#93314: Health Issues Distinctive to Women

The Office on Women's Health (OWH) has noted that women are living longer, facing more chronic conditions by virtue of lifespan, and coming from a variety of cultural backgrounds, necessitating a focus on the health of women across the lifespan to encourage well-being and functional outcomes. Both demographic changes and increasing incidence rates of conditions such as heart disease, diabetes, and breast cancer provide justification for further advancement of health issues facing women. The population increase of aging or elderly women is significant. An estimated 55.8 million Americans are 65 years of age and older, approximately 55% of whom are women. This percentage of older persons, which now comprises 13% of the population, is expected to grow to 98.2 million by the year 2060, or approximately 25% of the population [3,4,5,6]. The older population is also becoming more racially and ethnically diverse. Between 2022 and 2050, the share of the older population that is non-Hispanic White is projected to drop from 75% to 60% [6]. Black Americans accounted for 9% of this population in 2017. This number is projected to grow to 13% by 2060 [7]. Hispanic Americans accounted for 8% in 2017 and are expected to account for 21% by 2060 [7]. Asian Americans represented 4% in 2017 and are expected to represent 8% by 2060 [7].

One in eight women, or approximately 13%, will develop breast cancer in their lifetime [8]. Aging is a serious risk factor for breast cancer. An estimated 84% of new cases occur in women 50 years of age and older, with the highest incidence rates (26%) occurring in women 50 to 69 years of age [9]. The older a woman, the greater her risk of both heart disease and breast cancer. While age is a well-established risk factor for chronic health conditions, research is lacking regarding differences, health needs, and interventions to maximize strengths in women living with these conditions.

As women age and the incidence of breast cancer, heart disease, and osteoporosis increases, nurses and healthcare professionals must recognize that health care impacts the physical, emotional, and spiritual lives of women. The Office of Research on Women's Health (ORWH) at the National Institutes of Health (NIH) has specified research priorities that "advance the understanding of biologic sex differences in health and disease at multiple levels, from genes to hormones to complex systems" [10]. Topical research priorities for the ORWH include studies on diseases and conditions that affect women, methodologic advances, education and career development of women in science, quality of life, and fostering research collaborations and partnerships to further women's health research [10].

The U.S. Department of Health and Human Services composed Healthy People 2030 with a global goal to promote health and well-being for women. This includes a need for improvements in screening, early diagnosis, and treatment of women of color with conditions such as heart disease, diabetes, and cancer [11].

Despite the evolution and political strength of the women's health movement, women's health advocacy in the United States does not consistently address experiences specific to women in ethnic, socioeconomic, and aging subgroups. In the past, women were generally excluded from research studies, leaving gaps in the body of knowledge relating to ways women respond to and deal with health and illness and creating assumptions that findings were the same for women as for men. Today, the NIH closely monitors the inclusion of women and minorities in research. In addition, extensive studies on women's health issues, such as the Women's Health Initiative (WHI), have provided scientific information previously lacking.

Gender-sensitive care should be the direction for the philosophical and theoretical development of women's health. Overcoming the limitations imposed by the dominant medical model in women's health requires theoretical bases that do not reduce women's health and illness experience into a disease. The gender-sensitive philosophy incorporates explanations of health and empowers women to effectively and adequately deal with their situations. The major components incorporated into the development of gender-sensitive care include:

These criteria have guided the philosophical premise of this course.

Nurses and health professionals have adopted a model of care that views women in a holistic way. The individual woman, her family, and her community cannot really be separated but are treated as one and the same. This philosophy of care provides women with a means to grow and change. Women are confronted with a variety of psychological and physiologic stresses over the course of their lifespan. Nurses and other health professionals should offer holistic approaches, support, and advocacy to improve and maintain health. Health concepts include the development of a theory in relation to empowerment, collaboration, stages of change, learning, participation, and equity [12].

Health care may be viewed as a global term that defines actions intended to promote health. Health promotion includes the complex dimensions of health education, marketing the health message, lifestyle modification, engaging in social and environmental change, and addressing the patient's set of values. Health professionals perform a thorough health history to elicit each woman's definition of these dimensions in relation to her health behaviors and choices. Health care includes both self-management strategies and interventions implemented by healthcare professionals. Therapies to promote and maintain health include both traditional and complementary therapies, which are nontraditional therapies that complement or augment the usual traditional therapies.

Although the organisms, transmission, and complications of STIs are known, healthcare professionals have not been able to control these diseases. The incidence of many STIs has increased in the last few decades to more than 25 million new infections per year [15]. They now result in an estimated $16 billion in direct medical costs annually [15]. The spread of STIs dramatically demonstrates that the social determinants of disease must be addressed. Healthcare professionals should become more informed regarding the pathophysiology and the social ramifications of genital/oral infections and STIs and provide education and anticipatory guidance to patients of all ages at each stage of the lifespan.

STIs are caused by a spectrum of organisms. More than 100 diseases and syndromes are recognized as being sexually transmissible. Although some STIs affect one anatomical area alone, such as the labia or cervix, other organisms ascend the female reproductive tract, where further invasion is possible. These organisms can move upward from the vagina, through the cervical canal, and into the uterus, from which colonization into the fallopian tubes, ovaries, and entire pelvis may occur. Infections such as chlamydia, gonorrhea, syphilis, herpes, and acquired immunodeficiency syndrome (AIDS) can cause serious threats to future reproductive viability as well as to life itself. Other infections are transmitted to or via the oral cavity and facial area.

Each organism requires a unique diagnostic strategy and treatment. There is considerable variation in the symptoms and treatment options. Therefore, the following information is given as a general guide for major STIs for adults in the United States. The information is not intended to be exhaustive, and other textbooks and resources will be needed to describe care in more detail. The Centers for Disease Control and Prevention (CDC) remains the central body of expertise on treatment protocols for STIs [16,17].

Care for Commonly Acquired STIs

The most common (new and existing) STIs in the United States are human papillomavirus (HPV) (42.5 million infections), genital herpes simplex virus (HSV-2) (18.6 million infections), trichomoniasis (2.6 million infections), chlamydia (2.4 million infections), human immunodeficiency virus (HIV) (0.9 million infections), gonorrhea (209,000), syphilis (156,000), and hepatitis B (103,000 infections) [15]. These are the STIs that will be discussed in this section. As noted, the CDC treatment guidelines remain the gold standard for information and treatment of STIs [16].

Human Papillomavirus

To date, 150 types of HPV have been isolated from humans, and more than 40 can infect the genital tract [16]. These types have been classified into the relative risk categories of low, intermediate, and high. Low-risk viruses include types 6, 11, 42, 43, and 44. These are rarely associated with cancer of high-grade squamous intraepithelial lesion (HSIL). Visible genital warts are often caused by HPV types 6 and 11. Intermediate-risk types 31, 33, 35, 39, 51, and 52 are infrequently associated with invasive cervical cancer. Types 16, 18, 45, and 58 are high-risk HPV types found in women with HSIL [21]. It is important to remember that the presence of HPV does not always mean that disease will develop. Studies continue to show that only a small proportion of women remain HPV-positive over time. Women at greatest risk for HPV-related cervical disease are those who lack an adequate immune response to HPV exposure and those in whom high-risk HPV infection persists [16,21].

The Advisory Committee on Immunization Practices routinely recommends human papillomavirus vaccination at 11 or 12 years of age; vaccination can be given starting at 9 years of age. Catch-up vaccination is recommended for girls and women through 26 years of age.

(https://www.cdc.gov/mmwr/volumes/68/wr/mm6832a3.htm Last Accessed: July 12, 2024)

Level of Evidence: Expert Opinion/Consensus Statement

Most HPV infection is not visible, but the most common recognized visible manifestation of HPV is the presence of genital warts [21]. If left untreated, warts may resolve on their own, remain unchanged, or increase in size.

Both patient-applied and provider-applied treatments are available. Factors that influence treatment choices include wart size, number, location, morphology, cost, and convenience. Treatment is not recommended in the absence of warts for subclinical genital HPV, as the lesions typically clear spontaneously [16]. The most effective strategy is the prevention of HPV through immunization. Bivalent, quadrivalent, and nine-valent HPV vaccines are approved for the prevention of HPV-related diseases [16,22]. The immunizations are recommended for girls, boys, and young women and men up to 26 years of age [16,23,24].

Genital Herpes

Genital HSV is a chronic, lifelong viral infection. Symptoms may occur immediately or as late as a year after contact; in some cases, there are no symptoms at all. If apparent, symptoms include an itching, tingling sensation followed by painful vesicles that appear in clusters [16,25]. Women may be asymptomatic with cervical lesions, and outbreaks may occur in a sporadic manner. Antiviral medications offer relief to most symptomatic patients and are also used to treat recurrent episodes or as daily suppressant therapy. Patients should be treated with an antiviral at the first clinical presentation to reduce the incidence of prolonged or severe symptoms, which can develop even if the initial episode is mild [16]. Acyclovir is the first-line recommended treatment for antiviral and suppressive therapy, followed by valacyclovir or famciclovir. Famciclovir is less effective at reducing viral shedding [16].

Valacyclovir has been shown to reduce transmission of genital herpes. A 500-mg dose once daily cuts transmission by 50% [26]. Patients taking valacyclovir to suppress transmission should be counseled on the following points [16,27]:

• Medication must be taken daily. When the medication is stopped, transmission risk goes back up.

• While this drug is an effective assistance, it is not a cure.

• The use of condoms during asymptomatic periods with a partner who understands the risks and total abstinence from sex during outbreaks is still necessary.

Trichomoniasis

Infection with Trichomoniasis vaginalis is the most common nonviral STI in the United States, especially among ethnic minority women (prevalence 6.9% in Black women, compared with 1.2% in non-Hispanic White women and 1.5% in Mexican American women) [16,28]. The infectious organism is a protozoan species. The symptoms of trichomoniasis are typically mild or absent in women, but a small percentage of patients will experience a diffuse, foul-smelling, or yellow-green vaginal discharge that may or may not be accompanied by vulvar irritation [29]. All women presenting with abnormal vaginal discharge should be tested for trichomoniasis, but routine screening for the infection in asymptomatic women with low risk is not recommended [16]. Screening should be considered for asymptomatic, high-risk women (e.g., history of STI, multiple sex partners, sex workers, illicit drug users) or women in high-prevalence settings (e.g., correctional facilities, STI clinics). High sensitivity/specificity testing (versus wet-mount microscopy), including nucleic acid amplification testing (NAAT) and the APTIMA T. vaginalis assay (RNA detection), is recommended by the CDC [16]. Other U.S. Food and Drug Administration (FDA)-cleared DNA assays are available and are recommended over wet-mount microscopy, if available [16]. Treatment of trichomoniasis includes a single 2-g oral dose of metronidazole or tinidazole. Alternatively, patients may be prescribed oral metronidazole 500 mg twice per day for seven days. To reduce the possibility of a disulfiram-like reaction, patients should be instructed to abstain from alcohol until at least 24 hours after completion of metronidazole and 72 hours after tinidazole [16].

Chlamydia/Nongonococcal Urethritis/Cervicitis

The Centers for Disease Control and Prevention (CDC) recommends annual chlamydial infection screening of all sexually active women younger than 25 years of age as well as screening of older women at increased risk for infection (e.g., women 25 years of age or older who have a new sex partner, more than one sex partner, a sex partner with concurrent partners, or a sex partner who has an STI).

(https://www.cdc.gov/std/treatment-guidelines/chlamydia.htm Last Accessed: July 12, 2024)

Level of Evidence: Expert Opinion/Consensus Statement

Infection with Chlamydia trachomatis is the most common bacterial STI in the United States, especially among adolescents and young adults [16,30]. Although many women have no symptoms, any of the following may occur one to three weeks after contact [16]:

• Frequent, uncomfortable urination

• Cervicitis with scant cervical discharge

• Lower abdominal pain

• Pelvic inflammatory disease (PID)

Chlamydia is also a major cause of nongonococcal urethritis (NGU) and lymphogranuloma venereum (LGV) in men [16]. Diagnosis is frequently made in men as NGU and in women after treatment of a male partner for NGU, or on a routine pregnancy screening in asymptomatic women. Laboratory testing has become more sophisticated, with NAAT used to detect the specific DNA of C. trachomatis, (e.g., polymerase chain reaction tests) [16]. A vaginal swab, either collected by a provider or self-collected in a clinic, is the recommended test for women. Antibiotic treatment is doxycycline, 100 mg orally twice per day for one week. Azithromycin and levofloxacin are alternative options [16,27].

HIV/AIDS

Infection with HIV produces a condition that progresses from a latent or asymptomatic state to AIDS. Progression varies from a few months to years. Management of HIV involves a complex team of behavioral, psychosocial, and medical services. Referral to a provider or center specializing in HIV care is recommended [16].

Gonorrhea

Most gonorrheal infections among men produce symptoms (e.g., burning on urination, discharge) that cause them to seek treatment, thus preventing complications. However, many women have no symptoms, leading to upper reproductive infection and PID [16]. When symptoms are present, any of the following may occur one to three weeks after contact: pus-like vaginal discharge; lower abdominal pain; painful urination; and urinary frequency. Diagnosis is obtained by culture of the organism from the vagina, cervix, pharynx, or rectum or NAAT of endocervical swabs, vaginal swabs, or urine specimens. Patients infected with gonorrhea are often co-infected with chlamydia and are routinely treated with a regimen effective against both organisms. Treatment recommendations no longer include quinolone, as quinolone-resistant strains of gonorrhea have disseminated throughout the United States. Cephalosporins are the only class of antimicrobials available for treatment of gonorrhea [16]. The preferred regimen for uncomplicated urogenital, rectal, or pharyngeal infection is ceftriaxone 500 mg IM in a single dose (or cefixime 800 mg orally in a single dose) [16].

Syphilis

The first-stage symptoms of syphilis appear 10 to 90 days after infection, most often within three weeks, and include rash, flulike symptoms, and a painless genital chancre. Diagnosis is via a blood test and physical examination. Treatment consists of an antibiotic regimen of parenteral penicillin G, 2.4 million units in a single dose. The preparation, dosage, and length of treatment depend on the stage and clinical manifestations of the infection and whether the patient is pregnant [16,31].

Hepatitis B

Hepatitis B is caused by the hepatitis B virus, which produces a symptomatic illness in approximately half of infections and has an onset of six weeks to six months [16]. The infection can be chronic or self-limited, largely depending upon age when acquired; chronic infection develops in approximately 90% of infants, 30% of children, and 2% to 6% of adults. Usual risk factors among female adolescents and adults are history of STIs, injection drug use, unprotected sex, and multiple sex partners, with premastication and poor infection control in healthcare settings being less common identified risk factors [16].

The diagnosis of hepatitis B relies on serologic testing. Treatment is mainly supportive, but there are FDA-approved drugs that can suppress viral replication and support liver disease remission in patients with chronic infection. Referral to a specialist is recommended. Prevention strategies include hepatitis B immune globulin (for postexposure prophylaxis) and the hepatitis B vaccine. The vaccine is recommended for all children, adolescents, high-risk adults, and any adults who want to have protection from the virus, including unvaccinated STI clinic patients [16]. All pregnant women should be tested for hepatitis B, and those at high-risk should be vaccinated. Pregnant women who are found to be hepatitis B positive should be referred to a specialist and enrolled in a perinatal hepatitis B prevention program [16].

Despite the availability of public health information, the discussion of contraception, safer sex, and sexual concerns are complex communication issues. Conflict with religious beliefs, inconvenience, cost, stigma, and responsibility are just a few communication barriers that persist between the woman and the provider. Communication techniques to enhance a frank discussion of sexual health needs should include:

Health professionals should provide women with a teaching plan for perineal hygiene and the prevention of infections. The goal is to prevent infections from organisms, such as Escherichia coli, from causing vaginitis and urethritis [18,32]. Women should be instructed to wash their hands before and after genital contact and after using the restroom. The woman should always wipe the perineum from front to back, not back to front or back and forth, and discard the tissue. This single front to back motion should be used after urination, bowel movement, sex, or menses [33]. Women should also avoid products that may disturb the normal flora of the vagina or cause irritation and allergic reaction of the genital area. If a woman is prone to vaginitis, she should use only white, unscented tissue and unscented pads or tampons [32,33]. Women should not use feminine hygiene sprays or any sprays near the perineum. They should avoid deodorant or scented tampons and pads, and when using tampons, be sure that the string does not slip back to the rectal area. If it does, the tampon should be changed immediately.

Douches are rarely necessary. Douching washes out the normal balance of bacteria in the vagina and puts the woman at risk for developing bacterial vaginosis. Women do not need to douche, unless otherwise instructed by a healthcare provider [18,33,34]. Women should avoid the use of perfumed or flavored douches. Vaginal deodorants, sprays, gels, or powders are not recommended for routine hygiene [33,34].

Women are often at risk for genital infections or vaginitis because of microbial growth in the warm, moist environment of the vagina. Wearing cotton underpants with a cotton crotch, especially under pantyhose, girdles, and exercise suits, can decrease this risk [33]. Cotton pants are best during any exercise activity (e.g., aerobics, jogging, biking). Women should avoid nonabsorbent clothing as much as possible, especially when exercising. Showers are preferable to tub baths. Women prone to vaginitis and urinary tract infections should avoid bubble bath and other bath additives. If a lubricant is necessary during sexual intercourse, an over-the-counter water-soluble vaginal lubricant may be used [18]. Vaseline is not water soluble and is not recommended as a vaginal lubricant. Allowing time for proper sexual arousal is often the only lubrication technique necessary. However, vaginal dryness may occur with perimenopausal changes or when taking certain medications.

Changes in vaginal physiology or a rise in the pH makes women more vulnerable to vaginal infections [32,33]. Caution women that risk factors for reduced vaginal acidity include pregnancy, use of high-estrogen oral contraceptives, antibiotic therapy, and uncontrolled diabetes. Women in these situations should follow the suggested techniques for avoidance in addition to a protocol for care for that specific risk factor. If the woman is taking antibiotics, taking probiotics either from food sources or as supplements may help to prevent vaginal infections. Some women will need prophylactic antifungal therapy in conjunction with antibiotic therapy. If a woman has itching, irritation, burning, sores, or odor, she should be examined to determine the exact cause. There are many different types of vaginal infections, each with different treatments [33,35].

Transmission of organisms to and from sexual partners should be avoided. During any treatment for vaginal infections, the woman should either refrain from sexual contact or ensure the use of a condom. If the woman gets irritations easily, she should check with her partner, as his or her soap or other personal products could be the problem.

The Papanicolaou (Pap) test, or smear, is a safe and inexpensive tool for the early detection of cervical cancer. Developed by Dr. George Papanicolaou in the 1940s, the Pap test became a regular component of the gynecologic examination during the 1950s. It has been the gold standard for the last 50 years; however, reports of false negatives occur in as many as 50% of samples [21]. The Pap test involves scraping the endocervix with a swab, brush, or spatula to obtain a sample of cells [21,35,39]. Most women barely feel the scraping of the cervix during the Pap test. Barriers to gynecologic checkups and Pap tests include fear, denial, lack of information, cultural beliefs, social status, embarrassment, absence of symptoms experienced, lack of access to health care, and cost.

Since the introduction of the Pap test, the incidence of invasive cervical cancer and the death rate from cervical cancer have declined significantly in the United States, but the number of women with cervical intraepithelial neoplasia (CIN) has increased at alarming rates [40]. When diagnosed early, the cure rate for CIN is almost 100%. However, approximately 4,360 women die each year from this disease [41]. Approximately 91% of women whose cervical cancer is localized (stage I) at diagnosis are alive five years later, while only 19% of those with metastatic disease (stage IV) at diagnosis are alive at five years [42]. The percentage of Pap screening is lower among minorities, the elderly, and those without insurance [43,44]. Women who have never been screened for cervical cancer account for approximately 50% of the cases diagnosed in the United States, with an additional 10% of cases diagnosed in women who have not been screened in the previous five years [40,45,46]. Eligible and underserved women should be informed that the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) offers free or low-cost Pap tests and mammograms [47].

Colposcopy is an office-based procedure using a lighted microscope that permits close and direct examination of the cervix and vagina as well as biopsy and removal of the abnormal tissue. The magnified view of the cervix, vagina, and vulva allows the practitioner to locate and define the size and distribution of CIN [48]. The goal of colposcopy is to detect pre-invasive disease and prevent development of invasive cervical cancer [49]. Lack of skilled technicians, potential for overtreatment, increased risk to patients, and high cost prohibit the widespread use of colposcopy as an adjunct to the Pap test [21,40]. Consequently, new screening technologies have been developed, including liquid-based Pap (LBP) technologies and computer-assisted screening methods. The liquid-based technologies have shown a greater sensitivity to squamous epithelial lesions (SIL), fewer unsatisfactory samples, and improved sample quality than the conventional Pap test, but equivalent sensitivity to CIN as the Pap test [21,50,51]. The newer methods have been shown to increase life expectancy, but they are associated with a higher cost per screening than the conventional Pap test.

HPV DNA testing is a molecular technique used to identify high risk types of HPV. In 2009, the FDA approved two HPV DNA diagnostic tests: the Cervista HPV HR and the Cervista HPV 16/18 [52]. The Cervista HPV HR is designed to identify 14 high-risk types of HPV. The Cervista HPV 16/18 is designed to specifically detect HPV types 16 and 18, which cause about 70% of all cervical cancers. Both tests are approved for use with LBP samples and should be used in conjunction with the Pap test and patient history to help the practitioner determine needed follow-up, such as colposcopy and/or repeat cytology sampling. The tests are indicated for women 30 years of age and older who are at high risk of disease. They are not recommended for routine screening [16,21,40]. Since 2009, three additional DNA tests have been approved: the Aptima HPV Assay (identifies 14 high-risk types), the Aptima HPV 16 18/45 Genotype Assay (differentiates HPV 16 from HPVs 18/45, but cannot differentiate HPV 18 from HPV 45), and the COBAS HPV Test (specific HPV 16 and 18 genotyping and detects 12 other high-risk types) [16,53].

Most risk factors for cervical cancer are related to sexual history. Although the exact cause is unknown, it is thought that cervical cancer is the result of cellular changes in the cervix due to insult from viruses (as discussed) and multiple partners. Women with cervical cancer often report a history of cervical infection and virtually all test positive for HPV [40]. Infections that may lead to cervical carcinoma are caused by HSV-2; HPV types 16, 18, 31, 33, 45, and 58; HIV; and perhaps cytomegalovirus.

HPV 16 is most frequently linked to squamous cancers and HPV 18 to adenocarcinomas [16,21,32,40]. These viruses alter the DNA of nuclei of immature cervical cells. HPV DNA testing may be performed to identify women at high risk for disease. Women whose high-risk HPV infection persists in genital skin cells are at greatest risk for subsequently developing cervical cancer [40]. These women require close follow-up treatment and repeat Pap tests. For example, a patient with ASC-US may often require repeat Pap testing every 3 to 6 months over 6 to 12 months. With an abnormal Pap test, and certainly when three consecutive Pap tests over 12 months demonstrate epithelial cell abnormalities, a cervical biopsy under magnified visualization with colposcopy should be done [16,21,32,40]. Fortunately, most women with an abnormal Pap test have an easily treatable precancerous condition of mild dysplasia (CIN 1).

Risk factors for cervical cancer include [16,21,32,40,60]:

The fact that most of the predisposing factors relate to patterns of sexual activity may lead to barriers for early detection and treatment of cervical cancer. Health professionals should be sensitive to women to decrease any embarrassment. Discussions of psychosexual factors and the implications for risk of cervical cancer should be nonjudgmental. Communication should convey that sexual health is regarded as a part of total health, and women should not feel ashamed of what is a normal physiologic function. Societal norms today often differ from the norms of 40 years ago. For example, women often marry later, divorce and remarriage are relatively frequent, and most women have more than one sexual partner in their lifetime (average: 4) [61]. These changes should be considered a social norm, not as a stigma associated with a risk factor for cervical cancer. Health professionals should educate themselves and the women with whom they work regarding sexual health and the risk factors for cervical cancer. Because many women will learn about their positive HPV status at the time that they learn about an abnormal Pap test result, it is important for health professionals to teach women about HPV as early as possible [21]. Health professionals should also encourage sexually active women to participate in regular gynecologic checkups and Pap tests and utilize safe sex practices, such as limiting sexual partners and using latex condoms.

While gynecologic cancers can affect any part of the reproductive tract, the most common type is cancer of the uterus. The three layers comprising the uterus are the inner layer or lining, which is called the endometrium, the middle muscular layer, which is called the myometrium, and the layer of tissue that coats the outside of the uterus, which is known as the serosa [65]. Most uterine cancers begin in the endometrium [65].

Risk factors for endometrial cancer include advancing age, hormone imbalance, estrogen therapy, use of birth control pills, use of an intrauterine device, breast or ovarian cancer, early menarche (i.e., before 12 years of age), use of the drug tamoxifen, infertility or no pregnancies, obesity, high-fat diet, diabetes, and family history [65,66]. Research has indicated that a relationship of mismatch repair (MMR) gene mutations to endometrial cancer may be present. MMR genetic abnormalities are also considered causal in hereditary nonpolyposis colorectal cancer (HNPCC), which may be a risk factor for endometrial cancer [65,67]. More research is necessary to fully understand the genetics involved in the development of HNPCC-associated uterine cancers.

The one and only early sign of endometrial cancer is abnormal vaginal bleeding or spotting, especially in postmenopausal women. Therefore, women must be instructed to seek treatment when any abnormal bleeding occurs. Endometrial biopsy is the most commonly conducted test, and it may be performed in the office with a pelvic examination. A transvaginal ultrasound may be done before the biopsy to help the physician detect suspicious areas for biopsy. Following a positive biopsy result, the mainstay of treatment is a hysterectomy (simple or total). A bilateral salpingo-oophorectomy may be performed in conjunction with the hysterectomy. Other treatments, depending on the stage of the cancer, include radiation and chemotherapy. Early detection and treatment of endometrial cancer has a very high survival rate because these tumors tend to be well differentiated and localized [64,65].

Ovarian cancer is the fifth leading cause of cancer-related death in women [68]. It is the most fatal of all cancers in women because it is very difficult to detect and diagnose in an early stage. If diagnosed and treated before the cancer has spread beyond the ovaries, the survival rate is about 92%. However, only 20% of all ovarian cancers are found at this early stage [68]. By the time it is diagnosed, the cancer may have already spread throughout the pelvis.

Screening for early ovarian cancer remains a scientific challenge, because the symptoms can be somewhat vague. The most common sign of ovarian cancer is enlargement of the abdomen. Women may complain of inability to fasten pants and skirts. Other symptoms may include pelvic pressure or stomach pain, trouble eating or feeling full quickly, and ascites [68]. The exact cause remains unknown; however, evidence suggests a link to endocrine function. The number of times a woman ovulates also may be a factor in the development of the disease, as protection is provided in women who conceive before 25 years of age, experience early menopause, and/or use oral contraceptives for years [68].

Age is a primary risk factor for ovarian cancer. It occurs most frequently in women 40 to 70 years of age, with more than half occurring in women 63 years of age and older. Survival rate in these women is only about 35% [68]. Other risk factors include family history (with an increase as much as 50% in women who have a mother or sister with ovarian cancer), obesity, no pregnancy before 30 years of age, breast cancer, estrogen or hormone replacement therapy, fertility treatment, and environmental factors (e.g., exposure to asbestos) [64,68].

Due to the high mortality rate associated with ovarian cancer, these women and their loved ones require extensive case management with an entire treatment team of surgeons, oncologists, oncology nurse specialists, social workers, and pastoral care. Health professionals should provide these women with the latest information to make informed choices about their treatment options. Radiation therapy is only rarely used in the United States as the main treatment. The recommended treatment of ovarian cancer is surgery followed by chemotherapy. Standard treatment includes three to six courses of chemotherapy with a combination of carboplatin (or cisplatin) and paclitaxel (or docetaxel) [69].

Methods that may help prevent ovarian cancer include the removal of both ovaries (bilateral oophorectomy) in women who are undergoing hysterectomy for other medical reasons and who have a family history of ovarian cancer. Oophorectomy can be performed by laparoscopy, decreasing the cost, risks, and recovery time for the woman. Tubal ligation and hysterectomy may also lower the risk of getting ovarian cancer; however, these should be performed only for valid medical reasons, not just as preventive measures [70].

Gynecologic cancer is not always a visible disease. Consequently, the full impact of the cancer is sometimes minimized or further hidden by women, their families, and healthcare professionals. An appreciation and understanding of the magnitude of adjustments for the woman and for the people who care about her is essential. Concerns about treatment, sex, and childbearing are common. Guilt, embarrassment, shame, and body image disturbances are common reactions to the diagnosis of any gynecologic condition. Women may also feel their personal privacy is intruded upon. They may feel defensive and angry about the healthcare team having to treat such a private part of themselves. Some women will associate cancer in the genital area with forms of punishment for real or imagined sexual expression. Shame and guilt associated with the diagnosis can be diminished if healthcare providers communicate with an accepting and nonjudgmental approach. Assessment of how the disease affects a woman's self-image is necessary. Factual information on how the disease or treatment may interfere with normal sexual function should be addressed.

Feelings of guilt, anger, and shame may prevent women from asking questions or initiating a discussion on the subject of sexual activity. The general interactions that should be included in the care of women with gynecologic cancer are [71]:

Although hormone replacement therapy (HRT) is an option for management of menopausal symptoms, it is not without risk and is not a viable option for every woman. All therapies, including HRT, have risks and benefits.

The NIH established the WHI in 1991 to address cardiovascular disease, cancer, osteoporosis, and quality of life issues in postmenopausal women [78,79]. One component of the Initiative was a randomized clinical trial involving postmenopausal women 50 to 79 years of age. A portion of the trial was conducted to examine the risks, benefits, and long-term effects of hormone therapy. Women with intact uteruses received combined HRT (estrogen plus progestin) or placebo. The study was halted in 2002, three years early, because the WHI safety board found both an increased risk of breast cancer in study participants and a persistence of previously identified risks (i.e., heart attacks, strokes, blood clots in the lungs and legs). The numbers of women who had hip and other fractures or colorectal cancer were lower, and there were no differences in the incidence or mortality rates for women with endometrial cancer. However, when compared to an equal number of women (10,000) taking placebo, there were 8 more breast cancers, 7 more heart attacks, 8 more strokes, and 18 more instances of blood clots to the lungs or legs in the women taking the combined therapy. These results led the safety board to conclude that estrogen plus progestin therapy neither prevents heart disease nor offers benefits sufficient to outweigh the overall risks [78,79].

The WHI also completed a study in which it tested the relative risks and benefits associated with estrogen-only hormone therapy for postmenopausal women without uteruses [80]. It found that although the risks with estrogen-only therapy were significantly less than those identified with estrogen plus progestin, they nonetheless outweighed the benefits. The WHI also found a significant increase in the risk of stroke, a slight increase in the risk for dementia or cognitive decline, a decrease in the risk of hip fracture, and no change in the risk for breast cancer or heart disease. This study was halted in 2004, one year earlier than anticipated [79,80,81].

While the numbers of adverse events are small, it is important to remember that behind each number are a woman, her family, and her community. The following general approach to HRT has been recommended [78,79,82,83]:

The USPSTF recommends against the use of combined estrogen and progestin for the primary prevention of chronic conditions in postmenopausal persons. They also recommend against the use of estrogen alone for the primary prevention of chronic conditions in postmenopausal persons who have had a hysterectomy [84].

According to the North American Menopause Society, the appropriate, often lowest, effective dose of systemic estrogen therapy consistent with treatment goals that provides benefits and minimizes risks for the individual woman should be the therapeutic goal.

(https://www.menopause.org/docs/default-source/professional/nams-2022-hormone-therapy-position-statement.pdf Last Accessed: July 12, 2024)

Level of Evidence: III (Based primarily on consensus and expert opinion)

The decision to take HRT rests with the individual. Women experiencing difficult menopausal symptoms that are dramatically affecting their quality of life and ability to function may be candidates for HRT in the absence of absolute contraindications. It is best for health professionals to perform a thorough personal and family history, educate women about estrogen, and be willing to help them objectively evaluate the pros and cons of HRT. For women who decide to discontinue HRT, it is best to taper off the drugs to decrease symptoms. However, symptoms may recur. The woman's perception of her experiences, her history of cancer, uncontrolled hypertension, or thrombophlebitis, and her knowledge and concerns about sexuality should all be assessed. Also, women who take HRT should be cautioned about the increased risk of breast cancer and instructed to have regular mammograms as well as clinical breast exams for the duration of the HRT.

The U.S. Preventive Services Task Force recommends that primary care clinicians assess women with a personal or family history of breast, ovarian, tubal, or peritoneal cancer or who have an ancestry associated with breast cancer susceptibility 1 and 2 (BRCA1/2) gene mutations with an appropriate brief familial risk assessment tool. Women with a positive result on the risk assessment tool should receive genetic counseling and, if indicated after counseling, genetic testing.

(https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/brca-related-cancer-risk-assessment-genetic-counseling-and-genetic-testing Last Accessed: July 12, 2024)

Strength of Recommendation: B (Clinicians should provide the service to eligible patients based on at least fair evidence that it improves important health outcomes and concludes that benefits outweigh harms.)

An understanding of breast health and breast cancer is important for all women. Aside from nonmelanoma skin cancers, breast cancer is the most frequently diagnosed cancer in women. It is also one of the most treatable, if detected early. One in eight women in the United States will develop breast cancer [8]. Although the cause of breast cancer remains essentially unknown, some risk factors have been identified. The greatest risk factor is being a woman. Other risk factors include current age, age at first menstrual period, age at first live birth, obesity, physical inactivity, race, and personal and family history of breast cancer [8,9]. Many women diagnosed with breast cancer do not have any known risk factors.

Approximately 5% to 10% of women diagnosed each year with breast cancer have a form of the disease resulting from inherited alterations in the genes called BRCA1 and BRCA2 (breast cancer 1 and breast cancer 2). The incidence is highest in women with a family history of breast cancer. The risk of developing breast cancer in women with clinically significant gene mutations is 45% to 65% by 70 years of age, compared with 12.3% of the general population [86,87]. Testing for BRCA1 or BRCA2 is done on a blood sample and can range from several hundred to several thousand dollars [88]. Genetic counseling and risk assessment should accompany the testing. Routine referral is not recommended for women with no family history of breast cancer. However, women with one or more relatives with a BRCA mutation should be offered genetic counseling and testing following evaluation with a validated risk stratification tool [86].

The ACS, NCI, USPSTF, and others have recommended several methods and timelines for the early detection of and screening for breast cancer in women [89,90,91,92,93]. The health professional should communicate to women and their families that these recommendations are based on the generalized population of women. Individual risk factors and informed choice should still guide each woman.

The impact of breast cancer extends beyond the threat of death and includes an altered self-image, role changes, and changes in support systems and family relationships. The many options for treatment contribute to the complexities that the diagnosis of breast cancer brings to the woman, her family, and her friends. The treatment options depend on the stage of the disease and on other factors, including [98,99,100]:

Women diagnosed with breast cancer should discuss treatment plans with their physicians. Family and support persons should also be included in the discussions. Many women want a second physician to review their diagnosis and treatment plan. Health professionals should reassure women that a short delay while a second opinion is sought should not reduce the success of their treatment. Many patients find it useful to record the sessions during which treatment options are discussed, as it may be difficult to remember the overwhelming amount of information discussed [98].

Advances in understanding the biology of cancer have occurred over the last few decades. Treatment is based on the theory that breast cancer is a systemic disease. The hope that the cancer has been fully removed has proven to be only part of the biology of breast cancer, and consideration must be given to the fact that micrometastases could be present with or without nodal involvement. Therefore, treatment choices involve not only the surgical procedure, but adjuvant therapy as well. Adjuvant therapies (i.e., methods that enhance survival and complement surgical effectiveness) include chemotherapy, hormone therapy, and radiation therapy. Before decisions can be made about adjuvant therapy, prognostic information must be obtained. Factors that affect prognosis and that should be considered when making treatment decisions are [32,100,101,102]:

The most important prognostic factor is nodal status. The number of positive axillary nodes has a direct relationship to clinical outcome. For women with negative nodes, tumor size is the most important prognostic factor [101]. The significance of progesterone receptors (PRs) is not as clearly understood as that of estrogen receptors (ERs). About 80% of breast cancers are ER-positive, and about 65% of ER-positive cancers are PR-positive. About 13% of breast cancers are ER-positive and PR-negative. About 2% of breast cancers are ER-negative and PR-positive [103]. Patients with ER-positive breast cancer generally respond favorably to the anti-estrogen agent tamoxifen [104].

ERBB2, a growth factor, is emerging as an important prognostic marker. The ERBB2 protein is expressed at low levels in normal breast tissue, but in about 25% to 30% of women with breast cancer, this protein is overexpressed. This overexpression is correlated with poor disease-free survival [105]. The FDA has approved trastuzumab, a monoclonal antibody, for use in conjunction with paclitaxel to target cells that overexpress ERBB2 [106,107]. Clinical trials have indicated that women with breast cancer who are overexpressing ERBB2 and who receive chemotherapy in addition to trastuzumab have a higher survival rate [108]. Triple-negative breast cancer (TNBC) is defined as the absence of staining for ERs, PRs, and ERBB2. TNBC is insensitive to some of the most effective therapies available for breast cancer treatment, including HER2-directed therapy (e.g., trastuzumab) and endocrine therapies (e.g., tamoxifen, aromatase inhibitors). Combined chemotherapy is the standard therapy for early-stage TNBC [100]. A 2014 review and meta-analysis of the adjuvant use of platinum agent to treat TNBC showed a three-fold increase in complete response compared to neoadjuvant therapies containing no platinum agent [109]. Immunotherapy is emerging as a novel and promising treatment option for TNBC. Immunotherapeutic approaches that have been developed and tested include the blockade of immune checkpoints using neutralizing or blocking antibodies, induction of cytotoxic T lymphocytes (CTLs), adoptive cell transfer-based therapy, and modulation of the tumor microenvironment to enhance CTL activity [110,111,112].

In 2019, the FDA granted accelerated approval of fam-trastuzumab deruxtecan (Enhertu) for treatment of unresectable or metastatic HER2-positive breast cancer in patients who have received two or more prior anti-HER2-based regimens [113]. Fam-trastuzumab deruxtecan is a HER2-directed antibody and topoisomerase inhibitor conjugate, targeting changes in HER2 that help cancer grow, divide, and spread [27,113]. The FDA approval was based on results of a clinical trial that enrolled 184 female patients with HER2-positive, unresectable, and/or metastatic breast cancer who had received two or more prior anti-HER2 therapies. These patients were heavily pretreated in the metastatic setting, receiving between 2 and 17 therapies prior to receiving fam-trastuzumab deruxtecan. Patients in the clinical trial received fam-trastuzumab deruxtecan every three weeks and tumor imaging was obtained every six weeks. The overall response rate was 60.3%, which reflects the percentage of patients that had a certain amount of tumor shrinkage with a median duration of response of 14.8 months [113]. Fam-trastuzumab deruxtecan includes a boxed warning advising healthcare professionals and patients about the risk of interstitial lung disease and embryo-fetal toxicity [27,113].

Until recently, a radical mastectomy was the standard treatment for breast cancer. While surgery remains a primary component of treatment, it often conserves more breast tissue and is combined with other therapies [100]. If the woman has carcinoma in situ, for example, the treatment option might be a modified mastectomy or lumpectomy and radiation therapy, with or without hormonal therapy [100]. Women who have stage I or stage II cancer are often candidates for breast-conserving surgery (e.g., lumpectomy, breast radiation, surgical staging of the axilla) [100]. While not all women are candidates for this approach, it has demonstrated the same survival rate as other surgical techniques while preserving breast tissue [32].

The epidemiology of breast cancer indicates that, in many women, it is a hormonally influenced malignancy. Cancer cells are tested after surgical removal, and hormonal therapy may be used when the cancer is sensitive to estrogen (i.e., ER-positive) [103]. Tamoxifen is a synthetic anti-estrogen that has been found to effectively treat women with ER-positive or ER-unknown breast tumors. The optimal duration of tamoxifen appears to be 5 years; however, there is some evidence that 10 years of tamoxifen may be beneficial [100,114]. Serious side effects of tamoxifen include blood clots, strokes, uterine cancer, and cataracts; other common side effects include hot flashes, night sweats, and vaginal dryness [100,115]. Tamoxifen is not recommended in women with a prior history of deep vein thrombosis, pulmonary embolus, stroke, or transient ischemic attack [104].

In summary, the treatment choices for breast cancer include:

The following case studies of women with breast cancer illustrate the range of treatment choices available. They also illustrate the necessity for healthcare providers to have a broad knowledge base from which to communicate information and provide support during this decision-making period. The case studies also provide mental health providers with the opportunity to be supportive from an informed position.

Breast reconstruction is a plastic surgery that rebuilds and recreates natural-looking breasts for women who have lost theirs to cancer. Reconstruction can be achieved by inserting saline-filled or silicone gel-filled implants beneath the skin and chest muscles. The silicone implants are used less frequently than in the past due to concerns about immune system diseases. However, studies have allayed some of the concern about this risk, and the FDA approved silicone implants again in 2006. Newer types of silicone implants use a thicker "cohesive" gel that reduces the risk of leakage should the implant rupture [116]. Breast reconstruction can also be achieved with tissue flap reconstruction, which uses tissue from another part of the body, such as the buttocks, abdomen, or back [116,117]. The two most common types of tissue flap reconstruction are the transverse rectus abdominis muscle (TRAM) flap surgery, which involves constructing a breast from the lower abdominal skin and fatty tissue, and the latissimus dorsi flap, which uses tissue from the upper back. Other flap procedures include the deep inferior epigastric artery perforator (DIEP) procedure and the gluteal free flap. The DIEP procedure is similar to the TRAM, except that it does not use muscle to form the breast mound. The gluteal free procedure (also similar to the TRAM) uses tissue from the gluteal muscle of the buttocks [118]. Nipple reconstruction involves using tissue obtained from the opposite nipple areola complex or tissue from the upper portion of the inner thigh. The reconstructed breast and nipple may not have the same level of sensation during sexual arousal [119,120]. The transverse upper gracilis flap (TUG flap) is a newer option for women who are either not eligible for or are not interested in the TRAM or DIEP flaps. The TUG flap uses muscle and fatty tissue from along the bottom fold of the buttock extending to the inner thigh. The TUG flap is a good option for women who need a smaller or medium-sized breast [118]. Some physicians have begun using FDA-regulated products made of donated human skin (e.g., AlloDerm, DermaMatrix) or an animal-skin acellular dermal matrix (ADM) (e.g., Strattice). These products are another new option in breast reconstruction; outcome studies are still in progress [121]. In 2021, the FDA issued a safety communication advising that certain ADM products used in breast reconstruction may have a higher chance for complications. Additionally, while some ADMs have been approved for use in certain types of surgeries (e.g., hernia surgery), their use in breast construction is off-label [122].

In the wake of the controversy about silicone gel and saline-filled implants, more women are choosing reconstruction using their own tissue. The TRAM flap approach offers the advantage of creating a softer, more natural-appearing breast mound of autogenous tissue, without the risks associated with manufactured implants [118,120]. It also produces an abdominal lipectomy, or "tummy tuck," in the donor area, which some women find beneficial.

It is important for healthcare professionals to educate women and their families about the surgical procedures when discussing treatment options. Preoperatively, any woman considering reconstruction should meet with a plastic surgeon to discuss her candidacy for the TRAM procedure. Women with obese abdomens are at much higher risk for flap loss and are poor candidates [119]. Likewise, heavy smokers and diabetics are at risk for consequences of poor flap vasculature due to prolonged healing times and infection. Any previous surgery that transected the abdominis muscle may preclude that particular muscle for the flap [123].

Most experts agree that good results can be obtained with reconstruction when the cancer surgeon and the plastic surgeon plan the surgeries together [119,123]. In some instances, the reconstruction may be done simultaneously with the mastectomy, with the two surgeons working in concert. However, immediate reconstruction is not possible for some women. Women with advanced cancer, who will need further procedures, may be advised to postpone reconstruction because of its potential to interfere with treatment. Those undergoing radiation may not be good candidates for reconstruction if they have any damage to the skin [119,123].

Some women who are eligible for immediate reconstruction may delay the procedure to give themselves time to recover from the mastectomy and ensure that the cancer is gone. Some of these women may not want to go through another surgery and do not elect to have the reconstruction. Delaying the procedure gives women time to think about the decision, decreases time under anesthesia, and decreases stress on the body during the mastectomy. A mastectomy alone takes about 1.5 to 3 hours. Reconstruction with saline implants adds another 1.5 hours. A TRAM procedure takes four to eight hours, depending on the type [124].

Reconstruction is a serious procedure, and some women find it difficult to make decisions about it when already dealing with the life-and-death questions regarding their cancer treatment. Women should decide if they want reconstruction in the immediate future, at a later date, or not at all. If they elect to have reconstruction, they should decide which procedure is best for them [123]. A thorough psychosocial assessment of the woman's feelings about reconstruction should also be completed. It is important that the woman feel confident and comfortable with herself, with or without reconstruction. The breast can have a strong impact on body image, sexual attractiveness, and intimacy.

For any woman with breast cancer, with or without reconstruction, rigorous follow-up is needed. The importance of educating the patient and family on the significance of follow-up diagnostic tests and visits cannot be overstated. The woman should perform monthly breast exams, and clinical breast exams with the oncologist or surgeon should be done. Yearly mammograms are generally not deemed necessary; however, if an area of concern is found during a physical examination, a diagnostic mammogram may be done. These women should be screened carefully for recurrence [125].

The goal of adjuvant therapy is to find the most effective therapeutic regimens while minimizing toxicities. Studies have shown that adjuvant therapy may increase the chance of long-term survival by preventing a recurrence [126]. Available treatment options have expanded to include new medications and combinations of medications for the adjuvant management of breast cancer [127]. For example, multiple trials of polychemotherapy have demonstrated that treatment with combination therapy and/or tamoxifen produces a reduction in the risk of relapse and death [127]. Because breast cancer is so common, even a modest improvement in therapy will save many lives.

Adjuvant systemic therapy is an important and essential component of the management of primary breast cancer. Aromatase inhibitors (AIs), such as anastrozole, letrozole, and exemestane, are commonly used in postmenopausal women in both early and advanced breast cancer, either after tamoxifen therapy or instead of tamoxifen therapy [100]. These inhibitors work by blocking production of androgenic precursors, thereby depriving breast cancer cells of estrogen. Anastrozole is generally well tolerated, and clinical trials have indicated that AIs are as effective as tamoxifen, without some of the side effects, such as hot flashes, thromboembolic disease, and increased risk of endometrial cancer. Anastrozole has also demonstrated improved efficacy for five years over tamoxifen alone [128,129]. Ovarian ablation or suppression to reduce the amount of estrogen produced by the body (either permanently or temporarily) may be recommended for some premenopausal women [130,131]. However, evidence suggests that ovarian ablation alone is not an effective substitute for other systemic therapies, and the addition of ovarian ablation to chemotherapy and/or tamoxifen has not been found to significantly improve outcomes [100,132,133].The burden on oncologists is to balance the benefits to each individual patient against the potential toxicities that may develop, based on the prognostic risk factors of the particular breast cancer diagnosis.

It is beyond the scope of this course to discuss all the new cytotoxic drugs and their combinations. One exciting area of research is the identification of specific molecular abnormalities of cancer cells. As previously mentioned, trastuzumab, a humanized monoclonal antibody against the ERBB2 oncoprotein, has produced objective responses with ERBB2-overexpressing breast carcinoma and has improved the efficacy of various combinations of cytotoxic drugs [100]. All breast cancer patients should have their ERBB2 status analyzed, including women with either node-positive or node-negative breast cancer. This analysis may help patients and their healthcare providers with the decisions about adjuvant chemotherapy.

Healthcare professionals should stay informed about the latest trends, results of clinical trials, and new standards of adjuvant breast cancer treatment to most effectively inform women and their families about treatment options. After the decisions have been made, it is the responsibility of the health professional to provide the woman with physical and emotional comfort interventions throughout the course of treatment.

Regardless of the type, staging, or treatment for breast cancer, the woman and her support persons will have unique needs. Clinical experience and research findings have indicated that the important health issues for women with breast cancer include [134]:

The following techniques are measures to address the experiences and needs of women as they learn to live with the diagnosis and treatment of breast cancer [115]:

Experience: Confronting the diagnosis of cancer.

Experience: Developing strengths in living with diagnosis

Experience: Maintaining connections with family and friends and spirituality

Cardiovascular diseases are the leading cause of mortality in women [135]. The incidence of cardiovascular disease in women continues to rise markedly in perimenopause and menopause. Research has shown that both natural and surgically induced menopause are associated with changes in serum lipid profiles, with a decline in high-density lipids (HDL) and an increase in low-density lipids (LDL) [136]. These cholesterol changes may be factors in the development of a woman's increased risk of postmenopausal heart disease.

The primary pathologic risk for heart disease is driven by the deposition of cholesterol in plaque-laden arterial walls. Angina pectoris occurs when the patient experiences a deficit of oxygen being infused through the myocardium. The pain sensation is thought to occur due to a state of anaerobic physiology. Myocardial infarction (MI) occurs with a necrosis of the myocardial cells due to an anaerobic insult. These anaerobic conditions may be caused by a clot or spasm or by atherosclerotic plaque in the coronary arteries. The most common cause is atherosclerosis. Contrary to common belief, many women (two out of every three) who die suddenly of coronary heart disease (CHD) have no prior symptoms [137]. This highlights the need for preventive screening with blood pressure monitoring, lipid profiles, weight management, smoking cessation, and prevention and management of diabetes mellitus.

CHD, especially MI, has historically not been thought of as a woman's disease either by practitioners or by women. This may be in part because cardiovascular disease patterns show interesting gender differences. Nurses and other health professionals can play a key role in educating their peers and patients about the facts of heart disease in women.

There are several key gender differences in cardiovascular disease that require consideration for healthcare practice [64,135,137,138,139,140,141,142]. Between 25 and 35 years of age, men have three times the incidence of CHD as women. Women tend to show signs of cardiovascular disease at a more advanced age than men. Although menopause decreases women's estrogenic protection from heart disease, this biologic advantage persists until 65 to 70 years of age. At older ages, women who have heart attacks are twice as likely as men to die from them within one to five years, particularly Black women [138]. Women represent slightly more than half of all deaths from cardiovascular disease annually in the United States. Overall, the lifetime risk of a woman dying as a result of heart disease is one in three [138].

The signs and symptoms of CHD in women often differ significantly from those in men. Women may have unspecified pain and vague symptoms, which may often lead both the physician and the patient to look for other causes. Healthcare professionals should suspect MI in women just as they would in men. Women should be asked about how their symptoms change in response to exercise, extremes in temperature, and heavy meals. Common indications of CHD and acute MI in women include chest, arm, back, and neck pain, although women are less likely to report chest pain during a heart attack than men [138]. Women with MI have been found to be more than twice as likely as men to present with back pain. Other symptoms include fatigue, chest pain at rest, shortness of breath, and weakness.

The American Heart Association recommends routine assessment of sex-specific risks for ischemic heart disease in screening, history, and physical examination by all primary care providers and gynecologists, and assessment of risk factors for and ways to reduce risk as part of every clinic visit for women.

(https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000381 Last Accessed: July 12, 2024)

Level of Evidence: Expert Opinion/Consensus Statement

The differences in symptomatology in women compared with men may be in part attributed to anatomical and physiologic differences in their cardiovascular systems. Women's hearts are generally smaller, with smaller arteries and a higher resting heart rate. Research has also suggested that women may deposit plaque more diffusely than men. This diffuse distribution of plaque is not as easily visualized using traditional angiograms as the large, obstructive blockages that are more common in men.

Diabetes is more prevalent in women than in men and is a major risk factor for cardiovascular disease. Health professionals should emphasize that heart disease is not an inevitable consequence of aging; it is a disease process that can be greatly influenced by lifestyle behaviors, such as diet, exercise, not smoking, maintaining proper weight, and monitoring blood pressure and cholesterol. It can also be influenced by pharmacotherapy, when appropriate. Healthcare providers, women, and the general community should recognize that the years surrounding menopause are accompanied by a higher risk for coronary disease. The major risk factors for heart disease in women are [143]:

The American Heart Association (AHA) reports that women represent only 33% of NIH-funded cardiovascular studies [144]. Approximately 75% of cardiovascular clinical trials do not report sex-specific results, and women are under-represented in studies of FDA-approved medical devices. Gender differences in response to cardiac medications have also been identified. The AHA has encouraged Congress to pass legislation that would help eliminate the cardiovascular health disparities that women face.

Patients have combinations of multiple social, psychological, cultural, physical, and addictive behaviors that contribute to negative lifestyle behaviors. The major modifiable risk factors for CHD are cigarette smoking, hyperlipidemia, hypertension, diabetes, physical inactivity, excessive alcohol consumption, substance abuse, stress, birth control pills, and excessive weight.

There are many steps that women can take to reduce their risk of cardiovascular disease. The first step is to increase awareness of the need to take responsibility at a younger age and develop health behaviors that will decrease her cardiovascular risk as she ages and becomes more prone to heart disease. Childhood is the best time to develop positive health behaviors, but it is never too late.

While MIs are uncommon in premenopausal women, the factors that affect the change after menopause are not exactly clear. Because women present with heart disease at different ages and with different signs and symptoms, they may not be taken as seriously as men. Women are usually diagnosed with heart disease when they are in an older age cohort, more likely to be on other medications, and have other conditions, such as diabetes, hypertension, and osteoporosis.

In 2017–2018, the age-adjusted prevalence of obesity in U.S. adults was 42.4%, and there were no significant differences between men and women among all adults or by age group [145]. Health professionals should respond to this public health epidemic by educating women and by supporting their efforts to change behaviors involving their diet and exercise routines. Regular exercise has many benefits, such as preventing unhealthy weight gain, helping with weight loss, and lowering a woman's risk of heart disease, stroke, and high blood pressure [146]. Exercise has also been shown to affect muscle growth and metabolism [147,148]. When working with women who continually struggle to maintain weight control, it is important to develop a teaching plan that emphasizes the relationship between diet and exercise.

Metabolic rate is a measure of energy utilization, or how fast one's body burns calories [35]. Many factors affect metabolic rate, including gender, age, heredity, food intake, body composition, activity level, and frequent cycles of weight loss [149,150]. Frequent weight loss through severe caloric restriction followed by increased caloric intake and weight gain seems to slow metabolic rate in many people. This is commonly called "starvation metabolism," "yo-yo dieting," or "weight cycling." It is as though the body fears starvation and becomes more efficient at conserving and storing energy. This weight loss cycling is harmful to a woman's health, as well as discouraging, and some studies suggest a link to hypertension, gallbladder disease, heart disease, diabetes, and depression [147,151]. Maintaining a healthy weight is best achieved by combining healthy eating and physical activity [146].

When counseling women who either need or desire to lose weight, it is important to emphasize that regular physical activity provides major health benefits that are generally independent of body weight. Exercise guidelines should take a lifespan approach that emphasizes lifetime physical activity [152]. Nurses and health professionals may suggest the following measures to encourage the habit of lifelong exercise [146,152,153]:

The U.S. Department of Agriculture has developed MyPlate, which offers personalized information designed to help individuals plan, assess, and meet general nutritional needs and make food choices based on sound dietary guidelines [154]. In general, women should select vegetables, fruits, whole grain foods, legumes, fish, poultry, and lean meats low in saturated and trans fats and cholesterol and use methods of cooking such as broiling. While vitamins and minerals are provided in adequate amounts in a balanced diet, special consideration should be given to each woman's history and developmental life events. For example, the menopausal woman should balance cholesterol and calcium needs by consuming low fat dairy products for a daily calcium intake of 1,000–1,200 mg [155]. Losses of iron due to menstruation and increased needs during pregnancy place women at greater risk for iron deficiency anemia. Health professionals should be alert to the following situations [64,156]:

Iron absorption is a complex process that varies with the foods consumed. Eating foods high in vitamin C facilitates the body's absorption of iron. Therefore, vitamin C intake from fruits, fruit juices, or vegetables should be encouraged at meals in combination with the selected iron food source. While moderate amounts of lean meat contribute to iron status, the consumption of meat is not essential for adequate iron. Vegetarians should consume legumes and nuts for iron as well as protein. Choosing breads, cereals, and pasta enriched with iron also supplies a fair amount of iron for women [157]. Groups of women who are at greater risk for low iron levels include adolescent girls of childbearing age, pregnant women, and female athletes who engage in regular, intense exercise. These women should be screened for iron deficiency and prescribed supplements if needed [157]. Experts no longer simply recommend a diet low in total fat. Instead, there is greater emphasis on awareness of the type of fat and on reducing the intake of saturated fats, cholesterol, and trans fats. All fats are composed of fatty acids, which are the building blocks of fat. The amounts and mixtures of fatty acids determine the attributes of fats. Fatty acids may be saturated, monosaturated, or polyunsaturated, differing in the amount of hydrogen they contain [158]. Saturated fatty acids are mainly found in foods derived from animals, such as meat, poultry, butter, and milk. Polyunsaturated fatty acids are found in plant foods, such as corn and sesame oils, as well as fish and seafood. Monosaturated fatty acids are found in plant foods, such as canola, peanut, and olive oils, as well as nuts and avocados. Trans fats are present in a wide range of foods, including most foods made with partially hydrogenated oils, such as baked goods, fried foods, and some margarine. Through hydrogenation, unsaturated fatty acids can be made more saturated, resulting in the formation of a more stable semisolid form (trans fat) [158]. Health professionals should educate women that fats are essential for health but that moderation in the amount and type of fat consumed is important. Women should be advised to consume a majority of the fat in their diet as polyunsaturated and monosaturated fat, while reducing the amount of saturated and trans fat. The American Heart Association recommends eating at least two servings of fish rich in omega 3 oil, such as salmon, trout, and herring, every week [159]. Portion control is a major component of weight management as is a decrease in consumption of fat and overall calories.

When counseling women about exercise and nutrition, health professionals should begin by obtaining the woman's health history. Inquire about whether she exercises, and document the specifics of her exercise routine, including the type, amount, frequency, and her level of satisfaction with the routine. Encourage her to maintain a diary of eating and exercise patterns. Discuss nutrition concerns such as weight control, lowering cholesterol, and food likes and dislikes. If she is allergic to milk products, discuss other sources of dietary calcium and calcium supplementation. Discuss ways to balance cholesterol and calcium by consuming low-fat yogurt, skim milk, pudding made with skim milk, and low-fat cheese. Ask her to log her fat, iron, and calcium intake for two weeks to increase awareness about her dietary choices. Help her to plan an exercise routine that slowly increases in intensity, and conduct follow-up discussions to evaluate her progress and recommend alternatives, when necessary. Consult with a dietician and physician as needed.

The health provider who does a thorough health and diet history to identify nutritional risks for the various developmental stages of women will be able to adapt the dietary guidelines to meet the additional special dietary needs for that woman. Table 1 provides an example of a nutrition teaching plan for women.

With three-quarters of Americans overweight or obese, the rising incidence of the constellation of obesity, dyslipidemia, heart disease, and diabetes in women is a critical public health issue [145]. Diabetes is a major source of morbidity, mortality, and economic burden in the United States, yet it can frequently be prevented by lifestyle changes [162]. Public health education marketed toward women that includes information about weight management, exercise, controlling blood glucose levels, and preventive diabetic health may reduce the incidence of diabetes. In 2021, the FDA approved semaglutide injection for chronic weight management in adults with obesity or overweight with at least one weight-related condition, including high blood pressure, type 2 diabetes, or high cholesterol [163]. Semaglutide is approved as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes [27]. It may be administered orally or intravenously. The oral dose is 3 mg once daily for 30 days, after which it is increased to 7 mg once daily. The dose may be increased to 14 mg once daily after the initial 30 days if the 7 mg dose does not achieve glycemic goals [27]. Intravenous administration is 0.25 mg once weekly for four weeks, after which it is increased to 0.5 mg once weekly. It may be increased to 1 mg once weekly after the initial four weeks if glycemic goals are not achieved at the lower dose [27]. Semaglutide is contraindicated in individuals with a family history of medullary thyroid carcinoma and in patients with multiple endocrine neoplasia syndrome type 2. Side effects include abdominal pain, nausea, diarrhea, and vomiting. Use should be discontinued for two or more months prior to a planned pregnancy [27].

There are two main types of diabetes: type 1 and type 2. Type 1 diabetes is caused by autoimmune destruction of the pancreatic islets. Type 2 diabetes, which is more prevalent, is a defect of insulin secretion, actions, and insulin resistance. Risk factors for type 2 diabetes include [162,164]:

Persons presenting with any of the listed risk factors should be screened for diabetes on a yearly basis. Any person presenting with polyuria (frequent urination), polydipsia (extreme thirst), unexplained weight loss, and/or repeated infections should also be screened [162]. Screening consists of a comprehensive history and physical along with blood glucose levels, both fasting and two hours post-prandial. A fasting blood glucose of 99 mg/dL or less is well within the normal range. An elevated blood glucose of 126 mg/dL or greater on more than one occasion supports the medical diagnosis of diabetes [165].

Although genetic susceptibility and environmental factors have a role in the development of type 2 diabetes, the current epidemic can be primarily associated with particular lifestyle behaviors. These behaviors include the lack of regular exercise, consumption of high saturated fat diets, dyslipidemia, obesity, and smoking. Moderate sustained weight loss and regular moderate-to-vigorous exercise can decrease the risk of developing type 2 diabetes.

Education and prevention are of great importance in decreasing the incidence of diabetes in women and promoting self-management practices to reduce complications when it is diagnosed. Self-management decisions and actions are taken by patients in response to their environment and situation in order to improve their health status. Women need the skills, information, and community and financial resources for effective self-management. Healthcare providers should help prevent the onset of the disease, promote early detection, and encourage preventative services to reduce the number of short- and long-term complications. These interventions can improve patient outcomes and ultimately reduce healthcare costs. To accomplish these objectives, a multifaceted management approach should be adopted that consists of patient and family education, promotion of self-management, a well-established communication plan between the healthcare providers and the patient, and regular up-to-date feedback on the patient's outcomes. Early, preventative interventions may reduce the morbidity, mortality, and economic burden of diabetes. Table 2 provides a quick reference of specific interventions for the prevention of selected long-term complications of diabetes.

Pharmacologic management of osteoporosis offers an opportunity to increase bone density and decrease the incidence of fracture and the accompanying debilitating symptoms. Women and their families should be informed that [167,169]:

Depressive disorders are more common in women than in men, and early detection and treatment of depression may be enhanced with screening as a component of the annual exam. Depression may result in physical and psychological symptoms that cause a significant amount of distress and impairment to the woman and her family, and it may occur in the absence of mania. The risk factors for depression are [18,183,184]:

Depression may occur as a single occurrence, or it may periodically reoccur, but it remains independent of life events. The woman will either demonstrate a depressed mood, or she will express a lack of interest in all or most of her routine activities. Women with depression experience a constellation of symptoms. According to the fifth revised edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), major depressive disorder is diagnosed when five or more of the following symptoms are present for at least two consecutive weeks and represent a change in recent functioning; one of the symptoms must be either loss of interest or pleasure or depressed mood [185]:

Additionally, the patient must have both [185]:

Note: The episode should not be considered a depressive disorder if the symptoms are related to a significant loss (e.g., bereavement), as these may be a normal part of the grieving process, for example. The DSM-5-TR criteria also require that the patient's depression should not be better explained by a psychotic disorder (e.g., schizophrenia, schizoaffective disorder, delusional disorder) and the patient has never had a manic episode or a hypomanic episode [185].

The USPSTF has recommended that adults be screened for depression in clinical practices that have the appropriate systems in place to assure accurate screening, diagnosis, and follow-up [183]. The following screening tools are some of the most widely used with established validity. All positive screening tests should be followed with an extensive interview and health history for a full diagnostic work-up [183,186]:

Suicide is a major, preventable public health problem and one of the leading causes of death among women (particularly adolescent and young women) in the United States [187]. A previous suicide attempt is one of the strongest predictors of subsequent suicide. Cognitive therapy has been shown to reduce by half the rate of repeated suicide attempt, because it helps those who attempt suicide to focus on alternative actions when thoughts of self-harm arise [188]. The risk factors for suicide may vary with age, gender, or ethnic group. They may occur in combination or change over time and may include [18,188]:

Women who die by suicide are frequently found to have seen a primary care provider in the year prior to death. This emphasizes the importance of providers being able to recognize and treat the risk factors to help prevent suicide [188].

Anxiety disorders affect about 40 million adults in the United States each year, and women are twice as likely as men to have an anxiety disorder in their lifetime [189]. They are characterized by symptoms of physiologic arousal (e.g., palpitations, sweating) with moods of excessive worry that interfere with normal functioning, persist over time, and worsen if not treated [190,191]. Anxiety disorders are further classified as panic disorder, agoraphobia, phobias, generalized anxiety disorder, separation anxiety disorder, selective mutism, social anxiety disorder, acute stress disorder, anxiety due to medical conditions, and other/unspecified disorders [185]. Women may exhibit several disorders simultaneously. For example, anxiety is common in depression disorders, and depressive symptoms are common in anxiety disorders. The most common risk factors for anxiety include [190]:

Anxiety disorders are generally treated with medication, psychotherapy, or both. The treatment choice will depend on the type of disorder and on the individual's preference [190].

Intimate partner violence is control by one partner over another [192]. Abusers physically, sexually, verbally, and/or emotionally abuse their partners and/or destroy their partner's property [191]. Economic control, stalking, and control of social contacts are all forms of violence against women. Experiencing fear in a relationship is characteristic of an abusive situation, regardless of whether there is physical violence. The fear of physical harm is enough to consider the relationship abusive [192].

The USPSTF recommends that clinicians screen women of childbearing age for intimate partner violence using a validated screening tool and provide or refer identified victims to intervention services [193]. Tools that have been studied and found to have high sensitivity and specificity include the HITS (Hurt, Insult, Threaten, and Scream), E-HITS (Extended-Hurt, Insult, Threaten, Scream), PVS (Partner Violence Screen), HARK (Humiliation, Afraid, Rape, Kick), and the Woman Abuse Screening Tool (WAST). Additionally, many major medical organizations and state licensing boards mandate screening for partner violence [193]. Direct questioning has been found to be effective for identifying women experiencing partner violence [194]. To assess women for the risks or presence of domestic violence, healthcare providers should ask, and encourage women to ask themselves, the following questions [191]:

Any questions answered affirmatively should be followed with additional questions in order to determine the following [191]:

The prevalence of violence in American society exceeds all other Western nations. Health professionals should increase awareness about safety, and the specific rules of gun safety, in the home. The American Academy of Pediatrics has recommended that gun safety education be included in each visit to the pediatrician. In 2021, gun violence was the leading cause of death for children 19 years of age and younger, surpassing motor vehicle accidents for the first time. More than 4,739 children and teens were killed with guns—one every 2 hours and 36 minutes. Deaths from firearms reached a 19-year in high in 2017 and increased nearly 40% in 2021 alone [195]. In the United States, unintentional firearm-related injuries result in almost nine times as many pediatric fatalities as the next 25 industrialized countries combined [196]. The key points for gun safety education are provided in Table 3 and Table 4.

Alcohol, drug, and tobacco abuse are prominent public health issues for women and their families. It is estimated that 8.7 million children 17 years of age or younger in the United States live with at least one parent with an active substance use disorder [198]. Consequences of the addictive use of alcohol, drugs, and tobacco are related to liver disease, heart disease, stroke, breast and lung cancer, HIV/AIDS, hepatitis, violence, sexual victimization, and auto accidents. One in four deaths is attributable to alcohol, tobacco, or illicit drug use [199].

Factors that may increase a woman's risk for substance abuse or dependence include genetic influences, early initiation of smoking and substance use, and victimization. At least part of the increased risk for substance abuse in women as compared to men may be attributed to gender-related differences in metabolism, brain chemistry, or genetic risk factors. Early assessment and treatment are key in increasing awareness and preventing serious consequences for women, their families, and the community.

Women commonly seek help for alcoholism from primary care clinicians; however, few are queried about alcohol or drug use when they visit a primary care physician [200]. Health professionals should assess adolescents and women for alcohol and substance use during the health history [201]. The screening tools available have wide applicability for screening high-risk patients. The CAGE questionnaire (Table 5) is a brief tool that uses "have you ever" questions to detect alcoholism in adults and in adolescents older than 16 years of age [202]. The CRAFFT screening test (Table 6) is a two-part test used to screen adolescents for substance-abuse problems and disorders. Part one, which contains six questions, is administered to the youth. Part two contains a list of items to discuss/investigate with the parent [203,204]. Other screening tools (Table 7) may be used based on patient population and time available. Women and girls whose scores indicate a problem should have extensive interviews and medical follow-up. Community resources and referrals should be provided to the women and their families.

Drug abuse prevention programs for adolescents should be adapted to emphasize the points that are meaningful to them (e.g., bad breath or ill-smelling clothes for those who smoke). Prevention programs also should increase academic and social competence with skills such as study habits and academic support, communication, self-efficacy, and assertiveness. The programs should also enhance protective factors (e.g., strong family bonds, parental monitoring, clear rules, training in drug education/information) and reduce or reverse risk factors (e.g., chaotic home environment, ineffective parenting, poor school performance). Research has indicated that many of the same protective/risk factors that apply to substance abuse also apply to youth violence, delinquency, risky sexual behaviors, and teen pregnancies. Early intervention is key [207].

Heart disease, cancer, and stroke are the first, second, and third leading causes of death, respectively, among Black women [187]. They have the highest age-adjusted death rate (724.2 per 100,000 population) of all other women of color and the shortest life expectancy at birth (74.8 years) [135,208,209]. While it is projected that by 2060 all women can expect to live longer, Black women will continue to have the shortest life expectancy [208]. Black women have more undetected diseases, higher disease and illness rates, and are sicker during their lifetimes and younger when they die than any other racial/ethnic group in the United States, with the exception of American Indian/Alaska Native women [208]. Rates of intimate partner violence are two to three times higher among Black women than White women. Pregnancy-associated intimate partner violence homicides are more common among Black women than are live births [208].

Only 36% of Black women are aware of the fact that heart disease is their biggest health risk, and only 20% believe that they personally are at risk. However, heart disease risk factors (e.g., overweight and obesity, diabetes, hypertension) tend to be more common in Black women than in other women and appear to affect Black women at a younger age [210,211]. A study presented to the American College of Cardiology in 2021 found a high prevalence of obesity, elevated blood pressure, and other lifestyle-related factors among Black women as early as their 20s and 30s. These factors may put Black women at increased risk to develop heart disease at a young age [211]. Targeted educational interventions should address the barriers to awareness about heart disease that have been cited by Black women, including confusing media messaging, the belief that health is determined by a higher power, and caretaking responsibilities [212]. Education also should address the disconnect between having knowledge about risk factors and being motivated to take preventive action [212].

Although White women are most likely to be diagnosed with cancer, Black women are more likely to die of cancer [208]. The reasons for racial and ethnic differences in cancer risk are not well understood, but they likely result from a complex combination of dietary, lifestyle, environmental, occupational, and genetic factors. Poverty and limited access to preventive measures and screening also likely contribute. Nearly 15% of Black women report working full-time but earning poverty-level wages [208]. Poorer overall health among women in poverty also may limit treatment options and decrease cancer survival rates.

Fifty percent of Black women have one or more risk factors for stroke, including high blood pressure, obesity, diabetes, high-sodium diet, sickle cell disease, and smoking [213]. Knowledge of stroke symptoms varies significantly among African American women, but tends to be lower among the uninsured and those with lower household income. The WISEWOMAN (Well-Integrated Screening and Evaluation for WOMen Across the Nation) program, administered by the Centers for Disease Control and Prevention (https://www.cdc.gov/wisewoman), serves low-income, uninsured, and underinsured women 35 to 64 years of age by providing free screenings and counseling about heart disease and stroke risk [214].

African American women have the highest rates of overweight or obesity, with approximately 80% of Black women being overweight or obese [215]. Obesity is partly related to a sedentary lifestyle, and more than one-half of Black women report that they lead sedentary lives [208]. Socioeconomic factors also disproportionately affect the prevalence of obesity and overweight among Black women. Additionally, research suggests that Black women may be more comfortable with their bodies regardless of medical or mainstream social norms regarding body size. One study assessed body size perception among Black women using cultural definitions of body size terms. Of the 69 women included in the study, 86% of overweight women (BMI 25–29.9) and 40% of obese women (BMI >30) did not self-classify as overweight or obese. Among participants with BMI ≥35, 65% did not self-classify as obese and 29% did not self-classify as overweight [216]. BMI in general is not as useful a motivating factor for Black woman as a holistic approach to health that considers cultural and psychosocial factors.

The reasons for the health disparities experienced by African American women are varied and include limited access to quality healthcare, influence of the surrounding environment or neighborhood, persistent racial discrimination, individual health behaviors, socioeconomic status, and genetics [217]. To lower the risk of poor health outcomes for Black women, knowledge of and attitudes toward their risk for disease should be assessed with the goal of developing effective interventions [218,219,220]. Lack of adequate health insurance and access to quality health care has been expressed as an urgent African American health issue [217].

An estimated 3.7 million people in the United States identify as AI/AN. Of this number, almost one-half (1.8 million) are women [208]. Cancer, heart disease, and unintentional injury are the first, second, and third leading causes of death, respectively, among AI/AN women [187,208]. They have the second highest age-adjusted death rate (905.2 per 100,000) among women of color and the highest prevalence (16.2%) of diagnosed diabetes [135,208]. One-third of all AI/AN families are headed by women, and 44% of these households have incomes below the federal poverty level [208]. Reliance on government commodity foods, which are high in fat and calories, and adoption of a sedentary lifestyle has led to an increase in obesity, with 68% of AI/AN women reported to be overweight or obese [208]. A high occurrence of alcohol and substance use disorders, mental health disorders, suicide, and violence is well-documented among AI/AN populations. AI/AN women experience the highest rate (39%) of intimate partner violence in the United States compared to all other racial groups [208].

AI/AN populations speak more than 200 distinct languages, making access to uniform health care a challenge [208]. Due to treaty obligations with the United States, AI/AN women may receive health care from the Indian Health Service (IHS), through clinics and hospitals available to all AI/AN who belong to one of the 574 federally recognized tribes and who live on or near the reservations in the IHS's 12 service areas [208,221]. These service areas contain the equivalent of county or city health departments. Some of these are operated by the IHS (mostly in rural areas) and some by AI/AN tribal governments, which provide care for AI/AN who live in urban areas and who, because of where they live, have lost eligibility for IHS care near their reservation. Services in both rural and urban areas often are limited, and long distances between facilities make it difficult for AI/AN women to access prenatal care [208,221]. Further, while the treaty obligations require the federal government to provide AI/AN with a reasonable level of health care, this level of care is based on the amount of federal funding the IHS receives, which has steadily decreased since 1993 [208].

Poverty and alcohol/substance use disorder additionally interfere with the ability of AI/AN women to seek preventive health care. Perceptions toward and attitudes about disease (e.g., cancer as a punishment), low literacy and reading comprehension, lack of culturally sensitive educational materials, and mistrust of healthcare providers all hinder AI/AN women's willingness and ability to seek effective preventive care [208]. AI/AN women require educational and preventive programs tailored to their needs and cultural beliefs. Incorporating traditional medicine (e.g., talking circles, sweat lodges, medicine wheels) into the provision of healthcare services is viewed as a more holistic approach to treatment than the Western treatment models that focus only on the disease [208].

As of 2020, the Hispanic/Latino populations constitute the second largest ethnic group in the United States at 62.1 million [222]. Women comprise more than one-half of the total Latino population [208]. Hispanics, along with African Americans, are more likely than White Americans to be among the working poor. More than 15% of all Hispanics and 16% of Hispanic women reported working full-time but earning poverty-level wages [208].

Cancer, heart disease, and stroke are the first, second, and fourth leading causes of death among Hispanic women, respectively [187]. Hispanic women are 40% more likely to be diagnosed with cervical cancer, and 30% more likely to die from it compared with White women, yet Hispanic women undergo significantly fewer Pap tests [223,224]. Hispanic women who have been in the United States for less than 10 years are less likely to have had a Pap test in the last three years compared with those who have been in the country 10 or more years. Hispanic girls have one of the highest rates of HPV vaccination; however, overall rates remain low [224]. Healthcare providers can help improve these rates by emphasizing the importance of completing the vaccination series [224]. More than one in nine Hispanic women have diabetes, including many who are unaware that they have the disease, and approximately one-half of Hispanic women are obese [213]. More than one in three Hispanic women have high blood pressure (a main risk factor for stroke), and nearly one-half do not have it controlled. To help Hispanic women manage stroke risk, healthcare providers should emphasize lifestyle changes, such as healthy eating, getting regular physical activity, and managing other health conditions, particularly diabetes and obesity [213].

Aspects of culture that can influence the health of Hispanic women include religion, folk healing, and family mores. These aspects dictate that Hispanics should first try home remedies, seek the advice of family and friends, or engage folk healers before turning to professional healthcare providers. Even when they engage the help of healthcare providers, Hispanics may continue to complement their care with traditional medicines or alternative therapies [208].

Asian Americans include individuals from more than 20 countries, speaking more than 100 different languages, and representing more than 60 different ethnicities [208]. Cancer has been the leading cause of death among Asian American women since 1980 [187,225]. Cervical cancer disproportionately affects certain subpopulations of Asian American women, yet despite high incidence rates, Asian American women often do not undergo a Pap screening test. This can be attributed, in part, to a lack of knowledge about the risk factors for cervical cancer and recommended screening guidelines. Few Asian American women are aware that HPV is a primary risk factor, and many believe that getting rest, eating right, and avoiding stress can prevent cervical cancer [226]. In one survey, only 62% of Asian American women believed that regular Pap tests could reduce the risk of cervical cancer, and only 61% believed cervical cancer was curable if caught early [227]. The lack of confidence in the importance of cervical cancer screening, combined with concerns about modesty and the pain and discomfort associated with this test, likely contribute to low testing rates [208]. Mammography also is underused by Asian American women. Breast cancer rates among Asian women in their native countries are between 25% and 50% of the rates among Asian American women. With immigration, however, breast cancer rates among Asian American women have increased to reflect the higher overall rates of women in the United States [208].

The health problems of Asian American women are exacerbated by a complex set of cultural, linguistic, structural, and financial barriers to care. A fear of difficulty in communicating, often compounded by shame, guilt, anger, or mental illness, can deter Asian American women from promptly seeking care [208]. These factors, as well as a shortage of healthcare providers who possess the necessary cultural and language skills, also limit the ability of nearly 50% of the AA population to access the mental health care system. Additionally, not all English medical and health terminology can be readily translated into the various Asian languages, nor can many Asian expressions describing physical and mental conditions be directly translated for U.S. healthcare providers [208].

According to a 2019 U.S. Census Bureau estimate, approximately 1.4 million NH/PI live within the United States, and approximately one-half are women [208,228]. Breast cancer is the most common cancer among NH/PI women and they have the highest breast cancer incidence of all women in Hawaii [208]. NH/PI women with breast cancer often are fatalistic and may consequently not vigorously battle their disease, turning to medical treatment only when self-care and traditional practices have failed. A cultural emphasis on the preservation of harmony (lokahi) may result in a tendency to minimize the significance of illness, meaning NH/PI women often are entering treatment at late stages of disease [228,229]. Because the experience of cancer sometimes includes shame and guilt for the NH/PI woman, she may be reluctant to use free screening services, particularly if she lacks health insurance [228]. Healthcare providers can address these cultural barriers by incorporating the roles of ho'omana (e.g., religion and spirituality) and haku (family liaison) into healthcare delivery for NH/PI women [228,229].

In recent years, there has been more focus on studying cardiovascular disease in diverse racial-ethnic groups and in women. However, significant gaps remain in understanding the cardiometabolic health disparities among NH/PI women [230]. Heart disease is the second leading cause of death among NH/PI women [187]. Yet less than one-half (44%) are aware of their risk for heart disease [230]. A 2019 study sought to improve cardiovascular disease risk awareness among NH/PI women on the island of Oahu by assessing participants' level of awareness of cardiovascular disease as the leading cause of death for this population; implementing a risk-reduction program; and evaluating the program's effectiveness in decreasing cardiovascular disease risk [230]. The participants included 20 NH/PI women 24 to 69 years of age who had at least one cardiovascular disease risk factor but no diabetes, previous cardiac event, hypertension, or high cholesterol. The authors used a mixed methods approach that included a cardiovascular risk awareness questionnaire (RAQ), a screening process using a matrix compiled by the AHA, and six educational sessions comprising the Wahine Heart Wellness Program (WHWP) [230]. The RAQ inquired about the women's knowledge of recommended levels of exercise, cholesterol, blood pressure, and daily servings of fruits and vegetables and was administered both pre- and post-program completion. The AHA matrix is from the organization's "Life's Simple 7" program, which identifies seven significant predictors of heart health (i.e., physical activity, cholesterol, healthy diet, blood pressure, BMI, blood glucose, smoking) and shows users how to achieve cardiovascular health. In the WHWP, participants received education about modifiable and non-modifiable risk factors for cardiovascular disease and were offered lifestyle intervention classes that included education about nutrition, exercise, hands-only CPR, and cardiovascular disease prevention. It also included behavioral support about barriers to lifestyle changes and problem-solving methods [230]. Discussions about diet included culturally-specific disease management information, including concepts such as pa'akai, which are salt traditions in NH cultures. Motivational interviewing techniques were employed to help participants achieve their lifestyle change goals [230]. The authors' goal was to have all participants score 80% or above on the RAQ post-test and to see a 2-point improvement in the participants' Life's Simple 7 scores. At the conclusion of the program, 90% of the participants scored an 80% or above on the RAQ post-test, and 75% of the participants improved their Life's Simple 7 score by 2 points [230].

Health professionals should improve culturally sensitive health education and screening programs to increase health awareness and promote positive health practices among women of color.

Aromatherapy utilizes the healing properties of essential oils extracted from plants and herbs to induce a certain reaction or feeling [237]. According to some practitioners, the chemical makeup of essential oils gives them a host of useful pharmacologic properties. Aromatherapy may act as an antibacterial, antiviral, or antispasmodic agent, as well as a diuretic, vasoconstrictor, or relaxation agent [237]. Treatments may be administered through inhalation, from candles or steam, or external applications to the skin via baths, massage, or compress. Lavender candles have been noted to be effective as relaxation agents, and a drop of lavender on the pillow at night has been used clinically to induce sleep in patients with insomnia [238]. Again, because aromatherapy products have not been researched by a regulatory agency, it is best to seek expert advice before using them.

Guided imagery is defined as access to the imagination through a mental guide [239]. When a patient uses general healing imagery, she forms an image of an event, such as a healing light, forgiveness, or a specific treatment healing the body. Guided imagery is best known for its direct effect on physiology. Through imagery, an individual attempts to stimulate changes in body functions usually considered inaccessible to conscious influence. Imagery serves as a bridge for connecting body, mind, and spirit. Imagery is noninvasive and cost-effective, and it can be practiced by the patient either alone or with guidance. By definition, imagery involves information from all the senses—hearing, seeing, touching, tasting, and feeling. Visualization involves primarily the visual sense. Visualization may be utilized as part of the body-mind imagery information process. For example, pregnant women are often taught guided imagery and visualization techniques to use during labor contractions. Guiding the mother through a series of images during contractions is intended to soothe, distract, reduce sympathetic nervous stimulation, and enhance relaxation. The image and visualization is selected by the mother during her pregnancy. The process is intended to allow her to incorporate her personal image to create a dominant parasympathetic response. For example, some women choose climbing a mountain or the rise and fall of the ocean tide to visualize during labor contractions.

Interventions, such as relaxation techniques, imagery, and visualization, work for two main reasons. First, they provide novel stimuli, and the body-mind responds to this information. Second, they facilitate mind modulation of the autonomic, endocrine, immune, and nervous systems. Preliminary studies have demonstrated that imagery may be an effective part of treatment in a wide variety of conditions, from childbirth to cancer [240,241]. Stress-related conditions, such as headaches, back pain, spastic colon, and fatigue, often respond well to imagery techniques. In addition, the emotional aspects of illness can be eased through imagery, which may encourage both physical and emotional healing.

Meditation has a long history of use for increasing calmness and physical relaxation, improving psychological balance, coping with illness, and enhancing overall health and well-being [242]. Meditation is a safe, simple, and cost-effective way to balance a person's physical, emotional, mental, and spiritual energy states. It is easy for patients to learn and has been used as a complementary therapy in treating everything from occupational stress to cancer and menopause. It has also been employed as part of an overall therapeutic treatment for hypertension and heart disease [243]. There are many types of meditation, but most have four elements in common: a quiet location with few distractions; a specific, comfortable posture; a focus of attention; and an open attitude [242]. Meditation requires practice but is easy for the patient to master. Patients are encouraged to set time aside each day for the process of concentrating and focusing one's attention while maintaining a passive and unworried attitude. Relaxation makes it possible to retreat mentally from one's surroundings, stresses, and health concerns. Benefits of meditation and relaxation techniques include decreasing anxiety, easing muscle tension, and providing a period of rest as beneficial as a nap. Meditation is generally considered safe for people in good health. However, those with physical limitations should talk to their healthcare provider prior to beginning a meditative practice [242].

The meaning of the word "yoga" is union, or the integration of the physical, mental, and spiritual energies. It began as a spiritual practice but has gained popularity as a secular way of promoting physical and mental well-being [244]. Yoga is among the oldest known systems of health practiced in the world today. Research into yoga has had a strong impact on the fields of stress reduction, mind/body medicine, and cardiovascular disease. The physical posture, breathing exercises, and meditation practices of yoga have been proven to reduce stress, lower blood pressure, and regulate heart beat [243]. Yoga is often best practiced when it is learned from an expert, as it is not as easily taught as are other simple meditation techniques. Women who have access and the financial resources for yoga classes may benefit from the concentration, relaxation, and sense of well-being provided by this ancient physical movement form. Also, given its rise in popularity, there are a variety of online yoga instruction courses, which may be accessed for little to no fee, for those with limited financial resources. While yoga is an overall philosophy as well as an exercise, patients do not need to embrace the philosophy to benefit from the activity. When practiced for relaxation, such as during menopause or cancer therapy, it involves breathing and stretching exercises. Because yoga practices and postures vary from the basic to advanced, starting with the gentle stretches and breathing techniques makes it ideally suited for patients undergoing the demands of chemotherapy or for women who have been sedentary and are attempting to begin an active relaxation and exercise program.

The interactions of movement, exercise, and relaxation are important in complementary therapies. Physical expressions of energy benefit patients by reducing depression, elevating mood, increasing energy levels, assisting in addiction programs for alcohol and smoking, and strengthening the immune system. Movement and exercise also have many physiologic benefits for women, particularly in relation to decreasing the percentage of body fat, increasing bone density, and increasing both glucose sensitivity and glucose tolerance [146]. Health professionals should encourage women to try new expressions of movement, such as yoga, dancing, Tai Chi, or qi gong, which include both meditative elements and physical ones [244].

Healing or therapeutic touch is described as an energy field interaction between two or more people with the intent to rebalance or repattern the energy field in order to facilitate relaxation and self-healing [245]. Healing touch is a collection of noninvasive, energy-based techniques intended to make energy available to the patient [231]. It involves localized and systemic techniques to enhance relaxation and balance energy. Two theories suggest how therapeutic touch works. One suggests that pain (e.g., from infection, injury, difficult relationship) is stored in the cells of the body, which creates a disruption in normal cell function, thereby promoting disease. Therapeutic touch promotes health by restoring normal communication between cells [246]. The second theory is based on the principles of quantum physics. Blood contains iron, and as it circulates throughout the body, it produces an electromagnetic field, or an aura, which was once easily seen by all but is now seen only by those who practice therapeutic touch [246].

Touch or healing therapy includes a broad range of hand techniques that a practitioner may use either on or near the body to support balance and function. The hand may be used to apply pressure and motion on the skin and on the underlying muscle of the patient for purposes of relaxation, improvement of circulation, relief of pain, and other therapeutic effects. Touch as a therapeutic intervention in the United States remained underdeveloped until research demonstrated its benefits in the 1950s [231]. Following this, therapeutic massage became widely used during childbirth in the form of backrubs, abdominal massage over the uterus, and perineal massage at the time of delivery. Research studies have demonstrated that touch helps women cope with labor [231]. Older people are likely to receive the least amount of touch, and less mobile elderly people particularly respond positively to touch.

The process of healing touch involves much more than skin contact. It involves many aspects of being present with the patient and nonverbal interaction and response. Nurses refer to the "hands on" practice of nursing as touch therapy, therapeutic touch, healing touch, and a variety of other terms. Despite the different labels, the intent is to demonstrate care to another through touch. The objectives of these techniques are also the same: to provide relaxation, relieve physical and emotional discomfort, and aid in healing. However, just as not all nurses choose to work with the technology in intensive care, not all will choose to learn therapeutic touch techniques. Courses that teach healing or therapeutic touch are available for healthcare professionals. Generally, nurses know after a few encounters with therapeutic touch technique if this approach works for them as health professionals.

Touch is an ancient practice, and most cultures have developed forms of touch therapy that utilize rubbing, massaging, and holding as manifestations of the desire to heal and care for one another [245]. However, attitudes vary among cultures. One group may view touch as natural, while others view it as taboo. The healthcare provider must be aware of personal and cultural beliefs regarding touch.

There has been a growing interest in health and whole-person theology within the healthcare profession. It is crucial to emphasize that spirituality and religion are not synonymous. Spirituality may be defined as the unifying force of a person and a source of inner strength [247]. It is expressed and experienced uniquely by each individual through and within connections to a Higher Power, Life Force, the environment, nature, other people, or the self. Religion refers to a belief system and practices of worship. Religion is defined as an individual's beliefs in relation to the supernatural and usually includes a structured community of believers [247]. Religion per se is chosen. Spirituality is not subject to choice but is simply a manifestation of the person's wholeness.

Any approach to discussions of spirituality will depend upon the patient's background and beliefs. Spiritual care may be provided in many ways by healthcare professionals. Many healthcare providers may be uncomfortable with the concept, because they feel that spiritual care is intrusive and do not consider the wide variety of ways to provide spiritual comfort. Spiritual care also includes serving as a therapeutic presence and listening and talking to patients. Other traditional interventions include praying with patients, referring them to chaplains or clergy, and providing them with reading materials. While much is discussed in theory about the spiritual dimension, spiritual care, or spirituality, the practice of such care is infrequently carried out. Suggestions have been made that healthcare leaders and educators work toward increasing the comfort of providers in offering spiritual care by providing resources and education. The healthcare provider should learn to convey openness to the patient's expression of spirituality. Emphasis on spiritual care has declined within the healthcare professions in the pursuit of professionalism, and the trend has been to leave these aspects unattended altogether or strictly left to the clergy.

General guidelines for responding to the spiritual concerns of the patient can initiate from the basic premise that persons are spiritual beings. Healthcare practitioners should encourage patients to share concerns. Patients may need assistance in sharing very difficult aspects of their illness with others. Encouraging the patient to tell stories, show pictures, and connect with important milestones in their life is essential to spiritual expression. A health professional should have a willingness to be present with uncertainty, pain, or suffering, seeking not to "fix" but to be in the mystery with another. It is important for the healthcare provider to make statements to acknowledge the patient's spiritual states. It is also important to clarify with the patient if any specific resources or referrals are needed to help her deal with her concerns.

Based on the philosophy that menopause is not an "illness" but a normal life event, there are many complementary therapies that women may find effective during this life transition. Scientific findings remain uncertain about the long-term consequences of untested complementary therapies. It also remains unclear how women weigh the risks and benefits of all the variables, including osteoporosis, coronary disease, breast and endometrial cancer, herbal remedies untested and unapproved by the FDA, cost of therapies or prescriptions, and monitoring adverse events. It is thought that healthcare providers are most interested in disease prevention and that women are most interested in relief of menopausal symptoms. Women's decision patterns regarding complementary therapies often fall into these major categories [78,79,82]:

Healthcare professionals should make an effort to help women maintain a positive attitude toward menopause, seek as much current information as possible regarding both traditional and complementary therapies, and maintain a program of follow-up care to monitor the progress or adverse outcomes of the therapies selected.

A diagnosis related to health risk/health-promoting behavior often occurs in women with risk factors and/or symptoms of heart disease, weight gain, osteoporosis, or cancer. Specific health needs for these women include [134]:

Healthcare professionals may intervene in the following ways to ensure that women's health needs are addressed [134]:

As health professionals practicing in collaboration with other healthcare and community professionals, it is vital to be knowledgeable regarding proper health screening for women. In educating women and conducting health screenings, health professionals play a key role in the prevention of illness and the optimization of good health. Health professionals and patient advocates have an obligation to help patients truly understand and integrate the need for routine screening as a preventive strategy. Within these general guidelines, and practicing in collaboration with other professionals, it is important to take into account each woman's history and risk factors. Table 8 summarizes health screening guidelines, laboratory and diagnostic tests, and immunization recommendations to be used for patient education, referral, and clinical practice.

Immunizations are not only recommended for children. Each year, vaccine-preventable diseases have a costly impact, resulting in doctor's visits, hospitalizations, and premature deaths [255]. It is the health professional's responsibility to ensure the well-being of patients by adhering to immunization recommendations. Table 9 lists the 2024 CDC immunization schedule for women 19 years of age or older [256].