The Continuum of Care in Women's Health Issues: Interview with a women's health practitioner.

Women's Health In General Practice

[00:00:00] Dr Gavin Nimon: In Aussie Med Ed, we've covered a lot of areas of medicine. One area of medicine we haven't covered as much of is general practice. It's such a huge spectrum of medical conditions that need to be covered. It's amazing general practitioners can keep track of it all.

[00:00:13] Consequently, over time, general practitioners have become more super specialised in their areas as well.

[00:00:18] And one area is Women's Health.

[00:00:20] 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.

[00:00:27] Pinky's going to talk to us about her medical practice in women's health and also what other areas she covers.

[00:00:32] Dr Gavin Nimon: 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. 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.

[00:00:53] Dr Gavin Nimon: 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 [00:01:00] helps the channel grow. 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. I'm very pleased about to welcome Pinky to us. Pinky works in general practice in Brighton area but also practices up in Alice Springs in women's health.

[00:01:21] Dr Gavin Nimon: Her sub specialties include women's health, children's health, as well as indigenous health and lifestyle medicine.

[00:01:28] Dr Gavin Nimon: Welcome Pinky. Thank you very much for coming on board.

[00:01:30] Dr Ingeborg (Pinky) Van Leuwin: Thankyou Gavin for having me, I'm very excited to be here.

[00:01:31] Dr Ingeborg (Pinky) Van Leuwin: Well, perhaps

[00:01:32] Dr Gavin Nimon: you can actually start off by describing what women's health actually is. What main conditions does it cover in general?

[00:01:38] Dr Ingeborg (Pinky) van Leeuwin: Gee,

[00:01:39] Dr Ingeborg (Pinky) Van Leuwin: as you said, it covers a broad range of

[00:01:42] Dr Ingeborg (Pinky) Van Leuwin: conditions. If we start from a very young age,

[00:01:46] Dr Ingeborg (Pinky) Van Leuwin: it's the pre pubertal girls going, through adolescence with menstrual problems, heavy

[00:01:53] Dr Ingeborg (Pinky) Van Leuwin: periods, irregular periods and other aspects of adolescent health,

[00:01:58] Dr Ingeborg (Pinky) Van Leuwin: especially in

[00:01:59] Dr Ingeborg (Pinky) Van Leuwin: [00:02:00] the females. 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.

[00:02:41] Dr Ingeborg (Pinky) Van Leuwin: And try to support them

[00:02:43] Dr Ingeborg (Pinky) Van Leuwin: as best

[00:02:44] Dr Ingeborg (Pinky) Van Leuwin: we can as general practitioners. All the way through, I'm just skipping a whole lot of course, but supporting young mums, very important. And through to perimenopausal women,

[00:02:58] Dr Ingeborg (Pinky) Van Leuwin: through to [00:03:00] postmenopausal women

[00:03:00] Dr Ingeborg (Pinky) Van Leuwin: and the elderly.

[00:03:01] Dr Ingeborg (Pinky) Van Leuwin: women.

[00:03:02] Dr Ingeborg (Pinky) Van Leuwin: It's too much to to explain in a podcast really, isn't it?

[00:03:06] Dr Gavin Nimon: 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?

[00:03:19] Dr Ingeborg (Pinky) Van Leuwin: Of course, that is a frustration I think that a lot of general practitioners will share with me. you. 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.

[00:03:37] Dr Ingeborg (Pinky) Van Leuwin: 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.

[00:03:49] Dr Gavin Nimon: Why did you choose to go down the path of women's health? What was your main reason for doing so?

[00:03:53] Dr Ingeborg (Pinky) Van Leuwin: Well I trained in the Netherlands

[00:03:54] Dr Ingeborg (Pinky) Van Leuwin: and I always wanted to be an Obstetrician / Gynaecologist and I [00:04:00] went to the United States to do

[00:04:01] Dr Ingeborg (Pinky) Van Leuwin: some research in obs and gyne, in endometriosis and recurrent pregnancy loss.

[00:04:07] Dr Ingeborg (Pinky) Van Leuwin: Still with the intention to do obs and gynae. Came back and worked as a service registrar for a year and a half. 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. 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.

[00:04:32] Dr Gavin Nimon: Perhaps you can describe a typical day in a general practice looking after women's health. What's your typical day? So for those thinking about heading down this path, they've got an idea of what it involves.

[00:04:43] Dr Ingeborg (Pinky) Van Leuwin: Well, of course I'm mostly a general practitioner. So anything from an itchy earlobe to tinea to a heart attack to a dog bite can walk in my door.

[00:04:54] Dr Ingeborg (Pinky) Van Leuwin: But I also have a lot of women who come in for advice, and I have

[00:04:59] Dr Ingeborg (Pinky) Van Leuwin: some procedures

[00:04:59] Dr Ingeborg (Pinky) Van Leuwin: [00:05:00] that I usually do. Apart from talking, there are, is some doing as well, which I'm sure you would like as a surgeon yourself, Gavin. . So, usually, iud insertions and removals, implanon, but also an ingrown toenail.

[00:05:14] Dr Ingeborg (Pinky) Van Leuwin: And then, as you mentioned before, I travel to Alice Springs every 4 - 6 weeks to do mainly women's health and IUD insertions

[00:05:25] Dr Ingeborg (Pinky) Van Leuwin: .

[00:05:25] Dr Ingeborg (Pinky) Van Leuwin: insertions there.

[00:05:26] Dr Gavin Nimon: So as a general practitioner, are you working five days a week, seeing patients non stop? Are there other administration aspects of your job as well? Are there other areas of training that you have time for?

[00:05:36] Dr Gavin Nimon: How does it actually work in general practice?

[00:05:38] Dr Ingeborg (Pinky) Van Leuwin: 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 [00:06:00] abnormal.

[00:06:01] Dr Ingeborg (Pinky) Van Leuwin: But it does involve a little bit more than just your

[00:06:04] Dr Ingeborg (Pinky) Van Leuwin: nine to five job,

[00:06:07] Dr Gavin Nimon: It is quite a shortage of general practitioners worldwide. 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.

[00:06:19] Dr Gavin Nimon: What would you say the most enjoyable part of your job is

[00:06:22] Dr Ingeborg (Pinky) Van Leuwin: I absolutely agree. it's never a boring day. 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. So that's the good thing. You can have your area of interest and it is it's a shame that not more medical students choose general practice as their. profession.

[00:06:55] Dr Gavin Nimon: Hopefully this will help inspire them. I hope

[00:06:56] Dr Ingeborg (Pinky) Van Leuwin: I hope so.

[00:06:58] Dr Gavin Nimon: What are some of the more common [00:07:00] things, that you see day in, day out?

[00:07:02] Dr Ingeborg (Pinky) Van Leuwin: Contraception is a huge deal. I think there are a lot of, women, especially young women , who seek contraception, who are not aware of the new options we have.

[00:07:12] Dr Ingeborg (Pinky) Van Leuwin: 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

[00:07:30] Dr Ingeborg (Pinky) Van Leuwin: simple

[00:07:30] Dr Ingeborg (Pinky) Van Leuwin: 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.

[00:07:42] Dr Ingeborg (Pinky) Van Leuwin: So it's good to give them advice and that's where the lifestyle medicine

[00:07:45] Dr Ingeborg (Pinky) Van Leuwin: comes in handy

[00:07:46] Dr Ingeborg (Pinky) Van Leuwin: as well.

[00:07:47] Dr Gavin Nimon: Can you outline to me what lifestyle medicine involves? Is it part about preventative medicine? About looking after general health as well of the patient? Or, what do you consider as lifestyle medicine encompasses?

[00:07:58] Dr Ingeborg (Pinky) Van Leuwin: It is both prevention [00:08:00] of chronic

[00:08:00] Dr Ingeborg (Pinky) Van Leuwin: disease,

[00:08:01] Dr Ingeborg (Pinky) Van Leuwin: but also treatment. And of course sometimes it won't be the only treatment. And there will

[00:08:06] Dr Ingeborg (Pinky) Van Leuwin: be tablets

[00:08:06] Dr Ingeborg (Pinky) Van Leuwin: involved or other or procedures but it definitely should be part of the management of.

[00:08:14] Dr Ingeborg (Pinky) Van Leuwin: prevention and treatment of chronic diseases

[00:08:17] Dr Gavin Nimon: 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. It's quite a busy job you've got there. Must be quite enjoyable, but also taxing as well.

[00:08:31] Dr Ingeborg (Pinky) Van Leuwin: I am very busy but my mother used to say you have to pick

[00:08:34] Dr Ingeborg (Pinky) Van Leuwin: a profession

[00:08:34] Dr Ingeborg (Pinky) Van Leuwin: that you love and it won't feel like work and that's right, it doesn't feel like work. I enjoy it.

[00:08:39] Dr Gavin Nimon: So he talked about the mental anguish of body image issues and this obviously causes a lot of problems in women's health. But also what about monetary issues too?

[00:08:47] Dr Gavin Nimon: There's a lot of monetary pressures at the moment as we come out of this COVID era. Is that causing a lot of anguish and mental issues at the same time as well and double impact?

[00:08:57] Dr Ingeborg (Pinky) Van Leuwin: Absolutely, I think any general practitioner will [00:09:00] deal a lot with mental health.

[00:09:02] Dr Ingeborg (Pinky) Van Leuwin: I don't know exactly what it is, why there is such huge problem with anxiety and depression. And it is very rewarding to discuss those things. The good thing as a general practitioner is that you don't have to fix all their problems in one consultation. You won't have time for that. 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.

[00:09:33] Dr Ingeborg (Pinky) Van Leuwin: But also sorry to

[00:09:34] Dr Ingeborg (Pinky) Van Leuwin: have to

[00:09:35] Dr Ingeborg (Pinky) Van Leuwin: 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.

[00:09:47] Dr Gavin Nimon: So what's the pathway for a medical student heading down the path of general practice and then into women's health? How do you actually head down this pathway? Are there any particular training courses or other Aspects of training that a general practitioner has to do as they head [00:10:00] down the path of women's health.

[00:10:02] Dr Ingeborg (Pinky) Van Leuwin: think there are a lot of ways where you can arrive, with this as your area of interest. As I said, myself, I trained a little bit in obs and gynae and, did lots of deliveries in the Netherlands.

[00:10:14] Dr Ingeborg (Pinky) Van Leuwin: But I think the Royal College of

[00:10:17] Dr Ingeborg (Pinky) Van Leuwin: GPs

[00:10:17] Dr Ingeborg (Pinky) Van Leuwin: also provides modules that the registrars can train to arrive with that as their special interest.

[00:10:25] Dr Gavin Nimon: And of course you probably get support from other colleagues along the way.

[00:10:28] Dr Gavin Nimon: we a WhatsApp group.

[00:10:31] Dr Ingeborg (Pinky) Van Leuwin: , through MedCast, and that's very helpful. You can't do it alone. And I've got a couple of very nice gynecologists that I can always call. Thank God.

[00:10:42] Dr Gavin Nimon: Yeah that's the great thing about medicine. It is a team approach.

[00:10:45] Dr Gavin Nimon: So what is your general approach for treating delicate topics? You've talked about the mental anguish. Also, there's, on ones we haven't touched upon, there's also, there's a lot of domestic violence issues now. Violence against women, which is really terrible.

[00:10:58] Dr Gavin Nimon: We're hearing more about it in the media. Yeah.

[00:10:59] Dr Gavin Nimon: [00:11:00] Which, a general approach to dealing with these sort of things.

[00:11:02] Dr Ingeborg (Pinky) Van Leuwin: Of course, the first thing is to think about those things to think

[00:11:06] Dr Ingeborg (Pinky) Van Leuwin: about domestic violence.

[00:11:07] Dr Ingeborg (Pinky) Van Leuwin: If you don't think about it, that it could be happening, you will miss it. 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.

[00:11:26] Dr Ingeborg (Pinky) Van Leuwin: And to gently probe and ask to see if there are symptoms and signs of that. And to offer them help. I think the main thing is to not be judgmental or to try and solve it for them. 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.

[00:11:51] Dr Gavin Nimon: I presume you'd always make another appointment at some stage for a follow up in that scenario or?

[00:11:57] Dr Ingeborg (Pinky) Van Leuwin: So if they know you're open for it we [00:12:00] definitely screen pregnant women, because then it's not enough to just keep your eyes open. Then you have to actually ask, because it's sadly quite common in pregnancy domestic violence.

[00:12:12] Dr Ingeborg (Pinky) Van Leuwin: So it's really important to screen for that at that time. Yes.

[00:12:17] Dr Gavin Nimon: there's a lot to watch out for.

[00:12:18] Dr Ingeborg (Pinky) Van Leuwin: Yes, But the good thing

[00:12:19] Dr Ingeborg (Pinky) Van Leuwin: is we know them, hopefully. We know them, we know their background, sometimes we know their parents, we know their history, and we have time as our friend.

[00:12:29] Dr Ingeborg (Pinky) Van Leuwin: And that really helps. We don't have to solve problems, as I said before, in one consultation.

[00:12:35] Dr Gavin Nimon: Pinky, what's your approach to dealing with lifestyle issues as well? 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. What's your approach to dealing with all these other lifestyle conditions in medicine?.

[00:12:58] Dr Ingeborg (Pinky) Van Leuwin: That's always tricky to [00:13:00] balance your time. There's never enough of it, of course.

[00:13:03] Dr Ingeborg (Pinky) Van Leuwin: 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.

[00:13:17] Dr Ingeborg (Pinky) Van Leuwin: And usually I ask for permission, Can I check your blood pressure?

[00:13:20] Dr Ingeborg (Pinky) Van Leuwin: Is it okay if I check your weight? Because it is relevant for your acute problem, for example. I offer them a blood test. And most patients, when you ask for permission and ask it in a non judgmental way, are quite open for it, I think.

[00:13:36] Dr Gavin Nimon: Yeah. I think

[00:13:36] Dr Ingeborg (Pinky) Van Leuwin: expect it,

[00:13:38] Dr Gavin Nimon: Yeah. And the other things too, smoking and vaping,

[00:13:41] Dr Gavin Nimon: what are your thoughts on dealing with that and how do you address that for any person coming through the process?

[00:13:46] Dr Ingeborg (Pinky) Van Leuwin: 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?

[00:13:56] Dr Ingeborg (Pinky) Van Leuwin: And if they do, then I will tell them, In very [00:14:00] clear terms that this is very unhealthy and a threat to their health and that I would recommend for them to quit.

[00:14:05] Dr Gavin Nimon: quit. Yeah. And are there any particular tips I can learn from you to help broach that issue?

[00:14:11] Dr Ingeborg (Pinky) Van Leuwin: Ooh,

[00:14:12] Dr Ingeborg (Pinky) Van Leuwin: 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. But of course, as we learn as general practitioners, you want to assess first if they are ready to change their behavior. and if they're

[00:14:31] Dr Ingeborg (Pinky) Van Leuwin: not ready to

[00:14:31] Dr Ingeborg (Pinky) Van Leuwin: change their behavior. You don't want to waste your time trying to convince them.

[00:14:36] Dr Ingeborg (Pinky) Van Leuwin: You can give them the facts and tell them to come back , if they want some help in quitting. if they're not ready to quit, then there is, it's a waste of your energy. And I would give them some handouts and some phone numbers, like the quit line, things like that.

[00:14:51] Dr Gavin Nimon: Let's say a patient comes through to you, a lady who wants a general screen to make sure she's okay.

[00:14:56] Dr Gavin Nimon: If she's thinking about trying for a child and she hasn't had any [00:15:00] success. 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?

[00:15:12] Dr Gavin Nimon: a lot

[00:15:13] Dr Ingeborg (Pinky) Van Leuwin: of of topics to discuss with that lady.

[00:15:16] Dr Ingeborg (Pinky) Van Leuwin: 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. 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.

[00:15:39] Dr Ingeborg (Pinky) Van Leuwin: 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,

[00:15:55] Dr Ingeborg (Pinky) Van Leuwin: And also family history. Are there any chromosomal or genetic [00:16:00] conditions in the family? Since November last year, I believe we now can offer genetic carrier screening to women who are in the reproductive age.

[00:16:11] Dr Ingeborg (Pinky) Van Leuwin: Ideally before they fall pregnant, but if they are already pregnant we offer it as well, but there's just less options. So we offer them genetic screening for cystic fibrosis, a fragile X, and spinal muscular atrophy. 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.

[00:16:40] Dr Ingeborg (Pinky) Van Leuwin: and

[00:16:40] Dr Ingeborg (Pinky) Van Leuwin: her husband's or a partner's health is also very important. We forget the partner usually, but apparently that's paternal health, is very important as well. Okay. And then we would offer some blood tests. We would check

[00:16:53] Dr Ingeborg (Pinky) Van Leuwin: if Rubella

[00:16:54] Dr Ingeborg (Pinky) Van Leuwin: antibodies are significant. If she's had Varicella, Chicken pox [00:17:00] 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.

[00:17:11] . Well, it's fairly extensive, so there's a lot to go through there. You wouldn't be able to do all that in one visit, of course.

[00:17:17] Dr Ingeborg (Pinky) Van Leuwin: NO but very important, good opportunity to do a general health check really

[00:17:23] Dr Gavin Nimon: 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.

[00:17:39] Dr Gavin Nimon: How do you approach that and what's your general technique of dealing with those scenarios then?

[00:17:43] Dr Ingeborg (Pinky) van Leeuwin: That's one of my favourites as

[00:17:44] Dr Ingeborg (Pinky) Van Leuwin: well. I

[00:17:45] Dr Ingeborg (Pinky) Van Leuwin: think that it's important to think about it, so I think that I really appreciate the orthopaedic surgeon thinking of those things. Sometimes I think they just might get treatment but then somewhere get lost in the system and then not get [00:18:00] screened for osteoporosis.

[00:18:01] Dr Ingeborg (Pinky) Van Leuwin: But usually if it's, especially if it's a low energy trauma, I would want to know her family history.

[00:18:08] Dr Ingeborg (Pinky) Van Leuwin: As

[00:18:08] Dr Ingeborg (Pinky) Van Leuwin: 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.

[00:18:30] Dr Gavin Nimon: Right, and once you've done your DEXA scan looking for osteoporosis, what's your mainstay of treatment in that scenario? Do you manage the full gambit up to biophosphate commencement or do you involve another specialty in that area?

[00:18:44] Dr Ingeborg (Pinky) Van Leuwin: 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 [00:19:00] super important. We lose body

[00:19:05] Dr Ingeborg (Pinky) Van Leuwin: muscle mass about 8 percent every 10 years, I believe. So that's really important for her bones as well.

[00:19:11] Dr Ingeborg (Pinky) Van Leuwin: 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] Dr Gavin Nimon: Excellent. Going on this sort of area of scenarios,

[00:19:33] Dr Gavin Nimon: the

[00:19:33] Dr Gavin Nimon: 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] Dr Gavin Nimon: How do you approach both the diagnosis and also then the prevention,

[00:19:44] Dr Ingeborg (Pinky) Van Leuwin: well, of course,

[00:19:44] Dr Ingeborg (Pinky) Van Leuwin: Any woman in the reproductive age, we have a very low threshold for STD screening anyway. So, I usually ask for consent and, swab when possible, and explain to them that this is important, [00:20:00] 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] Dr Ingeborg (Pinky) Van Leuwin: So most women are happy with that. 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. 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] Dr Gavin Nimon: spread. And which ones do you need to trace? Is it all of them,

[00:20:43] Dr Ingeborg (Pinky) Van Leuwin: usually would have to look that up, but of course the most common

[00:20:46] Dr Ingeborg (Pinky) Van Leuwin: STD

[00:20:47] Dr Ingeborg (Pinky) Van Leuwin: that I would see in general practice would be Chlamydia. and That is a notifiable disease.

[00:20:53] Dr Ingeborg (Pinky) Van Leuwin: And usually we would treat them, and then repeat a urine test or swab [00:21:00] ideally a swab three months later to make sure they haven't caught it again

[00:21:06] Dr Gavin Nimon: treatment was Okay.

[00:21:08] Dr Gavin Nimon: When I was going through, there was a lot of emphasis put on HIV, but that's better controlled nowadays. 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] Dr Ingeborg (Pinky) Van Leuwin: Is that less of an issue nowadays? Touch wood. I've only seen one case in my career so far, but we do screen for it standard. During pregnancy we do. But we,

[00:21:29] Dr Ingeborg (Pinky) Van Leuwin: I don't think

[00:21:31] Dr Ingeborg (Pinky) Van Leuwin: that

[00:21:32] Dr Ingeborg (Pinky) Van Leuwin: in my general practice settings HIV is a huge problem.

[00:21:36] Dr Ingeborg (Pinky) Van Leuwin: Unfortunately, an upcoming problem is syphilis. So we do screen, we have very low threshold for that as well. And sometimes in pregnancies we would screen multiple

[00:21:47] Dr Gavin Nimon:

[00:21:48] Dr Gavin Nimon: 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] Dr Gavin Nimon: That must be a very common [00:22:00] scenario for you, how do you approach that?

[00:22:01] Dr Ingeborg (Pinky) Van Leuwin: Very common, indeed. Usually, unfortunately there's still a huge anxiety in women about HRT, which I think is very unjustified. Of

[00:22:14] Dr Ingeborg (Pinky) Van Leuwin: course, the first thing will be to discuss lifestyle. You can see how lifestyle medicine comes in handy with all my patients.

[00:22:21] Dr Ingeborg (Pinky) Van Leuwin: So, a lot of women find that with a healthy lifestyle, their symptoms improve. And especially alcohol consumption can make their symptoms worse. 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] Dr Ingeborg (Pinky) Van Leuwin: And I'm like let's start some HRT that's absolutely fine. We know that the first five years of HRT there is no increased risk.

[00:22:55] Dr Ingeborg (Pinky) Van Leuwin: of breast cancer, because that's the main concern that they have.

[00:22:59] Dr Ingeborg (Pinky) Van Leuwin: If women [00:23:00] have had a hysterectomy and only need estrogen and no progesterone, even after five years, there is no increased risk, and with the newer progestogens, like the micronized progesterone, that risk is also not increased after five years. If somehow we do a combined treatment with estrogen and progesterone

[00:23:22] Dr Ingeborg (Pinky) Van Leuwin: More than five years.

[00:23:23] Dr Ingeborg (Pinky) Van Leuwin: There is a small increase in breast cancer, but that's about the same risk as a woman drinking a glass of alcohol every day.

[00:23:32] Dr Gavin Nimon: Really?

[00:23:33] Dr Ingeborg (Pinky) Van Leuwin: There are other ways to reduce their risk, and usually we would try to limit the duration of treatment for less than five years if possible. But if they need it for longer, we would treat it for

[00:23:45] Dr Gavin Nimon: Yeah, it's amazing when you think of it in that, that terms, because certainly a lot of people might drink more than one in a glass

[00:23:51] Dr Gavin Nimon: and also,There are the newer HRT options that so

[00:23:57] Dr Ingeborg (Pinky) Van Leuwin: make it possible to give them topical [00:24:00] treatment, so a gel or a patch, that will also reduce their risk of blood clots, because we know oral can increase their risk clots slightly.

[00:24:11] Dr Ingeborg (Pinky) Van Leuwin: So there's a lot of ways to reduce that risk and to really, I think there is certainly a role for HRT in women who are very symptomatic.

[00:24:21] Dr Gavin Nimon: was training I used to hear about women who'd have DICs and curatages for excessive menstruation. Is that an issue nowadays with the current medications and things?

[00:24:30] Dr Gavin Nimon: Does that still occur ,

[00:24:31] Dr Ingeborg (Pinky) Van Leuwin: does still occur, but I remember a gynecologist Almost complaining that, the amount of hysterectomies have reduced significantly since the introduction of the Mirena, so the IUD with a little bit of progesterone in it, because that works very well around menopause when women have troublesome

[00:24:52] Dr Gavin Nimon: Excellent, in this era of diversity, obviously all the people I know who treat women's health are women.

[00:24:58] Dr Gavin Nimon: Is there a role for male [00:25:00] doctors treating women's health, and are there many that do

[00:25:02] Dr Ingeborg (Pinky) Van Leuwin: It's funny Gavin, why are there, are there a lot of male gynaecologists but not male general practitioners who do women's health? I don't have the answer, but you're right, it's mainly women who do so, and I think there is a role for male GPs to do so as well, because we have a shortage of, general practitioners, especially, I need to travel all the way to Alice Springs to insert IUDs .

[00:25:28] Dr Ingeborg (Pinky) Van Leuwin: And I wish there were more male general practitioners who would do insertions

[00:25:34] Dr Ingeborg (Pinky) Van Leuwin: and

[00:25:35] Dr Ingeborg (Pinky) Van Leuwin: who would be interested in women's health. So when I have medical students in my consultation room, I always encourage them to stay and to do a pap smear under my supervision, to watch an IUD insertion, et cetera, And I think they feel a bit awkward perhaps, but usually the patients are absolutely fine with that.

[00:25:55] Dr Gavin Nimon: So it should be an area that should be encouraged for the future. [00:26:00] Yeah, okay. We haven't actually talked much about the pre pubertal adolescent coming through the ranks. Do they present with any issues at all that you see commonly and that are actually a minefield to watch out for?

[00:26:11] Dr Ingeborg (Pinky) Van Leuwin: Absolutely. What I see very commonly is a little girl with vulval vaginitis / irritation who is complaining about discomfort while urinating, who is constantly itching her vulval region and I have come across it a couple of times where they had presented in the emergency department prescribed antibiotics for suspected UTI but actually had Vulval irritation.

[00:26:43] Dr Ingeborg (Pinky) Van Leuwin: So

[00:26:43] Dr Ingeborg (Pinky) Van Leuwin: it's really

[00:26:44] Dr Ingeborg (Pinky) Van Leuwin: important that you have a look.

[00:26:46] Dr Ingeborg (Pinky) Van Leuwin: because

[00:26:47] Dr Ingeborg (Pinky) Van Leuwin: Of course you have to check the urine, but it could just be irritation from running around in wet bathers, from not wiping front to back when they have done a number two. It [00:27:00] could be from bubble baths, very commonly, where they sit in soapy baths for an hour, and that really irritates that fragile skin.

[00:27:10] Dr Ingeborg (Pinky) Van Leuwin: They don't usually get thrush. Not before, puberty and not after menopause. Women tend to not get thrush but more other types of irritation. So in the elderly women you may need to give her some estrogen cream and in the younger girl,

[00:27:27] Dr Ingeborg (Pinky) Van Leuwin: just Sudocrem

[00:27:28] Dr Ingeborg (Pinky) Van Leuwin: And stopping with wet wipes and things like that can be as simple as that.

[00:27:34] Dr Gavin Nimon: Certainly in the older age group too, I believe urinary tract infections are very common as well. So how do you treat those ones?

[00:27:40] Dr Ingeborg (Pinky) Van Leuwin: Right in an older lady I would consider, especially if you can see a lot of vaginal atrophy, prescribing estrogen cream because that can certainly help to prevent UTIs and of course making sure that they drink enough apparently as we get older our brain [00:28:00] doesn't tell us when we're thirsty or not until you're really thirsty so making sure they up their fluids and just simple hygiene that you don't need to use soap in that area but sometimes a bit of estrogen cream local.

[00:28:13] Dr Gavin Nimon: Right, okay, A urinary tract infection, though, can present with quite significant confusion and loss of balance as well. In that scenario do you see patients present in that situation where they get confused from a urinary tract infection at all? Or is this something that more presents to a hospital

[00:28:28] Dr Ingeborg (Pinky) Van Leuwin: a hospital situation?

[00:28:29] Dr Ingeborg (Pinky) Van Leuwin: we do see that, especially when there is already a history of cognitive impairment and then they suddenly get extra confused and they can't quite localise what the problem is. then it's of course very important to check their urine. Absolutely, because you could miss that UTI.

[00:28:45] Dr Gavin Nimon: Excellent. We've covered a huge spectrum of things.

[00:28:48] Dr Gavin Nimon: From talking about lifestyle to the actual regular scenarios that occur from all different age groups. Which part of the whole women's health spectrum do you prefer most of all?

[00:28:58] Dr Ingeborg (Pinky) Van Leuwin: I think it's the the [00:29:00] variation, the variety that I like most. And especially because I've been working in general practice for quite a while, I see this young woman first, then she becomes pregnant, and then she comes back with a little baby.

[00:29:13] Dr Ingeborg (Pinky) Van Leuwin: And then we have to treat her baby who's become a child, and then an adolescent, and then So just all phases of life being there to support them is really a privilege.

[00:29:24] Dr Gavin Nimon: Well, it's been fantastic having you on Aussie Med Ed to hear about women's health in general. I look forward to hearing a little bit more about lifestyle medicine at some stage as well.

[00:29:33] Dr Ingeborg (Pinky) Van Leuwin: It was a pleasure to be here. I think we could talk another hour about women's health, but Time is limited. very

[00:29:40] Dr Gavin Nimon: Well, thank you very much again, Pinky, for coming on Aussie Med Ed. It's been great having you here today. And I really appreciate your time. And I hope the general practitioners and the medical students get a lot out of it. Cause certainly, it's been really excellent hearing about this really important topic.

[00:29:53] Dr Gavin Nimon: Thank you very much.

[00:29:54] Dr Ingeborg (Pinky) Van Leuwin: Thanks for having me.

[00:29:55] Gavin Nimon: Thank you very much for listening to our podcast today. I'd like to remind you that the information provided is [00:30:00] just general advice and may vary depending on the region in which you are practicing or being treated.

[00:30:04] Gavin Nimon: If you have any concerns or questions about what we've discussed, you should seek advice from your General Practitioner. I'd like to thank you very much for listening to our podcast, and please subscribe to the podcast for the next episode. Until then, please stay safe.