Women’s Health by the Decades

By Megan Willome

Part I: The 20s — A proactive generation

BWhen I sit at my favorite coffee shop and visit with women friends, we talk a lot about health concerns. Some of us are young and still having children, some are middle-aged with new aches and pains, and some are dealing with first one medical issue followed by another. We learn from each other.

For the next few months, the Wacoan is launching a series on women’s health, one decade at a time. We begin this month with the 20s, when most women are at their healthiest. It’s also a decade that sets the wellness stage for what is to come.

Jenny Lee Brakovec, M.D., has worked in Waco as an OB-GYN since 2011. She attended medical school at Creighton University, in Omaha, Nebraska, and did her residency at Baylor Scott & White Medical Center in Temple. She also obtained a general certification from the American Board of Obstetrics & Gynecology. Brakovec now practices at Baylor Scott & White’s OB-GYN clinic here in town.

But when she began studying to be a physician, working in this area of medicine was not on her radar.

“If you’d asked me, I would’ve said that would be the last field I’d go into. I had no experience with it at all,” Brakovec said. “When I had my first child, when I was a second-year medical student — that was a whole endeavor — that experience really opened my eyes to what it could be. Then I did my rotation in OB-GYN as a third-year, and it just clicked: That’s what I was going to do.”

Wacoan writer Megan Willome spoke with Dr. Brakovec by phone to learn what health issues women in their 20s face, what tips she has for women in this age group to stay healthy and what to expect when a woman is expecting.

WACOAN: Tell me a little about your background.

Brakovec: I grew up in Montana and Colorado and moved to Omaha, Nebraska, for medical school. Then I did my residency at Scott & White in Temple.

WACOAN: And when did you start working for Baylor Scott & White? Was that right after your residency?

Brakovec: I’ve been here in Waco since graduating in 2011. As a staff member I’ve always been here in Waco.

WACOAN: Nationally a lot of women are delaying starting a family, but I understand that here women still start in their 20s.

Brakovec: In Waco we don’t necessarily see that trend. We actually have a lot of Baylor [University] graduates that get married after Baylor and stick around Waco. They’re entrepreneurs or involved in the community. They don’t have that tendency to delay childbearing if having a family is important to them. I have a lot of patients in their 20s.

WACOAN: What should all women in this age group be doing to stay healthy before pregnancy?

Brakovec: The best thing people can do going into pregnancy is to be healthy before you get pregnant. Optimize issues if there are medical problems. Be at a healthy weight. Eat a healthy diet. Be exercising regularly. These are the things we tell everyone and try to stress. Most of our 20-year-olds — they haven’t had enough life experience to worry about long-term medical kinds of stuff.

WACOAN: What have you noticed about women you see in their 20s, as opposed to your older patients?

Brakovec: The younger generation is trying to get back to less medical intervention. They’re interested in a more natural childbirth.

WACOAN: So given that expectation, what is your role as their physician, especially when a woman has specific ideas of how she wants her labor and delivery to go?

Brakovec: We try to be supportive of that. We also try to set realistic expectations. If it’s your first labor, you don’t know how you’re going to respond to pain, how you’re gonna do. We help them know what to expect and try to steer them on how to do things safely.

WACOAN: Do a lot of women approach you with a birth plan?

Brakovec: There’s a lot circulating on the internet about birth plans. Women come in and ask, ‘Do I need to make a birth plan?’ The vast majority of people who don’t have expectations about how delivery goes don’t need to make a birth plan. There’s a certain number of patients that have specific desires they want addressed during labor and delivery. They are the ones who make a birth plan and give it to us. It’s helpful because we can review it and let them know what we can accommodate and what’s unrealistic.

WACOAN: Where are some areas where those patients may have unrealistic expectations?

Brakovec: Occasionally they have specific views about caesarean deliveries or whether they’ll accept certain medications. I’ve had patients try to refuse certain medicines we give as standard of care during labor. We have to have a discussion about the rationale of why we do things and why they would be beneficial.

WACOAN: Are there certain myths that women in this age group bring to you?

Brakovec: They wax and wane. With the internet, those things circulate more readily. I feel like it depends on where you’re getting your medical resources. If it’s a lay website, a lot of things aren’t true medical facts. More and more people are aware that you need to get information from reputable science sources, like the Mayo Clinic website.

WACOAN: Here are a couple potential myths that came up in the office: Does being on birth control for a long time affect your fertility when you do want to become pregnant?

Brakovec: Depo-Provera, the shot, hypothetically could, but it’s not going to make you infertile. You just can have a longer delay to fertility than with other forms of birth control.

WACOAN: Another question was does getting an epidural stall labor?

Brakovec: There’s not good evidence to support that. I understand that concern. Medical literature doesn’t support that.

WACOAN: What do you tell your patients about when to start prenatal vitamins?

Brakovec: We want them to be on them before they even get pregnant. Ideally they should start them while they’re trying to conceive. The folic acid prevents birth defects, such as spina bifida. The ideal time to be on them is before conception.

WACOAN: What has surprised you about women in this age group?

Brakovec: This group is very proactive in their medical care, accessing medical data on the internet. They’re more savvy, more savvy about getting in touch with their provider via email. At Baylor Scott & White they can email us through MyChart. [Editor’s note: MyChart is a website and app that allows patients to view their medical records, request prescription refills, schedule appointments, etc.]. They’re also more willing to access care and advice through that.

WACOAN: The recommendation for annual Pap smears changed a few years ago, from once a year to once every three years. Has that had a positive effect on younger women’s willingness to see you for checkups?

Brakovec: That changed in 2012. With that change they stopped recommending Paps before the age of 21. We did that with good reason because rates of cervical cancer are extremely low [for that age group]. And because putting young girls through a pelvic exam might deter them from seeking care later in life.

Now that there’s an understanding about the change, girls aren’t so fearful of their first pelvic exam because they’re more aware of the benefits of it. And we’re doing it at a later age, so it’s less traumatic. For me, at 18, I remember my first exam and it being terrible, so I try to avoid that whenever possible.

WACOAN: What do you recommend for new moms who are having trouble breastfeeding?

Brakovec: Most hospitals have lactation specialists. They’re available even after you’re dismissed from the hospital. They’re your best resource for any lactation or breastfeeding concerns. They are usually nurses with special training beyond their nursing degree; it’s usually a certification. They are fantastic.

I would encourage people to either contact their doctor’s office for referrals or contact the hospital if they’re having concerns. Usually [the lactation specialist is] available for the first year after the baby is born, for outpatient visits as well.

Another good local resource, most communities have a La Leche League. [Editor’s note: La Leche League is an international nonprofit promoting breastfeeding, with local chapters that offer group meetings to support mothers.]

WACOAN: How do you address postpartum depression?

Brakovec: Our goal in the postpartum period is to help people recover from delivery, however they delivered. We address mental health and postpartum depression. We address medical issues that need to be dealt with long term, like hypertension, diabetes. We talk about future family planning as well, options for contraception and planning for future pregnancies.

WACOAN: Was this aspect of mental health part of your training in med school?

Brakovec: Most of that training came during residency, in terms of managing postpartum depression. I feel like we’re doing a better job in screening for it and treating it because more women are aware of the issue. There’s more media attention.

Where we really benefit is our pediatrician colleagues screen moms. There are some postpartum depression scales we use. There’s a 10-question assessment [Edinburgh Postnatal Depression Scale]. Their responses are graded, and their score can show if they’re suffering from depression. Then we talk about treatment options.

WACOAN: That collaboration with pediatricians is new since I gave birth.

Brakovec: We’ve done that for about the last year or two. If [depression] is something that develops in the first couple weeks after giving birth, before they’ve seen me, my pediatric colleagues can send me a message and let me know so we can intervene sooner than their scheduled postpartum visit.

WACOAN: I tend to think of infertility as an issue for women in their 30s or older, but do you see it in women in their 20s?

Brakovec: We do. I feel like usually we have to temper expectations and educate them on what is infertility and what is normal in trying to conceive. I have a lot of 20-year-olds that expect to get off birth control and conceive immediately. It can take time to conceive. There is only a 20% chance to conceive per [menstrual] cycle. It doesn’t happen right away for everybody, but that doesn’t necessarily indicate a problem.

Generally, we call it infertility if you’ve been trying to conceive for one year if you’re under 35, and we intervene earlier if you’re over 35. We use the six-month mark then.

WACOAN: To what degree do you handle infertility concerns and to what degree is that referred to a specialist?

Brakovec: It depends on the patient. It may depend on the source of infertility, also on how interventional the patient wants to be and how aggressive. We can generally manage mild infertility and the initial workup in a general office. Most people with complex problems, something nonresponsive to mild infertility agents, see a reproductive endocrinologist.

WACOAN: Does that mean the woman would go to Temple?

Brakovec: There is no reproductive endocrinologist in Waco. They generally go to Temple, Austin or Dallas.

WACOAN: What do you recommend for women in their 20s regarding sexually transmitted diseases?

Brakovec: They should be routinely screened for exposure, for younger women not in a monogamous relationship. We routinely offer that screening when women come in for annuals in their younger years and beyond. We do know, nationally, the trend is toward those rates going up. We try to educate people and promote safe sex habits.

We have a lot of people that put blinders on and think, ‘That won’t happen to me.’ Just because you’re not having symptoms doesn’t mean you’re not infected. It’s something we recommend even if you’re asymptomatic.

WACOAN: Has much has changed in the standard of care since you’ve been practicing?

Brakovec: If you compare [obstetrics and gynecology] to other fields, it doesn’t change as much as those. When you’re taking care of pregnant women you won’t have a lot of randomized, controlled trials that redefine things. There are not new medicines we’re experimenting with. Certain approaches to things have changed, as far as surgical techniques, with laparoscopy and robotics. That’s changed the field some. Obviously, with prenatal diagnosis and high-risk OB patients and ultrasound, that’s changed it quite a bit, but I’ve always practiced with it.

WACOAN: You said working as an OB-GYN wasn’t your first inclination. Over the years I’ve talked with other OB-GYNs who like the variety of care they get to offer. Has that been true for you, in your practice?

Brakovec: Yes, I like the broad range. I like the combination of being able to do surgery but also do some of the medicine side as well.

The other thing that appealed to me is the continuity of care we get to see. I’ve been here long enough that I’ve taken care of women with period problems in their teenage years, then I help them with pregnancy, then later in life they [will] need to talk through menopause. It’s nice to get to know those people through all walks and stages of life.

WACOAN: What overall advice do you have for women in their 20s, whether or not they’re planning to get pregnant soon?

Brakovec: I’d be an advocate for women being responsible for their overall health, not just during pregnancy but in all walks of life. Living a healthy lifestyle. That’s beneficial for pregnancy and beyond. I feel like if you go into your 20s and carry through those [good] habits, if you don’t gain a lot of weight and continue to exercise regularly, that will benefit you completely in the long-term.