Despite women making up nearly 50% of the global population, significant gender disparities in healthcare continue to be reported. Whilst diagnoses of hysteria may be a thing of the past, a continuing lack of education about female anatomy and women’s health makes it clear that inequalities persist in the 21st century.
In this feature, we take an in depth look at some common women’s health problems and the steps being taken to make the healthcare system easier to traverse for women and girls. We also dive into at the ever-increasing role of genomics in the field, and the social complexities involved in addressing women’s health.
The history of women’s health
Looking back through history, it is clear to see that the medical field has been dominated by men for millennia. The acceptance of woman doctors is a relatively recent phenomenon – the first recognised female physician was Elizabeth Blackwell, who obtained her degree in 1849. A lack of women’s voices in the field, coupled with deficient education regarding women’s health and anatomy, led to misconceptions and inequalities in the field that still exist today.
Figure 1: Image of a commemorative stamp celebrating Blackwell’s achievements. Designed in 1974 by Joseph Stanley Kozlowski. Credit: Syracuse University Medical School Collection.
For centuries, many diseases suffered by women were attributed solely to the reproductive system. Ancient Egyptians and Greeks believed in the concept of the ‘wandering uterus’ – the latter group believing that the womb could become ‘sad’, manifesting in a variety of mental and physiological symptoms that were deemed inappropriate in a woman. These misconceptions persisted until beyond the Victorian era, when women were given traumatic treatments for the condition dubbed ‘hysteria’, rather than appropriate care for real mental and physiological illnesses. Shocking examples of this include overlooked epilepsy diagnoses.
Hysteria diagnoses continued until as recently as the 1970s. However, in the 20th century, more care and attention was given to women’s health, and the Women’s Health Movement of the 1960s and 70s highlighted issues relating to bodily autonomy and reproductive rights. However, this movement did not mean that health equality was automatically reached. Today, there is still an ongoing lack of female representation in healthcare research, with many researchers exclusively experimenting on male mice due to ‘hormonal complications.’ This has led to inadequate testing of drugs in women, meaning that efficacy and side effects are often not sufficiently documented. For example, many cancer treatments cause a wider and more severe range of side effects in women. It is also still shockingly common for health problems in women to be attributed, wrongly, to the menstrual cycle or hormonal issues, with accurate diagnoses often taking years following a slew of inappropriate treatments and lack of testing.
A long journey to diagnosis
A classic example of the plight of women’s health is endometriosis. Endometriosis is a disease of the reproductive system that is thought to effect around 10% of women. The condition is characterised by the growth of endometrial tissue outside of the uterus, often around the bladder and ovaries. This can cause significant pain, particularly during menstruation, and up to half of endometriosis patients suffer from infertility. The disease was first characterised in the 1800s yet is still massively overlooked in a healthcare and research setting.
There is no cure for the disease, and there are still very few treatments for the symptoms. Early therapies included invasive surgeries such as hysterectomies to remove the affected organs, even when this was unnecessary. Today, recommendations include the use of over-the-counter painkillers and hormonal contraceptives to alleviate the symptoms of endometriosis, but many believe these treatments do not go far enough. In extreme cases, surgeries can still be the best course of action.
However, it can be a struggle to even get to the point of discussing treatment. Endometriosis can only be truly confirmed through laparoscopy, an invasive test that women can struggle to obtain a referral for. This problem is largely due to symptoms overlapping with those of other conditions and a misconception that severe pain is a ‘normal’ part of the menstrual cycle. These misunderstandings can lead to women being sent away with little more than a prescription for paracetamol, and the average time from symptom onset to diagnosis for endometriosis is a shocking eight years.
Figure 2: Image showing some of the instruments used in laparoscopy. The invasive diagnostic technique is one reason many women feel scared of pursuing a diagnosis.
Endometriosis has been seen to run in families, leading to obvious questions about how the disease is inherited and the mechanisms at play. Researchers have used whole exome and genome sequencing and GWAS approaches to uncover the processes underpinning the condition. Recently, a study identified over 40 risk loci associated with endometriosis, some of which were also linked to migraines and back pain, implying that the genetic basis of endometriosis is intrinsically linked to pain signalling. Whilst these findings could one day be used in therapies or to develop non-invasive diagnostics, the use of genomic medicine to combat endometriosis is sadly still lacking.
Inequalities in the cancer field
Concerns about the overarching effects of endometriosis do not end there. A 2022 study revealed a genetic link between endometriosis and ovarian cancer risk. Women suffering from the former condition were at higher risk of developing this form of cancer than their unaffected counterparts, although the researchers were keen to stress that the risk was still relatively low. The study suggested that women with endometriosis could perhaps be screened more closely for signs of ovarian tumours, yet with such a long period where women do not have an official diagnosis, there are concerns over the potential for missed cancer diagnoses.
Ovarian cancer, and other ‘women’s’ cancers, represent a further spectrum of diseases that have historically been overlooked. Many gynaecological cancers present in a similar way in their early stages to many other illnesses, with easily overlooked symptoms such as bloating and irregular bleeding. However, reports suggest that whilst GPs can be prone to missing the signs of gynaecological cancers – sometimes suggesting that the symptoms are the result of less life-threatening diseases like IBS – often it is the patient themself who overlooks the symptoms. This points towards a lack of education surrounding one’s own body, something that some charities are trying to tackle. This educational deficit likely persists because, historically, many anatomy lessons and health tips have been geared towards men, despite women’s bodies needing their own approach.
Women are also often turned away from more extensive testing due to beliefs that they are ‘too young’ to have certain cancers. This has sparked debate around the minimum age for smear tests. At present, only women over the age of 25 are offered this procedure, with younger women mostly denied this test even in the presence of other concerning symptoms. Furthermore, in 2019, statistics revealed that less than half of women invited for the test attended their appointment. Low uptake has been attributed to fears about the test being painful, a lack of knowledge regarding the importance of the test, or a simple lack of initiatives to encourage uptake.
This is in stark contrast to the screening system for bowel cancer in the UK, which is completed by around 70% of those who it is offered to. This screening system has been complemented by national adverts on television with a kit posted straight to your front door. This highlights a significant health gap between a form of cancer that affects all genders, compared to one which only impacts women.
Thankfully, vast efforts are being made in the field of cancer genomics to improve the outlook for gynaecological cancers. Genomic screening for variants that can lead to increased risk of these diseases is steadily improving. For example, BRCA1 and BRCA2 screening for those with direct relatives suffering with ovarian cancer is much more commonplace now and pathogenic variants are widely studied. There is also a growing range of targeted treatments depending on one’s tumour profile, such as PARP inhibitors. As for wider screening opportunities, a 2022 study showed that analysis of DNA methylation markers was effective in identifying women at risk of cervical cancer, suggesting that the epigenome could be utilised to improve outlook for women with, or at risk from, these diseases.
The mental health struggle
Whilst mental health care has undoubtably improved since the days of hysteria diagnoses and the ‘wandering uterus’ fallacy, there is still a lot to be done to improve care for all genders. However, many women still report that their psychological symptoms are often not taken seriously. The gap in mental health care is further exacerbated by the use of hormonal contraception to treat physical illnesses, which often comes with side effects such as severe depression and even suicidal thoughts. So, despite the strides made in the field, it is clear that there is still a gender gap in mental health care. While around 1 in 8 men are thought to suffer from illnesses such as depression and anxiety, around 20% of women suffer from these conditions. Women are also more likely to suffer from eating disorders.
However, a mental health condition that more specifically impacts women is post-partum depression (PPD). Thought to be experienced by around 1 in 7 new mothers, PPD can manifest in the form of low mood, trouble sleeping, and, crucially, extreme anxiety surrounding the welfare of their infant. Many mothers have reported feeling unsupported by the system, with medical professionals often referring to the severe symptoms as ‘baby blues’ – a more common experience that typically disappears within a couple of weeks. True PPD is far more sinister, and severe cases can end with mother and child admitted to a mother-baby unit for care.
Thankfully, PPD has been receiving far more attention in recent years, and treatment is slowly improving. Researchers have begun to investigate the genomic basis of the condition – a 2019 study linked DNA methylation patterns with PPD onset and in 2021 researchers discovered that altered gene expression levels led to immune system alterations in PPD patients. These findings have not yet made it to the clinic, but are a stepping stone on the route to determining PPD risk or developing targeted treatments.
A real headache
Stepping away from issues that typically only affect one gender, there are still health inequalities surrounding illnesses and ailments that are suffered by both sexes. A classic example of this is migraine – this painful condition is found in three to four times more women than men. The exact mechanisms that cause this difference are generally thought to be the result of hormonal differences between the sexes, but like many other women’s health problems, the painful symptoms of migraine are often overlooked and attributed to side effects of the menstrual cycle.
Overlooking women’s pain in this manner is an unfortunately common occurrence, despite men facing the same levels of pain being taken seriously and offered treatment – a phenomenon dubbed the ‘gender pain gap.’
A social stigma
Unfortunately, sometimes social stigma surrounding these issues can prevent women from seeking help. Many women have reported being shamed by doctors when trying to access reproductive healthcare and have felt uncomfortable discussing ‘women’s’ issues with male doctors. Shockingly, however, the mistaken beliefs that permeate the healthcare system can often be perpetuated by woman doctors. In a 2022 survey over 84% of women claimed they felt overlooked by their primary health professional, regardless of their gender.
This extends beyond gender-specific illnesses – women have also reported that they are often dismissed when they have real symptoms due to being ‘too emotional.’ Many patients have also highlighted that symptoms that were taken seriously in men were dismissed when women approached their GP about them, highlighting an inherent bias based on gender and little else. With the road to diagnosis often long and gruelling, it is no shock that many women feel helpless when they get caught in this system.
There can also be a taboo surrounding many women’s health issues – young girls are often told that periods are shameful and that issues related to their reproductive system are not to be discussed. This can lead to them hiding their symptoms even from other women. Couple this with the highly invasive nature of many diagnostic tests for women’s health issues and it is no surprise that many women will fail to seek help even if it is available.
The other side of the coin
But whilst we discuss the term ‘women’s health’, it is important to remember that some conditions that are traditionally viewed as a women’s disease actually impact men as well. And due to the belief that these illnesses only affect women, some men may also feel overlooked and dismissed by their GP.
A classic example of this is breast cancer. Arguably one of the most famous ‘women’s’ diseases, with campaigns characterised by pink icons and puns about the female body, you would be forgiven for believing this illness only affects one gender. This is simply not the case, with 350 men diagnosed with breast cancer in the UK every year. The characterisation of breast cancer as a women’s disease can leave many men at risk of being overlooked or simply feeling too much stigma to seek out medical help or support from loved ones.
Figure 3: Breast cancer symbols are often displayed in a traditionally ‘feminine’ manner. This contributes in part to the stigma faced by men with the condition.
Another example is the human papilloma virus (HPV). A common cause of cervical cancer, HPV prevention came about in the form of a vaccine approved for use in 2006. Initially offered only to young girls in the United Kingdom, boys have been offered the vaccine in recent years also, given that the virus can contribute to the onset of other cancers in men.
Furthermore, a little-known fact is that men can also suffer from a condition similar to polycystic ovarian syndrome. The disorder was more common in men whose female relatives suffered from PCOS, and manifested in hormonal and metabolic alterations that led to similar symptoms.
A complex term
So what value is there to using the term ‘women’s health’ if there are so many caveats? Whilst of course it is helpful to strive towards better healthcare for all, there is still a clear gender bias within the healthcare and research fields, and the use of this umbrella term allows for the issues to be highlighted.
But what about when the term does not fit? Many of the illnesses we have discussed are also applicable to trans individuals or those with sex chromosome disorders, for whom their biological risk of disease does not necessarily align with their gender expression. Alongside this are concerns around the messaging surrounding certain ‘women’s issues’; a lot of this messaging can focus on reproductive organs and the ability to bear children, which can leave those who cannot have children feeling overlooked and less worthy of care. It’s important therefore to approach the issue whilst considering the nuance of the term and consider everyone’s health as an individual case. That said, with such a clear gender-based bias in the health field, a defined movement to address these problems is vital.
So, what is the future of the women’s health field, and what role is genomics going to play in improving prospects for women going forward?
One significant way in which the gender-related health gap is closing is the introduction of more female doctors. At present there are around 20,000 more men than women in the medical profession in the UK, although women do remain well represented within general practice. However, more and more young women are signing up to medical courses at universities, and so the gender gap within the field should shrink even more in the coming years. This trend is mirrored across all OECD countries.
In the last couple of years, issues surrounding the menopause have gained traction in mainstream media. Previously overlooked and simply seen as a necessary part of a woman’s life, the often debilitating symptoms of the menopause could last for years and seriously impact the wellbeing and livelihood of many women. With nearly half of the world experiencing the menopause at some point in their life, it is shocking that it took so long for the issue to gain such widespread attention. However, recent high profile campaigns and even prominent storylines in popular soap operas have drawn attention to the real issues of the menopause. It is clear that this particularly stigmatised aspect of women’s health is beginning to become less taboo.
In a bid to improve healthcare for those struggling, researchers have begun to identify some of the genomic mechanisms that explain the menopause. For example, a 2021 study showed that genetics can influence the age of menopause onset. And in 2016, a review discussed the utilisation of personalised medicine in treating menopause symptoms. Whilst genomic medicine for the menopause has yet to make it to the clinic, the fact that this once off-limits conversation is now at the forefront of peoples’ minds is a huge step forward.
Elsewhere, genomics research to combat women’s health problems is ramping up. For example, the International Endometriosis Genome Consortium now contains data from over 60,000 patients and has been key to the discovery of genetic variants associated with the disease. And in a similar vein, large-scale research into the genetics of polycystic ovarian syndrome has highlighted new avenues for investigation – with one study suggesting that the genetic pathways responsible for the disease are not in fact linked to the ovaries. By understanding these mechanisms, there is more scope for better diagnostics and personalised treatments.
Given how young the field is, it is not shocking that few genomic medicine approaches for women’s health have made it to the clinic. However, a brilliant example of something that is well on its way to implementation is BRCA-Direct. BRCA-Direct is a digital platform that aims to streamline the process of genetic screening for breast cancer-associated variants by providing results online. Still in its early days, over 1000 women were involved in the program’s pilot phase, and the platform should hopefully be rolled out within the NHS in the not-too-distant future.
The shifting attitude towards women’s health can only serve as a step forward in closing the health gap. Women’s health is one of the most talked about issues in the healthcare field in 2023, and with an ever-increasing amount of research, we should soon see a vast improvement in health equality.
Figure 1: Public Domain, https://commons.wikimedia.org/w/index.php?curid=3516695
Figures 2 and 3: Canva