Women's health is an example of population health, where health is defined by the World Health Organization (WHO) 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.
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 related 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 among nonsmoking men. Despite this, breast cancer remains the most common cancer in women in developed countries, and is one of the major chronic diseases of women, while cervical cancer remains one of the most common cancers in developing countries, associated with human papilloma virus (HPV), a sexually transmitted infection. 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.
In 176 out of 178 countries for which records are available, there is a gender gap in favor of women in life expectancy. In Western Europe, this has been the case at least as far back as 1750. 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 has a distinct difference compared to men's health. 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 diseases 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, rape and the struggle for access to abortion create other burdens for women.
Definitions and scope
Women's experience of health and disease differ from those of men, due to unique biological, social and behavioral conditions. Biological differences vary from phenotypes to the cellular biology, and manifest unique risks for the development of ill health.
Women who are socially marginalised are more likely to die at younger ages than women who are not. Women who have substance abuse disorders, who are homeless, who are sex workers, and/or who are imprisoned have significantly shorter lives than other women. At any given age, women in these overlapping, stigmatised groups are approximately 10 to 13 times more likely to die than typical women of the same age.
Social and cultural factors
alt=Logo combining the male and female symbols and an equal sign in the centre to denote gender equality, as used in the fifth Sustainable Development Goal which addresses Gender Equality|thumb|Logo of [[Sustainable Development Goal 5: Gender Equality]]
Women's health is positioned within a wider body of knowledge cited by, amongst others, the World Health Organization, which places importance on gender as a social determinant of health. Low dietary diversity jeopardizes nutrient adequacy.
Even after succeeding in accessing health care, women have been discriminated against, 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.
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. All of these necessitate caution in extrapolating information derived from biomarkers from one sex to the other. Young women and adolescents are at risk from STIs, pregnancy and unsafe abortion, while older women often have few resources and are disadvantaged with respect to men, and also are at risk of dementia and abuse, and generally poor health.
Reproductive and sexual health
Women experience many unique health issues related to reproduction and sexuality and these are responsible for a third of all health problems experienced by women during their reproductive years (aged 15–44), of which unsafe sex is a major risk factor, especially in developing countries. 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. Research has shown the most effective programmes are those focussing on patient and community education, prenatal care, emergency obstetrics (including access to cesarean sections) and transportation. As with women's health in general, solutions to maternal health require a broad view encompassing many of the other MDG goals, such as poverty and status, and given that most deaths occur in the immediate intrapartum period, it has been recommended that intrapartum care (delivery) be a core strategy. New guidelines on antenatal care were issued by WHO in November 2016.
Obstetrical fistula
thumb|Women in an [[Ethiopian fistula hospital|alt=A row of women patients in bed in an Ethiopian fistula hospital]]
Of near miss events, obstetrical fistulae (OF), including vesicovaginal and rectovaginal fistulae, remain one of the most serious and tragic. Although corrective surgery is possible it is often not available and OF is considered completely preventable. If repaired, subsequent pregnancies will require cesarean section. Worldwide 222 million women have no or limited access to contraception. Some caution is needed in interpreting available data, since contraceptive prevalence is often defined as "the percentage of women currently using any method of contraception among all women of reproductive age (i.e., those aged 15 to 49 years, unless otherwise stated) who are married or in a union. The "in-union" group includes women living with their partner in the same household and who are not married according to the marriage laws or customs of a country." This definition is more suited to the more restrictive concept of family planning, but omits the contraceptive needs of all other women and girls who are or are likely to be sexually active, are at risk of pregnancy and are not married or "in-union". In comparison to men, taboos, and discrimination against women living with HIV are more pervasive throughout the MENA region. Women in the MENA region are more vulnerable to HIV because of gender inequity, gender-based violence, and restricted access to comprehensive healthcare systems.]]
It has affected more than 200 million women and girls who are alive today. The practice is concentrated in some 30 countries in Africa, the Middle East and Asia. According to data, the frequency of FGM among women between the ages of 15 and 49 is high: 94% in Djibouti, 87% in Egypt and Sudan, 19% in Yemen, and 7% in Iraq.
Many couples seek assisted reproductive technology (ART) for infertility. In Egypt, 17% of women in the 20–24 age group, 13% in Morocco, 28% in Iraq, 8% in Jordan, 6% in Lebanon, and 3% in Algeria were married or engaged before turning 18. Most child marriage involves girls. For instance in Mali the ratio of girls to boys is 72:1, while in countries such as the United States the ratio is 8:1. Marriage may occur as early as birth, with the girl being sent to her husbands home as early as age seven.
There are a number of cultural factors that reinforce this practice. These include the child's financial future, her dowry, social ties and social status, prevention of premarital sex, extramarital pregnancy and STIs. The arguments against it include interruption of education and loss of employment prospects, and hence economic status, as well as loss of normal childhood and its emotional maturation and social isolation. Child marriage places the girl in a relationship where she is in a major imbalance of power and perpetuates the gender inequality that contributed to the practice in the first place.
Equally challenging for women are the physiological and emotional changes associated with the cessation of menses (menopause or climacteric). While typically occurring gradually towards the end of the fifth decade in life marked by irregular bleeding the cessation of ovulation and menstruation is accompanied by marked changes in hormonal activity, both by the ovary itself (oestrogen and progesterone) and the pituitary gland (follicle stimulating hormone or FSH and luteinizing hormone or LH). These hormonal changes may be associated with both systemic sensations such as hot flashes and local changes to the reproductive tract such as reduced vaginal secretions and lubrication. While menopause may bring relief from symptoms of menstruation and fear of pregnancy it may also be accompanied by emotional and psychological changes associated with the symbolism of the loss of fertility and a reminder of aging and possible loss of desirability. While menopause generally occurs naturally as a physiological process it may occur earlier (premature menopause) as a result of disease or from medical or surgical intervention. When menopause occurs prematurely the adverse consequences may be more severe. 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.
Cancer
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. Globally the three most common types of cancer of women in 2020 were breast, lung and colorectal cancers. These three account for 44.5% of all cancer cases in women. Other types of cancers specifically affecting women include ovarian, uterine (endometrial and cervical) cancers.
While cancer death rates rose rapidly during the twentieth century, the increase was less and happened 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 until it was overtaken by lung cancer in the 1980s. All three cancers (lung, breast, uterus) are now declining in cancer death rates, 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.
In addition to mortality, cancer is a cause of considerable morbidity in women. Women have a lower lifetime probability of being diagnosed with cancer (38% vs 45% for men), but are more likely to be diagnosed with cancer at an earlier age.
Breast cancer
Breast cancer is most common type of cancer among women. Globally, it accounts for 25% of all cancers. The countries with the highest age-standardized prevalence rates per 100,000 females in the region were Bahrain, Qatar, and Lebanon. Because it is largely asymptomatic in its earliest stages and lacks an effective screening programme, 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.
Mental health
Almost 25% of women will experience mental health issues over their lifetime. Women are at higher risk than men from anxiety, depression, and psychosomatic complaints. 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, menstruation, pregnancy, childbirth and the menopause. Women also metabolise drugs used to treat depression differently to men. Suicide rates are less in women than men (<1% vs. 2.4%),
Dementia
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 dementia, so that they bear both the risks and burdens of this disease. The lifetime risk for a woman of developing Alzheimer's disease 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 part as may differences in gene expression. Deaths due to dementia are higher in women than men (4.5% of deaths vs. 2.0%).
Bone health
Osteoporosis ranks sixth amongst chronic diseases of women in the United States, with an overall prevalence of 18%, and a much higher rate involving the femur, neck or lumbar spine amongst women (16%) than men (4%), over the age of 50. Osteoporosis is a risk factor for bone fracture and about 20% of senior citizens who sustain a hip fracture die within a year. 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%, 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 has since led to a decline in HRT usage.
Anaemia
Anaemia is a major global health problem for women. 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). 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%. Anaemia affects over one-third of the population in the Middle East and North Africa, caused by iron deficiencies or a combination of other factors, with women making up the bulk of those affected. In Saudi Arabia, 40% of women in the 15–49 age range suffer from anaemia. 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.
Violence
Women experience structural and personal violence differently than men. The United Nations has defined violence against women as;
Violence against women may take many forms, including physical, sexual, emotional and psychological and may occur throughout the life-course. Structural violence may be embedded in legislation or policy, or be systematic misogyny by organisations against groups of women. Perpetrators of personal violence include state actors, strangers, acquaintances, relatives and intimate partners and manifests itself across a spectrum from discrimination, through harassment, sexual assault and rape, and physical harm to murder (femicide). It may also include cultural practices such as female genital cutting.
Violence was declared a global health priority by the WHO at its assembly in 1996, drawing on both the United Nations Declaration on the elimination of violence against women (1993) and the recommendations of both the International Conference on Population and Development (Cairo, 1994) and the Fourth World Conference on Women (Beijing, 1995) This was followed by its 2002 World Report on Violence and Health, which focusses on intimate partner and sexual violence. Meanwhile, the UN embedded these in an action plan when its General Assembly passed the Millennium Declaration in September 2000, which resolved among other things "to combat all forms of violence against women and to implement the Convention on the Elimination of All Forms of Discrimination against Women". One of the Millennium Goals (MDG 3) was the promotion of gender equality and the empowerment of women, which sought to eliminate all forms of violence against women as well as implementing CEDAW.
National and international initiatives
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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.
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Bibliography
Symposia and series
Articles
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Reproductive and sexual health
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Maternal health
Books
Chapters
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Reports and documents
United Nations reports
Websites
News
Women's health research
Organizations
- see American Congress of Obstetricians and Gynecologists
- see Human Rights Watch
- see Save the Children
Women's health providers
United Nations Web sites
WHO
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CDC
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Further reading
External links
- Women’s Health: Why do women feel unheard? at the NIHR Evidence website.