April 11, 2024
The Continuum of Care in Women's Health Issues: Interview with a women's health practitioner.
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Embark on an enlightening journey through the multifaceted realm of women's health with Dr. Ingeborg van Leeuwen, affectionately known as Pinky. With her extensive expertise, our latest episode promises a treasure trove of insights. From the angst-filled teenage years and menstrual mysteries to the transformative phase of menopause, Pinky offers her seasoned perspective on the array of challenges that women encounter throughout their lives. Additionally, she shines a light on her role in shared obstetric care, children's health, and Indigenous health, showcasing how general practitioners like her weave a tapestry of knowledge to adeptly manage the diverse needs of their patients.
Navigating sensitive health topics with grace and empathy, Pinky provides a masterclass in addressing issues and offering a beacon of non-judgmental support. We uncover the nuanced art of fostering lifestyle changes, tackling obesity and smoking, while Pinky outlines a comprehensive and empathetic fertility counseling method. This conversation is a solemn reminder of the delicate care and understanding needed when delving into the most intimate aspects of health and wellness.
In our final chapter, myths about hormone replacement therapy are unraveled, and the conversation pivots to how innovations like IUDs have revolutionized options for women, minimizing the need for more invasive procedures like hysterectomies. Pinky also applauds the role of male practitioners in women's health, dispelling any reservations about their capacity to contribute meaningfully. We conclude by addressing pediatric concerns and the cognitive effects of urinary tract infections in older women, alongside an emphasis on the importance of continuous learning for medical professionals. This episode is an essential listen for anyone vested in the intricate layers of women's health, with practical advice and compassionate insights from Dr. van Leeuwen.
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Transcript
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In Aussie Med Ed, we've covered a lot of areas of medicine.
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One area of medicine we haven't covered as much of is general practice.
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It's such a huge spectrum of medical conditions that need to be covered.
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It's amazing general practitioners can keep track of it all.
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Consequently, over time, general practitioners have become more super specialised in their areas as well.
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And one area is Women's Health.
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well today we're lucky enough to be joined by a general practitioner who specialises in that, Dr Ingeborg van Leeuwen, also known as Pinky to her friends.
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Pinky's going to talk to us about her medical practice in women's health and also what other areas she covers.
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G'day and welcome to Aussie Med Ed, the Australian medical education podcast, designed with a pragmatic approach to medical conditions by interviewing specialists in the medical field.
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I'm Gavin Nimon, an orthopaedic surgeon based in Adelaide, and I'm broadcasting from Kaurna Land I'd like to remind you that this podcast podcast players and is also available as a video version on YouTube.
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I'd also like to remind you that if you enjoy this podcast, please subscribe or leave a review or give us a thumbs up as I really appreciate the support and it helps the channel grow.
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I'd like to start the podcast by acknowledging the traditional owners of the land on which this podcast is produced, the Kaurna people, and pay my respects to the Elders both past, present and emerging.
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I'm very pleased about to welcome Pinky to us.
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Pinky works in general practice in Brighton area but also practices up in Alice Springs in women's health.
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Her sub specialties include women's health, children's health, as well as indigenous health and lifestyle medicine.
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Welcome Pinky.
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Thank you very much for coming on board.
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Thankyou Gavin for having me, I'm very excited to be here.
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Well, perhaps
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you can actually start off by describing what women's health actually is.
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What main conditions does it cover in general?
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Gee,
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as you said, it covers a broad range of conditions.
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If we start from a very young age, it's the pre pubertal girls going, through adolescence with menstrual problems, heavy periods, irregular periods and other aspects of adolescent health, especially in the females.
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And then through to adult women who come in, for example, for advice on fertility, or for preconception advice, and then through to pregnancy, I am lucky enough to be able to cover shared obstetric care, which means that together with, public hospitals, we share the care of pregnant women, and most of their antenatal visits will be with their GP, and then from 36 weeks onwards we sent them back to the public hospital, and that's where they have their babies, And then of course afterwards, we're lucky enough to see the mother with their bubs.
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And try to support them as best we can as general practitioners.
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All the way through, I'm just skipping a whole lot of course, but supporting young mums, very important.
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And through to perimenopausal women, through to postmenopausal women and the elderly.
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women.
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It's too much to to explain in a podcast really, isn't it?
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Well that's a huge area to cover and as you're talking about, women's health as well I recall that you aslo look after indigenous health and also lifestyle medicine, how do you keep abreast of all these latest developments in these areas and keep upto date in this area?
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Of course, that is a frustration I think that a lot of general practitioners will share with me.
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you.
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know a little bit about a lot of things, and perhaps with women's health I know a little bit more about that particular area, but it's still difficult to be an expert in everything.
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So it is always trying to read, to go to conferences, but also to accept that you won't know everything, and that we have very good specialists that we can refer to if need be.
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Why did you choose to go down the path of women's health?
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What was your main reason for doing so?
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Well I trained in the Netherlands and I always wanted to be an Obstetrician / Gynaecologist and I went to the United States to do some research in obs and gyne, in endometriosis and recurrent pregnancy loss.
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Still with the intention to do obs and gynae.
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Came back and worked as a service registrar for a year and a half.
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And then I fell in love with a surgeon and we thought we would have children and I thought that's a little bit difficult.
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The huge time investment and I thought, I think I'm going to doing general practice, but I will try to focus on women's health a little bit as well.
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Perhaps you can describe a typical day in a general practice looking after women's health.
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What's your typical day?
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So for those thinking about heading down this path, they've got an idea of what it involves.
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Well, of course I'm mostly a general practitioner.
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So anything from an itchy earlobe to tinea to a heart attack to a dog bite can walk in my door.
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But I also have a lot of women who come in for advice, and I have some procedures that I usually do.
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Apart from talking, there are, is some doing as well, which I'm sure you would like as a surgeon yourself, Gavin.
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. So, usually, iud insertions and removals, implanon, but also an ingrown toenail.
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And then, as you mentioned before, I travel to Alice Springs every 4 - 6 weeks to do mainly women's health and IUD insertions.
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insertions there.
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So as a general practitioner, are you working five days a week, seeing patients non stop?
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Are there other administration aspects of your job as well?
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Are there other areas of training that you have time for?
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How does it actually work in general practice?
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It's tricky because The admin you'll have to do in your own time and I do that in the evening, sometimes on a Saturday, sometimes I will do some phone calls some telehealth consultations in the weekend as well, especially when I'm in Alice Springs, I still have to call my patients in Adelaide and vice versa if I have results that are abnormal.
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But it does involve a little bit more than just your nine to five job,
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It is quite a shortage of general practitioners worldwide.
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And I'm not sure why people are choosing to not go down this path, because it is quite a rewarding job looking after patients from the young to as they get older.
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What would you say the most enjoyable part of your job is
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I absolutely agree.
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it's never a boring day.
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And you have the opportunity to Do the things that you like even more so, as you said, I have, colleagues who do a lot of musculoskeletal pathology, who do palliative care, who are passionate about urology skin excisions.
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So that's the good thing.
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You can have your area of interest and it is it's a shame that not more medical students choose general practice as their.
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profession.
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Hopefully this will help inspire them.
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I hope
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I hope so.
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What are some of the more common things, that you see day in, day out?
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Contraception is a huge deal.
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I think there are a lot of, women, especially young women , who seek contraception, who are not aware of the new options we have.
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For example, IUDs are very suitable for young girls as well, and a lot of them seem to believe that you have to have had children to be able to have an IUD, which is not And I see a lot of mental health and a lot of girls seeking advice about simple things about their body not aware of, who are very conscious of their body, frustrated about their body, who feel that their body image is distorted.
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So it's good to give them advice and that's where the lifestyle medicine comes in handy as well.
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Can you outline to me what lifestyle medicine involves?
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Is it part about preventative medicine?
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About looking after general health as well of the patient?
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Or, what do you consider as lifestyle medicine encompasses?
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It is both prevention of chronic disease, but also treatment.
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And of course sometimes it won't be the only treatment.
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And there will be tablets involved or other or procedures but it definitely should be part of the management of.
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prevention and treatment of chronic diseases
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okay, so you're not only doing women's health and indigenous health, looking after children to adulthood and then to older age, but also you look after preventative medicine as well.
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It's quite a busy job you've got there.
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Must be quite enjoyable, but also taxing as well.
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I am very busy but my mother used to say you have to pick a profession that you love and it won't feel like work and that's right, it doesn't feel like work.
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I enjoy it.
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So he talked about the mental anguish of body image issues and this obviously causes a lot of problems in women's health.
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But also what about monetary issues too?
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There's a lot of monetary pressures at the moment as we come out of this COVID era.
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Is that causing a lot of anguish and mental issues at the same time as well and double impact?
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Absolutely, I think any general practitioner will deal a lot with mental health.
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I don't know exactly what it is, why there is such huge problem with anxiety and depression.
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And it is very rewarding to discuss those things.
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The good thing as a general practitioner is that you don't have to fix all their problems in one consultation.
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You won't have time for that.
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So you can always get them to come back and have them book a longer appointment, organize a mental health plan for them, refer them to a psychologist if need be.
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But also sorry to have to mention lifestyle medicine again, but exercise as treatment for mental health problems is very important and talking about their diet and body image in general as we mentioned before.
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So what's the pathway for a medical student heading down the path of general practice and then into women's health?
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How do you actually head down this pathway?
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Are there any particular training courses or other Aspects of training that a general practitioner has to do as they head down the path of women's health.
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think there are a lot of ways where you can arrive, with this as your area of interest.
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As I said, myself, I trained a little bit in obs and gynae and, did lots of deliveries in the Netherlands.
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But I think the Royal College of GPs also provides modules that the registrars can train to arrive with that as their special interest.
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And of course you probably get support from other colleagues along the way.
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we
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a WhatsApp group.
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, through MedCast, and that's very helpful.
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You can't do it alone.
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And I've got a couple of very nice gynecologists that I can always call.
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Thank God.
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Yeah that's the great thing about medicine.
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It is a team approach.
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So what is your general approach for treating delicate topics?
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You've talked about the mental anguish.
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Also, there's, on ones we haven't touched upon, there's also, there's a lot of domestic violence issues now.
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Violence against women, which is really terrible.
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We're hearing more about it in the media.
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Yeah.
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Which, a general approach to dealing with these sort of things.
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Of course, the first thing is to think about those things to think about domestic violence.
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If you don't think about it, that it could be happening, you will miss it.
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To then say if it's a young girl to ask for permission to speak with her alone, or if someone comes in with their partner to see if you can speak with the patient on their own without their partner.
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And to gently probe and ask to see if there are symptoms and signs of that.
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And to offer them help.
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I think the main thing is to not be judgmental or to try and solve it for them.
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They might not be ready for that and offering your support now but also in the future is really important so that they know that they can come to you when the time's right.
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I presume you'd always make another appointment at some stage for a follow up in that scenario or?
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So if they know you're open for it we definitely screen pregnant women, because then it's not enough to just keep your eyes open.
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Then you have to actually ask, because it's sadly quite common in pregnancy domestic violence.
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So it's really important to screen for that at that time.
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Yes.
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there's a lot to watch out for.
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Yes, But the good thing is we know them, hopefully.
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We know them, we know their background, sometimes we know their parents, we know their history, and we have time as our friend.
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And that really helps.
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We don't have to solve problems, as I said before, in one consultation.
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Pinky, what's your approach to dealing with lifestyle issues as well?
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Obviously a major issue at the moment is a raised BMI or some obesity, which can cause chronic problems in later life, as well as other issues that can occur, smoking and other drug related conditions.
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What's your approach to dealing with all these other lifestyle conditions in medicine?.
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That's always tricky to balance your time.
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There's never enough of it, of course.
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Usually, when they come in with an acute problem, I try to, of course, address that first, and then find some way into my lifestyle prevention health check point.
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And usually I ask for permission, Can I check your blood pressure?
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Is it okay if I check your weight?
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Because it is relevant for your acute problem, for example.
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I offer them a blood test.
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And most patients, when you ask for permission and ask it in a non judgmental way, are quite open for it, I think.
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Yeah.
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I think
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expect it,
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Yeah.
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And the other things too, smoking and vaping, what are your thoughts on dealing with that and how do you address that for any person coming through the process?
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Well, you have to screen for it, so, you know, now you don't just ask for if they smoke, if they use illicit drugs, if they drink alcohol, but also do you vape?
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And if they do, then I will tell them, In very clear terms that this is very unhealthy and a threat to their health and that I would recommend for them to quit.
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quit.
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Yeah.
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And are there any particular tips I can learn from you to help broach that issue?
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Ooh, I think if there is a particular acute problem that they came with and smoking has an effect on it, I can use that for a reason for them to quit.
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But of course, as we learn as general practitioners, you want to assess first if they are ready to change their behavior.
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and if they're not ready to change their behavior.
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You don't want to waste your time trying to convince them.
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You can give them the facts and tell them to come back , if they want some help in quitting.
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if they're not ready to quit, then there is, it's a waste of your energy.
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And I would give them some handouts and some phone numbers, like the quit line, things like that.
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Let's say a patient comes through to you, a lady who wants a general screen to make sure she's okay.
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If she's thinking about trying for a child and she hasn't had any success.
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What are your general approaches to both dealing with the initial problem, the lack of conception, but also just general checking for lifestyle issues too that may affect her long term?
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a lot
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of of topics to discuss with that lady.
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First of all, I want to know how old she is to see how long we would let mother nature do its thing to see if she would fall pregnant naturally.
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If she is less than 30 years old and she has tried for six months, I wouldn't be so worried, and I might tell her after checking, of course, what her menstrual history is like, to maybe try a bit longer.
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But of course, if she is approaching 35 to 40, we don't have that much time, and I would be in a bit more of a proactive I would check obstetric history, menstrual history, as I've discussed, And also family history.
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Are there any chromosomal or genetic conditions in the family?
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Since November last year, I believe we now can offer genetic carrier screening to women who are in the reproductive age.
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Ideally before they fall pregnant, but if they are already pregnant we offer it as well, but there's just less options.
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So we offer them genetic screening for cystic fibrosis, a fragile X, and spinal muscular atrophy.
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And I would check, as you said, blood pressure and body mass index see how active she is, what her lifestyle in general is and tell her that that can have an impact on her fertility.
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and her husband's or a partner's health is also very important.
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We forget the partner usually, but apparently that's paternal health, is very important as well.
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Okay.
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And then we would offer some blood tests.
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We would check if Rubella antibodies are significant.
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If she's had Varicella, Chicken pox we would check vitamin D levels, iron levels, screen for STDs, and I have forgotten quite a lot, I'm sure, just telling you this on top of my head, but I would check my little checklist.
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Well, it's fairly extensive, so there's a lot to go through there.
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You wouldn't be able to do all that in one visit, of course.
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NO but very important, good opportunity to do a general health check really
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on to the other lady, the one I might send along back to you, who's fallen over and broken a wrist at 53 years of age, for instance, and Maybe she smokes occasional cigarettes and I'm concerned that she's broken her wrist and she needs an osteoporosis check.
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How do you approach that and what's your general technique of dealing with those scenarios then?
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That's one of my favourites as
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well.
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I think that it's important to think about it, so I think that I really appreciate the orthopaedic surgeon thinking of those things.
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Sometimes I think they just might get treatment but then somewhere get lost in the system and then not get screened for osteoporosis.
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But usually if it's, especially if it's a low energy trauma, I would want to know her family history.
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As you said, if she smokes, if she is active, what her body mass index is, if she is really skinny for example I would certainly offer her a bone density test and I would also x ray her spine to check for vertebral fractures to see what sort of management we have to go from there.
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Right, and once you've done your DEXA scan looking for osteoporosis, what's your mainstay of treatment in that scenario?
00:18:36.420 --> 00:18:43.181
Do you manage the full gambit up to biophosphate commencement or do you involve another specialty in that area?
00:18:44.020 --> 00:19:03.915
Usually unless there are complicating factors, we would manage that in general practice, yes absolutely and I would certainly try for perimenopausal and postmenopausal patients to start doing some resistance training super important.
00:19:03.915 --> 00:19:08.355
We lose body muscle mass about 8 percent every 10 years, I believe.
00:19:08.395 --> 00:19:11.326
So that's really important for her bones as well.
00:19:11.736 --> 00:19:27.685
And I would then send her to the dentist to make sure she doesn't need any major dental procedures and then discuss with her the options for treatment with bisphosphonates or the newer denosumab injections, calcium and vitamin D.
00:19:30.000 --> 00:19:30.490
Excellent.
00:19:31.030 --> 00:19:39.316
Going on this sort of area of scenarios, the the actual other one that comes to mind in women's health maybe is the lady who presents with some discharge and you're concerned about STD.
00:19:40.445 --> 00:19:44.016
How do you approach both the diagnosis and also then the prevention,
00:19:44.016 --> 00:19:51.316
well, of course, Any woman in the reproductive age, we have a very low threshold for STD screening anyway.
00:19:51.836 --> 00:20:08.330
So, I usually ask for consent and, swab when possible, and explain to them that this is important, that it is easy to miss, that they can be asymptomatic, in that it is very easy to treat and if left untreated can cause fertility problems.
00:20:08.340 --> 00:20:10.221
So most women are happy with that.
00:20:10.851 --> 00:20:29.486
And if I am afraid that a woman might have an STD, I would certainly do swabs and a blood test to check for a screen for STDs and then make sure I don't do a phone consult but get her back in face to discuss the results.
00:20:29.486 --> 00:20:40.596
And usually when I know the outcome, I will also print out some some patient information sheets because we then have to talk about Tracing the contacts to make sure that this doesn't spread.
00:20:40.650 --> 00:20:41.046
spread.
00:20:41.046 --> 00:20:42.346
And which ones do you need to trace?
00:20:42.346 --> 00:20:43.051
Is it all of them,
00:20:43.102 --> 00:20:50.211
usually would have to look that up, but of course the most common STD that I would see in general practice would be Chlamydia.
00:20:50.520 --> 00:20:52.580
and That is a notifiable disease.
00:20:53.020 --> 00:21:04.351
And usually we would treat them, and then repeat a urine test or swab ideally a swab three months later to make sure they haven't caught it again
00:21:06.749 --> 00:21:08.585
treatment was Okay.
00:21:08.585 --> 00:21:13.674
When I was going through, there was a lot of emphasis put on HIV, but that's better controlled nowadays.
00:21:13.954 --> 00:21:19.065
Is that still an issue or are there other conditions or infections that we need to be more concerned about or that you're worried about?
00:21:19.964 --> 00:21:22.037
Is that less of an issue nowadays?
00:21:22.037 --> 00:21:22.628
Touch wood.
00:21:22.628 --> 00:21:27.662
I've only seen one case in my career so far, but we do screen for it standard.
00:21:27.662 --> 00:21:28.846
During pregnancy we do.
00:21:29.296 --> 00:21:36.306
But we, I don't think that in my general practice settings HIV is a huge problem.
00:21:36.516 --> 00:21:39.796
Unfortunately, an upcoming problem is syphilis.
00:21:40.185 --> 00:21:43.776
So we do screen, we have very low threshold for that as well.
00:21:43.776 --> 00:21:46.701
And sometimes in pregnancies we would screen multiple
00:21:48.237 --> 00:21:58.406
moving on to a different spectrum then, what about the lady approaching menopause and having issues with hot flushes and concerns about whether to go on hormone replacement therapy and the risks and benefits for that?
00:21:58.727 --> 00:22:01.557
That must be a very common scenario for you, how do you approach that?
00:22:01.642 --> 00:22:03.152
Very common, indeed.
00:22:03.672 --> 00:22:13.521
Usually, unfortunately there's still a huge anxiety in women about HRT, which I think is very unjustified.
00:22:13.922 --> 00:22:16.862
Of course, the first thing will be to discuss lifestyle.
00:22:16.862 --> 00:22:21.192
You can see how lifestyle medicine comes in handy with all my patients.
00:22:21.672 --> 00:22:27.582
So, a lot of women find that with a healthy lifestyle, their symptoms improve.
00:22:28.037 --> 00:22:32.237
And especially alcohol consumption can make their symptoms worse.
00:22:32.676 --> 00:22:47.025
But there is Certainly a group of patients, of women, who suffer a lot and who cannot sleep, who have hot flushes and night sweats, vaginal dryness feel very anxious and beg me to them.
00:22:47.025 --> 00:22:50.301
And I'm like let's start some HRT that's absolutely fine.
00:22:50.701 --> 00:22:55.106
We know that the first five years of HRT there is no increased risk.
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