Ageism and Gender Bias

Ageism and gender bias can affect to whom and how we ask about sexual health, sexual activity, and concerning symptoms. Depending on your own level of comfort and cultural norms this can be a tough conversation for some providers but this is an important topic. As this week’s required NAMS videos discussed, women are wanting us to ask about sexual concerns. This week we also reviewed sexually transmitted diseases and the effects of ageism on the time to diagnosis so it is necessary to ask these questions and provide good education for all patients. You will not know any needs unless you ask.   Review the following Videos and Transcripts below and answer the following questions. Please note the questions and answer below the corresponding question as set out below   Discussion Questions: ·     Review the required NAMS videos. What was the most surprising statement or topic that you heard in the videos? Explain why this was surprising to you. anANSWER ·     What is GSM? What body systems are involved? How does GSM affect a woman’s quality of life? ANANSWER ·     Review one aspect of treatment that Dr Shapiro recommends for GSM and include an EBP journal article or guideline recommendation within the last 5 years (2015- 2020) in addition to referencing the video in your response. A ANSWER Sexuality and the older adult ·     What is your level of comfort in taking a complete sexual history? Is this comfort level different for male or female patients? If so, why? ANANSWER ·     How will this week’s information impact the way you will interact with your mature and elderly clients in the future? ANANSWER   TRANSCRIPT #1 – Tips for Taking a Sexual History – YouTube   TIPS FOR TAKING SEXUAL HISTORY Hello, I’m dr. Marla Shapiro.  I’m a professor in the Department of Family and Community Medicine at the University of Toronto and I sit on the board of trustees at the North American menopause society.  I’m joined today by Dr. Cheryl Kingsburg, a well known face for us, chief of behavioral medicine at McDonald Women’s Hospital and professor and reproductive biology and psychiatry.  So the topic of sexual health many physicians, Joan included, in their functional inquiry or their exam and, in fact, many feel that it doesn’t make the list of their top ten concerns.  So well one of the reasons they don’t think it’s in their top 10 concerns is because it’s not life-threatening. However, most women, just like most men, would consider sexual health critical to their quality of life.  So even though it may not be life or death, it is critical to their quality of life and they will perceive their office visit much better, they have much better doctor-patient satisfaction, more likely to adhere to what your treatment options are, if you’ve asked about sexual health. So I think the bias from physicians is is that if this is an issue for a woman, she would bring it up.  If she’s not bringing it up, how do I even begin to take the history and how long is this going to take?  Sure well I’ll give you some good news; it doesn’t take long.  But the truth is that women are uncomfortable bringing it up, they don’t know a that sexual dysfunctions are real.  Conditions a lot of health care professionals don’t recognize them as real but they are and they  don’t know that it’s appropriate to ask for help, particularly from their doctor or their nurse practitioner so that’s why they’re not bringing it up.  They are absolutely desperate for you to ask and to ask is not going to set you back by 45 minutes.  It will take two to three minutes and you can do it very easily.  First of all, you can use a screener in the waiting room if that’s what you want.  If if you’re looking at, for example, low sexual desire the most common sexual problem, there’s a decreased sexual desire screener which is five questions that gets at a diagnosis.  And B, whether you can rule out all the other factors that might be the real cause of a low desire, like a medical condition, a relationship factor, or super stress in somebody’s life it you can have it already done and scored in the waiting room.  Other than that simply asking open-ended questions.  I know every body kind of shrinks from that, but what sexual concerns do you have and then you can follow up with “do you have concerns with desire arousal orgasm or pain” which will get you all the key categories and then you can make some decisions about treatment options.  From there you don’t have to do the treatment, just asking, normalizing it for women, validating their right to a sexual health already makes them feel satisfied with your office visit.  How many women are we missing by not doing this history?  Probably about 10 percent of your population.  We know from large epidemiologic studies, that about 1 in 10 women meet the criteria for a sexual dysfunction.  So if you think of no women in my practice are having sexual concerns, you are not asking seems like a pretty simple approach to a problem that is so prevalent.  I promise it as simple, it will not take up the whole part of your day, and your patients will feel very satisfied and very relieved that you want the best.  Thank you so much thank you.   TRANSCRIPT #2   GSM Dr. Shapiro – Hello I’m dr. Marla Shapiro.  As a physician, I am sure you have heard this new term “genitourinary syndrome of menopause (gsm).”  What is it, does it replace anything else, what’s new that we need to know?  And helping us with that very question is Dr. Jan Shiver and welcome Jan. Dr. Shiver – hi Marla Dr. Shapiro – Jan is the director of the midlife Women’s Health Center at the Massachusetts General Hospital in Boston.  So for most physicians who take care of women, we’re intimately familiar with VVA or a volvo vaginal atrophy.  Now we have three new letters “GSM”.  What does it mean? Dr. Shiver – Well, GSM or genital urinary syndrome of menopause incorporates VVA, so we’re not completely doing away with the term.  But what’s important realize is that VVA really just describes estrogen deficiency changes of the vulva and the vagina, but GSM really is a whole syndrome that involves symptoms of the vagina and the urinary tract and also sexual symptoms.  And these symptoms need to be bothersome and not accounted for by anything else but estrogen deficiency for a woman to have a diagnosis of GSF.  So it’s a much broader term absolute than VVA.  So I guess the important question to ask is is painful sex always a result of vva or there are other things, as a health care provider ,that you should be ruling out.  The most common reason for painful sex after menopause is definitely GSM.  Up to 80% of women will have symptoms of GSM, and in those women, over fifty percent will have bothersome pain with intercourse.  So it’s really the number one cause of discomfort with intercourse after menopause.  But of course it’s important to think about other alternative diagnoses.  There could be a lesion in the vagina that would need to be seen on an exam and treated.  There could be another anatomic or structural change, such as endometriosis or pelvic mass so of course you do anything about other alternative explanations.  So many of these women have tried over-the-counter lubricants plus-minus moisturizers and don’t really get much better or still symptomatic and they end up in our office.  Often we don’t ask.  Hopefully physicians will ask so what’s available for treatment that we can offer them once they’ve tried moisturizers, once they’ve tried lubricants, and it’s it’s just not, you know, really helping all that much.  Well pelvic PT is one other non hormonal option that I do like women to think about.  It can make a big difference, but if moisturizers lubricants and pelvic PT for those women who may need it is not effective, really low dose vaginal estrogens are our most effective treatment.  So that’s physio therapy that you’re talking about right and where can doctors really find helpers to help them with this really specialized area.  Yeah I mean really we just you want to find a certified physical therapist who has a lot of expertise in the pelvic floor and this is really becoming a much more common referral in my practice.  Women with incontinence, women with pelvic pain, and women who’ve had.   Typically for my patients with GSM, it’s often women, let’s say, with a history of breast cancer.  And they have not been active for a while, during treatment and now they’re trying to reinitiate their sex lives and we’ll start with lubricants and moisturizers, but there’s still so many changes in the pelvic floor that they’re having a lot of discomfort and that group of women will really benefit often from the combination of moisturizers lubricants and pelvic PT.  So let’s go on now to local estrogen vaginal therapy..First the local therapies that are available, a word about them, there are three highly effective forms of low-dose vaginal estrogen, there’s a tablet that’s placed in the vagina twice weekly, creams that are placed in the vagina two or three times weekly, and it’s very simple to use vaginal ring that’s put the vagina.  Left in for three months again releases a very low dose of estrogen over the three months and for women with an intact uterus, is a progestin ever indicated.  You do not need to use a progestin when you’re using very low doses of vaginal estrogen .  Essentially the low dose vaginal estrogen products will not bump a woman’s blood level of estradiol, so there’s no need for concurrent estrogen along those lines.  Though I always say every postmenopausal woman should be reminded to report any bleeding after menopause, even if it’s after sex now.  Because it hardly bumps the level or doesn’t bump it at all.  What about women with breast cancer?  Those who are no longer on active treatment and the nthose that are on one tase inhibitors, for example.  Well so for, let’s say, we have a patient who’s not on an aromatase inhibitor, the majority of this woman really can safely use low doses of agile estrogens as you said.  Simply because the blood levels aren’t bumping. I typically do speak with a woman’s oncologist and make sure the oncologist is also on board with treatment, but many oncologists are especially if we may have tried other options and they’re still really distressed by changes in their sex life.  And for those on aromatase inhibitors the tricky thing there is that the goal of aromatase inhibitors is to take the low levels of estrogen that are present in postmenopausal women and basically reduce them to almost unmeasurable.  And so, although, low-dose vaginal estrogens don’t bump estrogen blood levels above typical levels for menopausal women, there will be a small amount absorbed.  And so for women on these it’s probably not a good idea.  And for older women, as often we will be seeing older women who were initiating therapy, hypertension heart disease can they be using the absolutely a history of a heart attack,stroke or leg or lung clot is not a contraindication to low doses of vaginal estrogens.  Blood levels don’t bump and they really should be very safe in those women, as well I guess.  The important messages is that we do have so many effective medications for general urinary syndrome of menopause yet so many women aren’t on therapy often because we just are not asking essentially.  Every clinician needs to ask every postmenopausal patient at every well visit every comprehensive visit to have any vaginal dryness discomfort with sexual activity any concerns about your sex life

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