Women's health is the effect of gender on disease and health that encompasses a broad range of biological and psychosocial issues.
Women's health is the concept that examines gender differences in health and disease states. The average life expectancy has almost doubled for women (79 years for women and 73 years for men), when compared with averages during the turn of the century. Because of the gender gap in lifespan, women comprise approximately two thirds of the population older than 65 and three fourths of the population aged 85 years and older. Currently the fastest growing group in the United States is persons aged 85 years and older. Because of gender life expectancy differences, it is estimated that at the beginning of the twenty-first century, women will outnumber men in the 85 years and older category by 3:1. The reasons for this variance are primarily due to physiological differences among men and women.
During different phases of a women's life cycle there are complex interactions that exist between sex hormones, physiological changes, and emotional issues. Physiological changes occur as early as embryonic development when hormones program structural differences between male and female brains. During reproductive years, sex hormones profoundly influence reproduction and development, which creates a spectrum of gender specific health issues. With advancing age and onset of menopause, women's risk factors for disease is comparably similar to men's. Although the same disease may affect women as men, it is thought that biological mechanisms and psychosocial differences influence the clinical course of the disease (natural history) differently in women. The number of women working has doubled within the past 50 years. The effect of work stress, new environmental exposures and multiple roles is expected to have health and social impact.
The leading causes of death among women are cardiovascular disease, malignant cancer, cerebrovascular disease, chronic lung disease, pneumonia/influenza, and diabetes. Additionally, women can be prone to osteoporosis, alcohol abuse, psychological disorders, human immunodeficiency virus infection, and violence.
Heart Disease accounts for approximately a third of all deaths in women. About 250,000 women die annually of coronary heart disease or a one in three chance after age 40 years. The incidence of heart disease occurs about 10 years later in women than in men, since estrogens in premenopausal women has a protective effect. African American women are more prone to die from heart disease up to age 75. Beyond 75 years of age the propensity is reversed. Native American and Hispanic women have lower death rates from heart disease.
Malignant cancers are the most common cause of premature death among women. Breast cancer is the second leading cause of death in women and the most commonly diagnosed cancer. Lung cancer, secondary to cigarette smoking is the leading cause of cancer death among women.
Cerebrovascular disease, or stroked related deaths account for approximately 6% of all deaths in women and it is the third leading cause of mortality. The least common form of stroke, subarachnoid hemorrhage, is the more common cause in women.
The prevalence of cigarette smoking has increased greatly in women and this is correlated with pulmonary disease. Death rates for pulmonary disease including cancer and infectious causes of death are expected to rise for women.
Diabetes, a leading cause of death in women is more prevalent among Hispanic, African American, and Native American women. Past age 45, diabetes affects about one in six women.
Women can also develop:
- osteoporosis, or loss of the quantity of bone, common in postmenopausal women who have estrogen changes.
- alcohol abuse, characterized by repeated usage of alcohol despite negative consequences. These women frequently do not seek treatment because of fear of consequences (i.e., loss of child custody). This disease can also have adverse affects on fertility and in the developing fetus if the mother continues to consume alcohol (fetal alcohol syndrome).
- psychological disorders, such as depression and eating disorders.
- acquired immunodeficiency syndrome (AIDS ), which represents the highest percent increase in death rates.
- violence, a leading cause of death, primarily caused by a perpetrator who is or was a partner.
Causes and symptoms
Cardiovascular disease can be caused by blockage of a blood vessel, high blood pressure, or a secondary complication to another disease. There may be an abnormal heart rhythm or cell death. Patients may complain of a broad spectrum of symptoms that may include pain chest discomfort, high blood pressure, or strain during physical exertion.
When attempting to define the cause and symptoms of cancer, it is important to assess the type of cancer and location. Additionally, if the tumor is localized (benign) or has spread to other areas (malignant), is vital for treatment planning and overall prognosis. In cases of breast cancer there mat be a lump discovered during self-examination or mammography (special breast x rays).
Cerebrovascular disease may cause tremors (shaking), loss of balance and coordination, or functional and sensation loss of some parts of the body. Patients may have sudden transient strokes that could result in temporary loss of consciousness and amnesia of the incident. Patients may also develop chronic neurological states that causing memory loss and behavioral changes (Alzheimer's disease ).
Patients with pulmonary (lung) cancer may develop shortness of breath, fatigue, weight loss, worsening cough, and coughing up bright red blood with sputum. Lung infections such as pneumonia may present with high fever, weakness, difficulty breathing, and abnormal breathe sounds heard with a stethoscope during physical examination.
Diabetes is a syndrome with disordered metabolism and high blood sugar due to an abnormality in the chemical that regulates sugar levels. It is characterized by an increased thirst, urination, and chronic skin infections.
Osteoporosis may cause the bones to be brittle and weak. It is usually not detected until bones start to break.
The alcohol abuser will continue to drink despite negative repercussions. The person may not seek treatment to evade legal and/or child custody problems. The patient may hide alcohol, or confine drinking to specific times. The disease progresses to where there may be permanent liver damage, memory blackouts and malnutrition.
Depression may manifest a loss of interest and desire. Patients may have difficulty getting out of bed. They may lack motivation to work or tend to daily activities.
Patients with AIDS may not have symptoms for years. When active disease occurs, patients will typically develop recurrent infections that are the usual cause of death.
Domestic violence is usually associated with a perpetrator who is in a relationship with the affected person. Abuse can be manifested by physical violence and/or homicide.
Diagnosis can be accomplished with a history, physical examination, and specialized tests or procedures. For cardiovascular disease an electrocardiogram can determine the activity of the heart. Additional tests may include echocardiography (ultrasonic waves that generate an image), stress testing, and studies that require placing a catheter with a probe to examine the damage to heart tissue. Special tests with dyes may also be injected to enhance visualization. Cancer may be detected using specialized test called tumor makers and imaging studies such as MRI and CAT scans. Cerebrovascular disease can be detected with a complete neurological examination and specialized imaging technology. Diabetes is usually detected by a careful history presence of risk factors (obesity ) and blood analysis of glucose levels. Osteoporosis can be evaluated with specialized bone densitometry. Alcohol abuse can be established by a bio-psycho-social assessment and standardized tests which screen for this disorder. Psychological evaluation (such as the Minnesota Multiphasic Personality Inventory, MMPI) can usually detect depression or eating disorders. AIDS can be established by a careful history, belonging to high-risk groups and Western blot analysis (examination of blood to detect the protein of human immunodeficiency virus). Violence can be established by physical signs of beating, such as cuts and bruises.
Treatment depends on the extent of disease and the present health status of the patient. Additionally, in some cases treatment may stopped at sometime, or it may altogether be refused. Treatment for cardiovascular disease may include surgical intervention and/or conservative medical treatment with medications. Diet, exercise, and weight reduction are important parameters for treatment planning. Appropriate referrals, counseling, and follow up are usually indicated. Treatment for cancer may include a combination of surgery, chemotherapy or radiation therapy. These treatment modalities may be given singly or in combination or at different times during disease progression. Cerebrovascular disease can be treated surgically and/or with medications that thin the blood. Symptomatic care may be indicated in addition to close monitoring if the patient develops disability and/or cognitive impairment. Diabetes can be treated by dietary modifications and medications, which treat abnormal levels of blood glucose (sugar). Osteoporosis can be treatment with estrogen replacement and regular vitamin/mineral intake. Alcohol abuse may require long-term therapy, inpatient treatment and medications. Community centered support group meeting are also recommended as a form of treatment maintenance. To date there is no treatment for AIDS, other than medications, that offer symptomatic relief. Alcohol abuse, psychological disorders and violence require therapy, possible medication, and community centered support group meetings.
There are numerous studies which support intake of coenzyme Q10 for cardiovascular health. Studies have shown that beta-carotene and vitamin E and C have no effect for cancer. Some studies indicate positive results for reproductive health using acupuncture. Some advocates proposed certain herbs may be beneficial during menopause. According to most medical literature, further research using scientific method is vital for general acceptance.
The prognosis depends on the extent of disease and the physical and emotional status of the patient. Prognosis is also related to tolerance of treatment, adverse drug effects, and complication during or after surgery, disease resurgence and patient compliance with treatment recommendations.
One of the most reliable measures of prevention is education and training. The Council on Graduate Medical Education has provided funding for numerous centers to research women health issues. On more individual level preventive and personal habits are vital for good health. Most physicians believe that a baseline physical examination is a reliable comparative tool. Women should receive counseling for special issues concerning cigarette smoking, exercise, diet, primary disease prevention, safe sexual practices, alcohol abuse, psychological disorders, and violence. Additionally, knowledge of family history is important since many diseases have a strong propensity among first-degree relatives. Blood pressure should normally be measured every other year. Screening tests for breast, cervical, and colorectal cancer is recommended. Pap smears taken during routine pelvic examinations can screen for disease processes in the reproductive tract. Serum cholesterol monitoring and reduction are advised. Patients may require postmenopausal estrogen replacement therapy and vitamin/mineral supplements.
Ryan, Kenneth J., et al, editors. Kistner's Gynecology & Women's Health. 7th ed. Mosby, Inc., 1999.
Lautenbach, G. L., and M. Petri. "Women's Health: GeneralMedical Care of the Patient with Rheumatic Disease." Rheumatic Diseases Clinics of NorthAmerica 25 (August 1999).
Electrocardiogram— An instrument that monitors heart rate and rhythm.
Despite obvious differences between women and men—biologically, psychologically, and socially—the concept of viewing the totality of women's health as different from men's health arose in Western medicine only in the last two decades of the twentieth century. As recently as the 1980s, students in most Western medical schools were taught that, except for issues related directly to reproductive anatomy and function, women were medically identical to men. According to this belief system, medical research could be carried out on men, and the results could simply be applied to women. As a result, only health care providers who specialized in areas related to reproduction were expected to be knowledgeable about issues particular to women.
In order to understand the modern definition of women's health, it is important to understand the history of how women's health care has been viewed by the medical and medical research establishments. Traditionally, the health of women has been seen as synonymous with maternal or reproductive health. Clearly, the Western medical profession's view of women's health as "maternal health" was concordant with societal mores that valued women mainly for their ability to bear children. However, until well into the twentieth century, the major causes of illness and death in women did, in fact, relate to reproductive issues. Childbirth and sexually transmitted diseases, including cervical cancer, have been the most important health issues for women in all ages and places—except in the West and certain other countries in the twentieth century. Prior to 1900, the majority of elderly persons in the United States were men, reflecting the toll that childbearing took on the health of women.
In 1970 the book Our Bodies, Ourselves became a touchstone of the women's health movement. Authored by a group of women participating in a course on health, sexuality, and childbearing, the book emphasizes the importance of women attaining knowledge about their health and being active participants in health care in both an individual and societal sense. Our Bodies, Ourselves also considers the social context of health, including effects of sexism, racism, and financial pressures on the health of women. Throughout the 1970s, major focuses of the women's health movement included reproductive freedom, understanding health in a broader social context, and a critical orientation toward the medical establishment.
In the 1980s, women's health advocates began to argue for a broader definition of women's health and increased participation of women in research studies. A major new focus became changing the medical establishment. The reasons for this change in orientation, particularly toward the participation by women in research studies, were complex. They included, but were not limited to, the growing number of women living beyond their reproductive years and the growing number of women reaching positions of influence within academic medicine.
In 1983 the United States Public Health Service commissioned a task force on women's health. This task force broadly defined women's health issues to include not only reproductive and social issues, but also biological differences between men and women. The modern field of women's health includes the study of illnesses and conditions that are unique to women, more common or serious in women, have distinct causes or manifestations in women, or have different outcomes or treatments in women. Since the 1980s, research on gender differences in health and disease has had important implications for the treatment and prevention of a variety of common serious illnesses, including heart disease, stroke, lung cancer, depression, colon cancer, and dementia. Research in all these areas is ongoing.
Integral to this new expanded view of women's health has been a change in how medical research has been viewed by the public. In the 1970s, the focus of women's health advocates in the United States was on "protecting" women from potential abuses by seeking to avoid their inclusion in medical research studies. It should be noted that women were excluded from medical research during this time because of a variety of factors, and not solely, or even mainly, because of popular advocacy. Medical research was conducted almost exclusively by male physicians, and because most research scientists believed that effects of the reproductive cycle of women might lead to unreliable research results, most supported the belief that research should be conducted on men and then applied to women. Even most medical research on rats during this period was conducted using male rats.
However, by the 1980s, women's health advocates had realized that because women were being excluded from research studies, knowledge about the diagnosis and treatment of a wide variety of common diseases in women lagged far behind knowledge of diseases in men. A major focus of the women's health movement in the 1980s and 1990s was improving knowledge about disease in women by promoting the inclusion of women in research studies, mainly through mandating inclusion of women in federally funded research studies.
A greater understanding of the factors influencing women's health from a biological perspective has been paralleled by a greater understanding of the psychosocial and societal factors that affect women's health status. As an example, research published in the early 1990s showed that because women were more likely than men to require ongoing, rather than episodic, treatment for their health conditions, federally sponsored insurance in the United States (Medicare) actually covered less overall health costs for women than for men. Differences in employment patterns also result in fewer women being medically insured than men, strongly affecting access to health care and health status. Research on domestic violence, which disproportionately victimizes women, underlined the short-and long-term health effects of what had previously been considered either a nonissue or a law enforcement issue.
Some have suggested that the term "women's health" be replaced by the term "gender-based medicine," in part to reflect that medical research that promotes a greater understanding of the effect of gender on health benefits both women and men. However, others believe that the term "women's health" is most accurate, since it incorporates not only biomedical issues, but also the psychosocial and societal factors that ultimately influence the overall health status of women.
The field of women's health seeks to promote an understanding of the biological and psychosocial factor affecting women's health, and to integrate this understanding into public health initiatives, including training of health care providers. Recognition by the medical research establishment of the need to study health and disease in women as well as men has been essential to this new paradigm. Despite the strong influence of biological factors, psychosocial issues still remain the single most important determinant of health status for many women.
Janet P. Pregler
(see also: Domestic Violence; Gender and Health; Maternal and Child Health; Reproduction; Women, Infant, and Children Program [WIC] )
The Boston Women's Health Book Collective (1998). Our Bodies, Ourselves for the New Century. New York: Simon and Schuster.
Clancy, C. M., and Massion, C. T. (1992). "American Women's Health Care." Journal of the American Medical Association 269:1918–1920.
Council on Graduate Medical Education (1995). Fifth Report: Women in Medicine. Washington, DC: U.S. Department of Health and Human Services.
Haseltine, F. P., and Greenberg-Jacobson, B. (1997). Women's Health Research: A Medical and Policy Primer. Washington, DC.: Health Press International.
Healy, B. (1995). A New Prescription for Women's Health. New York: Penguin.
Schroeder, P. (1999). 24 Years of House Work and the Place Is Still a Mess: My Life in Politics. Kansas City, MO: Andrews McMeel Publishing.
Walzer Leavitt, J. (1999). Women and Health in America. Madison, WI: University of Wisconsin Press.
WOMEN'S HEALTH. Feminist health activism grew out of the women's liberation movement of the 1960s, which argued that ideas of female inferiority pervaded the gender-segregated health care system. In The Feminist Mystique (1963) Betty Friedan assailed physicians who proscribed addictive tranquilizers to dissatisfied suburban housewives; protesters at the 1968 Miss America pageant rejected stereotypical notions of femininity; and New York City's Redstockings and other radical feminists organized "speak-outs" to break society's silence about abortion and rape.
Women's physical and mental health was, feminists argued, best maintained outside the hospital and doctor's office, and self-help groups and alternative clinics sought to demystify medical knowledge. The Feminist Women's Health Center of Los Angeles, founded in 1972 by Carol Downer and Lorraine Rothman, taught women to monitor their gynecological health without intervention of a physician, and issued pamphlets like "How To Stay Out of the Gynecologist's Office." Birthing centers providing drug-free, midwife-assisted childbirth challenged standard high-tech obstetrical care. Initiated at a 1969 feminist conference's workshop on women's health, the comprehensive health text Our Bodies, Ourselves, written by the Boston Women's Health Book Collective, was first a pamphlet and then gained a commercial publisher in 1973; it remains popular in many countries, even in publishing markets now full of other women's health texts.
Activists achieved significant political, professional, and legal reform. Journalist Barbara Seaman's provocative book The Doctors' Case Against the Pill (1969) inspired activism that led to the inclusion of patient packet inserts with each pill prescription. In 1970 the Women's Equity Action League threatened American medical schools with a sex discrimination class-action suit, and the acceptance rates for women candidates suddenly doubled from the standard quota of the previous seven decades of approximately 6 percent. Under the pseudonym Margaret Campbell, Harvard Medical School pediatrician Mary Howell detailed the continuing discrimination women students faced in Why Would a Girl Go Into Medicine? (1973). Working with the National Abortion Rights League, feminists demanded legal reform in the name of equal rights, while others, like the underground Chicago service "Jane" (1969–1973), provided access to illegal abortions. In Roe v. Wade (1973) the Supreme Court ruled that abortion was a private decision between a woman and her doctor, and that the state could not intervene until the fetus was "viable"—a term that has shifted in meaning with improving medical technologies. In 1975, during congressional hearings on the synthetic hormone DES, Barbara Seaman, Mary Howell, Alice Wolfson, and Belita Cowan organized a memorial service to protest the death of women who had taken the drug approved by the Food and Drug Administration (FDA) to prevent miscarriage and as a morning-after pill. The National Women's Health Network, which they then founded, forced the FDA to include lay consumers on its advisory committees. DES-daughter activists later pressured Congress to require research by the National Institutes of Health (NIH) on DES and fetal abnormalities. Frustrated with the unresponsive criminal justice system, groups like Women's Advocates in St Paul, Minnesota, set up the first crisis hotline in 1972; shelters and half-houses for battered women followed. Take Back the Night marches and Susan Brownmiller's Against Our Will (1975) led to changes in state rape laws; federal funding for domestic violence programs; and training for police, prosecutors, and judges.
Most of the early feminist health activists were white, middle-class women, but the movement gradually recognized the class, race, and ethnic diversity of women's health. In 1981 Byllye Avery founded the National Black Women's Health Project, and later Latina, Asian American, and American Indian activists organized separate women's health organizations. The Committee to End Sterilization Abuse publicized the numbers of low-income women of color who, during childbirth or while under heavy medication before a Caesarean section, had been forced to agree to a tubal ligation or hysterectomy. In 1973, media coverage of the case of the twelve-and fourteen-year-old daughters of the African American Relf family, whose illiterate mother was forced by a federal family planning clinic in Montgomery Alabama, to consent to their tubal ligation, resulted in a federal lawsuit that forced the Department of Health, Education and Welfare to revise its informed-consent guidelines.
The growing power of the New Right conservative movements, especially the Right to Life Coalition and later Operation Rescue, led Congress to pass the Hyde Amendment (1976), which severely restricted access to abortion for poor women. During the 1980s and 1990s, the Supreme Court allowed states to impose additional restrictions on abortion access, such as waiting periods and some forms of parental consent, but it has also continued to reaffirm the right to privacy. The training of doctors qualified to perform abortions declined dramatically, however, as did the number of counties with clinics or hospitals providing abortion services.
Lobby groups around women with specific disabilities proliferated during the 1980s and 1990s. In The Cancer Journals (1980) poet Audre Lorde spoke of the inter-connected oppression of race, gender, and disease, and by the 1990s, women's breast cancer coalitions expanded public awareness of mammograms, and gained federal funding for women's health centers. Outraged by the number of clinical trials using few if any women as subjects, feminists in and outside of Congress in the late 1980s forced the NIH to require all funded researchers to include women and minorities in study populations for clinical research. In 1990 the NIH established an Office of Research on Women's Health, and a year later appointed its first female director, cardiologist Bernadine Healy, who announced a "moon walk for women": the Women's Health Initiative, a $625 million, fourteen-year clinical study of 160,000 women aged fifty to seventy-nine. New technologies, including sophisticated prenatal diagnosis, fetal therapies, embryo transfer, and the possibility of human cloning have continued to shape the debate over reproductive rights.
Kaplan, Laura. The Story of Jane: The Legendary Underground Feminist Abortion Service. New York: Pantheon, 1995.
More, Ellen S. Restoring the Balance: Women Physicians and the Profession of Medicine 1850–1995. Cambridge, Mass.: Harvard University Press, 1999.
Weisman, Carol S. Women's Health Care: Activist Tradition and Institutional Change. Baltimore: Johns Hopkins University Press, 1998.