Many Spokane-area obstetricians-gynecologists are far ahead of newer guidelines that encourage them to screen for heart disease risk factors among the women they see for annual Pap tests and wellness exams, observers here say.

A National Institutes of Health 2010-2020 agenda for women's health research calls for increased education and materials for ob-gyns to integrate screening for cardiovascular disease, which the American Heart Association cites as the leading cause of death for women in the U.S.

As the doctor that women typically see most often, sometimes as their primary-care physician, ob-gyns in recent years also have heard more from the American College of Obstetricians and Gynecologist, a 55,000-member national group, about ways to monitor women's heart health. These steps include raising their patients' awareness about heart disease and routinely checking blood pressure and cholesterol levels.

The organization offers guidance for ob-gyns, noting a woman's risk of heart disease is higher with such factors as a family history of heart disease, high cholesterol, high blood pressure, lack of exercise, smoking, diabetes, obesity, and being 55 or older.

"The problem for women is heart disease is under-recognized, underdiagnosed, and undertreated," says Dr. Scott Schade, a gynecologist and section head of the Rockwood Clinic OB/GYN Center. "ACOG over the past five to eight years has worked to help the ob-gyn address this because about 50 to 65 percent of women go to the gynecologist for primary care."

He adds that nationally, the medical profession as a whole has taken more notice in raising awareness and education over the past six to eight years about heart disease in women. "Ten years ago, we underestimated the impact. There's been a big push to re-educate physicians and patients," Schade says.

Heart disease, most commonly a narrowing of blood vessels to the heart due to the buildup of plaque, for many years was widely perceived as a man's disease, although that attitude started to shift about a decade ago, says Dr. Janice Christensen, a cardiologist with Providence Spokane Cardiology.

"Women present with more vague and diffused symptoms," Christensen says. "Women tend to have fatigue and nausea as opposed to just chest pain. It makes it more challenging to diagnose."

Today, she estimates almost 10 percent of her referrals to see patients about cardiology concerns come from Spokane-area gynecologists.

"I actually get a lot of referrals from gynecologists because so many women use gynecologists as their primary-care physician," Christensen says. "They'll be doing their annual visit with a patient for a Pap smear and say, 'Your blood pressure is kind of high today. Do you have a history of heart disease in your family?'"

She adds, "When I came here 10 years ago, I was kind of surprised by that. It's not that they want to take over the primary-care doctor role, but a lot of these women don't have access to or haven't maintained a relationship with a primary-care physician."

Christensen also says that a lot of female patients will say they want records from her office sent to a gynecologist when asked which doctor they regularly see for care. While Christensen thinks it's best that women have a primary-care doctor to check overall health concerns, she says a number of women tell her they only go to an ob-gyn provider.

"We've had some shortages in primary-care doctors in Spokane, and a lot of women don't see the need," she says. "They say, 'I'll go to urgent care if there is something concerning.'"

Christensen adds, "It's been very hard for Medicare patients to get into a primary-care provider because so many practices don't accept Medicare patients any more. Women over 65 are high risk for heart disease. Those women go to see the gynecologist, though, for a need, and the gynecologist will notice a problem. Those are a lot of the women who end up in our office."

Additionally, Christensen says she gets a number of ob-gyn referrals when women are preparing to have a procedure done such as a mastectomy or hysterectomy. "They do a lot more preoperative risk stratification to make sure the heart can undergo risks of a procedure," she says. "They'll come to my office to have preoperative testing."

Meanwhile, Schade, who is part of a 10-member, multi-specialty team for the Rockwood Clinic OB/GYN Center, located at 801 W. Fifth, says that group often does basic risk assessment for heart disease, and that screening work might increase if patients don't have a primary physician.

"A majority of our patients have a primary-care doctor, but we do some counseling in terms of smoking and obesity, or if there are any other risk factors," Schade says. "We can often draw blood tests if they haven't had them done. We're all on electronic records, so I can look through and see if they have had these."

Although more people are aware of heart disease's impact on women, many women still have a perception that cancer poses a greater risk, Schade says. "If you ask women what they're going to die of, their perception is they'll die of cancer," he adds. "They actually have one in 30 chance of dying of cancer, but one out of three will die of heart disease."

The American Heart Association's guidelines, updated in 2011 for the prevention of cardiovascular disease in women, estimate that about 422,000 women die each year from cardiovascular disease—more than the next four causes of death combined. Those causes include cancer, chronic lower respiratory disease, Alzheimer's disease, and accidents. Each year, 55,000 more women than men have a stroke, the AHA says.

The guidelines also say, "Reversing a trend of the past four decades, coronary heart disease death rates in U.S. women 35 to 54 years of age now actually appear to be increasing, likely because of the effects of the obesity epidemic."

Also, in a recent AHA national survey, only 53 percent of women said the first thing they would do if they thought they were having a heart attack was to call 911.

Schade says he agrees that many women tend to put off their own health issues. He adds that studies indicate women are more likely to delay going to urgent or emergency care when experiencing symptoms leading up to a heart attack, for example.

"A majority of women are worried about everyone else in the family, but they're aware of the need to go in for a regular Pap smear," Schade says. "Many women don't see a primary-care doctor, so we need to do a better job recognizing the risk factors and telling the patients."

He adds, "Heart disease is one disease that for the most part is preventable. If we make a better effort to identify and help patients reduce the risk, we can make an impact."