A woman goes to the doctor. She is in pain. Chances are, since the pain sits in her abdomen, just above the bikini line, she has gone to her gynecologist. The doctor examines her. That doubles her pain. She is not pregnant. The tests are all negative. When is the pain worst? the doctor asks. The woman replies: During sex. The doctor nods. He looks concerned. Your husband is perhaps a little rough? The woman looks surprised. No, not at all. The doctor nods. There is nothing wrong with you, dear, he says. There is nothing medically wrong with you.
The woman goes home. Perhaps she cries. She puts up with the pain. She puts up with the pain for years, until it becomes unbearable, then she goes back.
More tests, all negative. But what's this shadow on the ultrasound? The doctor looks. It's nothing. He nods. You're in perfect health.
But that shadow . . .
She goes to her family practitioner. The pain is here? He examines her stomach, her kidneys, her gallbladder, her appendix. Have you seen a gynecologist? When she refuses to go back, he refers her to second gynecologist, a woman, in another city.
The new gynecologist examines her. She has the ultrasound sent. She sees the shadow. It could be a hernia, she says. She recommends surgery. The insurance company requests a second opinion. The consulting doctor disagrees. Such a hernia would be very rare.
The patient despairs. The internist persists. The surgery is done in a teaching hospital. The internist calls in all her students. It's the largest enterocoele hernia anyone has ever seen.
Is this story extreme? Perhaps. It's also true.
Luanne Thorndyke, a physician herself with a practice of some 2,000 patients, tells a story very much like it. "In internal medicine," she explains, "we study abdominal pain with the exclusion of the reproductive tract. If a woman presents with abdominal pain, as a classically trained internist I would think of the stomach, the gallbladder . . . If I ruled everything out, I'd tell her to go see a gynecologist. Women have always needed two physicians.
"And the two doctors usually don't even talk to each other," she adds, "except through the patient, through you. It's a division that makes no physiological sense. It's not a good organizational structure." As assistant dean for continuing medical education and an assistant professor of medicine in Penn State's College of Medicine, Thorndyke sees that as something to fix. "The organization of how we teach about women and the care of women has to change. The male is still the standard model for physicians. Women are viewed as "male plus reproductive system'—either that or simply as "the Other.' But it's much more complex than that. The differences need to be sorted out."
"The amount of research that has been done on women has been pitiful and unacceptable," adds Thorndyke's colleague, Joanna Cain. In addition, notes Cain, who is director of the division of obstetrics and gynecology in the Penn State Geisinger Health System, "Women tend not to be good advocates for themselves.
"As a gynecological oncologist, I see it in two diseases," she says, "ovarian cancer and endometrial cancer. I've had a patient come in and tell me, "My abdomen has been getting bigger and bigger, but I thought I was just eating too much.' She had vague gastro-intestinal symptoms, which is common with ovarian cancer. She was 50 to 60, the right age range. The doctors she went to see never did a pelvic exam. I said, "Didn't you have pain in that area? What did you do?' She told me, "I just didn't eat for a week. I drank liquids.'
"Now men and women with cancer are a unique group, but women put up with a whole lot more without saying a word. They are much more stoic about suffering then men are. They just accept it as a part of life.
"Women's pain isn't treated—their cardiac disease isn't treated—because they just don't speak up. If you're used to pain every month, and it may be excruciating pain, you'll say, "My pain control isn't very good,' and put up with it."
Cain and Thorndyke are behind the new Women's Health Center at Penn State's Hershey Medical Center, Cain as its director, Thorndyke as chair of the task force that recommended it. An autonomous building done up (with the input of focus groups) in slate blue, rose, and sea green, the Center sits on Cherry Drive, a few miles from the hospital. Its marketing brochure exclaims, "A woman is more than a body," and lists the Center's specialities: annual exams, family-centered obstetrics, high-risk pregnancy care and genetic counseling, family planning, infertility and endocrinology, pregnancy loss and bereavement counseling, breast care and mammography, nutrition and weight management, adolescent health, eating disorders, sexually-transmitted diseases, sexual dysfunction, PMS, female incontinence, osteoporosis care and prevention, menopause and transition management, health lifestyles and stress management, and anxiety and depression management— or, as Thorndyke put it, "one-stop shopping" offered in a "gender sensitive" manner.
"The question about women's health centers," Thorndyke admits, "is where do they fit in? Are they offering a higher quality of care? Or are they just catering to a marketing niche?"
In a June 22 New York Times article, women's health centers were labelled "a medical mall," by one patient, noted for their "boutique health care" by another, dismissed as "a big marketing attempt" by a (female) doctor, and commended for hiring "doctors who will collaborate not dictate." From 1991-92, the paper reported, the number of hospitals with a women's health center rose 19 percent, according to the American Hospital Association. The Times calls them the logical next step in a progression that began with maternity hospitals and proceeded through family planning clinics, birthing centers, and breast-cancer centers; Thorndyke sees them as an outgrowth of the women's movement. In the '60s and '70s, "women's rights really meant equal opportunity and access, while women's health meant reproductive rights and control over one's own body," Thorndyke says. Women started family planning clinics, pushed for the legalization of abortion and the availability of birth control. Later came a resurgence of support for midwifery. Birthing centers became common in hospitals, and the number of female physicians rose. Women also turned their attention to medical research, to improving their health by increasing research on breast cancer and reproductive issues, especially infertility, a movement that culminated with the appointment of Bernardine Healy to head the National Institutes of Health and the passage of legislation forcing the inclusion of women in drug trials and in federally funded studies of disease.
"The movement now, at the end of the '90s, is to empower women to make decisions, to bring the new research about women's health to bear. What we're trying to do at Hershey Medical Center," Thorndyke continues, "is to pull together a multidisciplinary approach. We're more than just an ob-gyn group that's calling itself a Women's Health Center. Our approach is a little different. We'll have gynecologists, internists, and pediatricians all in the same building. The difference is the way you organize on-going care. This gets to the heart of how health care is provided."
There will also be a large library, a Community Health Information Center, with books and pamphlets, computer connections to the state and local library systems, a CD-Rom collection, videos, and the TVs needed to screen them. Says Thorndyke, "We want the Women's Health Center to be a focal point for the dissemination of information about women's health issues, a place to organize new educational programs both for health professionals and for the general public."
Cain agrees. "Basically it's a site for training physicians in patient communications. That's what the Women's Health Center is all about. This building is the first of two hubs"—the other to be built at Geisinger Medical Center in Danville, PA—"that will connect to libraries and cooperative extension offices and physicians' practices and beauticians and whatever works to get health-care information out to women."
"Part of the problem in women's health care," says Cain, "is that many assumptions in medicine are made, not really by the art of medicine, but by practice that has been passed down from generation to generation. The art of medicine is understanding where an individual woman is coming from."
What is women's health? When the New York Times ran a special section on the topic, it covered women's health centers, how to deal with doctors, a dozen (women) who have risen to prominence, teen pregnancy, HMOs, menopause, smoking, women's knowledge of health issues, breast cancer, pap smears, depression, books about women's health, diet drugs, postpartum workouts (with baby along), a woman's life cycle, emergency rooms, contraception, screening tests, living longer, family violence, medical education, research funding, fitness, health foods, and the ground-breaking book, Our Bodies, Ourselves. Advertisements ran for cars, retirement centers, breast cancer treatments, breast reduction, athletic shoes, infertility, clothes and fashion, menopause treatments, hospitals, beautiful legs, thinning hair, fashion shoes for problem feet, investments, health books, drug companies, anxiety medicines, health-care programs, arthritis, and hormones.
According to Phyllis Mansfield, a Penn State psychologist and health educator who specializes in women's health, the Times's grab-bag list might not even be all-inclusive. "Women's health is a field that arises not just because women's bodies are different from men's," Mansfield says, "but because of the particular conditions and circumstances that surround the issue of women getting good health care. Women are in a position in our culture that makes getting good health care much more difficult. They're stereotyped, marginalized.
"Part of it is recognizing the stigma around certain health conditions that women experience that makes these topics ignored or considered unimportant. There's been a lack of interest, for example, in understanding premenstrual syndrome. There are misconceptions surrounding pregnancy and the post-partum period. There's silence surrounding menopause and all aspects of menstruation.
"And we have to consider, too, the effects of violence towards women: how the culture of violence, in all its forms, from harassment to rape to domestic abuse and incest, affects women's health, from the most obvious ways, such as beatings, to the incessant fear women carry around with us whenever we have to walk on dark streets. The long-term effect of this fear or suppressed anger on our bodies is unknown, but I'm certain it's significant.
"This is just one example of how the field of "women's health' must go way beyond the physical body to include issues of gender and gender roles."
Gender roles in a different context explain why women have always needed two doctors, a GP and a gynecologist. Explains Thorndyke, "The medical profession really started with two major divisions. There was surgery and then there was medicine. Physicians, who practiced general medicine, took care of both men and women, but as late as the 1800s, they were not permitted to examine women in the reproductive area. Reproductive issues were left to the midwives, who were female.
"Then, in 18xx, surgical gynecology became a subspecialty under surgery. By the late 1800s, surgeons were pulling obstetrics into the specialty, drawing reproductive issues into the medical arena, and excluding the nurse midwives from the medical profession.
"At the same time medical subspecialties were developing, such as cardiology, gastroenterology, neurology, endocrinology. So you had this division of a woman's body into two different areas. Reproductive health came out of the surgical tradition; the rest of a woman's body was in medicine.
"The women's health centers started out of a desire to draw those parts back together."
Currently Cain and Thorndyke are researching the problem of how to educate women, and in particular the rural women of central Pennsylvania, about their health. Will women pick up health pamphlets placed in beauty shops, or would it be better to go through their physicians? Or county extension agents? Or local TV?
"We need to develop advocacy," Cain stresses. "A patient needs to be able to come in and say, "Here are my symptoms,' and the physician needs to be able to answer, "Here's the range of what's normal.'"
For instance, post-menopausal bleeding could be an early sign of endometrial cancer, determined by a simple biopsy during an office visit. "It's not as difficult as it used to be to diagnose," Cain says, "and it's curable—if women pay attention. What concerns me is when a younger woman says she's getting heavy bleeding with her periods and she's ignored. She might also need an endometrial biopsy. There's a range. If she's bleeding heavily—two pads an hour, two big pads—and if it doesn't resolve easily, that is if we put her on birth control pills and it doesn't immediately go away, then she could need a test for endometrial cancer.
"We have to find vehicles for women to become comfortable talking about symptoms like heavy bleeding. It might be we don't take seriously the issue of heavy bleeding every month, we don't take seriously the effect of PMS and anemia, how much it all impacts a woman's work life and home life.
"It's a two-sided problem: Physicians write it off and don't deal with it, women write it off and miss important signals."
The Penn State Women's Health Center opened in February. Joanna Cain, M.D., is director of the division of obstetrics and gynecology, Penn State Geisinger Health System, Hershey Medical Center, P.O. Box 850, Hershey, PA 17033-0850; 717-531-8629; email@example.com. Luanne Thorndyke, M.D., is assistant dean for continuing medical education in the College of Medicine,Hershey Medical Center; 531-8161; firstname.lastname@example.org. Phyllis Kernoff Mansfield, Ph.D., is professor of women's studies and health education, College of the Liberal Arts, 14 Sparks Bldg., University Park, PA 16802; 814-863-0356; email@example.com. The New York Times special section on Women's Health was published Sunday, June 22, 1997.