Current Issues in Women’s Health

By Veena Goud & Kristina Knight

 

Women play a vital role in the health of our nation; as members of service professions, personal caregivers, mothers, partners, leaders, teachers and health care professionals. Women represent 51 percent of the total U.S. population; 59 percent of the over-65 population; and 71 percent of Americans older than age 85, the fastest growing segment of the population (National Center for Health Statistics, 2002). A woman’s health reflects both her individual biology and her socio-cultural, economic, and physical environments. All these factors affect both the duration and the quality of her life. For example, the average life expectancy for a woman varies considerably according to her race (Smedley et al., 2002). Women who live in poverty or have less than a high school education have shorter life spans; higher rates of illness, injury, disability, and death; and limited access to high-quality health care services.

According to the Boston Women’s Health Collective, women have historically been the primary health care providers and health decision makers for their families. In addition women seek medical care more often than do men (National Center for Health Statistics, 2002). Now, more than ever, women are actively involved in national health issues, as well as their own health. This chapter is designed to cover some of the current issues in women’s health and direct readers towards where they can find more information on these issues. The goal is to arm women with the knowledge to make better, more informed decisions about their own and their families' health.

 

Barriers to Women’s Health Care

Medical Research

 Historically, men’s bodies have been seen as the norm and to which women’s bodies are compared against. This idea has carried over to medical research where most of the focus has been on men and the findings are generalized to women (Sarto, 2004). Over the years women have been intentionally excluded from clinical trials and other research for a number of reasons.  One of the primary reasons for the exclusion of women was the possible harm caused to a fetus.  Whether a woman was pregnant or not, she would not be considered based on the possibility that exposure to unknown drugs, treatment and therapies could have lasting harmful reproductive effects.  Researchers also believed that because of the complex hormonal changes in women the results of the research would not be generally applicable (Evelyn et al., 2001).   The resulting treatments, drug therapies and diagnostic measures were designed based on male biology and physiology.  It is clear that female biology and physiology is different, as traditional methods of treatments and diagnostic tools for various diseases have remarkably lower success in women (Wizeman, 2001).

In addition, medical research has largely ignored many health issues important to women. In the past, research on women’s health focused on diseases that affect fertility and reproduction, while many studies on other diseases focused on men (Sarto, 2004). Currently, most women receive diagnoses and treatment based on what has worked for men. However, the efforts of women’s health advocates and the unveiling of inequities in medical research have led to a broadened research agenda. The Food and Drug Administration (FDA) has imposed new guidelines, now half of all subjects in large scale drug studies are female. This research is beginning to yield insights into the health-related similarities and differences between men and women.

 

Health Care Practices

Some believe that the current health system has created and contributed to increased morbidity and gender inequalities in health and medicine.  As a result women are advocating for gender equity in healthcare and the development of a comprehensive women’s health system.  The World Health Organization (WHO) defines gender equity in health as “the elimination of unnecessary, unjust, and avoidable differences between men and women and their potential for enjoying good health and in the likelihood of becoming ill, disabled or dying from preventable causes.” Historically, gender equity has focused on equal opportunity in the workplace, fair pay and violence against women.  Although these issues continue to deserve further investigation and analysis, gender equity in health and medicine has become a major focus of women’s right advocates.

Women often face a fragmentation in the health care system itself. National studies have indicated that women may not be as satisfied with the information they receive from their health care providers as are men or with the level of communication with their provider (Scholle et al., 2000). Furthermore, several studies have found that health care providers treat women differently than they do men. Compared with the treatment given to men, health providers may give women less thorough evaluations for similar complaints, minimize their symptoms, provide fewer interventions for the same diagnoses, prescribe some types of medications more often, or provide less explanation in response to questions (Collins et al., 1999).

 

Access to Health Insurance

According to the American College of Physicians report on health insurance, since 1990, the proportion of uninsured women has grown at a faster rate than the total uninsured population. Between 1990 and 1999, the proportion of uninsured women increased by 16.8 percent while the total uninsured population increased by 11.5 percent and the proportion of uninsured men increased by 7.1 percent. This disproportion is indicative of the gender disparities that still remain in American society. More dramatic still, the proportion of women under 65 who lacked health insurance for all or part of 1998 was a staggering 26 percent, according to the 1998 Commonwealth Fund Survey of Women’s Health. The women who are most likely to have no health insurance are those who earn low or moderate incomes, women of color, and women with health problems.

In today’s health system lack of insurance severely compromises both the accessibility and quality of health care.

Gender Analysis in Health Care

In an effort to reduce gender inequities in healthcare, researchers are now changing their approach to women’s health.  Gender analysis is being implemented to eliminate gender inequities and address women’s health needs.    Gender refers to men and women’s socially determined roles and responsibilities. Gender analysis examines how being a women (or a man) may place an individual at more or less risk, and how those risks affect diagnosis and treatment (Fathalla, 1998).  It is a systematic approach that also takes into account factors such as race, socioeconomic status, education and other factors that interact with gender to affect health.  The results will be used to develop diagnostic, treatment, and prevention measures to better serve the health needs of women and men.  The focus of recent research involving gender analysis is based on the following gender differences and inequities in women’s health:

 

The Definition of Sex

Men and women are genetically, biologically, and physiologically different.  Of the 46 chromosomes that combine to determine the genetic make-up of an individual, only one chromosome provides the information necessary for determination of sex.   This genetic distinction enables differing biological characteristics in men and women.  For example, the reproductive systems of men and women have unique organs and functions.  Physiological aspects of women and men’s bodies such as, the higher fat content of the female body and the high muscular content of the male body are recognized as additional differences between the sexes. 

 

Sex specific Disease & Disorders

Disease patterns differ between men and women in several ways.  Genetic make-up, hormonal changes and lifestyle behavior play a major role in the paths of disease.  Some diseases strike women and men at different ages.  Cardiovascular disease (CVD) affects men at a younger age then women.  In fact, when women have CVD they are more likely to have increased severity of symptoms and are more likely to die from the disease.  Some diseases are more prevalent in women, such as autoimmune diseases like lupus and sclera derma, which almost never affect men.  Other diseases and disorders only affect women, such as pelvic inflammatory disease (PID) and cervical cancer. 

Morbidity & Mortality

On average women live longer than men.  While men die sooner, they generally live healthier lives.  Studies have shown that women are more likely to seek medical treatment.  In fact, of the millions of doctors visits that occur every year in the United States, two-thirds of the patients are women (Mastroianni 1994).  Despite seeking care and living longer, women are experiencing greater morbidity from illness and disease. 

Diseases & Chronic Disorders Affecting Women

Some of the leading causes of morbidity and mortality disproportionately affect women, including cardiovascular disease, autoimmune disorders and cancer.  The alarmingly high rates of these diseases and chronic conditions have caused researchers to investigate their potential causes and develop preventative measures to decrease the prevalence rates among women.  Overall, cardiovascular disease is among the top five leading causes of death in the United States. However, cardiovascular disease is the number one cause of death among American women, killing more women than breast and lung cancer combined.  Using a gender analysis approach, researchers are investigating the causes of the diseases mentioned in this section.  The hope is that diagnostic measures, treatment, and prevention measures will be developed to reduce the affects of these chronic and debilitating diseases. 

Cardiovascular disease

Cardiovascular disease can be defined as any disease of the heart or surrounding blood vessels.  Examples of cardiovascular diseases include high blood pressure, coronary artery disease, and atherosclerosis. The major cause of cardiovascular disease is an excess of fat and cholesterol in the blood.  When the heart or arteries, through which blood flows, become diseased the entire body suffers the effects. Over time, the blocked arteries narrow because of plaque build-up, nutrients and oxygen are unable travel throughout the body, and the heart muscle is weakened.  In this weaken state may result in a heart attack, stroke, or another debilitating condition.  Although it is typically viewed as a man’s disease, more women actually die of heart disease each year than do men (Mosca, 1997).

In a fashion similar to most clinical research, the majority of medical trials for cardiovascular disease have been done with men only.  Because cardiovascular disease is the number one cause of death for women, there is a drastic need for research involving women and cardiovascular disease.  Pharmaceuticals and diagnostic measures used to treat and diagnose cardiovascular disease have been unsuccessful in women (Freidman 1999).  With the use of current diagnostic methods, coronary artery disease is poorly recognized and often remains undiagnosed among women. 

Current research has found that pre-menopausal women are at a lesser risk for heart disease.  It is believed that this is probably due to higher levels of estrogen in the blood.  However, after menopause more women die of cardiovascular disease than any other condition.  Research also indicates that women are more likely than men to suffer a second heart attack within one year of their first heart attack (Freidman 1999).  Continuing sex specific research will increase the understanding of the disease process and provide a better understanding how heart disease and other cardiovascular disease progress differently in women.

For more information about heart disease please contact the following organization:


American Heart Association

1615 Stemmons Freeway

Dallas, Texas 75207

1-800-AHA-8721 www.americanheart.org


 

Cancer

Cancer refers to any disease that is characterized by the uncontrolled growth and spread of useless, abnormal cells (Guyton 1997).  It may affect women of all ages but usually those over age 40.   Researchers have identified several risk factors that increase the risk of cancer in women:  being over forty, having an immediate female relative (mother or sister) who has cancer, beginning menstruation at age 12 or younger, starting menopause at age 55 or older, having no children, or using HRT for a period greater than 10 years, or having been previously diagnosed with cancer (Benderely 1997).  At one time uterine cancer was one of the most frequent causes of death from cancer in women.  However, the use of the pap test has enabled uterine cancer to be detected and treated early.  The most common forms of cancer affecting women are breast, lung, and cervical cancer.  Below are some statistics regarding the most common forms of cancer in women:


 

Ø      Cancer is the second leading cause of death in n women.

Ø      Lung cancer is the leading cause of cancer deaths in women. 

Ø       Breast cancer is the most common form of cancer affecting women.  About one out of eleven women will develop breast cancer in her lifetime.

Ø      Women whose mothers or sisters had breast cancer were more than two times as likely to develop the disease as women with no family history of breast cancer.

Ø       African-American women have lower rates of breast cancer but higher mortality rates.

(www.cdc.gov)


 

Over the past decade, there has been a successful campaign to promote breast cancer awareness.  The focus of the campaign has been awareness and prevention.  Women have been encouraged to do monthly breast self-exams, get annual medical check-ups, and after age forty get a yearly mammogram. Recently there has been controversy over the effectiveness of mammograms as effective tools for early detection of breast cancer.  New research indicates that mammograms aren’t nearly as successful as once indicated at detecting early stages of breast cancer (Timins, 2005).

Lung cancer is the cause of most cancer deaths in women.  Research clearly shows that cigarette smoking is the main cause of lung cancer in women.  The tobacco industry spends four billions dollars a year in advertising, much of which is specifically targeted to women (White 1990).  These advertisements send messages that cigarettes help women lose weight, gain independence, and retain their youthfulness.  The greatest increase in new smokers is among teenage girls and young women.  Studies show that the risk of lung cancer increases the younger a woman starts smoking (Carlson 1996). 

Cervical cancer is the third most common form of cancer in women.  Detection of cervical cancer has increased because more women are getting regular pap smears.  Most cases of cervical cancer are thought to be cause by specific strains of the human papillomavirus (HPV).  It is thought that HPV weakens the immune system, allowing cervical cancer to develop.  Having multiple sexual partners and becoming sexually active at an early age increases the risk for cervical cancer. 

For more information about cancer please contact the following organization:


The American Cancer Society

1599 Clifton Road NE

Atlanta, GA 30329

1-800-ACS-2345

www.cancer.org


 

Autoimmune disorders

As with many other systems of the body, the immune systems of men and women differ.  The immune system is designed to fight foreign elements, bacteria, viruses, chemical and other microorganisms that constantly invade the body.  The immune system exists for the specific purpose of fighting off foreign invaders.  There are time however when the immune system turns on the very body that it should be protecting, attacking and injuring normal tissue.   Women are generally considered to have stronger immune systems than men, but women also have a unique set of hormonal activities that complicate the functioning of the immune system and may lead to what is known as an autoimmune disorder. 

There are several theories as to why the immune system malfunctions in this manner.  Since autoimmune diseases disproportionately affect women it is believed that the female sex hormones play a critical role.  Sex hormones have a major part in the regulation of the immune system.   The female hormone estrogen serves as an immune system suppressor.  Another female hormone, progesterone, has been shown to increase the level of antibodies in the blood. The two hormonal conditions combined with the higher levels of auto-antibodies found in women, may create an environment within the body which may lead to autoimmune disorders.  There are a wide range of autoimmune disorders, some more common than others.  Some of the most common autoimmune disorders include lupus and rheumatoid arthritis (RA).  

Lupus, clinically known as systemic lupus erythematosus (SLE) is an autoimmune disorder that affects the connective tissue in the body as though it were foreign.  Antibodies within the body settle in locations around the body designed to collect them, causing an inflammatory response that may affect joints, kidneys, the brain, and heart.  The vast majority of individuals affected with lupus are women in their childbearing years. 

Rheumatoid arthritis, an immune disorder, affects 2.5 million Americans and three times as many women as men.  RA is an inflammatory disease that damages the tissue connecting the bones and joints.  It is a painful and debilitating disorder of multiple joints that can occur at any age.  Research indicates that there is a low incidence of RA among oral contraceptive users.  It is believed that the regulation of the female hormones may inhibit the development of RA.  It has also been shown that relief of the symptoms of RA may occur in menopausal women on hormone replacement therapy (HRT).  In this situation it thought that the regulation of the female hormones suppresses the immune system.  Another interesting discovery is that there is an emotional component to the progression of RA in women.  Researchers have found that women with depression and anxiety disorders tend to have a more aggressive form of RA (Schuna, 2002).

For more information about autoimmune disorders please contact the following organizations:


Lupus Foundation of America

1300 Piccard Drive,
Suite 200

Rockville, MD 20850-4303

 (301)670-9292
www.lupus.org

 

The Arthritis Foudation of America

P.O.Box 19000

Atlanta, GA 30326

1-800-283-30326

www.arthritis.org


Mental Health

As Scientists learn more about mental health they learn more about how mental illnesses affect women and men differently. Some disorders are more common in women, and some express themselves with different symptoms. A few of these mental illnesses include depression, anxiety disorders and eating disorders.  One in ten Americans experiences an episode of depression each year. Major depression and dysthymia (a less severe, more chronic form of depression) affect approximately twice as many women as men. An estimated 12 percent of women in the United States experience a major depression during their lifetimes, compared with 7 percent of men; and 4.2 percent of women have dysthymia (Blehar, 1995). Women are two to three times more likely to have certain types of anxiety disorders, including anxiety, panic, and phobic disorders. At least 90 percent of all cases of eating disorders occur in women. In addition, a high correlation appears to exist between eating disorders and depression and between eating disorders and substance abuse according to the American Psychiatric Association Work Group on Eating Disorders.

For more information about mental health contact the following organizations:


             

Center for Mental Health Services
Substance Abuse and Mental Health Services Administration
Rm 12-105 Parklawn Building
Rockville, MD 20857
Phone: 301-443-8956
Fax: 301-443-9050
URL: http://www.samhsa.gov/

 

National Institute of Mental Health
Office of Communications

6001 Executive Boulevard, Room 8184, MSC 9663
Bethesda, MD 20892-9663
Phone: 301-443-4513
Fax: 301-443-4279
TollFree: 1-866-615-NIMH (6464)
TTY: 301-443-8431
Email: nimhinfo@nih.gov
URL: http://www.nimh.nih.gov


Gender-based Violence

Violence is a major public health problem for American women. According to the National Women’s Health Information Center more than 4.5 million women are victims of violence each year. Of these women, nearly two of every three are attacked by a relative or someone they know. Women are 6 times more likely to be abused by someone they know than are men and 10 times more likely to be victims of sexual assault. It is estimated that 10 to 20 percent are the victims of sexual abuse. The prevalence of violence during pregnancy appears to range from 4 percent to 8 percent. Applying these percentages to the 3.9 million U.S. women who delivered live-born infants in 1995 yields the conclusion that 152,000 to 325,000 women experienced violence during their pregnancies (Gazmararian, 1996).

For more information about gender-based violence contact the following organizations:


Office on Violence Against Women
800 K Street, N.W., Suite 920
Washington, DC 20530

(202) 307-6026 phone
(202) 307-3911 fax
(202) 307-2277 TTY

http://www.ojp.usdoj.gov/vawo

 

National Sexual Violence Resource Center

 123 North Enola Drive 

Enola, Pennsylvania  17025
877-739-3895 (tollfree)

 717-909-0710 (phone)

717-909-0714 (fax)

717-909-0715 (TTY)

 www.nsvrc.org


 

Reproductive Health

Women’s reproductive capacity plays an important role in shaping their lives and health experiences. According to the National Women’s Health Information Center over 80 percent of all American women have had a child by the age of 45, and the average woman has 2.2 children. While motherhood is a defining feature of adult life for many women, most spend the greater part of their reproductive years trying to avoid pregnancy. Sixty-four percent of women ages 15 to 44 use some form of contraception, up from 56 percent in 1982 and 60 percent in 1988.

Gynecological health is not only an important component of women’s health during their reproductive years, but throughout the course of their lives. The average woman spends a third of her life beyond menopause. While many older women mistakenly believe that regular gynecological exams are no longer necessary, this is precisely the point in life when they are at higher risk for cancers of the reproductive system and other gynecological problems such as uterine prolapse (O'Rourke, 2004).

Younger women are particularly at risk for reproductive health problems associated with sexually transmitted diseases (STDs). Two-thirds of all STD cases occur among individuals younger than 25 years, and one in four teenagers’ contracts an STD each year. Women are more susceptible biologically to becoming infected with STDs than are men, and younger women are more at risk than their older counterparts due to differences in their cervical anatomy. Women are less likely than men to experience symptoms of STD infection. In addition to the direct health problems caused by STD infection, high rates of STD infection in adolescent women contribute to an increased susceptibility to HIV.

For more information about reproductive health contact the following organizations:


American Social Health Association
P.O. Box 13827
Research Triangle Park, NC 27709

Voice: (919) 361-8400 Fax: (919) 361-8425

www.ashastd.org

 

Welcome to the CDC
National STD Hotline

(800) 227-8922 or (800) 342-2437
En Español (800) 344-7432


 

 

Chronic Disabling Conditions

In part because they live longer than men, women are more likely to be affected by such chronic disabling conditions as diabetes, osteoporosis, and Alzheimer’s disease. These conditions not only limit function, but over time they may be life-threatening. Each of these disorders is characterized by a long trajectory of increasing impairment. Chronic illnesses exert an untoward effect not only upon the person experiencing them but also upon family members and other care givers. One study found that the greater prevalence of nonfatal disabling conditions, including fractures, osteoporosis, back problems, osteoarthritis and depression, contributes substantially to greater disability and diminished quality of life among aging women compared with men (Murtagh et al. 2004). More research is needed to determine whether specific gender-related factors contribute to the increased incidence of these illnesses in women.

According to the National Institutes of Health, diabetes overview, there are 18.2 million people in the United States, or 6.3% of the population, who have diabetes. While an estimated 13 million have been diagnosed with diabetes, unfortunately, 5.2 million people are unaware that they have the disease. Approximately 9.3 million or 8.7% of all women over the age of 20 in the United States have diabetes. An estimated 16 million Americans have diabetes. The prevalence of diabetes is 2 to 4 times higher among Black, Hispanic, American Indian, and Asian Pacific Islander women than among white women.

Osteoporosis is a disorder characterized by the thinning and increasing brittleness of bones, a condition that can lead to bone fracture. According to the National Institutes of Health Osteoporosis overview, Osteoporosis is a major public health threat for 28 million Americans, 80% of whom are women. One out of every two women and one in eight men over 50 will have an osteoporosis-related fracture in their lifetime. Each year, osteoporosis causes 1.5 million fractures of the hip, wrist, vertebrae, and other bones. It accounts for 70 percent of all the fractures occurring every year annually in people over the age of 45. Twenty percent of the women who suffer a hip fracture die within one year of that event.

An estimated 4.5 million Americans, over half of whom are women, have Alzheimer's disease in the United States, a figure that is expected to more than triple by the year 2050 as the population ages (Kawas, 2003). Women far outnumber men as caregivers for family members with Alzheimer's disease. The chronic stress of caregiving can seriously affect a caregiver's health. In 1995, more than 13,600 women died from the disease. It is the most common cause of dementia for individuals over age 65. Alzheimer’s disease places a heavy burden on society, costing an estimated $80 to $100 billion each year.

For more information about chronic disabling conditions contact the following organizations:


 

American Diabetes Association
ATTN: National Call Center
1701 North Beauregard Street
Alexandria, VA 22311

1-800-DIABETES (1-800-342-2383)

www.diabetes.org/home.jsp

 

National Osteoporosis Foundation

1232 22nd Street N.W.
Washington, D.C. 20037-1292

(202) 223.2226

www.nof.org

 


 

The Future of Women’s Health

Women and men are differentiated by social and biological characteristics that are reflected in the patterns of health and illness found among them.  Gender equity and analysis promotes both women’s and men’s health.  It recognizes the significant influence of gender on health and attempts to address the underlying social and cultural differences.  Research on gender inequities in health has and will continue to lead to the development of different strategies addressing the needs of both women and men.  Specific outcomes of gender analysis include: the development of better-targeted programs, more gender sensitive practices, and more effective use of resources (Doyal 1998).  The development of a comprehensive women’s health strategy will address the needs of women from adolescence through adulthood producing better health outcomes.  Continued awareness and understanding of the importance of incorporating gender into health practice and policy will lead to improved health in both women and men. 

 

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