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Concurrent Health Issues

Topics
  • Women Veterans have a high rate of chronic medical conditions, many of which require ongoing treatment with medications.
  • As part of routine medical care, all women should be assessed for chronic and acute disease conditions known to impact women’s general health and well being as well as their reproductive health. Optimal management includes appropriate prevention counseling, testing, treatment, and coordination of care among primary and specialty care providers.
  • General principles:

    • Discuss the risks and benefits of medication treatment if pregnancy occurs (consider both risks of untreated disease and medication-related risks and benefits. Choose medication that offers best benefit/risk profile for the patient.
    • Planned pregnancies and pregnancies that occur when coexisting medical and mental health conditions are well controlled have better maternal and infant outcomes.
    • Encourage use of highly effective contraception for patients who should delay pregnancy to improve disease management before conception or who are not actively planning pregnancy (see Birth Control Methods.)
    • All women of childbearing age should consume at least 400 mcg folic acid daily (through diet and/or vitamin supplementation) to decrease the risk of neural tube defects. NOTE- Some women with specific medical conditions may require a higher dosage.
  • Medical Conditions

    • Asthma
    • Chronic Pain/Narcotic Dependence
    • Diabetes
    • HIV
    • Hypercoaguable Conditions & Thrombophilia
    • Hypertension
    • Lupus
    • Obesity
    • Renal Disease
    • Seizure Disorders
    • Sexually Transmitted Infections
    • Thyroid Disease
  • Mental Health Conditions

    • General Principles

      • Normal physiological hormonal transitions that occur during a woman’s life cycle may increase her vulnerability to mental health disorders or exacerbate existing mental health disorders.
      • Reproductive events including the menstrual cycle, pregnancy, lactation, and the postpartum period may affect management decisions.
      • Screen for mental health conditions in all women of childbearing age by asking about family history of mental health conditions (i.e. psychosis, depression, psychotic or affective disorders). Ask about mood disorders, personal history of depression, other psychiatric conditions and interpersonal violence.
      • VA requires that providers screen all Veterans for military sexual trauma (MST) as part of the mental health assessment. Screening questions:
        • While you were in the military, did you receive uninvited and unwanted sexual attention, such as touching, cornering, pressure for sexual favors, or verbal remarks?
        • While you were in the military, did someone ever use force or threat of force to have sexual contact with you against your will?
      • Women at risk should receive a formal psychiatric assessment.
      • Appropriate contraception should be offered to women who do not desire pregnancy.
      • If a Veteran requires immediate assistance with a mental health issue, confidential support is available 24 hours a day, 7 days a week, 365 days a year through the Veterans Crisis Line (1-800-273-8255 and Press 1).
    • Counsel on Increased Risk With Pregnancy

      • For patients with a mental health diagnosis, consider a referral to a mental health specialist if they are not already connected to a mental health provider.
      • There are several very effective methods for the treatment of a wide range of mental health disorders.
      • Preconception care should be provided collaboratively with the mental health provider and primary care provider and ob/gyn involved when needed.
      • Treatment is provided during pregnancy when the risk to the mother and fetus from the disorder outweighs the risk of the intervention.
      • Patients with similar illness histories may make different decisions regarding treatment during pregnancy when presented with the risks and benefits of medication treatment and other available therapies.
      • No decision is risk-free.
      • Risks of untreated psychiatric illness during pregnancy include:
        • Relapse or exacerbation of symptoms.
        • Higher rates of C-section, preterm birth, low birth weight, being small for gestational age.
      • Additional risks with pregnancy may occur with co-existing relationship difficulties, financial strain, and interpersonal violence.
      • Screening for past and current interpersonal violence, including Military Sexual Trauma (MST), is indicated for all patients. Support for these issues should be made available (See Resources).
    • Contraception Counseling

      • Work with the patient to identify the method that best meets her contraceptive and reproductive health plan needs.
      • Make patient aware of potential advantages of intrauterine and subdermal contraception (e.g. IUDs, Nexplanon).
    • Non-Pharmacologic Treatment

      • Refer patient to Mental Health team.
      • Treatment options may include various types of therapy depending on the patient needs and condition.
    • Condition Specific Risks and Medication Management

      • Anxiety Disorders (not including PTSD)
      • Bipolar Affective Disorder
      • Depression
      • PTSD
      • Schizophrenia
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