Women's health

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For the women's lifestyle magazine, see Women's Health (magazine).
Logo depicting women's health
Symbol of women's health

Women's health refers to the health of women, which differs from that of men in many unique ways. Women's health is an example of population health, where health is defined by the World Health Organization as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity". Often treated as simply women's reproductive health, many groups argue for a broader definition pertaining to the overall health of women, better expressed as "The health of women". These differences are further exacerbated in developing countries where women, whose health includes both their risks and experiences, are further disadvantaged.

Although women in industrialised countries have narrowed the gender gap in life expectancy and now live longer than men, in many areas of health they experience earlier and more severe disease with poorer outcomes. Gender remains an important social determinant of health, since women's health is influenced not just by their biology but also by conditions such as poverty, employment, and family responsibilities. Women have long been disadvantaged in many respects such as social and economic power which restricts their access to the necessities of life including health care, and the greater the level of disadvantage, such as in developing countries, the greater adverse impact on health.

Women's reproductive and sexual health places a unique burden on them. Even in developed countries pregnancy and childbirth are associated with substantial risks to women with maternal mortality accounting for more than a quarter of a million deaths per year, with large gaps between the developing and developed countries. Comorbidity from other non reproductive disease such as cardiovascular disease contribute to both the mortality and morbidity of pregnancy, including preeclampsia. Sexually transmitted infections have serious consequences for women and infants, with mother-to-child transmission leading to outcomes such as stillbirths and neonatal deaths, and pelvic inflammatory disease leading to infertility. In addition infertility from many other causes, birth control, unplanned pregnancy, unconsensual sexual activity and the struggle for access to abortion create other burdens for women.

While the rates of the leading causes of death, cardiovascular disease, cancer and lung disease, are similar in women and men, women have different experiences. Lung cancer has overtaken all other types of cancer as the leading cause of cancer death in women, followed by breast cancer, colorectal, ovarian, uterine and cervical cancers. While smoking is the major cause of lung cancer, amongst nonsmoking women the risk of developing cancer is three times greater than amongst nonsmoking men. Despite this, breast cancer remains the commonest cancer in women in developed countries, and is one of the more important chronic diseases of women, while cervical cancer remains one of the commonest cancers in developing countries, associated with human papilloma virus (HPV), an important sexually transmitted disease. HPV vaccine together with screening offers the promise of controlling these diseases. Other important health issues for women include cardiovascular disease, depression, dementia, osteoporosis and anemia.

A major impediment to advancing women's health has been their underrepresentation in research studies, an inequity being addressed in the United States and other western nations by the establishment of centers of excellence in women's health research and large scale clinical trials such as the Women's Health Initiative.

Definition[edit]

Women's experience of health and disease differ from those of men, due to unique biological, social and behavioural conditions. Biological differences vary all the way from phenotype to the cellular, and manifest unique risks for the development of ill health.

The World Health Organization defines health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity".[1] Women's health is an example of population health, the health of a specific defined population.[2] Although many of the issues around women's health relate to their reproductive health, including maternal and child health, genital health and breast health, and endocrine (hormonal) health, including menstruation, birth control and menopause, a broader understanding of women's health to include all aspects of the health of women has been urged, replacing "Women's Health" with "The Health of Women".[3] Conditions that affect both men and women, such as cardiovascular disease, osteoporosis, also manifest differently in women.[4] Women's health issues also include medical situations in which women face problems not directly related to their biology, such as gender-differentiated access to medical treatment and other socioeconomic factors.[4]

A number of health and medical research advocates, such as the Society for Women's Health Research in the United States, support this broader definition, rather than merely issues specific to human female anatomy to include areas where biological sex differences between women and men exist. Gender differences in susceptibility and symptoms of disease and response to treatment in many areas of health are particularly true when viewed from a global perspective.[5][6] Much of the available information comes from developed countries, yet there are marked differences between developed and developing countries in terms of women's roles and health.[7] The global viewpoint is defined as the "area for study, research and practice that places a priority on improving health and achieving health equity for all people worldwide".[8] Women also need health care more and access the health care system more than do men. While part of this is due to their reproductive and sexual health needs, they also have more chronic non-reproductive health issues such as heart disease, depression, diabetes and osteoporosis.[9]

Life expectancy[edit]

Main article: Life expectancy

Women's life expectancy is greater than that of men, and they have lower death rates throughout life, regardless of race and geographic region. Historically though, women had higher rates of mortality, prmarily from maternal deaths (death in childbirth). In industrialised countries, particularly the most advanced, the gender gap narrowed and was reversed following the industrial revolution. [4] Despite these differences, in many areas of health, women experience earlier and more severe disease, and experience poorer outcomes.[10]

Despite these differences, the leading causes of death in the United States are remarkably similar for men and women, headed by heart disease, which accounts for a quarter of all deaths, followed by cancer, lung disease and stroke. While women have a lower incidence of death from unintentional injury (see below) and suicide, they have a higher incidence of dementia - 4.5% of deaths vs. 2.0% (Gronowski and Schindler, Table I).[4][11]

Social and cultural factors[edit]

Women's health is positioned within a wider body of knowledge cited by, amongst others, the World Health Organisation, which places importance on gender as a social determinant of health.[12] Women's health is affected not just by their biology, but also by their social conditions, such as poverty, employment, and family responsibilities.[13][14]

Women have traditionally been disadvantaged in terms of economic and social status and power, which in turn reduces their access to the necessities of life including health care. Despite recent improvements in western nations, women remain disadvantaged with respect to men.[4] The gender gap in heath is even more acute in developing countries where women are relatively more disadvantaged. In addition to gender inequity, thre remain specific disease processes uniquely associated with being a woman which create specific challenges in both prevention and health care.[10]

Even after succeeding in accessing health care, women have been discriminated against,[15] a process that Iris Young has called "internal exclusion", as opposed to "external exclusion", the barriers to access. This invisibility effectively masks the grievances of groups already disadvantaged by power inequity, further entrenching injustice.[16]

Behavioral differences also play a role, in which women display lower risk taking including consume less tobacco, alcohol, and drugs, reducing their risk of mortality from associated diseases, including lung cancer, tuberculosis and cirrhosis. Other risk factors that are lower for women include motor vehicle accidents. Occupational differences have exposed women to less industrial injuries, although this is likely to change, as is risk of injury or death in war. Overall such injuries contributed to 3.5% of deaths in women compared to 6.2% in the United States in 2009. Suicide rates are also less in women (<1% vs. 2.4%).[17][18]

The social view of health combined with the acknowledgement that gender is a social determinant of health inform women's health service delivery in countries around the world. Women's health services such as Leichhardt Women's Community Health Centre which was established in 1974[19] and was the first women's health centre established in Australia is an example of women's health approach to service delivery.[20]

Women's health is an issue which has been taken up by many feminists, especially where reproductive health is concerned.

Biological factors[edit]

Women and men differ in their chromosomal makeup, protein gene products, genomic imprinting, gene expression, signaling pathways, and hormonal environment. All of these necessitate caution in extrapolating information derived from biomarkers from one sex to the other.[4]

Reproductive and sexual health[edit]

Main article: Reproductive health

Women experience many unique health issues related to reproduction and sexuality. Reproductive health includes a wide range of issues including the health and function of structures and systems involved in reproduction, pregnancy, childbirth and child rearing, including antenatal and perinatal care.[21][22] Global women's health has a much larger focus on reproductive health than that of developed countries alone, but also infectious diseases such as malaria in pregnancy and non-communicable diseases (NCD). Many of the issues that face women and girls in resource poor regions are relatively unknown in developed countries, such as female genital cutting, and further lack access to the appropriate diagnostic and clinical resources.[5]

Maternal health[edit]

Main article: Maternal health

Pregnancy presents substantial health risks, even in developed countries, and despite advances in obstetrical science and practice. Maternal mortality remains a major problem in global health. Nearly 800 women die every day[5] (others estimate 350,000 per year[4] ) in the world due to pregnancy-related causes, with large differences between developed and developing countries. Maternal mortality in western nations had been steadily falling, and forms the subject of annual reports and reviews.[23] Yet between 1987 and 2011, maternal mortality in the United States rose from 7.2 to 17.8 deaths per 100,000 live births.[23] By contrast rates as high as 1,000 per birth are reported in the rest of the world,[5] with the highest rates in Sub-Saharan Africa and South Asia.[24]

Non-reproductive health remains an important predictor of maternal health. In the United States, the leading causes of maternal death are cardiovascular disease (15% of deaths), endocrine, respiratory and gastrointestinal disorders, infection, hemorrhage and hypertensive disorders of pregnancy (Gronowski and Schindler, Table II).[4] In addition to death occurring in pregnancy and childbirth, pregnancy can result in many non-fatal health problems including ectopic pregnancy, preterm labor, gestational diabetes, hyperemesis gravidarum, hypertensive states including preeclampsia, and anemia.[25]

Sexual health[edit]

Main article: Sexual health

Sexually transmitted infections (STIs) are a global health priority because they have serious consequences for women and infants. Mother-to-child transmission of STIs can lead to stillbirths, neonatal death, low-birth-weight and prematurity, sepsis, pneumonia, neonatal conjunctivitis, and congenital deformities. Syphilis in pregnancy results in over 300,000 fetal and neonatal deaths per year, and 215,000 infants with an increased risk of death from prematurity, low-birth-weight or congenital disease.

Diseases such as chlamydia and gonorrhoea are also important causes of pelvic inflammatory disease (PID) and subsequent infertility in women. Another important consequence of some STIs such as genital herpes and syphilis increase the risk of acquiring HIV by three-fold, and can also influence its transmission progression.[26]

Other[edit]

Other issues in reproductive health include infertility and birth control. In the United States, infertility affects 1.5 million couples.[27][28] Many couples seek assisted reproductive technology (ART) for infertility.[29] In the United States in 2010, 147,260 in vitro fertilization (IVF) procedures were carried out, with 47,090 live births resulting.[30] In 2013 these numbers had increased to 160,521 and 53,252.[31] However, about a half of IVF pregnancies result in multiple-birth deliveries, which in turn are associated with an increase in both morbidity and mortality of the mother and the infant. Causes for this include imcreased maternal blood pressure, premature birth and low birth weight. In addition, more women are waiting longer to conceive and seeking ART.[31]

In the Cartwright Inquiry in New Zealand, in which research by two feminist journalists revealed that women with cervical abnormalities were not receiving treatment, as part of an experiment. The women were not told of the abnormalities and several later died. In many countries feminists have campaigned for the right to legal and safe abortion, arguing that it is a health rather than a moral issue. In countries where contraception is difficult to access, campaigns for readily available contraception are conducted on the same lines. Conversely, there have also been campaigns against potentially dangerous forms of contraception such as defective IUDs. Worldwide, women and girls are at greater risk of HIV/AIDS – a phenomenon associated with unsafe sexual activity that is often unconsensual.[32]

Other health issues[edit]

Women and men have different experiences of the same illnesses, especially cancer, cardiovascular disease, depression and dementia.[33]

Cancer[edit]

Women and men have approximately equal risk of dying from cancer, which accounts for about a quarter of all deaths, and is the second leading cause of death. However the relative incidence of different cancers varies between women and men. In the United States the three commonest types of cancer of women in 2012 were lung, breast and colorectal cancers. In addition other important cancers in women, in order of importance, are ovarian, uterine and cervical cancers (Gronowski and Schindler, Table III).[4][34] Similar figures were reported in 2016.[35] While cancer death rates rose rapidly during the twentieth century, the increase was less and later in women due to differences in smoking rates. More recently cancer death rates have started to decline as the use of tobacco becomes less common. Between 1991 and 2012, the death rate in women declined by 19% (less than in men). In the early twentieth century death from uterine (uterine body and cervix) cancers was the leading cause of cancer death in women, who had a higher cancer mortality than men. From the 1930s onwards, uterine cancer deaths declined, primarily due to lower death rates from cervical cancer following the availability of the Papanicolaou (Pap) screening test. This resulted in an overall reduction of cancer deaths in women between the 1940s and 1970s, when rising rates of lung cancer led to an overall increase. By the 1950s the decline in uterine cancer left breast cancer as the leading cause of cancer death till it was overtaken by lung cancer in the 1980s. All three cancers (lung, breast, uterus) are now declining in cancer death rates (Siegel et al. Figure 8),[35] but more women die from lung cancer every year than from breast, ovarian, and uterine cancers combined. Overall about 20% of people found to have lung cancer are never smokers, yet amongst nonsmoking women the risk of developing lung cancer is three times greater than amongst men who never smoked.[33]

In addition to mortality, cancer is a cause of considerable morbidity in women. In 2016, breast cancer is the commonest cancer diagnosed amongst women, accounting for nearly 30% of all cases. Women have a lower lifetime probability of being diagnosed with cancer (38% vs 45% for men), but are more likely to be dagnosed with cancer at an earlier age. Breast cancer is amongst the ten commonest chronic diseases of women, and a substantial contributor to loss of quality of life (Gronowski and Schindler, Table IV).[4][9]

Globally, cervical cancer is one of the commonest cancers amongst women, particularly those of lower socioeconomic status. Cervical cancer is associated with human papillomavirus (HPV), which has also been implicated in cancers of the vulva, vagina, anus, and oropharynx. Almost 300 million women worldwide have been infected with HPV, one of the commoner sexually transmitted infections, and 5% of the 13 million new cases of cancer in the world have been attributed to HPV.[36][26] In developed countries, screening for cervical cancer using the Pap test has identified pre-cancerous changes in the cervix, at least in those women with access to to health care. Also an HPV vaccine programme is available in 45 countries. If applied globally, vaccination at 70% coverage could save the lives of 4 million women from cervical cancer, since most cases occur in developing countries.[4]

By contrast, ovarian cancer, the leading cause of reproductive organ cancer deaths, and the fifth commonest cause of cancer deaths in women in the United States, lacks an effective screening programme, and is predominantly a disease of women in industrialised countries. Because it is largely asymptomatic in its earliest stages, more than 50% of women have stage III or higher cancer (spread beyond the ovaries) by the time they are diagnosed, with a consequent poor prognosis.[35][4]

Cardiovascular disease[edit]

Cardiovascular disease is the leading cause of death (30%) amongst women in the United States, and the leading cause of chronic disease amongst them, affecting nearly 40% (Gronowski and Schindler, Tables I and IV).[4][9][33] The onset occurs at a later age in women than in men. For instance the incidence of stroke in women under the age of 80 is less than that in men, but higher in those aged over 80. Overall the lifetime risk of stroke in women exceeds that in men.[17][18] The risk of cardiovascular disease amongst those with diabetes and amongst smokers is also higher in women than in men.[4] Many aspects of cardiovascular disease vary between women and men, including risk factors, prevalence, physiology, symptoms, response to intervention and outcome. [33]

Mental health and depression[edit]

Almost 25% of women will experience mental health issues over their lifetime.[37] Globally, depression is the leading disease burden. In the United States, women have depression twice as often as men. The economic costs of depression in American women are estimated to be $20 billion every year. The risks of depression in women have been linked to changing hormonal environment that women experience, including puberty, menstration, pregnancy, childbirth and the menopause.[33] Women also metabolise drugs used to treat depression differently to men.[33][38]

Dementia[edit]

The prevalence of Alzheimer's Disease in the United States is estimated at 5.1 million, and of these two thirds are women. Furthermore, women are far more likely to be the primary caregivers of adult family members with depression, so that they bear both the risks and burdens of this disease. The lifetime risk for a woman of developing Alzeimer's is twice that of men. Part of this difference may be due to life expectancy, but changing hormonal status over their lifetime may also play a par as may differences in gene expression.[33]

Bone health[edit]

Osteoporosis ranks sixth amongst chronic diseases of women in the United States, with an overall prevalence of 18%, amd a much higher rate involving the femur, neck or lumbar spine amongst women (16%) than men (4%), over the age of 50 (Gronowski and Schindler, Table IV).[4][9][39] Osteoporosis is a risk factor for bone fracture and about 20% of senior citizens who sustain a hip fracture die within a year.[4] [40] The gender gap is largely the result of the reduction of estrogen levels in women following the menopause. Hormone Replacement Therapy (HRT) has been shown to reduce this risk by 25–30%,[41] and was a common reason for prescribing it during the 1980s and 1990s. However the Women's Health Initiative (WHI) study that demonstrated that the risks of HRT outweighed the benefits[42] has since led to a decline in HRT usage.

Proton pump inhibitors (such as Lansoprazole, Esomeprazole, or Omeprazole) that decrease stomach acid, are a risk for bone fractures if taken for two or more years, due to decreased absorption of calcium in the stomach.[43]

Anaemia[edit]

Anaemia is a major global health problem for women.[44] Women are affected more than men, in which up to 30% of women being found to be anaemic and 42% of pregnant women. Anaemia is linked to a number of adverse health outcomes including a poor pregnancy outcome and impaired cognitive function (decreased concentration and attention).[45] The main cause of anaemia is iron deficiency. In United States women iron deficiency anaemia (IDA) affects 37% of pregnant women, but globally the prevalence is as high as 80%. IDA starts in adolescence, from excess menstrual blood loss, compounded by the increased demand for iron in growth and suboptimal dietary intake. In the adult woman, pregnancy leads to further iron depletion.[4]

Women in health research[edit]

Changes in the way research ethics was visualised in the wake of the Nuremberg Trials (1946), led to an atmosphere of protectionism of groups deemed to be vulnerable that was often legislated or regulated. This resulted in the relative underrepresentation of women in clinical trials. The position of women in research was further compromised in 1977, when in response to the tragedies resulting from thalidomide and diethylstilbestrol (DES), the United States Food and Drug Administration (FDA) prohibited women of child bearing years from participation in early stage clinical trials. In practice this ban was often applied very widely to exclude all women.[46][47] Women, at least those in the child bearing years, were also deemed unsuitable research subjects dut their fluctuating hormonal levels during the menstrual cycle. However, research has demonstrated significant biological differences between the sexes in rates of susceptibility, symptoms and response to treatment in many major areas of health, including heart disease and some cancers. These exclusions pose a threat to the application of evidence-based medicine to women, and compromise to care offered to both women and men.[4][48]

The increasing focus on Women's Rights in the United States during the 1980s focused attention on the fact that many drugs being prescribed for women had never actually been tested in women of child-bearing potential, and that there was a relative paucity of basic research into women's health. In response to this the National Institutes of Health (NIH) created the Office of Research on Women's Health (ORWH)[49] in 1990 to address these inequities. In 1993 the National Institutes of Health Revitalisation Act officially reversed US policy by requiring NIH funded phase III clinical trials to include women.[33] This resulted in an increase in women recruited into research studies. The next phase was the specific funding of large scale epidemiology studies and clinical trials focussing on women's health such as the Women's Health Initiative (1991), the largest disease prevention study conducted in the US. Its role was to study the major causes of death, disability and frailty in older women.[50] Despite this apparent progress, women remain underepresented. In 2006 women accounted for less than 25% of clinical trials published in 2004,[51] A follow up study by the same authors five years later found little evidence of improvement.[52] Another study found between 10–47% of women in heart disease clinical trials, despite the prevalence of heart disease in women.[53] Lung cancer is the leading cause of cancer death amongst women, but while the number of women enrolled in lung cancer studies is increasing, they are still far less likely to be enrolled than men.[33]

One of the challenges in assessing progress in this area is the number of clinical studies that either do not report the gender of the subjects or lack the statistical power to detect gender differences.[54][55] These were still issues in 2014, and further compounded by the fact that the majority of animal studies also exclude females or fail to account for differences in sex and gender. for instance despite the higher incidence of depression amongst women, less than half of the animal studies use female animals.[33]

A related issue is the inclusion of pregnant women in clinical studies. Since other illnesses can exist concurrently with pregnancy, information is needed on the response to and efficacy of interventions during pregnancy, but ethical issues relative to the fetus, makle this more complex. This gender bias is partly offset by the iniation of large scale epidemiology studies of women, such as the Nurses' Health Study (1976),[56] Women's Health Initiative[57] and Black Women's Health Study.[58][4]

National initiatives[edit]

In addition to addressing gender inequity in research, a number of countries have made women's health the subject of national initiatives. For instance in 1991 in the United States, the Department of Health and Human Services established an Office on Women's Health (OWH) with the goal of improving the health of women in America, through coordinating the women's health agenda throughout the Department, and other agencies. In the twenty first century the Office has focussed on underserviced women.[59][60] Also, in 1994 the Centers for Disease Control and Prevention (CDC) established its own Office of Women's Health (OWH), which was formally authorised by the 2010 Affordable Health Care Act (ACA).[61][62] Internationally, bodies such as the World Health Organization (WHO) maintain specific programs on women's health.[63]

Goals and challenges[edit]

A group of women in India receiving instruction in health education
Women receiving health education in India
Nepalese women learning oral health
Women in Nepal learning oral health

Research is a priority in terms of improving women's health. Research needs include diseases unique to women, more serious in women and those that differ in risk factors between women and men. The balance of gender in research studies needs to be balanced appropriately to allow analysis that will detect interactions between gender and other factors.[4] Gronowski and Schindler suggest that scientific journals make documentation of gender a requirement when reporting the results of animal studies, and that funding agencies require justification from investigastors for any gender inequity in their grant proposals, giving preference to those that are inclusive. They also suggest it is the role of health organisations to encourage women to enroll in clinical research. However, there has been progress interms of large scale studies such as the WHI, and in 2006 the Society for Women's Health Research founded the Organization for the Study of Sex Differences (OSSD) and the journal Biology of Sex Differences to further the study of sex differences.[4]

Research findings can take some time before becoming routinely implemented into clinical practice. Clinical medicine needs to incorporate the information already available from research studies as to the different ways in which diseases affect women and men. Many "normal" laboratory values have not been properly established for the female population separately, and similarly the "normal" criteria for growth and development. Drug dosing needs to take gender differences in drug metabolism into account.[4]

Globally, women's access to health care remains a challenge, both in developing and developed countries. In the Unites State, before the Affordable Health Care Act came into effect, 25% of women of child bearing age lacked health insurance.[64] In the absence of adequate insurance, women are likely to avoid important steps to self care suchas routine physical examination, screening and prevention testing, and prenatal care. The situation is agggravated by the fact that women living below the poverty line are at greater risk of unplanned pregnancy, unplanned delivery and elective abortion. Added to the financial burden in this group are poor educational achievement, lack of transportation, inflexible work schedules and difficulty obtaining child care, all of which function to create barriers to accessing health care. These problems are much worse in developing countries. Under 50% of childbirths in these countries are assisted by healthcare providers (e.g. midwives, nurses, doctors) which accounts for higher rates of maternal death, up to 1:1,000 live births. This is depite the WHO setting standards, such as a minimum of four antenatal visits.[65] A lack of healthcare providers, facilities, and resources such as formularies all contribute to high levels of morbidity amongst women from avoidable conditions such as obstetrical fistulae, sexually transmitted diseases and cervical cancer.[4]

These challenges are included in the goals of the Office of Research on Women's Health, in the United States, as is the goal of facilitating women's access to careers in biomedicine. The ORWH believes that one of the best ways to advance research in women's health is to increase the proportion of women involved in healthcare and health research, as well as assuming leadership in government, centres of higher learning, and in the private sector.[50] This goal acknowledges the glass ceiling that women face in careers in science and in obtaining resources from grant funding to salarries and laboratory space.[66] The National Science Foundation in the United States states that women only gain half of the doctorates awarded in science and engineering, fill only 21% of full-time professor positions in science and 5% of those in engineering, while earning only 82% of the remuneration their male colleagues make. These figures are even lower in Europe.[66]

See also[edit]

References[edit]

Bibliography[edit]

Symposia[edit]

Articles and chapters[edit]

Books and reports[edit]

Websites[edit]

Women's health research[edit]

CDC[edit]

WHO[edit]