Book Review

Health Care for the Older Woman

N Engl J Med 1997; 336:592February 20, 1997

Article

Health Care for the Older Woman
Edited by Morton A. Stenchever. 400 pp., illustrated. New York, Chapman & Hall, 1996. $99.95. ISBN: 0-412-05401-9

Reviewing a book on women's health care requires a vision of this field if one is to have a standard against which to test the book's coverage and organization. There is no consensus on such a vision. For some, women's health care is nothing more than a marketing concept. For others, it is the name of an emerging specialty. For still others, it refers to the medical aspects of women's organ systems.

As a way of approaching this book, I propose the following, admittedly preliminary, definition. Women's health care is the process of providing high-quality integrated health care to women not only for diseases unique to women but also for those that differ in manifestation or frequency between women and men. Thus, my proposed definition is, in the now-fashionable language of total quality management, “customer-centered,” characterizing care as that given in response to patients' needs, rather than according to traditional specialties, and in a way that provides for continuity over time and across conditions.

Given this definition of women's health care, Health Care for the Older Woman is trying to do the right thing. It is, however, better in concept than in implementation. The book is a compendium of discussions related to aging and the medical care of older women. Such a broad perspective appropriately tries to bring together the many aspects of women's health. However, the coverage of topics appears to reflect the knowledge and interests of the authors more than a comprehensive and systematic review of the field. (Seventeen of the 20 chapters are by the editor or his colleagues at the University of Washington, Seattle.)

Several chapters are excellent, conveying specialized knowledge clearly and facilitating the integrated approach that should characterize women's health care. The chapter on hormone-replacement therapy (by Donald E. Moore) covers some fundamental issues often omitted by other reviewers, such as decision making at the personal level versus decision making at the public health level, skin changes, and current knowledge about the effects of progestin on cardiovascular disease. The references are up to date. The chapter on exercise and aging (by M. Elaine Cress and Felicity A. Green) brings to the reader's attention both specific problems and specific solutions with which physicians are generally not familiar. The chapter on aging and pharmacotherapy (by George N. Aagaard) summarizes the mechanisms by which aging may be related to adverse drug reactions and offers practical suggestions for optimizing drug therapy in older women.

Some areas of great importance in the care of older women — who are often widowed and living alone — are not addressed, including social isolation, end-of-life decisions, and alternative living arrangements. The chapter on nutrition discusses nutritional interactions with a wide variety of drugs but is not integrated with other discussions or referred to elsewhere in the book. The book also suffers from an apparent lack of attention to detail and editing. For example, on page 340, the date on the figure legend is 19XX. Also, the photographs on pages 346 and 347, showing an examiner's ungloved hands on the vulva, are inappropriate for a textbook published in 1996.

The intended audience for this book is sometimes unclear. The chapter on pelvic support describes in detail how to perform surgical procedures — information that is more appropriate for a surgical textbook than a general textbook. If this book is intended for surgeons as well as ambulatory care physicians, why aren't the various types of breast surgery described?

In short, despite several excellent chapters, this book suffers from some of the very problems that women's health care is designed to overcome: lack of integration, duplication, and gaps in coverage.

Susan Haas, M.D.
Harvard Medical School, Boston, MA 02115