Book Review

Primary Care of Women

Women's Primary Health Care: Office practice and procedures

N Engl J Med 1995; 333:1361-1362November 16, 1995

Article

Primary Care of Women
Edited by Dawn P. Lemcke, Julie Pattison, Lorna A. Marshall, and Deborah S. Cowley. 583 pp. Norwalk, Conn., Appleton & Lange, 1995. $34.95. ISBN: 0-8385-9813-7

Women's Primary Health Care: Office practice and procedures
Edited by Vicki L. Selzter and Warren H. Pearse. 825 pp., illustrated. New York, McGraw-Hill, 1995. $65. ISBN: 0-07056225-3

Why should anyone buy a textbook about women's health? Many general internists have at least one textbook of ambulatory medicine on their bookshelves. Before deciding whether to purchase a separate book on women's health, these physicians must first decide whether they “buy” the field of women's health at all. As one of my generalist colleagues once said to me, “If you're doing women's health, what am I doing?” Her puzzlement over the proliferation of women's health centers is shared by many physicians.

If some physicians are skeptical about the need for women's health as a discipline, many of the women who are their patients are not. Voting with their feet, patients have been flocking to women's health centers for the past decade. One reason is that, in the traditional model of care, the care of women is often fragmented. Primary care physicians are trained to give general medical care and to refer patients to specialists for specific problems. Since many generalists feel uncomfortable treating women's gynecologic and mental health problems, women often shuttle back and forth among several physicians for their care.

Beyond the inefficiency and miscommunication generated by this system, there were also important gaps in expertise among most physicians about the health issues that women face. For example, a decade ago, no one thought to ask patients about domestic violence. Today, such questions are routine parts of history taking for medical students and residents, largely because of the integration of women's health issues into training programs.

Knowledge about women's health issues has often been passed from teacher to student all too informally, and the process of making this information accessible by means of reference works is just beginning. Two new textbooks, Primary Care of Women and Women's Primary Health Care, are welcome resources.

Primary Care of Women is a textbook that is aimed at helping primary care providers offer comprehensive, “one-stop shopping” care to women. Its 57 well-written chapters will be most useful to primary care physicians who are internists and family-medicine practitioners, although gynecologists with a generalist bent may also find it helpful. Much of this book provides information that cannot be found in traditional internal-medicine textbooks or even in textbooks of ambulatory medicine. For example, there are chapters on lesbian medicine, sexual abuse, and domestic violence — topics that are not covered in any of the other textbooks in my library.

The chapters in Primary Care of Women are organized consistently, with sections on incidence and risk factors, clinical findings, treatment, screening, controversies, and criteria for referral to a specialist. These chapters are clearly written and full of helpful information for clinicians actively involved in patient care.

The editors of Primary Care of Women were wise to limit their subject matter to diseases that either affect women predominantly or affect women differently from men. For example, there are chapters on urinary incontinence, but not renal failure, and on thyroid disorders, but not diabetes. They made no effort to create a comprehensive textbook of ambulatory medicine for women. There are no chapters on hematology or pulmonary diseases, for example, and the gastroenterology section is limited to one chapter on liver diseases, the focus of which is diseases that affect women predominantly, such as autoimmune hepatitis and liver disease in pregnancy. On the other hand, there are extensive sections on psychiatric disorders and issues that challenge women's health care providers daily — anxiety and panic disorders, mood disorders, and domestic and sexual violence. There are appendixes containing daily patient logs for recording symptoms of the premenstrual syndrome and a questionnaire on weight management.

Women's Primary Health Care is also aimed at helping clinicians provide comprehensive care to women, but it has a slightly different focus than Primary Care of Women. The strength — and weakness — of this book is that it covers a very broad range of topics. The first two sections include short, well-written chapters on screening and prevention that are full of practical information. There are useful tables of screening tests for women in different phases of the reproductive life cycle. A chapter on life beyond the menopause contains a state-by-state list of services available to the elderly. The review of preconception counseling has a table of common conditions encountered in pregnancy and appropriate actions that physicians should take in treating these conditions.

The weakest chapters are those that are similar to but not as comprehensive as corresponding chapters in traditional textbooks of medicine. The chapters on pulmonary medicine and renal disease, for example, do not add any special information about the care of women with these diseases. Similarly, chapters on gynecological procedures such as office endovaginal ultrasonography and colposcopy will be too technical for internists and not detailed enough for gynecologists.

On the other hand, the book contains material that women's health care providers will find quite informative and that is not covered in most other textbooks. For example, there are chapters on common plastic-surgery procedures, including breast augmentation and reduction mammoplasty, and on nonmalignant changes in the reproductive tract related to exposure to diethylstilbestrol.

The emergence of women's health as a discipline, with women's health care centers and women's health fellowship and residency programs cropping up around the country, signals the beginning of an exciting new era. Meeting the health needs of women is challenging work that requires familiarity with numerous disciplines. Those who choose to rise to this challenge will find these two new textbooks beneficial, if not essential.

Soheyla D. Gharib, M.D.
Brigham and Women's Hospital, Boston, MA 02115