PART

2

Women at War

FOUR

Medical Issues for Women Warriors on Deployment

ANNE L. NACLERIO

Women have been serving in critical positions in war as far back as the American Revolution. On recent battlefields, although the laws have defined distinctions on where women can be functioning in the US military, the front lines have become blurred and it is impossible to distinguish “combat roles” from “combat support” roles. Women are serving at the “tip of the spear” on female engagement teams, helping US special forces gather intelligence, and they are serving on reconstruction teams interacting with indigenous populations, with transportation units moving across dangerous territory, and with logistics, police, medical, and engineering units (Naclerio, Stola, Trego, & Flaherty, 2011). In all these positions, women are serving in very austere, harsh environments with a constant threat of enemy engagement inside and outside “the wire.” The recent “lifting of the ban” of women from combat roles by the US Secretary of Defense will allow an expansion of women into jobs previously classified as “combat” (DoD, 2013). Hopefully this will remove any further artificial sense that women are not, and have not, been serving in a multitude of dangerous positions that potentially affect their physiologic and psychological health status.

In fiscal year 1994, the Defense Women’s Health Research Program (DWHRP) was established to support research aimed at addressing the health-related needs of military women. The US Army Medical Research and Materiel Command managed the congressionally funded program, which supported over 100 intramural and 30 extramural research projects aimed at addressing the health-related needs of military women. A gap analysis was also funded and conducted by the Institute of Medicine (IOM); the findings were published in the IOM report entitled Recommendations for Research on the Health of Military Women (Friedl, 2005; Institute of Medicine, 1995). Ongoing research is critical to ensure that the Military Health System (MHS) is properly prepared to care for its female warriors. This chapter will review the existing literature on the challenges to maintaining physical health that are unique to female warriors and will focus on what is being done and what can be done to help ameliorate existing problems.

The austere environment of a theater of war presents different issues for women than men (Czerwinski et al., 2001; Doherty & Scannel-Desch, 2012; Trego, 2012), including something as simple as how and where to urinate privately and safely in the field, or how to dispose of feminine hygiene products. While these issues may sound minor, they have real second- and third-order effects on health; for many of these issues, better prevention and preparation strategies are the key. We must also ensure that the MHS in theater is equipped to handle the unique but common health conditions faced by women as far forward as women are serving—such as menstrual irregularities, pregnancy, and even the prevention and treatment of urinary tract and vaginal infections. Rarer or more serious conditions (ectopic pregnancy, suspected malignancy) unique to women would be handled like any other emergency, by movement through the echelons of care and out of theater as necessary. All of these are undoubtedly within the capabilities of the modern US military healthcare system. However, the military is not conventionally prepared or trained to maintain the health of women troops while deployed; rather, it is equipped for a predominantly male force.

This chapter will strive to educate healthcare professionals on the specific health needs of female warriors in hopes that all providers caring for this population will be “armed and ready,” so to speak, to care for them comprehensively. It is important also for the mental healthcare professionals reading this text to be aware of the raw physical stressors faced daily by these women while serving, which can undoubtedly affect their psyche. The chapter will also explore what is already being done across the Department of Defense to improve and prevent women’s health issues in theater and will make recommendations regarding what still needs to be accomplished and where further research is needed.

Preparation and Prevention for Success

In the fall of 2011, an assessment of the theater Health Service Support (HSS) across the Combined Joint Operations Area-Afghanistan (CJOA-A) was undertaken, and one of the nine focus areas was on women’s health (Naclerio et al., 2011). In December of 2011, in what would be one of the first actions by the 43rd Army Surgeon General of the United States, a Task Force was established to look further into the findings and recommendations made in their report.¹

The assessment team deployed to Afghanistan and conducted interviews, town halls, and surveys of over 150 Servicewomen. Many of the women serving in enlisted positions were very young, and as noted by their more senior counterparts, many hadn’t learned even basic hygiene practices at home before coming into the Service. Now compound that with a very austere environment, where they may be away from washing facilities for their clothes or their bodies for several days at a time, hot and humid climates, and situations where they are unable to find privacy without risking their own lives and the lives of others. Several Servicewomen told the author that they served in transport companies and were often the only woman in a crew of six, working outside the wire on long transports for up to 36 hours at a time. What do you do when you need to urinate or change a tampon? When facilities are limited or as basic as the one shown in Figure 4.1—they become medical threats without the right preparation and education (Figure 4.1).

FIGURE 4.1 Women’s bathroom in Austere enviroment.

Urogynecologic Issues

Urinary Tract Infections

This chapter first looks closer at urination, er, women were found to be significantly less likely to go to a provider during deployment than when at their home station (p < 0.001) (Ryan-Wenger & Lowe, 2000).which has been fairly well studied and reported on by other authors for almost two decades (Hawley-Bowland, 1995; Lowe & Ryan-Wegner, 2003; Nielson et al., 2009; Steele & Yoder, 2013; Trego 2012; Wilson & Nelson, 2012). The CDC reports that 25%–40% of all US women will experience a urinary tract infection (UTI) between the age of 20 and 40 (CDC, 2005). Nielson found that 47% of Army women presenting to a Combat Support Hospital in Iraq experienced at least one during their deployment (Nielson et al., 2009), which for Army women averages 10.5 months in length (DMSS, 2013). A recent analysis found that the rate of UTIs for deployed females was over 20-fold greater than for deployed males; however, in a somewhat counterintuitive finding, the incidence of UTIs during the same period was 26%–55% higher among the non-deployed than deployed females (Armed Forces Health Surveillance Center, 2014). It remains unclear how much of this difference may be due to under-reporting, self-treatment, resolution without medication, or treatment at a remote post without electronic medical record-keeping. Under-reporting is suggested by the survey results of nearly 850 Servicewomen, in which 48% reported that they had symptoms of urogynecologic infections during their deployment (Ryan-Wenger & Lowe, 2000). However, women were found to be significantly less likely to go to a provider during deployment than when at their home station (p < 0.001) (Ryan-Wenger & Lowe, 2000).

Servicewomen face many issues while deployed that drive behaviors which can impact their health negatively. All Service members wear heavy protective gear as well as weapons, ammunition, and other load-bearing equipment to help keep them safe. However, for women, the gear makes it very cumbersome to urinate traditionally, as the gear has to all come off prior to being able to drop their uniform pants. Also, while on patrol, convoy, or in flight, there is often no privacy, so urinating would require disrobing in front of male teammates or potentially dismounting in hostile territory. In locations where port-a-potties are available, they have been described by women as often unclean and very tight to maneuver in with all their gear, and they are therefore often avoided (Trego, 2007). These factors drive behaviors such as withholding fluids (Albright et al., 2005).

As far back as 1995, researchers recognized the benefits of devices that Servicewomen could use to void without undressing in order to prevent practices that could lead to negative health consequences (Hawley-Bowland, 1995). The female urinary diversion device (FUDD) is a commercially available, funnel-shaped device that can slip into the fly opening in military pants or flight suits to allow women to urinate standing up or into a small opening (such as a bottle). These products are most widely used by campers, climbers, and outdoorswomen, but have not gained general acceptance across the services (Figure 4.2).

FIGURE 4.2 Female Urinary Diversion Device (FUDD).

During the 2011 HSS assessment, women reported that they were not willing to stop and dismount their vehicles to urinate, as they were frequently in hostile territory and the possibility of ambush was always a reality. Most women surveyed reported that they were not familiar with the FUDD. The lack of use of adaptive processes, such as the FUDD, in combination with maladaptive behaviors like urinary retention and water deprivation, in an austere environment with hot, humid climates and poor sanitation, puts Servicewomen at risk for UTI (Lowe & Ryan-Wegner, 2003; Steele & Yoder, 2013; Trego, 2012). Disturbingly, many women working outside the “wire” reported wearing diapers and withholding the intake of fluids to avoid the need to urinate, which reflects little improvement in the situation after over more than a decade of war.

The proposed benefit of the FUDD is to decrease the need to withhold urine, purposefully dehydrate, or sacrifice their humility by disrobing or wearing diapers, thereby decreasing their risk of genitourinary irritation and infection. At the time of the assessment in 2011, the FUDD was in the US theater supply system and was available at the locations we visited; however, it was listed under a not so obvious name, “Urinal, Female” (Naclerio et al., 2011), which sounds more like a hospital bedpan. But in talking to many women, the nomenclature alone was not the problem. The problem was that most of the Servicewomen encountered had never even heard of these devices, much less had ever tried to use one, or to think to ask for one (Naclerio et al., 2011). These reports were very consistent with Nielson’s findings from Combat Support Hospitals in Iraq in 2005–2006, which reported that only 4.5% of women serving in Iraq had used the devices, and 33% had never heard of the them (Nielson et al., 2009).

Vaginitis

It is also not surprising that Servicewomen may suffer from vaginitis more commonly while deployed. Vaginitis is an inflammation or irritation of the vagina. It is often caused by an imbalance of the normal flora and pH, allowing an overgrowth of yeast or bacteria. Risk factors include use of antibiotics, which can upset the normal balance, douching or perfumed sprays that can cause a chemical irritation or raise the pH, and the use of estrogens and IUDs (ACOG, 2006).

While vaginitis is not quite as commonly diagnosed in theater as urinary tract infection, 6.5% of women in theater between 2006 and 2008 utilized care for this condition (USAPHC, 2010a). This statistic likely under-represents the frequency that women are affected by this distracting condition, as noted by Ryan-Wegner & Lowe in 2000. Many of the risk factors discussed for UTI, such as limited opportunities for washing and the wearing of incontinence pads or briefs, may also affect the incidence of vaginitis, as well as other factors, such as the need to take antimalarial prophylaxis drugs like doxycycline (Tan, Magill, Parise, & Arguin, 2011). Researchers have also found that many Servicewomen are using estrogenic contraceptives, douching, or using feminine hygiene sprays while deployed (Lowe & Ryan-Wegner, 2003). A report in 2007 found a 3% higher utilization rate for female genitourinary encounters during Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) than in garrison from 2005 to 2007 (Cox, 2007).

Addressing the Urogynecologic Issues

Urinary Tract Infection

The Women’s Health Task Force (WHTF) worked with appropriate agencies to rename the FUDDs in the supply system to the more accurate description of “Female Urinary Diversion Device,” and in conjunction with US Army Public Health Command (USAPHC) has developed educational brochures, posters, and videos to educate Servicewomen on what they are and how to use them. Resources can be found on the recently developed USAPHC Women’s Health Portal. Healthcare practitioners can refer patients to the site, or can download reference materials for patients. On the topic of FUDDs, the Women’s Health Portal has developed a YouTube video to help teach Servicewomen on their use and care, and has created reference cards that fit into a patrol cap or pocket, which can be downloaded or ordered from their site (Table 4.1).

TABLE 4.1 Resources Referenced, Available at the Time of Publication

Resources Available for Servicewomen	Web Link
USAPHC Women’s Health Portal	http://phc.amedd.army.mil/topics/healthyliving/wh/Pages/default.aspx
YouTube video on use and care of the Female Urinary Diversion Device	https://www.youtub

The WHTF is also addressing changing from a “pull” to a “push” system of supply. This allows the FUDDs to be provided to Servicewomen at points in time when they may be needed (such as prior to deployments into the field or austere environments). Currently, it remains a “pull” system, so women must know to ask for them. The task force is also working to add education on the FUDD to basic and advanced military training and to leaders’ courses. Both male and female Soldiers, as well as those who lead them, need to be educated that they exist and when, why, and how they should be used in order to maintain combat power on the battlefield (or during a field exercise). As providers, we have an opportunity to ask and an obligation to educate. Providers must be familiar with the device and educate. Only then will their use become inculcated into the routine of Servicewomen (Figure 4.3).

FIGURE 4.3 US Servicewomen preparing to go outside of wire. FUDD as a routine piece of her equipment.

Once your patients are aware of the options that allow them to discretely urinate standing up into a bottle or behind a bush without undressing in a group of males, you can move on to talk to them about the importance of staying hydrated. Hydration is key, not only to the prevention of heat injuries, but also for the prevention of urinary tract infections (Albright, Gehrich, Buller, & Davis, 2005) and renal calculi (Loris et al., 1996).

Vaginitis

Prevention efforts overlap with the urinary hygiene addressed above to avoid the need for adding additional layers of incontinence briefs, or feminine hygiene pads that can restrict airflow and even tighten the fit of garments, causing both an increase of heat and moisture and friction on the perineum. All of these have been suggested to promote the colonization of microbes and the translocation of bacteria from the perianal area to the vaginal or urethral openings (Omli et al., 2010; Rao, Bhatt, Houghton, & Macfarlane, 2004; Steele & Yoder, 2013). Additionally, Servicewomen should be counseled to avoid the use of scented products, such as feminine sprays, douches, and scented menstrual hygiene products. Such perfumed products upset the vaginal pH and balance of flora, leading to bacterial vaginosis.

Another measure to advise your female Service members on is the use of unscented, alcohol-free wipes to freshen the urogenital region from front to back when out for consecutive days without access to showers or other bathing facilities. The WHTF has worked with the Army Quartermaster to ensure that these unscented, alcohol-free wipes replace the scented variety in the comfort kits offered to deploying Soldiers to prevent the upset in pH and vaginal flora that the scented varieties can cause. More research is needed to determine if uniform modifications may be helpful in promoting airflow; decreasing the amount of heat and humidity and friction in the perineal area could be beneficial in decreasing the risks of genitourinary infections in female Service members.

Menstruation

In the general population across multiple developed nations, even without the stressors of austere environment and limitations in hygiene, researchers report that 50%–90% of menstruating women suffer from dysmenorrhea, with 10% of those with pain, being severe and accounting for 1–3 missed days of productivity per month (Andersch & Milsom, 1982; Charu, Amita, Sujoy, & Thomas, 2012; Jamieson & Steege, 1996; Pullon, Reinken, & Sparrow, 1988; Sundell, Milsom, & Andersch, 1990). In a more recent study of 500 military women who had deployed to an area of combat operations, 13% reported lost duty days for menstrual-related issues (Powell-Dunford et al., 2011). In a review of 98 English-language articles, the prevalence of abnormal uterine bleeding among women of reproductive age was found to be 10%–30% (Liu, Doan, Blumenthal, & Dubois, 2007). In a survey of 397 deployed women in Iraq between August 2005 and March 2006, 35% had at least one gynecologic problem during deployment, and irregular menstrual bleeding was the most common (21%) gynecologic problem encountered (Nielson et al., 2009). Irregular menses is not surprising, considering that their bodies are undergoing physical, mental, and circadian stress during deployment.

Theater Medical Data Store (TMDS) is the authoritative theater database for collecting, distributing, and viewing Service members’ medical information. An analysis by the Army Patient Administration Systems and Biostatistics Agency (PASBA) of TMDS data by gender and the Agency for Healthcare Research and Quality (AHRQ) Clinical Classification System (CCS) Diagnostic Categories on outpatient visits between 2006 and 2012 revealed 22,410 visits for contraceptive and procreative management, with an additional 8,583 visits for menstrual disorders (accounting for 4.4% of all visits by female Service members) (PASBA, 2014). Many of these disorders may have been preventable or at least modifiable with current hormonal therapies.

Now consider having to deal with potentially preventable, painful, or irregular bleeding in an austere environment, where even privacy and the availability of feminine products may be very limited. This makes it paramount that providers caring for Servicewomen must be aware and comfortable with counseling women on options for menstrual regulation with hormonal methods during routine care visits, whether they choose to use them immediately or not.

Women can use hormonal methods to either control the timing of withdrawal bleeding or to suppress withdrawal bleeding. Well-established advantages of menstrual regulation include the reduction of bleeding episodes, the control of the timing of menstruation, and decreasing the symptoms associated with the ovulatory cycle to include mood swings, breast tenderness, headaches, and dysmenorrhea.

Studies of US Army women found that they were receptive to menstrual regulation, with a strong preference for amenorrhea (lack of menses) while in field environments (Powell-Dunford, 2003; Powell-Dunford, Cuda, Moore, Crago, & Deuster, 2009). In Nielson’s 2009 report, only one-third reported receiving any pre-deployment counseling on menstrual cycle control, and of those, only 13.5% were given several options for cycle regulation (Nielson et al., 2009). Our assessment in 2011 suggested that little improvement had occurred since his report (Naclerio et al., 2011).

Some authors have recommend that hormonal contraception should be viewed as an essential medication to ameliorate the effects of ovulation and the menstrual cycle and to prevent the potential morbidity of a variety of conditions ranging from ovarian cysts to anemia (Christopher & Miller, 2007). Focus and education on these non-contraceptive benefits will help remove the perception that oral contraceptive pills (OCPs) are only for the prevention of pregnancy. During the Persian Gulf conflict, the belief that OCPs were only for sexual activity led many women to go off hormonal contraception “since they would not be having sex,” and the numbers of unintended pregnancies became the leading cause of evacuation of women from theater during Dessert Storm (Christopher & Miller, 2007; Hanna, 1992).

Therefore it is imperative that providers caring for these women be familiar with the basic methods for menstrual cycle regulation using either oral, transdermal, or vaginal hormonal contraceptives; a levonorgestrel-releasing intrauterine device; a progestin implant; or a depot medroxyprogesterone injection (Hicks & Rome, 2010). All of these regimens should be instituted at least three to six months prior to deployment or field exercise in order to optimize desired benefits. All regimens are not equally ideal in the austere environment, emphasizing the importance of all primary care providers understanding at least the basics of menstrual cycle regulation.

The following is a brief review of the advantages and disadvantages of hormonal contraception, with an emphasis on menstrual cycle regulation, that providers should consider when working with military women. This review assumes the goals listed in Table 4.2. Irrespective of method, the reduction of dysmenorrhea and menorrhagia can decrease fatigue from anemia and can improve performance/attendance, which is even more critical on the battlefield (Armed Forces Health Surveillance Center, 2012; Wilson, McClung, Karl, & Brothers, 2011). When counseling women for options for contraceptive use, providers need to cross-reference with US Medical Eligibility criteria published by the Centers for Disease Control and Prevention (CDC, 2010).

TABLE 4.2 Goals for Hormonal Contraception Therapy in Servicewomen

• Decreased cycle-associated discomforts/dysmenorrhea • Decreased bleeding/Ability to achieve amenorrhea • Positive side effect profile (improved acne, decreased mood swings, decreased breast tenderness) • Effectiveness as a contraceptive in case of planned or unplanned consensual sex, rape/captivity • Safety of regimen • Suitability in austere environment

Estrogen/Progestin Combination Therapy

The following three delivery modes all contain a combination of low-dose estrogen (Ethinyl estradiol) and a progestin (levonorgestrel for continuous or extended OCPs, norelgestromin in the patch, and etonogestrel in the ring).

ORAL CONTRACEPTIVE PILLS

For young, healthy women without a contraindication to estrogen, there are many advantages to the use of OCPs, extending well beyond prevention of pregnancy and menstrual regulation (ACOG, 2010). Their use suppresses ovulation and induces endometrial atrophy and has also been shown to reduce associated benign gynecologic conditions, resulting in fewer hospitalizations because of pelvic inflammatory disease (PID), a reduction in chronic pelvic pain and endometriosis complaints (Jensen & Speroff, 2000), and reductions in dysmenorrhea and menorrhagia (Davis, Westhoff, O’Connell, & Gallagher, 2005; Dmitrovic, Kunselman, & Legro, 2012). OCPs have also been shown to decrease the long-term risk of ovarian, endometrial, and colorectal cancer, as well as osteoporosis (Burkman, Schlesselman, & Zieman, 2004; Gierisch et al., 2013; Jensen & Speroff, 2000). Studies have also suggested that long-term use can preserve fertility by delaying or reducing incidence of endometriosis (Seracchioli, Mabrouk, & Frasca, 2010), while also reducing both inflammatory and non-inflammatory acne vulgaris (Arowojolu, Gallo, Lopez, & Grimes, 2012).

Prospective analysis done over three decades ago found the extended use of OCPs with withdrawal bleeding four times per year to be safe and effective (Loudon, Foxwell, Potts, Guild, & Short, 1977), and this is supported by more recent Cochrane analysis (Edelman et al., 2006) and a very recent study of over 3,700 women, which found ascending dose extended regimens to be both safe and effective (Portman et al., 2014). Amenorrhea rates in users of continuous oral contraceptives across three large studies found rates ranging from 59% and 88% by one year (Wright & Johnson, 2008).

The first brand to gain FDA approval for extended use was Seasonale in 2003 (Anderson & Halt, 2003). The first product to gain FDA approval for continuous use was Lybrel in May 2007 (FDA, 2007); however, off-label use has been done safely for years before FDA approval, for a variety of conditions that are exacerbated by the ovulatory cycle (Christopher & Miller, 2007; Wright & Johnson, 2008). When used continuously, OCPs are effective in inducing oligomenorrhea or amenorrhea, in over 70% of women by six months and some sooner (Miller & Hughes, 2003).

In studies comparing extended and continuous dosing regimens to conventional cyclic regimens, some authors have suggested that better compliance with continuous regimens may lead to fewer missed pills, and reduced chance of ovulation and unintentional pregnancy (Hicks & Rome, 2010; Powell-Dunford et al, 2011). While modern OCPs are safe for the majority of female Service members, providers should remain knowledgeable of the contraindications to estrogen use and cross-reference the eligibility requirements set forth by the World Health Organization (WHO, 2009), reviewed by the CDC (2010).

The major disadvantage of this method is the requirement for daily dosing, and long-term studies suggest a slight increase in the risk of breast cancer (Gierisch et al., 2013). However, researchers have found advantages to continuous versus conventional dosing, showing twice the compliance rate and significantly less lost duty days (Powell-Dunford et al., 2011). Combination pills are readily available to deployed Servicewomen, with many forms available; they do not require special care or handling, and slight variations in the time of day taken do not have significant negative effects.

Transdermal Patch

Ortho-Evra is a combination low-dose estrogen/progestin combination agent delivered transdermal that provides protection against pregnancy at similar rates to OCPs. While the patch has better compliance rates than OCPs, discontinuation rates are higher (Lopez et al., 2013). Extended use is off-label, and continuous use has not been studied. In the only extended use trial, women randomized to the 12-week extended regimen had fewer days of bleeding, while only 12% achieved amenorrhea. Spotting and unscheduled bleeding were still common, and the risk for adverse events doubled (Stewart et al., 2005). Higher serum levels of estrogens have been found with normal regimens as compared to OCPs and the vaginal ring (van den Heuvel, van Bragt, Alnabawy, & Kaptein, 2005). These higher levels may explain the increase in side effects experienced, which include breast discomfort, painful periods, nausea, and vomiting (Lopez et al., 2013). Also, increased thrombotic side effects have been reported (Cole et al., 2007) which could be exacerbated by dehydration states (Trenor et al., 2011), which are frequently encountered during deployments in austere environments for the reasons described earlier in the chapter. But most important for military Servicewomen, patch site irritation is reported in 15% of patients in a clean environment (Stewart et al., 2005) and is presumably worse in a dirty, hot, and sweaty environment. Poor adhesion is the biggest concern in the deployed environment, with 46% of Army women surveyed who were using the patch while deployed to OIF reporting patches “falling off” in the austere conditions and humid climates (Thomson & Nielson, 2006; Nielson et al., 2009). Therefore, if the Servicewoman desires this method, it is important to counsel on the need to keep extra patches and to be educated on how to replace patches mid-cycle if adhesion problems occur. Providers should also discuss the needed timeline for a transition plan if they choose to initiate its use in garrison but desire to change prior to future deployment.

Vaginal Ring

NuvaRing is a contraceptive ring labeled for a 21/7 cycle. The vaginal method of delivery has been shown to allow a low, continuous dosing, resulting in more stable serum concentrations as compared to the patch or OCPs, making it suitable for consideration for extended or continuous use (van den Heuvel et al., 2005). Ring users generally have fewer systemic side effects, but more vaginal irritation and discharge. NuvaRing’s extremely short shelf life (4 months) and inability to tolerate extremes of temperature limit its utility in deployment or austere environments. Servicewomen considering or using the vaginal ring should be counseled on the need for refrigeration or at least avoidance of extreme heat, making it more laborious a method for extended periods in austere locations. As with the patch, Servicewomen desiring to start this method should understand the transitioning timeline required to change to an alternative method for optimal result.

Progestin-Only Therapy

The following four delivery options are all suitable for women who are unable to use estrogen or who just desire to use a progestin-only method.

PROGESTIN-ONLY PILLS

These pills incompletely suppress ovulation, require very timely daily dosing for effectiveness, and irregular bleeding is very common (FSRH Guidance, May 2008), giving them many disadvantages for deployment (Christopher & Miller, 2007). Their advantage is for women who wish to continue to lactate.

PROGESTIN-ONLY INJECTIONS: DEPOT MEDROXYPROGESTERONE ACETATE (DMPA)

Depo-Provera inhibits ovulation, thickens cervical mucous, and thins the endometrium when delivered by intramuscular (IM) injection every 90 days (Kaunitz, 2000). Ovarian suppression and amenorrhea is about 70% at one year, taking up to two years to reach 90% of users (FSRH, 2009). While it is a convenient (dosing every 3 months) and efficacious form of birth control, it is a less ideal choice for menstrual regulation in military women due to the high rates of irregular bleeding (Nielson et al., 2009), especially early on, side effect of weight gain (Christopher & Miller 2007), and delayed return of fertility (Jain et al., 2004). Finally, the black box warning about significant bone loss when used for over two years is of particular concern in military women who are already involved in often arduous training and who already incur a higher incidence of stress fractures (IOM, 1998); however, more recent studies suggest that this risk lessens over time and is reversible on discontinuation (Cromer et al., 2008; Kaunitz, Miller, Rice, Ross, & McClung, 2006). In Servicewomen who cannot take estrogens and/or want to use this method, it should be instituted 6–12 months before deployment to minimize bleeding, and women should be counseled appropriately on bone loss risks and bleeding side effects (ACOG, 2008, 2014).

PROGESTIN-ONLY IMPLANT

There are two implantable rods available in the United States, Implanon (which is being phased out) and Nexplanon (which is replacing Implanon and is the same drug and dosing). These are very convenient forms of long-acting reversible contraception because they are good for three years at a time, providing pregnancy protection at rates similar to sterilization (CDC, 2010), without the problems of storage or missed dosing. In the deployed setting for pregnancy protection, this is an advantage. However, 78% of women continue to have regular cycles, and only 20% are amenorrheic, making this a poor choice for suppression of menses. Moreover, 50% having infrequent, frequent, or prolonged bleeding (FSRH, 2009). Their association with erratic bleeding patterns makes them a less than ideal choice for women who may deploy.

PROGESTIN-RELEASING INTRAUTERINE SYSTEM (IUS)

Mirena^® IUS was the first medicated (releasing levonorgestrel) intrauterine device (IUD), and it is also FDA approved for treatment of heavy menstrual bleeding in IUD users (FDA, 2010). The IUS works by inhibiting implantation and sometimes preventing fertilization; however, it does not necessarily suppress ovulation (NICE, 2005). It has many advantages, mainly five years of highly effective reversible pregnancy prevention without having to carry any supplies. The newest progestin-releasing IUD, called Skyla™, has similar effectiveness for pregnancy prevention, but is only labeled for three years (AHC, 2013). Very reliable pregnancy prevention, without any thought or supplies, may be especially important as women take on increasingly forward roles and the risk of women being taken captive increases (Christopher & Miller, 2007). A 90% reduction in menstrual blood loss has been demonstrated over 12 months of use with Mirena (FSRH Guidance, 2009), making it a good choice for menstrual suppression.

While the copper IUD is not a form of hormonal contraception, we will discuss it here briefly for completeness. The copper IUD works by preventing fertilization and preventing implantation. It provides 10 years of pregnancy prevention without remembering to do anything (except to check periodically for the string) or carrying any supplies. It has no effect on ovulation and therefore no effect on ovulatory-related symptoms. Heavier bleeding and dysmenorrhea are likely. Therefore for Servicewomen desiring long-term pregnancy prevention it is highly effective; however, it is not a good option if menstrual regulation is desired (NICE, 2005).

Advantages of the Levonorgestrel-releasing IUS as compared to the copper IUD were significantly lower incidence of pregnancy and PID and a significant increase in hemoglobin, all beneficial to our predominantly young and active military population (Andersson, Odlind, & Rybo, 1994). Initial labeling for the copper IUD in 1988 specified its intended use in women who have had at least one child; however, that language was removed when it was relabeled in 2005. While the label for the Mirena IUS still says that its intended use is for women who have had a child, the current consensus opinion of the American College of Obstetricians and Gynecologists (ACOG, 2011), Society of Family Planning (SFP, 2010), and World Health Organization (WHO, 2009), and US medical eligibility criteria for contraceptive use (CDC, 2010) support its use in nulliparous women, which is in line with current widespread practice (Hubacher, 2007; Suhonen, Haukkamaa, Jakobsson, & Rauramo, 2004). Both Mirena^® and Paraguard^® can be placed postpartum and are safe to use while breastfeeding (CDC, 2010). The only disadvantage of note is that at least 50% continue to ovulate, and therefore it does not provide relief from pain from ovarian cysts and other cyclic symptoms like breast tenderness and mood changes (NICE, 2005).

Unintended Pregnancy

In a recent report, based upon data from 3,745 active duty military women ages 18–44 who participated in the 2005 Department of Defense Survey of Health Related Behaviors, Lindberg (2011) describes a very high rate of unplanned pregnancy in US military women, almost double that of the general population, and the rate appears to be rising (Grindlay & Grossman, 2013a). Studies have attributed unintended pregnancies to both contraceptive failures and non-use (Goyal, Borrero, & Schwarz, 2012; Holt, Grindlay, Taskier, & Grossman, 2011). Higher rates have also been associated with younger, less educated, non-white, and married or cohabitating women (Grindlay & Grossman, 2013a).

It is unclear why the rates in US Servicewomen are so much higher than their civilian counterparts. Since the military population is completely covered with health insurance, as compared to a 20% uninsured rate in the civilian female population and as high as 27% in women 19–24 years of age (DeNavas-Walt, Proctor & Smith, 2013;, CPS: Annual Social and Economic Supplements, 2013), the data suggest that something other than financial barriers to contraception is the issue. Women are still reporting going off birth control when deploying, having to change methods just before or just after arrival into theater, or experiencing access issues to continuing their method due to difficulty getting refills (Ibis Reproductive Health, 2013). These findings suggest that current policies and logistical issues may be negatively affecting health-related behaviors (Manski et al., 2014).

Several recent reports also highlighted the lack of abortion services available to military women as compared to civilians. Title X U.S. Code §1093 prohibits the Department of Defense (DoD) from performing abortions except in cases of rape or incest, or risk to the mother’s life (Legal Information Institute, ND). This might account for some of the differences in rates of unintended births, as well as placing women’s health and careers at risk, especially overseas, where civilian abortion options are limited or nonexistent (Grindlay, Yanow, Jelinska, Gompers, & Grossman, 2011; Ibis Reproductive Health Brief, 2013). Much like for urogenital infections, the best strategy for unintended pregnancy is prevention.

Unfortunately, women in the military are also facing episodes of rape and sexual assault. A 2010 Workplace and Gender Relations Survey of AD Members found 4.4% of women reported unwanted sexual contact in the prior 12 months (DMDC, 2010) and the DoD estimates that 80% of affected Servicewomen who experience sexual assault do not report it to a military authority (DoD, 2010; Holt et al., 2011).

Providers need to do better at educating Servicewomen early in their career to establish contraceptive regimens that are optimal at home station and through deployments (Powell-Dunford et al., 2011; Thomson & Nielson, 2006; Trego, 2012). Even women who do not choose to use a regimen at home station should be educated to seek counseling on alternative methods in ample time before deployments or exercises in austere environments. It is imperative that all providers caring for military Servicewomen are counseling, or referring for counseling, on the pros and cons for various methods for contraception. Providers should be familiar with the benefits of an increased role for long-acting reversible contraceptives (LARCs). LARCs are defined as means of contraception that require less than monthly dosing and therefore have lower reliance on compliance and higher efficacy for prevention of pregnancy. LARCs include the progestin-releasing IUS, the copper IUD, and progestin injection or implant.

In summary, all Servicewomen, regardless of where they are in their career or deployment cycle, should be counseled by their healthcare providers on how they can be maximally prepared for what they may face if called to deploy. Preparation and prevention are the keys they need to optimize their success (Table 4.3).

Fit and Function of Uniforms

Another issue raised by women to the Women’s Health Assessment team was poorly fitting uniforms and protective gear. The individual body armor, designed primarily for male body habitus, was perceived to limit their function and cause painful chaffing and bruising over their hip area (Naclerio et al., 2011). Like most military items, the current and past designs were based upon male anthropometrics. One of the Women’s Health Task Force’s first initiatives was to make contact with the Army’s research and design team; the Task Force found that the Army had begun working on a female sizing system earlier in 2011. They had created prototypes, had conducted fit evaluations, and had begun refining them and conducting field evaluations in order to ensure that the protective gear better fit female Service members. The new armored vest prototype trialed in 2012 was a dramatic improvement, allowing full range of motion at the shoulder, improved quick release design, less bulk in the collar/yoke, darts to curve the front panel, and a much shorter torso so as to not interfere with high knee raise; because of the size options, the new design allows for smaller sized armored plates with correct fit, meaning smaller, lighter weight armor (Paquette, 2011; Miles, 2012). The new multisized female improved outer tactical vest (FIOTV) has been fielded to several hundred women, and 75,000 vests are scheduled for delivery by the fall of 2014. Providers should counsel patients to take the time to ensure that they receive the correct sized garments, as they remain connected with them throughout their deployments, and poorly fitted gear can add unnecessary strain to the body as well as potentially limiting function.

TABLE 4.3 Counseling Points for Military Servicewomen

• Even women without previous menstrual irregularities may experience issues in austere environment. • Hormonal contraception provides many advantages other than protection against pregnancy. • Menstrual cycle regulation is a broad term that includes using hormones to induce either regulation of (cyclic) withdrawal bleeding, decreased menses, or amenorrhea (no menses). • Urogenital hygiene is more difficult in the austere environment—planning and prevention are the best strategy. • Menstruation is not necessary except when pregnancy is goal. • For those already on hormonal contraception, withdrawal bleeding is not the same as menses. • Menstrual suppression is safe and many women prefer it in austere environments; however, it is best initiated 3–6 months before deployment. • Many forms of reversible contraceptive allow return of fertility shortly after discontinuation. • Many women who do not plan to have sex while deployed have unplanned encounters, usually consensual; however, you must also consider the risks of sexual assault, rape, and captivity. • Many forms of hormonal and non-hormonal contraception are available in the deployed settings with privacy protections. • The decision for menstrual regulation is a personal decision—but it should be an informed decision.

Lactation

Another issue women Service members face is how to handle deployment or field exercises when lactating after the birth of a child. Pregnant or postpartum Servicewomen may be concerned about how to handle this, and therefore providers should be prepared to counsel and educate them on their options. Currently all services defer deployment of postpartum women for at least six months, and the Navy currently defers for one year; however, this may not apply equally to field or training exercises. The six-month postpartum deferment policies are driven by the service personnel leadership and are based on the perceived needs for manpower. The Women’s Health Assessment Team recommended that the services re-examine these policies, however (Naclerio et al., 2011), as they conflict with the American Academy of Pediatric policy statement (AAP, 2005), The Surgeon General’s Call to Action (HHS, 2011a), the goals and objectives of Healthy People 2020 (HHS, 2011b), and the HHS Blueprint for Action on Breastfeeding (HHS 2000). While continuation of lactation during a prolonged deployment is generally not sustainable, women who are interested and committed to do so can maintain during shorter field training exercises.

While there is now a single case report of a dedicated healthcare provider assigned to a fixed facility in Afghanistan being able to maintain lactation for four and a half months and even successfully send some breast milk home (Sleudel, 2012), most field environments will be conducive to an “express and dump” method that all primary care providers should be ready to discuss or refer to a lactation expert to further assistance. This can be accomplished with a simple manual method or with the assistance of a hand pump when electricity is not available. If, however, the separation is for training or a location where electricity is available, a double electric pump allows for the most effective milk expression in the least amount of time.

Of note, legislative changes are currently underway in the FY15 Defense Authorization Act to ensure that Tricare, the health insurance for US Military members and their beneficiaries, provide breastfeeding support, supplies, and counseling during pregnancy and throughout the postpartum period that align with the Department of Health and Human Services’ implementation of the Patient Protection and Affordable Care Act requirement, applicable to group health plans and health insurance issuers.

As policy has changed on roles available to women in the services, a frequent concern has been related to what health conditions we will see in them and whether the MHS will be equipped to handle them. The WHTF has been recognized across the MHS as a means to convene experts, make recommendations, and share best practices across the Services to ensure that the MHS is ready. The answer to the first part of the question is fairly straightforward, as women have been serving in battle for hundreds of years,and for over a decade of war, an electronic medical record has provided us the data to answer this question.

The Most Common Conditions of Servicewomen

An analysis of outpatient records from theater between 2006 and 2012 shows that the top five most common conditions that affect women are the same conditions that affect men. Four of the top five conditions are musculoskeletal complaints, likely from wearing heavy body armor, high equipment loads over time, and repeated deployments. The fifth most common condition is upper respiratory infections (PASBA, 2014). These are all conditions that the MHS is well equipped to handle and do not generally show any uniqueness by gender.

When we do look a bit deeper, some differences begin to emerge. While the top five most common reasons for an outpatient visit have been the same as for men, the sixth most common reason is for management of contraceptives. In fact, if you combine visits for “contraception management” with those for “menstrual dysfunction,” which is often related to, or treated with, a hormonal contraceptive agent, this diagnostic category would move into the top five, surpassing the number for upper respiratory infections (PASBA, 2014). This does not account for visits for pregnancy or suspected pregnancy, which one could argue to be a related diagnostic category.

The seventh and eighth most common diagnostic groups encountered in OIF/OEF in 2006–2012, as shown in TMDS, were for urinary tract infections and genital disorders—mostly vaginitis (PASBA, 2014). A Force Health Protection Assessment reported a 3% higher utilization rate for female genitourinary encounters during Operation Iraqi Freedom (OIF)/Operation Enduring Freedom (OEF) than in garrison from January 2005 to July 2007 (Cox, 2007). While none of these is a life-threatening condition, these conditions are, at a minimum, distracting from the Service member’s mission, and a UTI left untreated carries a risk of progression into a more serious pyelonephritis (Brusch, Bavaro, Cunha, & Tessier, 2012). Studies suggest that the numbers presented above for the female-specific conditions may under-represent the true prevalence of these conditions. In a survey of 841 Servicewomen, while 48% of women reported having distracting physical urogynecologic symptoms, 25% of those stated that they would not seek care (Ryan-Wegner & Lowe, 2000).

Barriers and Gaps Identified

A recent, small, qualitative study of 25 women who deployed between May 2011 and January 2012 found that women reported the following barriers to seeking care: limited availability of female providers, a perception of stigma for seeking care (weak or negative consequences), logistical issues including lack of time or ability to get to a provider, a concern for lack of confidentiality, a lack of orientation to available health services, and a perception that women purposely become pregnant to avoid military service (Manski et al., 2014).

These barriers were strikingly similar to those heard by the Women’s Health Assessment Team in 2011 and reported by Ryan-Wegner & Lowe over a decade earlier. They found that the most commonly cited reason was lack of confidence in the provider (15.2%), followed by embarrassment (14.6%), distrust in confidentiality (14%), preference for a female provider (8.4%), and not wanting to take time away from their mission (7.8%) (Ryan-Wegner & Lowe, 2000). Their study also suggested a lack of understanding of the healthcare system available to them, as 68% of women reported that their “provider” was a medic or corpsman (Ryan-Wegner & Lowe, 2000), which is an unprivileged, more narrowly trained, and generally young male, enlisted Soldier or Non-Commissioned Officer (NCO). While this finding makes the concerns cited above seem more understandable, it certainly highlights other issues of lack of understanding of the military healthcare system.

Other concerns identified by researchers are reports of women going off hormonal contraception prior to deployment due to the policy forbidding sexual activity and a lack of pre-deployment counseling on the benefits of hormonal contraception (Ibis Reproductive Health, 2013; Manski et al., 2014), suggesting that policy changes may be needed. An online survey of almost 300 women who had deployed between 2001 and 2010 also found women reporting that they were denied access to IUDs because they did not have children, suggesting a gap in education in addition to policy (Grindlay & Grossman, 2013b; CDC, 2010).

Many of the most common female-specific visits may have been preventable with early education, planning, and intervention for cycle control.

Actions Underway to Address Gaps

To address many of the barriers noted by Servicewomen above, the Women’s Health Assessment Team recommended the fielding of a self-diagnostic kit for urinary tract and vaginal infections (Naclerio et al., 2011). A significant body of evidence has accumulated over the past 14 years on utilizing simple methods of self-diagnosis for these common, non-life-threatening, but highly distractible conditions and found them to be both safe and similar to clinical diagnosis of a provider, even in military populations (Lowe & Ryan-Wegner, 2000; Lowe, Neal, & Ryan-Wegner, 2009; Ryan-Wegner et al., 2010). The kits studied include simple point of care (POC) testing items to differentiate between bacterial or yeast vaginitis and/or for UTI, an algorithm incorporating signs and symptoms and results of POC testing, a thermometer, and education on the use of the kit (Ryan-Wegner et al., 2010). While it is not available commercially as a kit, the WHTF has been working with the researchers, Defense Logistics Agency, and US Army Medical Material Agency, to make one available to US Servicewomen, but to date have been hindered by a myriad of regulations.

In order to ensure that Servicewomen themselves are educated on basic preventative measures for urogenital hygiene (to include the use of the FUDD), menstrual regulation, and birth control options in an austere environment, basic education materials have been developed and are being approved for the addition of basic and advanced training courses for both men and women. Also in conjunction with the Public Health Command, the Female Soldier Guide to Medical Readiness, which had less than one page on contraception and nothing on hormonal control of menstruation, has been updated with expanded information and has been combined into one Warrior Readiness Guide in order to ensure that male and female Soldiers alike have the information they need to make them successful (USAPHC, 2010b).

The perception by many Servicewomen that their provider is a medic or corpsman suggests that education about the healthcare system in a deployed environment also needs to be added to education materials. It is important to note that as women move farther forward on the battlefield to remote forward-operating bases, it also is more likely that the first line of care is male and that a combat medic or corpsman may be the highest level of care 24/7, with physician assistant or independent duty corpsman backup, sometimes remotely located.

A review of Army medic algorithms for common gynecologic complaints reveals that the medic is not empowered to treat, but is directed to refer almost everything to a higher level of care, most often to the physician assistant (MEDCOM, 2011). In the military, physician assistants frequently serve as the first line, privileged provider for units and may be the only asset in a far forward location. A broad range of general, specialty and subspecialty providers, with varying levels of women’s healthcare training and experience, are called up to fill roles of general medical providers in the war zone. In order to standardize care provided to Servicewomen before, during, and after deployment by any type of provider, the WHTF also recommended the development of algorithms for common conditions to include abnormal uterine bleeding, counseling for hormonal contraception for menstrual regulation or for birth control, and treatment of UTI and vaginitis. Development of these clinical algorithms will then be extended where appropriate to medic algorithms to ensure a standard care level in the system, irrespective of the level at which care is accessed.

Finally, information on the same topics has been incorporated into pre-deployment leader’s briefs and medical threat briefs. In short, the WHTF is working to ensure that this information is woven into the core materials for all Servicewomen and leaders throughout all phases of education, much like foot care after lessons learned in Vietnam, or the importance of water discipline.

The Women’s Health Research Interest Group (WHRIG) is supported by the TriService Nursing Research Program. The WHRIG consists of a core group of dedicated researchers who have been working to identify, review, and document the existing literature on military women’s health and identify gaps to help direct future research.

In a literature search of medical, social, and psychological research databases from 2000 to 2010, the group has thus far identified nearly 300 peer-reviewed research articles that either address a health issue or delivery of care specific to US Servicewomen (Trego, personal communication, 2014). According to Trego (2014), of these articles, only 15% address gynecologic issues. Even fewer are specific to conditions in wartime. This suggests a gap in the literature on the identification, prevention, and treatment of gynecologic issues that arise in a conflict environment. Research efforts need to focus on identifying the health issues, including costs for transportation, treatment, and complications, that could be prevented. Building the foundation of literature will lead to evidence-based practices that are not only beneficial to women, but to the health of the total force.

Women have and will continue to be an effective force multiplier for the military. They already serve in roles where only women can serve, such as gathering intelligence from women in Middle Eastern countries, where a male would not be culturally acceptable to do so. They are already highly successful members of cohesive units. The successes to date are largely because involved and responsible civilian, political, and military leaders invested energy toward ensuring their success, and that is what needs to continue. The medical community has an active role in ensuring that ongoing quality research is available to inform leaders, drive policy, and serve as the basis for our care standards (Trego, Wilson, & Steele, 2010).

In 1951, the Secretary of Defense established the US Defense Department Advisory Committee on Women in the Services (DACOWITS), to provide advice and recommendations on matters and policies relating to the recruitment and retention, treatment, employment, integration, and well-being of women in the US Armed Forces. The committee’s 2011 and 2012 reports highlight successes and identify gaps in needed research and policy on both wellness and assignments (DACOWITS, 2011, 2012). Their continued diligence as an advisory body is critical to ensure that the DoD and policymakers implement the findings of the research community. Continued efforts to obtain funding and to focus research where it is most needed and to organize the growing body of data into texts like this one are critical.

In our recent wars, the level of care on the battlefield is unrivaled, and the trauma care that coalition forces receive is second to none, with survival rates the highest in history, at around 95% of those reaching a care facility (Hack, 2012). Despite being in some of the most primitive and remote areas of the Earth, the availability of trauma care exceeds what US citizens receive after a car accident in the more remote and rural areas of the United States (Hsia & Shen, 2011). However, the evidence presented suggests that the care women Service members are receiving for common female conditions are left wanting. It is logical that the MHS should be most proficient in the care of the most lethal injuries; however, MHS leaders are acutely aware of the need for providers to be expert and skilled in the conditions that all Soldiers are facing. In garrison, a Service member can choose his or her provider, and there is ample access to women’s health specialty care; however, in the deployed environment, we must ensure that our primary care providers are educated in the identification, prevention, and care of commonly encountered female conditions.

Recurring themes in this chapter are (1) the need for a strategy of preparation and prevention, and (2) education at all levels (Soldiers, Leaders and Health Care Providers). The ban on women in combat roles has been lifted. More women will be serving further forward on the battlefield in a wider range of positions than ever before. As the medical community who cares for them, it is our obligation to be ready to support them and to ensure that preventable and modifiable health considerations do not hinder their otherwise certain success.

The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of Defense.

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¹ The author served on the HSS assessment team as a Subject Matter Expert for Women’s Health, Effects of Deployments on Children and Families and Military Sexual Assualt and returned to serve as the first Chair of the Women’s Health Task Force. The comments in this chapter include both published and unpublished findings, as well as reporting on the current status of the recommendations.