. Abortion is also legal in the USA and most European countries. In England and Wales one in three women is likely to have an abortion in their lifetime (calculated from The Abortion Statistics England and Wales 2001) Ways of Abortions The type of abortion procedure depends upon the gestation of the pregnancy, the preference of the woman and the methods preferred by the clinic involved. In the UK an abortion is legal up until the 24th week of gestation although abortions occur within the first trimester. Nowadays, women can choose to have their abortion using either the D&C with a general or local anaesthetic A suction technique which can involve general or local anaesthetic or no anaesthetic The abortion pill which induces a miscarriage (later miscarriages may be managed through inducing labour)

21. Abortion is illegal in a number of countries in all circumstances except to save a woman’s life. These include Brazil, Chile, Mexico, Venezuela, Angola, Congo, Mali, Niger, Nigeria, Uganda, Afghanistan, Iran, Egypt, Libya, Syria, Bangladesh, Ireland and Malta. In addition, many countries only allow abortion to protect a woman’s health. These include Argentina, Peru, Cameroon, Ethiopia, Malawi, Zimbabwe, Kuwait, Saudi Arabia, Pakistan , Thailand, Poland and Portugal. Research focusing on abortions has addressed a range of issues including deciding to have an abortion, the provision of services, women’s experiences of such services, their experiences of having an abortion, the longer-term consequences of having an abortion and the impact of the mode of intervention used.

22. Deciding to Have an Abortion Freeman and Rickels Study (1993) Using quantitative data, the results illustrated that those who opted for an abortion had more Employment in their households 1 Were more likely to still be in school 2 Showed better course grades at school 3 4 Reported having friends and family who did not approve of early childbearing. believing that their mother did not approve of having a child while still a teenager. 5 Highlights

23. Deciding to Have an Abortion 01 02 03 04 The decision to have an abortion was related to social deprivation. 05 06 Lee et al. Study (2004) In a similar vein, Lee et al. (2004) carried out a qualitative study involving in-depth interviews. In addition, those who believed that their future life would include higher education and a career, Who had higher expectations of their life in the present, Who felt that they lacked the stable relationships to support them if they became a mother were more likely to have an abortion Who had a lack of financial independence In contrast, those who went on to have an abortion described how their parents saw abortion in a pragmatic way, regarding young motherhood as a more negative event .

24. The Provision of Services Research has highlighted that, despite increasing provision for abortion in the UK within the NHS, there remains wide variation in the level of NHS provision in different health authorities (Abortion Law Reform Association 1997) . In particular, figures revealed that, while on average 70.5 per cent of abortions are funded by the NHS in England and Wales. Clarke et al. (1983) examined why half the women in their study had their abortion in a private or charitable clinic despite generous provision of NHS abortion services. The study showed that an important reason for women bypassing the NHS was that they either thought or had been actually told by their GP or another doctor that it was difficult to get an abortion on the NHS. Other reasons for not having an abortion on the NHS included not wanting to delay the abortion, expectation of better personal treatment in a private clinic and wanting to ensure anonymity.

25. Women’s Experiences of Services Sociological research has emphasized the importance of women’s experiences of having an abortion Harden and Ogden (1999a) interviewed 54 women aged between 16 and 24 up to three hours after their abortion about their experiences. They reported that, overall, having an unwanted pregnancy was experienced as a rare event which was accompanied by feelings of lack of control and loss of status.

26. Psychological Impact Zolese and Blacker (1992) argued that approximately 10 percent of women experience depression or anxiety that is severe or persistent after an abortion. In contrast, although Major et al. (2000) found that 20 per cent of their sample experienced clinical depression within two years of an abortion some research has also considered what type of psychological reactions occur after an abortion. Söderberg et al. (1998) conducted interviews with a large sample of Swedish women (n = 845) a year after their abortion and found that 55 per cent experienced some form of emotional distress. Similarly, Alex and Hammarström (2004) conducted a study in Sweden of five women’s experiences and concluded that the women reported gaining a sense of maturity and experience.

27. In a similar vein, Major et al. (2000) explored the variation in emotional reactions over time and reported that negative emotions increased between the time of the abortion and two years. Kumar and Robson (1987) found that neurotic disturbances during pregnancy were significantly higher in those who had had a previous termination than those who had not immediate distress has been reported as being higher in those women who belong to a society that is antagonistic towards abortion (Major and Gramzow 1999), in those who experienced difficulty making the decision (Lyndon et al. 1996), and in those who are younger, unmarried, have the abortion later in pregnancy (which may be due to the features of women who delay), show low self-esteem, have had multiple abortions, and self-blame for the pregnancy or abortion. Longer-Term Impact Russo and Zierk (1992) followed up women eight years after their abortion and compared them to those who had kept the child. They found that having an abortion was related to higher global self-esteem than having an unwanted birth, suggesting that any initial negative reactions decay over time.

28. Impact of Mode of Intervention An abortion can be carried out using a D&C (surgical), vacuum aspiration (suction) or the abortion pill (medical) and may or may not involve a general or local anaesthetic. Some research has explored the relative impact of type of procedure on women’s experiences. For example, 01 Slade et al. (1998) examined the impact of having either a medical or surgical abortion. After the abortion, however, the medical procedure was seen as more stressful and was associated with more post-termination problems. It was also seen as more disruptive to life. Further, seeing the fetus was associated with more intrusive events such as nightmares, flashbacks and unwanted thoughts . Goodwin and Ogden (2006) suggest from their study that the abortion pill technique may result in a more negative experience for several women than other methods, as some women described seeing the fetus as it was expelled from their bodies. 02 03

29. Problems with termination Research Research exploring the impact of termination is therefore problematic because the researcher’s own views and experiences are highly likely to influence the research process. For example, an ideological position either for or against termination could affect the choice of research design, the selection of participants, the ways the data are analysed or the ways the data are interpreted and the results presented.

30. THE MENOPAUSE The pre-menopause refers to the whole of the woman’s reproductive life up until the end of the last menstrual period. The peri-menopause is the time prior to the final menstrual period when hormonal changes are taking place and continues until a year after the last menstrual period. The post-menopause stage refers to any time after the last menstrual period but has to be defined retrospectively after 12 months of no menstruation. The word menopause means the end of monthly menstruation and for the average woman this occurs at the age of 51 years, with 80 per cent of women reaching the menopause by age 54. the menopause is considered to be a transition which has been classified according to three stages.

31. Symptoms The most common symptoms are as following: Change in pattern and heaviness of periods. Hot flushes. Night sweats. Tiredness. Poor concentration. Aches and pains in joints. Vaginal dryness. Changes in the frequency of passing urine.

32. Conti.. As part of a large-scale survey, 413 women completed a questionnaire about their experiences of menopausal symptoms and their perceptions of severity. And the results showed that the most common symptoms were hot flushes, night sweats and tiredness, and of these, night sweats seemed to cause the most distress with over a third describing their night sweats as severe.

33. Physical changes Women also experience a range of physical changes which persist after the menopause has passed. In particular they show changes in their breasts and it is suggested that older women should have regular mammograms to check for breast cancer. There is a post-menopausal increase in cholesterol in the blood which places women more at risk of heart disease; bone loss becomes more rapid, increasing the chance of osteoporosis; the urinary organs can become less elastic and pliable, resulting in many women suffering from incontinence; and finally women experience vaginal dryness, making sexual intercourse uncomfortable .

34. The menopause therefore signifies the end of a woman’s reproductive capacity and brings with it a wide range of symptoms and physical changes. Ballard (2003) describes how the menopause experience is influenced by a range of social, cultural and biological factors which in turn have a psychological impact upon the individual. This reflects why the menopause is also referred to as ‘the change of life’. This is illustrated in Figure 16.6. Research exploring the impact of the menopause has highlighted the experience as a life transition and the social and psychological factors that affect this transition.

35. Menopause as a transition The women completed questions about their symptoms and health in general and then 65 per cent also completed a ‘free comments’ section. These data were then analyzed using both quantitative and qualitative methods. From this study the authors conclude that women experience the menopause as a ‘status passage’ which involves five stages. Expectations of symptoms: The results illustrate that, prior to the menopause onset, women are searching for symptoms and looking for signs of any biological changes. At this point some women seek help from the doctor and start to find further information. Experience of symptoms and loss of control: Women then start to experience symptoms such as night sweats, hot flushes and mood swings, which for some interfere with their sense of well-being and can make them feel out of control.

36. Conti.. Confirmation of the menopause: Once women sense a loss of control, they then try to confirm the onset of the menopause by visiting their doctor as a means to regain control. The doctor can use blood tests to measure hormone levels to confirm the onset of the menopause and at this stage many women are offered hormone replacement therapy (HRT). Regaining control: Women try to regain control in several ways. Some try to minimize the impact of their symptoms by taking HRT while others try a range of methods such as wearing different clothes to cope with hot flushes or taking alternative medicines. Freedom from menstruation: The end of menstruation is often welcomed by women as, for the majority, decisions about family size have been made long ago. Women therefore feel relieved that they do not have to experience the pain and bleeding from periods any more and the inconvenience that this can cause.

37. Social factors The menopause happens at a time in a woman’s life when she is probably also experiencing a range of other changes. Whether or not such changes have a direct or indirect effect upon the menopausal experience, research indicates that the menopause needs to be understood in the context of these changes and describes them and their effect upon the menopause as follows : Elderly relatives: At the time of the menopause women often find that they are also increasingly responsible for caring for elderly relatives. Further, this may come at a time when women are just starting to enjoy a newfound freedom from the children leaving home. The added pressure of elderly relatives can make women feel under stress and guilty and can affect their physical health, all of which may exacerbate their menopausal symptoms. Changes in employment and finance : In middle life many women increase their hours of work as the children leave home. This may bring with it new opportunities and a sense of rebirth.

38. Conti… Changing relationships: At the time of the menopause women often experience changes in their role as a mother as this is the time when children leave home, and a change in their relationship with their partner as they renegotiate a new life without children. Such changes can make the menopause seem more pertinent as it reflects the end of an era. Death of family or friends : As women reach their fifties they may experience the death of similar-age family or friends. The menopause may represent a sense of mortality which can be exacerbated by a sense of loss.

39. Psychological Effects Psychological factors influence the menopause in terms of symptom perception because symptoms such as hot flushes, night sweats, lack of concentration and tiredness are all influenced by processes such as distraction, focus, mood, meaning and the environment . In addition, the menopause has more direct effects upon the individual’s psychological state. Changes in body image: The menopause brings with it physical changes such as dryer skin, changing fat distribution and softer breasts, which can all impact upon a woman’s body image. In addition, becoming 50 is also seen as a milestone, particularly within a society that associates getting older with being less attractive. Ballard provides interesting descriptions of how women can suddenly catch themselves in a mirror and think ‘it’s my mum’ or ‘you are getting old’.

40. Conti.. Mood changes: Some women report experiencing moods such as anxiety and depression and some report having panic attacks. Given the many life changes that co-occur with the menopause, it is not surprising that women experience changes in their mood. However, many women view their emotional shifts as directly linked to their changing hormone levels. Self-esteem and self-confidence: Some women also report decreases in their self-esteem and self-confidence. They describe not feeling confident in everyday tasks such as cooking or work, and feeling less able to manage relationships

41. Conti… Lack of concentration: Several surveys report that women describe how the menopause disrupts their cognitive function in terms of concentration and memory. Experimental studies in controlled conditions, however, show no evidence for any cognitive decline that could be attributed to the menopause above and beyond standard age effects.

42. Menopause: Mode of Management Muhammad Usman

43. Some women simply carry on with their lives and wait for the symptoms to pass. For example: They may manage these symptoms using ‘tricks of the trade’ − such as wearing layered clothes rather than thick jumpers to make removing clothes easier, sleeping with the window open to cope with night sweats and buying lubricants to manage vaginal dryness. But they do not necessarily present their symptoms to the doctor. Others try alternative medicines for symptom relief including herbal remedies, homeopathy and preferring a more natural approach. Ways to Manage

44. Hormone Replacement Therapy (HRT) consists of treatment with estrogen or a combination of estrogen plus progestin. HRT was originally developed to reduce menopausal symptoms but has subsequently been shown to treat and prevent osteoporosis, Alzheimer’s disease, cardiovascular disease and depression. It also has its own risks, however, and has been associated with breast and endometrial cancer, heart attack, cerebrovascular disease and thromboembolic Disease. Hormone Replacement Therapy (HRT)

45. According to a survey, “The numbers of women taking HRT increased threefold between 1981 and 1990, up to 19 per cent, and increased to a rate of 60 per cent by 2000.” (Moorhead et al. 1997; Kuh et al. 2000; Ballard 2002) Use of HRT in Pakistan Use of HRT in West According to a survey, “Out of 102, only 02 (1.96%) respondents were aware of HRT. Most of respondents (94%) did not consider menopause to be a medical condition but a normal transition.” (Jinnah Medical College Hospital Karachi)

46. HRT may help to alleviate menopausal symptoms and can protect against menopause-related diseases, but at the same time evidence indicates that it can increase the risk of longer-term health problems. Women therefore have to weigh up the pros and cons of HRT if they are to decide how to manage their menopause . Deciding how to manage.. Research has explored how women decide whether or not to take HRT: Ballard (2002) studied why women take HRT. The results showed that the main reason was for the relief of symptoms, particularly hot flushes, tiredness and irritability. Similarly, Welton et al. (2004) study showed that, for those taking HRT, the main reason was perceived improvement in quality of life regardless of either the costs or benefits in the longer term. In addition, however, Ballard (2002) also reported that 58 per cent also took HRT to prevent osteoporosis. Symptom relief would therefore be the main factor influencing the decision-making process.

47. Cont... Research has also used the theory of planned behaviour (TPB) to predict the use of HRT, showing a role for attitudes to HRT and self-efficacy (Huston et al. 2010). Not all women, however, take HRT and Wathen (2006) explored women’s use of complementary and alternative medicines. This study used a mixed method approach and reported that 57 per cent of the Canadian sample had either considered or used alternative medicines as an alternative to HRT and that these women tended to be younger and had experienced worse symptoms than those who had not tried such remedies. Protection from illness, however, also seems to have a role to play. As a means to further understand the decision-making process, Buick et al. (2005) carried out a systematic study to explore women’s beliefs about HRT. The results support those described earlier and indicate that use and discontinuation of HRT are more related to symptom relief than considerations of long-term benefits. Further, the results indicate that those women who refuse HRT often believe that the menopause is a natural event that does not require chemical intervention and that women’s beliefs about the benefits of HRT are often countered by their concerns about potential adverse events.

48. Impact of HRT on symptoms Women report a wide range of menopausal symptoms which vary in their severity and the impact they have on their quality of life. Much research has explored the extent to which HRT does actually relieve menopausal symptoms. From the perspective of the patient, research indicates that women feel better when taking HRT and report improvements in their symptoms and quality of life. Researches showed that the majority of the women believed that HRT helped hot flushes, non-specific emotional changes, vaginal dryness, insomnia and loss of muscle tone. In contrast, however, a large randomized trial, which explored the effectiveness of HRT compared to a placebo, suggested that HRT may not be as effective as believed ( Utian et al. 1999). In particular this double-blind placebo-controlled study showed that HRT was only effective at relieving vasomotor symptoms such as hot flushes and night sweats. Similarly, another placebo-controlled trial showed that HRT only improved vaginal dryness, increased frequency of passing urine and the tendency to get urinary infections ( Eriksen and Rasmussen 1992). These data suggest no effect for insomnia and mood. Further, they were placebo controlled, suggesting that such changes cannot simply be attributed to women wanting to feel better. Rymer et al. (2003) explored the effectiveness of HRT and suggested that this discrepancy between perceived effectiveness and actual effectiveness may illustrate a domino effect . In particular, while HRT may only relieve hot flushes and vaginal dryness, which can be directly explained by oestrogen deficiency, such changes may in turn improve mood, sleep and general quality of life.

49. 1. The menopause happens to all women regardless of class, culture or time. Most research to date, however, has explored the experiences of western women for whom the menopause is often seen as an event that needs to be managed medically. It is likely that other cultures have very different beliefs and experiences of the menopause and that this influences their management strategies. 2. New research is constantly being published about the risks and benefits of HRT. Studies exploring women’s beliefs and use of HRT must therefore be located within the time that the data were collected and the current state of evidence at this time. This means that aggregating studies is problematic and drawing conclusions across time is difficult. Problems with Menopause Research

50. 4. 3. The menopause and HRT generate strong beliefs in researchers, clinicians and patients according to the need for any medical intervention, the dangers of HRT and the dangers of menopause-related disease. Interpreting research is therefore problematic as results and the ways in which results are presented may well reflect the beliefs of the people involved. Conti… Research on the menopause and HRT illustrates the complex problem of risk analysis and risk communication because symptoms, side-effects and longer-term costs and benefits will have different meanings to all the parties involved. There is a tendency within the literature to attempt to find the state of ‘truth’ within all these risks and probabilities. Future psychological research could focus on how different risks are managed and communicated without attempting to synthesize them.

51. Presented by: Syed Eice Muhammad Conclusion

52. There are many areas of health that are specific to women. This chapter has explored three of these which were chosen because they seemed to have generated the most research and most closely reflect the interests of the health psychology community.

53. 1.Miscarriage, 2.Termination 3.Menopause These are generally regarded as negative events that women often have to endure.

54. The results from the studies described indicate that, although these are difficult and often unpleasant times for women, many women report how they can also see the benefit in these experiences.

55. In particular, miscarriage is sometimes seen as a pivotal point in a woman’s life, enabling her to re-evaluate her past and future self. termination is often accompanied by feelings of relief and a return to normality. the menopause introduces a new period of life and a sense of liberation.

56. Furthermore, the research illustrates how women’s experiences of these events are influenced by the mode of management as all can be managed either medically or in a more natural way.