Women health: holistic view

The term women's health involves psychobiological health and gender issues, and women's sexual and reproductive rights. In this context, educational guidance by health professionals is essential for adequate health promotion ¹ . Traditionally, this concept adds values of quality of life and longevity, respecting the cultural and environmental aspects in which women live ¹ . In addition, the women participate in this process as a user, but they can also promote and disseminate self-care, which strengthens female health in society.

Women's health education involves a multidisciplinary team, which begins with care from prenatal care (mother and fetus), through childhood and adolescence, reaching the reproductive and climacteric period, ending in senescence ² .

Estrogen, produced by the ovaries after stimulation by gonadotropins, defines the characteristics of the sexual organs. It also influences the central nervous, cardiovascular, and musculoskeletal systems. The woman is born with a finite number of oocytes that undergo, during her reproductive life, the process of ovulation or atresia, in a natural and continuous process, until menopause (last menstruation). After this period, a state of hypoestrogenism appears, which is marked by vasomotor symptoms and repercussions on the genitourinary, endocrine, cardiovascular, nervous, tegumentary, and bone systems. There are also reflections on the optical, auditory, and gastrointestinal systems ^1–4 . Therefore, women's health must be viewed holistically.

In childhood, disorders of growth and pubertal development bring about several social and economic issues, but the most prevalent is genital discharge due to vulvoginitis resulting from the accidental introduction of a foreign body or inadequate clothing and hygiene habits. At puberty, the immaturity of the cortical-hypothalamic-pituitary axis draws attention because it can be confused with polycystic ovary syndrome, which can lead to psychological esteem for the rest of the woman's life ⁵ .

During childhood, the identification of abnormalities of the female genital organs (malformations or disorders of sexual development) of the girl that can be noticed from birth, but the partial forms can bring psychological disorders, requires a well-trained multidisciplinary team for the proper correction and minimizes the repercussions on the woman's life ⁶ . In some cases, there may be absence of menstruation due to obstruction of the drainage pathway or absence of internal genitalia or gonadal dysgenesis, as well as alteration of the cortical-hypothalamic-pituitary-ovarian axis, resulting in primary amenorrhea, as well as having an impact on sexual development and in growth, such as bone metabolism and the psychological aspect of children and adolescents ⁶ .

The reproductive period begins with the first menstruation and the cycles can be irregular and after 2 years on average, they can become regular most of the time. During this period, the woman acquires her full reproductive capacity. Therefore, special attention should be given to reproductive health; since in Brazil, teenage pregnancy rates are still very high, which brings socio-economic and emotional consequences for women and also for their offspring. Therefore, the concepts of family planning, involving contraception, as well as the prevention of sexually transmitted diseases, should be applied to adult women, but reinforced in adolescence ^5–7 . In this context, long-term methods, which do not depend on the memory of use, can be good options for contraceptive guidance in adolescence ⁷ .

Another phenomenon that occurs in part of the population is the postponement of pregnancy for economic, social, and professional reasons and even for misconceptions, such as the reproductive period is extending, as life expectancy increases ⁸ . Therefore, all health professionals should warn about the role of age as a factor of infertility, even before the age of 30 years, for correct family planning ⁸ .

In puberty and adulthood, polycystic ovary syndrome is the most frequent cause of menstrual and reproductive dysfunction, with tegumentary (acne, hirsutism and androgenic alopecia), cardiovascular (obesity and endothelial dysfunction), and endocrine (carbohydrate and lipid disorders) repercussions. Therefore, the complexity of this syndrome requires multidisciplinary follow-up and lifestyle changes. Menstrual dysfunction commonly leads the patient to seek medical assistance because of its repercussions on quality of life and also on general health, increasing the risk of anemia ⁹ .

We should also point out other conditions that frequently cause menstrual disorders, pelvic pain, and changes in quality of life, also having an impact on women's fertility, such as uterine leiomyoma, endometrial polyp, adenomyosis, endometriosis, pelvic inflammatory disease, and uterine malformations. These affections are related to the organic structure, and may affect other tissues or organs, as is the case of endometriosis and pelvic inflammatory disease ¹⁰ . Therefore, the knowledge of these conditions should not be restricted to the gynecologist, but in other specialties in which these diseases can affect, such as the gastrointestinal and peripheral neurological systems.

The climacteric is a period of transition in a woman's life, which goes from the end of the reproductive phase to senectude, with important physical and emotional changes. Menopause is just the date of the last menstruation, which is recognized after 12 months of amenorrhea. In Brazil, it occurs between 48 and 50 years. The climacteric is divided into two phases: transition to menopause and postmenopause ^3–4 . In the first phase, menstrual disorders are frequent and impact quality of life. At the end of this period, when the menstrual cycle becomes longer, with absence for two more cycles, vasomotor symptoms may appear, which will be more frequent and intense in the postmenopause. In this phase, the state of hypoestrogenism is more consolidated, leading to hot flashes, sweating, insomnia, and other correlated symptoms that can determine an important impact on the woman's life. This period is also an opportunity to screen for neoplasms, such as cervical cancer and breast cancer, and also provide guidance on healthy lifestyle practices and even initiate therapies to correct carbohydrate disorders and dyslipidemia, which can promote cardiovascular diseases ^4,5,11–13 . It should be noted that women often gain weight and may develop endothelial dysfunction that would result in systemic arterial hypertension or other cardiovascular diseases. In the study by Fonseca et al. ¹² , 70% of the women were overweight or obese at the first gynecological consultation during the climacteric. Therefore, there is a need for a multidisciplinary team to face and treat the repercussions of weight gain and the risk of cardiovascular disease, which can have a silent evolution in this period and manifest abruptly with acute myocardial infarction or stroke.

The repercussions of hypoestrogenism are related to the genitourinary syndrome and loss of bone mass, which can result in osteoporosis and fracture, compromising the well-being of women at the end of the climacteric and senectude. In this context, hormone therapy with estrogens is the most effective tool to mitigate changes in hypoestrogenism, but it must be individualized and well evaluated to reduce risks ² .

Multiprofessional programs in the transition to menopause and postmenopause should address factors such as changes in lifestyle, knowledge about menopause, attitudes and clarification about symptoms, encouragement of smoking cessation and alcoholism, combating sedentary lifestyle, and adequate food intake have influence on symptoms and quality of life. At the same time, regular physical exercise should be encouraged, as at least 150 min of moderate-intensity aerobic exercise per week reduces the incidence of cardiovascular disease and improves cognition, muscle strength, and quality of life. This aspect is important for women to reach senectude in a healthier way ^11,12 .

Another important aspect of women's health, regardless of age, is active immunization through vaccination. The women's vaccination schedule comprises a basic scheme divided into age groups: 10-19 years, 20-59 years, and over 60 years, in addition to pregnancy and the puerperium. In this regard, the vaccines recommended for non-pregnant women include viral triple, hepatitis A and B, HPV, chickenpox, influenza, double or triple bacterial, meningococcal C, and conjugate, pneumococcal. Yellow fever is indicated for those who live in risk areas according to the World Health Organization ^14,15 .

Every health professional who assists women must contextualize their stage of life and determine the best strategy for diagnosing conditions, planning treatment, and adopting preventive measures. Care should be given respecting women's sexual and reproductive rights, without prejudice and being aware that these women play different roles throughout their lives.