Individualizing management in women's health - taking time to understand everyone's personal needs.

Abstract

For many years we have appreciated that no two people experience pain or a variety of other symptoms the same way. It can be confusing as a clinician when one patient talks about excruciating agony and a second with a similar disease profile talks about a manageable discomfort. These divergences have frequently been explained as being due to cognitive factors or perception. However, the science remains unclear. In this edition we highlight why each patient must be managed as an individual. In some areas of medicine this is already well established. For example, we direct infectious disease pharmacology to the underlying cause of infection. In other areas it is emerging. For example, progress in understanding the mutations in specific tumors is helping redefine chemotherapy and immunotherapy for some malignancies. However, in other areas, especially pain, we still apply a general model of care. Yet we need to consider whether a more individualized approach may lead to better outcomes in women’s health. In a study by Barneveld et al., the authors explored how patient-specific affect impacts upon the lived pain experience in endometriosis [1]. Using 10 real time assessments across 7 days, women with endometriosis and healthy controls evaluated their perception of pain and affect. A concurrent and temporal relationship was identified. In some endometriosis patients this was almost linear, and in others less so. This suggests using real time assessments and managing according to both affect and pain perception may be required to enhance pain management [1]. If there is a strong relationship in an individual patient, then pain relief may be difficult to achieve without strategies that also promote a positive affect. In another study in this edition, Class, 2022 reported on a data linkage study involving the electronic medical records of 25,604 women evaluating the impact of overweight and obesity on the rate of cesarean section birth [2]. They found that cesarean section birth rates increased serially with each increase in body mass index category even after adjusting for maternal age, year of birth, gestational diabetes, and hypertensive disorders of pregnancy [2]. However, limiting gestational weight gain in overweight and obese women was able to mitigate the risk to some degree. How do we translate this into individualized care? Certainly, we should advise women that BMI does increase the risk of cesarean section birth and also advise that we can mitigate this risk to some degree through management of gestational weight gain. But should we go further and individualize advice to the woman’s circumstances? Rather than telling them of risks, can we instead ask how we can help work with them to reduce the risk of intervention in childbirth? Some women may seek reassurance that limiting weight gain in pregnancy is safe. Others may need help planning meals to optimize their diets. Others may just need our support. In an interesting study by Glidden et al., the method by which donor conceived people were advised about their genetic identity was explored. Whilst most individuals who discovered their identity over the age of 18 years or by a means other than through their parents had worse emotional wellbeing and familial relations, the results were diverse. This suggests again that one size does not suit everyone and making personal assessment about when to tell and who will do the telling are vital to try and improve the experience of donor conceived people [3]. When we teach our students, we often say that most of the diagnosis is in the history, However, if we wish to embrace individualized management then perhaps we also need to consider that most of the management is also in the history, and keep talking to our patients to ensure we are delivering the individualized management they deserve.