Women's health

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Women's health
Logo depicting women's health, symbol for female in red, with a blue staff entwined with a snake
Symbol of women's health
Reproductive and sexual health
Reproductive health
Reproductive tract
Maternal health
Reproductive life plan
Contraception & Family planning
Menstruation
Sexual health
Sexually transmitted infections
Other
Non-reproductive health
Violence against women
Non-communicable diseases
Gynecologic cancer
Other
Sociocultural factors
Politics, research & advocacy
United Nations
United States
Women's health by country

Women's health differs from that of

developing countries
where women, whose health includes both their risks and experiences, are further disadvantaged.

While the rates of the leading causes of death,

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

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

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.[3] The World Health Organization (WHO) defines health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity".[4] Women's health is an example of population health, the health of a specific defined population.[5]

Women's health has been described as "a patchwork quilt with gaps".

socioeconomic factors.[8] Women's health is of particular concern due to widespread discrimination against women in the world, leaving them disadvantaged.[3]

A number of health and medical research advocates, such as the

life-course), from in utero to aging effect the growth, development and health of women. The life course perspective is one of the key strategies of the World Health Organization.[10][11][12]

Global perspective

Main article: Global health

Gender differences in susceptibility and symptoms of disease and response to treatment in many areas of health are particularly true when viewed from a

human immunodeficiency virus (HIV), sexually transmitted infections, violence, mental health, non communicable diseases, youth and aging.[19]

Life expectancy

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, primarily from

industrial revolution
. [8] Despite these differences, in many areas of health, women experience earlier and more severe disease, and experience poorer outcomes.[20]

Despite these differences, the leading causes of death in the United States are remarkably similar for men and women, headed by

unintentional injury and suicide, they have a higher incidence of dementia.[8][21]

The major differences in life expectancy for women between developed and developing countries lie in the childbearing years. If a woman survives this period, the differences between the two regions become less marked, since in later life

non-communicable diseases (NCDs) become the major causes of death in women throughout the world, with cardiovascular deaths accounting for 45% of deaths in older women, followed by cancer (15%) and lung disease (10%). These create additional burdens on the resources of developing countries. Changing lifestyles, including diet, physical activity and cultural factors that favour larger body size in women, are contributing to an increasing problem with obesity and diabetes amongst women in these countries and increasing the risks of cardiovascular disease and other NCDs.[13][22]

Women who are socially marginalised are more likely to die at younger ages than women who are not.[23] 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.[24] 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.[24]

Social and cultural factors

See also: Gender equality and Gender disparities in health
Sustainable Development Goal
5: Gender Equality

Women's health is positioned within a wider body of knowledge cited by, amongst others, the

social determinant of health.[25] While women's health is affected by their biology, it is also affected by their social conditions, such as poverty, employment, and family responsibilities, and these aspects should not be overshadowed.[26][27]

Women have traditionally been disadvantaged in terms of economic and

developing countries where women are relatively more disadvantaged. In addition to gender inequity, there remain specific disease processes uniquely associated with being a woman which create specific challenges in both prevention and health care.[20]

Deeply ingrained cultural, religious, and patriarchal systems within the

MENA region perpetuate gender-based power dynamics within communities and lead to discrepancies in healthcare access. In a speech, UNFPA executive director Thoraya Ahmed Obaid outlined these difficulties and emphasized the need to change cultural and societal norms in order to improve the health of women in the area.[28]

Even after succeeding in accessing health care, women have been discriminated against,

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.[30]

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

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.[32][33]

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[34] and was the first women's health centre established in Australia is an example of women's health approach to service delivery.[35]

Women's health is an issue which has been taken up by many

reproductive health is concerned and the international women's movement was responsible for much of the adoption of agendas to improve women's health.[36]

Biological factors

Factors that specifically affect the health of women compared to

biomarkers from one sex to the other.[8] 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.[19]

Reproductive and sexual health

Main article:
Reproductive health
See also: Reproductive justice

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

female genital cutting, and further lack access to the appropriate diagnostic and clinical resources.[13]

Maternal health

Main article: Maternal health
Women receiving training in midwifery, using a model, in Papua New Guinea
Midwifery training in Papua New Guinea

Adolescent pregnancy represents a particular problem, whether intended or unintended, and whether within marriage or a union or not. Pregnancy results in major changes in a girl's life, physically, emotionally, socially and economically and jeopardises her transition into adulthood. Adolescent pregnancy, more often than not, stems from a girl's lack of choices. or abuse. Child marriage (see below) is a major contributor worldwide, since 90% of births to girls aged 15–19 occur within marriage.[42]

Maternal death

Main article:
Maternal deaths

In 2013 about 289,000 women (800 per day) in the world died due to pregnancy-related causes, with large differences between developed and developing countries.

AIDS can also endanger pregnancy. In the period 2003–2009 hemorrhage was the leading cause of death, accounting for 27% of deaths in developing countries and 16% in developed countries.[47][48]

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,

indicators, 5.1 the MMR and 5.2 the proportion of deliveries attended by skilled health personnel (physician, nurse or midwife). Early reports indicated MDG 5 had made the least progress of all MDGs.[51][52] By the target date of 2015 the MMR had only declined by 45%, from 380 to 210, most of which occurred after 2000. However this improvement occurred across all regions, but the highest MMRs were still in Africa and Asia, although South Asia witnessed the largest fall, from 530 to 190 (64%). The smallest decline was seen in the developed countries, from 26 to 16 (37%). In terms of assisted births, this proportion had risen globally from 59 to 71%. Although the numbers were similar for both developed and developing regions, there were wide variations in the latter from 52% in South Asia to 100% in East Asia. The risks of dying in pregnancy in developing countries remains fourteen times higher than in developed countries, but in Sub-Saharan Africa, where the MMR is highest, the risk is 175 times higher.[45] In setting the MDG targets, skilled assisted birth was considered a key strategy, but also an indicator of access to care and closely reflect mortality rates. There are also marked differences within regions with a 31% lower rate in rural areas of developing countries (56 vs. 87%), yet there is no difference in East Asia but a 52% difference in Central Africa (32 vs. 84%).[43] With the completion of the MDG campaign in 2015, new targets are being set for 2030 under the Sustainable Development Goals campaign.[53][54] Maternal health is placed under Goal 3, Health, with the target being to reduce the global maternal mortality ratio to less than 70.[55] Amongst tools being developed to meet these targets is the WHO Safe Childbirth Checklist.[56]

Improvements in maternal health, in addition to professional assistance at delivery, will require routine antenatal care, basic emergency obstetric care, including the availability of

cesarean sections) and transportation.[47] 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.[45] New guidelines on antenatal care were issued by WHO in November 2016.[58]

Complications of pregnancy

Main article: Complications of pregnancy

In addition to death occurring in pregnancy and childbirth, pregnancy can result in many non-fatal health problems including

preeclampsia, and anemia.[40] Globally, complications of pregnancy vastly outway maternal deaths, with an estimated 9.5 million cases of pregnancy-related illness and 1.4 million near-misses (survival from severe life-threatening complications). Complications of pregnancy may be physical, mental, economic and social. It is estimated that 10–20 million women will develop physical or mental disability every year, resulting from complications of pregnancy or inadequate care.[45] Consequently, international agencies have developed standards for obstetric care.[59]

Obstetrical fistula
Main article:
Obstetrical fistulae
Ethiopian
fistula hospital

Of near miss events,

UNFPA has made prevention of OF a priority and is the lead agency in the Campaign to End Fistula, which issues annual reports[63] and the United Nations observes May 23 as the International Day to End Obstetric Fistula every year.[64] Prevention includes discouraging teenage pregnancy and child marriage, adequate nutrition, and access to skilled care, including caesarean section.[13]

Sexual health

Main article:
Sexual health

Contraception

Main articles:
Contraception and Family planning
Women outside of a Family Planning Association office in Malaysia
Family Planning Association: Kuala Terengganu, Malaysia

The ability to determine if and when to become pregnant, is vital to a woman's autonomy and well-being, and contraception can protect girls and young women from the risks of early pregnancy and older women from the increased risks of unintended pregnancy. Adequate access to contraception can limit multiple pregnancies, reduce the need for potentially unsafe abortion and reduce maternal and infant mortality and morbidity. Some

human right that is central to gender equality and women's empowerment that saves lives and reduces poverty,[67] and birth control has been considered amongst the 10 great public health achievements of the 20th century.[68]

To optimise women's control over pregnancy, it is essential that culturally appropriate contraceptive advice and means are widely, easily, and affordably available to anyone that is

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."[70] 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".[71][72][65][66]

Three related targets of MDG5 were adolescent birth rate, contraceptive prevalence and unmet need for family planning (where prevalence+unmet need = total need), which were monitored by the Population Division of the UN

Subsaharan Africa (13 to 28%). The corollary, unmet need, declined slightly worldwide (15 to 12%).[43] In 2015 these targets became part of SDG5 (gender equality and empowerment) under Target 5.6: Ensure universal access to sexual and reproductive health and reproductive rights, where Indicator 5.6.1 is the proportion of women aged 15–49 years who make their own informed decisions regarding sexual relations, contraceptive use and reproductive health care (p. 31).[75]

There remain significant barriers to accessing contraception for many women in both developing and developed regions. These include legislative, administrative, cultural, religious and economic barriers in addition to those dealing with access to and quality of health services. Much of the attention has been focussed on preventing adolescent pregnancy. The

intrauterine devices (IUD)s, particularly the Dalkon Shield.[79]

Abortion

Main article: Abortion
Women carrying placards saying "Abortion Rights Now"
Women demonstrate for abortion rights, Dublin, 2012

Abortion is the intentional termination of pregnancy, as compared to spontaneous termination (miscarriage). Abortion is closely allied to contraception in terms of women's control and regulation of their reproduction, and is often subject to similar cultural, religious, legislative and economic constraints. Where access to contraception is limited, women turn to abortion. Consequently, abortion rates may be used to estimate unmet needs for contraception.[80] However the available procedures have carried great risk for women throughout most of history, and still do in the developing world, or where legal restrictions force women to seek clandestine facilities.[81][80] Access to safe legal abortion places undue burdens on lower socioeconomic groups and in jurisdictions that create significant barriers. These issues have frequently been the subject of political and feminist campaigns where differing viewpoints pit health against moral values.

Globally, there were 87 million unwanted pregnancies in 2005, of those 46 million resorted to abortion, of which 18 million were considered unsafe, resulting in 68,000 deaths. The majority of these deaths occurred in the developing world. The United Nations considers these avoidable with access to safe abortion and post-abortion care. While abortion rates have fallen in developed countries, but not in developing countries. Between 2010 and 2014 there were 35 abortions per 1000 women aged 15–44, a total of 56 million abortions per year.[47] The United nations has prepared recommendations for health care workers to provide more accessible and safe abortion and post-abortion care. An inherent part of post-abortion care involves provision of adequate contraception.[82]

Sexually transmitted infections

Main article:
Sexually transmitted infections

Important sexual health issues for women include

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.[83]

Diseases such as

gender-based violence, and restricted access to comprehensive healthcare systems.[86]

Female genital mutilation

Traditional midwife in Africa at a community meeting, explaining the dangers of cutting for childbirth
Traditional African midwife explaining the risks of FGC for childbirth at a community meeting

external female genitalia, or other injury to the female genital organs for non-medical reasons". It has sometimes been referred to as female circumcision, although this term is misleading because it implies it is analogous to the circumcision of the foreskin from the male penis.[87] Consequently, the term mutilation was adopted to emphasise the gravity of the act and its place as a violation of human rights. Subsequently, the term cutting was advanced to avoid offending cultural sensibility that would interfere with dialogue for change. To recognise these points of view some agencies use the composite female genital mutilation/cutting (FMG/C).[87]

FGM prevalence in the Middle East and Africa - 2016

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.

piercing.[90]

While defended by those cultures in which it constitutes a tradition, FGC is opposed by many medical and cultural organizations on the grounds that it is unnecessary and harmful. Short-term health effects may include hemorrhage, infection, sepsis, and even result in death, while long term effects include

cystitis.[91] In addition FGC leads to complications with pregnancy, labor and delivery. Reversal (defibulation) by skilled personnel may be required to open the scarred tissue.[92] Amongst those opposing the practice are local grassroots groups, and national and international organisations including WHO, UNICEF,[93] UNFPA[94] and Amnesty International.[95] Legislative efforts to ban FGC have rarely been successful and the preferred approach is education and empowerment and the provision of information about the adverse health effects as well the human rights aspects.[13]

Progress has been made but girls 14 and younger represent 44 million of those who have been cut, and in some regions 50% of all girls aged 11 and younger have been cut.[96] Ending FGC has been considered one of the necessary goals in achieving the targets of the Millennium Development Goals,[95] while the United Nations has declared ending FGC a target of the Sustainable Development Goals, and for February 6 to known as the International Day of Zero Tolerance for Female Genital Mutilation, concentrating on 17 African countries and the 5 million girls between the ages of 15 and 19 that would otherwise be cut by 2030.[96][97]

Infertility

Main article: Infertility

In the United States, infertility affects 1.5 million couples.[98][99] The rates of infertility in the Middle East and North Africa (MENA) are difficult to measure due to varying definitions of the condition. When intertility is defined as failure to have a successful birth, the MENA region has a very high rate at 33%. Morocco has the highest percentage of infertility among the MENA countries with an infertility rate of 56.8%. Rates of infertility, defined as failure to conieve (clinical infertility), are probably lower in the region but there is a lack of data on the exact numbers. There is a dearth of research on clinical infertility in the MENA region, with the exception of Iran, which is attributed to a societal reluctance to discuss infertility openly.[100]

Many couples seek

premature birth and low birth weight. In addition, more women are waiting longer to conceive and seeking ART.[103]

Child marriage

Main article: Child marriage
See also: Forced marriage
Poster of young African girl advertising a 2014 summit conference in London addressing Female Genital Mutilation and Child Marriage
Poster addressing the 2014 London Girl Summit dealing with FGM and Child Marriage

Child marriage (including union or cohabitation)[104] is defined as marriage under the age of eighteen and is an ancient custom. In 2010 it was estimated that 67 million women, then, in their twenties had been married before they turned eighteen, and that 150 million would be in the next decade, equivalent to 15 million per year. This number had increased to 70 million by 2012. In developing countries one third of girls are married under age, and 1:9 before 15.[105] The practice is commonest in South Asia (48% of women), Africa (42%) and Latin America and the Caribbean (29%). The highest prevalence is in Western and Sub-Saharan Africa. The percentage of girls married before the age of eighteen is as high as 75% in countries such as Niger.[13][105] Approximately one in five young women in the Middle East and North Africa were married before becoming eighteen, and one in twenty-five married before turning fifteen.[106] 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.[107] 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.[13]

There are a number of cultural factors that reinforce this practice. These include the child's financial future, her

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.[108][109] Also in the case of minors, there are the issues of human rights, non-consensual sexual activity and forced marriage and a 2016 joint report of the WHO and Inter-Parliamentary Union places the two concepts together as Child, Early and Forced Marriage (CEFM), as did the 2014 Girl Summit (see below).[110] In addition the likely pregnancies at a young age are associated with higher medical risks for both mother and child, multiple pregnancies and less access to care[111][13][108] with pregnancy being amongst the leading causes of death amongst girls aged 15–19. Girls married under age are also more likely to be the victims of domestic violence.[105]

There has been an international effort to reduce this practice, and in many countries eighteen is the legal age of marriage. Organizations with campaigns to end child marriage include the United Nations

inter alia[120]

Urges all States to enact, enforce and uphold laws and policies aimed at preventing and ending child, early and forced marriage and protecting those at risk, and ensure that marriage is entered into only with the informed, free and full consent of the intending spouses (5 September 2014)

Amongst

Young Women's Christian Association (YWCA), the International Center for Research on Women (ICRW)[122] and Human Rights Watch (HRW).[123] Although not explicitly included in the original Millennium Development Goals, considerable pressure was applied to include ending child marriage in the successor Sustainable Development Goals adopted in September 2015,[120] where ending this practice by 2030 is a target of SDG 5 Gender Equality (see above).[124] While some progress is being made in reducing child marriage, particularly for girls under fifteen, the prospects are daunting.[125] The indicator for this will be the percentage of women aged 20–24 who were married or in a union before the age of eighteen. Efforts to end child marriage include legislation and ensuring enforcement together with empowering women and girls.[105][108][110][109] To raise awareness, the inaugural UN International Day of the Girl Child[a] in 2012 was dedicated to ending child marriage.[127]

Menstrual cycle

Main articles: Menstrual cycle and Menopause
Diagram of human body showing parts affected by menopause

Women's menstrual cycles, the approximately monthly cycle of changes in the reproductive system, can pose significant challenges for women in their reproductive years (the early teens to about 50 years of age). These include the physiological changes that can effect physical and mental health, symptoms of

sanitary pads. This is particularly acute amongst poorer socioeconomic groups where they may represent a financial burden and in developing countries where menstruation can be an impediment to a girl's education.[128] In the Middle East and North Africa, period poverty and stigma have an influence on girls' education and general well-being. Misinformation and a lack of fundamental knowledge cause girls to miss school during their menstrual cycle and contribute to the prevailing stigma around getting your period.[129]

Equally challenging for women are the physiological and emotional changes associated with the cessation of menses (

premature menopause) as a result of disease or from medical or surgical intervention. When menopause occurs prematurely the adverse consequences may be more severe.[130][131]

Other issues

Other reproductive and sexual health issues include

health of their breasts and genital tract, which fall into the scope of gynaecology.[134]

Non-reproductive health

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

urinary tract infections than men.[3]

Cardiovascular disease

Main article: Cardiovascular disease in women

morbidity and death are increasing. At the same time, awareness and education on the disease, as well as research, are lacking in the region.[137]

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.[138]

While cancer death rates rose rapidly during the twentieth century, the increase was less and happened later in women due to differences in

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,[139] 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.[135]

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.[9]

Breast cancer

Main article: Breast cancer

Breast cancer is most common type of cancer among women. Globally, it accounts for 25% of all cancers.

chronic diseases of women, and a substantial contributor to loss of quality of life.[8] In 2016, breast cancer was the most common cancer diagnosed among women in both developed and developing countries, accounting for nearly 30% of all cases, and worldwide accounts for one and a half million cases and over half a million deaths, being the fifth most common cause of cancer death overall and the second in developed regions. In the Middle East and North Africa, there were 95,000 cases of breast cancer in 2019.[140] The countries with the highest age-standardized prevalence rates per 100,000 females in the region were Bahrain, Qatar, and Lebanon.[140] Geographic variation in incidence is the opposite of that of cervical cancer, being highest in Northern America and lowest in Eastern and Middle Africa, but mortality rates are relatively constant, resulting in a wide variance in case mortality, ranging from 25% in developed regions to 37% in developing regions, and with 62% of deaths occurring in developing countries.[19][141]

Cervical cancer

Main article: Cervical cancer

Globally, cervical cancer is the fourth most common cancer amongst women.

Middle Africa, cervical cancer is the commonest cancer in women. The case fatality rate of 52% is also higher in developing countries than in developed countries (43%), and the mortality rate varies by 18-fold between regions of the world.[142][19][141]

Cervical cancer is associated with

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.[143][84] 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 health care. Also an HPV vaccine programme is available in 45 countries. Screening and prevention programmes have limited availability in developing countries although inexpensive low technology programmes are being developed,[144] but access to treatment is also limited.[142] If applied globally, HPV vaccination at 70% coverage could save the lives of 4 million women from cervical cancer, since most cases occur in developing countries.[8]

Ovarian cancer

Main article: Ovarian cancer

Ovarian cancer is the eighth most common cancer globally.[138] It is predominantly a disease of women in industrialized countries and death from ovarian cancer is more common in North America and Europe than in Africa and Asia.[145] 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.[139][8]

Mental health

Almost 25% of women will experience

psychosomatic complaints.[19] 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.[135] Women also metabolise drugs used to treat depression differently to men.[135][147] Suicide rates are less in women than men (<1% vs. 2.4%),[32][33] but are a leading cause of death for women under the age of 60.[19] In the United Kingdom, the Women's Mental Health Taskforce was formed aiming to address differences in mental health experiences and needs between women and men.[148]

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 par as may differences in gene expression.[135] Deaths due to dementia are higher in women than men (4.5% of deaths vs. 2.0%).[8]

Bone health

Hormone Replacement Therapy (HRT) has been shown to reduce this risk by 25–30%,[151] 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[152]
has since led to a decline in HRT usage.

Anaemia

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.[8]

Violence

Main articles: Violence against women, Domestic violence, and Intimate partner violence

Women experience structural and personal violence differently than men. The United Nations has defined violence against women as;[156]

" any act of gender-based violence that results in, or is likely to result in, physical, sexual or mental harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life." (United Nations, Declaration on the Elimination of Violence against Women, 1993)

Violence against women may take many forms, including physical,

discrimination, through harassment, sexual assault and rape, and physical harm to murder (femicide). It may also include cultural practices such as female genital cutting.[157][158]

Non-fatal violence against women has severe implications for women's physical, mental and reproductive health, and is seen as not simply isolated events but rather a systematic pattern of behaviour that both violates their rights but also limits their role in society and requires a systematic approach.[159]

The World Health Organization (WHO) estimates that 35% of women in the world have experienced physical or sexual violence over their lifetime and that the commonest situation is intimate partner violence. 30% of women in relationships report such experience, and 38% of murders of women are due to intimate partners. These figures may be as high as 70% in some regions.[160] Risk factors include low educational achievement, a parental experience of violence, childhood abuse, gender inequality and cultural attitudes that allow violence to be considered more acceptable.[161]

The COVID-19 epidemic made

gender-based violence more common in Arab countries and worsened already-existing health disparities between the sexes. Yet millions of women in the Middle East and North Africa did not receive enough attention when it came to the provision of enhanced protection from gender-based violence.[162]

Violence was declared a global health priority by the WHO at its assembly in 1996, drawing on both the United Nations

CEDAW.[116] This recognised that eliminating violence, including discrimination was a prerequisite to achieving all other goals of improving women's health. However it was later criticised for not including violence as an explicit target, the "missing target".[167][97] In the evaluation of MDG 3, violence remained a major barrier to achieving the goals.[36][71] In the successor Sustainable Development Goals, which also explicitly list the related issues of discrimination, child marriage and genital cutting, one target is listed as "Eliminate all forms of violence against all women and girls in the public and private spheres" by 2030.[124][168][160]

Commission on the Status of Women[169] (2013).[170][171][172] To that end the 2014 UN International Day of the Girl Child was dedicated to ending the cycle of violence.[127] In 2016, the World Health Assembly also adopted a plan of action to combat violence against women, globally.[173]

Women in health research

Logo of Women's Health Initiative, depicting women of three different races to indicate diversity
Women's Health Initiative logo

Changes in the way

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.[174][175] Women, at least those in the child-bearing years, were also deemed unsuitable research subjects due to 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.[8][176]

The increasing focus on

phase III clinical trials to include women.[135] 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.[178] Despite this apparent progress, women remain underrepresented. In 2006 women accounted for less than 25% of clinical trials published in 2004,[179] A follow-up study by the same authors five years later found little evidence of improvement.[180] Another study found between 10 and 47% of women in heart disease clinical trials, despite the prevalence of heart disease in women.[181] 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.[135]

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

clinical trials such as the Women's Health Initiative
.

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, make this more complex. This gender bias is partly offset by the initiation of large scale epidemiology studies of women, such as the Nurses' Health Study (1976),[185] Women's Health Initiative[186] and Black Women's Health Study.[187][8]

Women have also been the subject of neglect in health care research, such as the situation revealed in the Cartwright Inquiry in New Zealand (1988), in which research by two feminist journalists[188] 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.[189]

The Women's Health Care Market is today a major pharmaceutical industry, projected to double in size within the five years from 2019 to 2024 and reach USD 17.8 billion. The by far most valued company worldwide whose leading products are in Women's Health is Bayer (Germany) with the focus area of Contraception.[190]

National and international initiatives

Logo for the United Nations Sustainable Development Goals with the UN symbol above the words "Sustainable Development Goals". The "O" in goals being a rainbow of colours
Logo of UN Sustainable Development Goals

In addition to addressing

Affordable Health Care Act (ACA).[193][194]

Internationally, many United Nations agencies such as the World Health Organization (WHO), United Nations Population Fund (UNFPA)[195] and UNICEF[196] maintain specific programs on women's health, or maternal, sexual and reproductive health.[3][197] In addition the United Nations global goals address many issues related to women's health, both directly and indirectly. These include the 2000 Millennium Development Goals (MDG)[165][49] and their successor, the Sustainable Development Goals adopted in September 2015,[53] following the report on progress towards the MDGs (The Millennium Development Goals Report 2015).[198][71] For instance the eight MDG goals, eradicating extreme poverty and hunger, achieving universal primary education, promoting gender equality and empowering women, reducing child mortality rates, improving maternal health, combating HIV/AIDS malaria and other diseases, ensuring environmental sustainability, and developing a global partnership for development, all impact on women's health,[49][13] as do all seventeen SDG goals,[53] in addition to the specific SDG5: Achieve gender equality and empower all women and girls.[124][199]

Goals and challenges

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.

funding agencies require justification from investigators 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 in terms 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 and the journal Biology of Sex Differences to further the study of sex differences.[8]

Research findings can take some time before becoming routinely implemented into

"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.[8]

A group of women in India receiving instruction in health education
Women receiving health education in India

Globally, women's access to health care remains a challenge, both in developing and developed countries. In the United States, before the Affordable Health Care Act came into effect, 25% of women of child-bearing age lacked

obstetrical fistulae, sexually transmitted infections and cervical cancer.[8]

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

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.[202]

See also

Women's health by country

Publications

Notes

  1. ^ Declared in 2011 and observed annually on October 11[126]


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Bibliography

Symposia and series

Articles

Reproductive and sexual health

Maternal health

Books

Chapters

Reports and documents

United Nations reports

Websites

News

Women's health research

Organizations

Women's health providers
United Nations Web sites
WHO
CDC

Further reading

External links
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