Battling biology: a look at women's health inequalities

Picture the scene.

It’s 8am and you’re running around trying to get ready for work after a terrible sleep as a result of nights sweats coupled with insomnia.

Your teenage daughter, powered by hormones, is furious with you because you didn’t wash her favourite top, and your husband is silently sulking because you weren’t in the mood for sex last night.

You have an important presentation to give at work and already your stress levels are through the roof and your temperature is quickly following suit.

And it’s only Monday.

Dr Heike Gleser stands before a room packed with women, all hooked on her every word, nodding simultaneously in agreement and giving knowing smiles to those sitting next to them.

It feels almost like a therapy session, the audience members clearly heartened by the fact that someone is depicting a scenario they can relate to. Someone – finally – knows what they are going through.

Gleser, a consultant in sexual and reproductive health at NHS Tayside, is describing a scene which is familiar not only to those in the room, but to around 400,000 women in Scotland who are experiencing the menopause transition right now.

Despite the vast number of women who are living with many – or even all – of the 34 known menopause symptoms, it isn’t something that they usually get to talk about so openly.

Women’s bodies have always been seen as being dirty and that association with filth is inescapable. Everybody wants to be clean and dry, and periods are messy. It doesn’t mean that you can’t manage it without feeling appalled by a normal physiological event.

But that shouldn’t come as a huge surprise for these women entering into this new chapter in their lives – most will probably have experienced the same kind of silence when it comes to talking about ‘women’s troubles’ since they were young girls.

From menstruation right at the start of the gynaecological lifecycle to unresolved postnatal issues, urinary incontinence and endometriosis, there has always been a culture of women suffering in silence.

“There’s been some interesting work done on marketing of menstrual products, how they’ve always had shame associated with them,” says Elaine Miller, a pelvic health physiotherapist. “The first adverts were saying this is an embarrassing thing that you mustn’t talk about and our packaging is quiet, nobody will hear you using it.

“It’s well documented that young girls are concerned about being heard outwith toilets when they’re unwrapping sanitary towels and it’s a real problem because it is a normal physiological event so why should it be any more shameful than blowing your nose?

“Women’s bodies have always been seen as being dirty and that association with filth is inescapable. Everybody wants to be clean and dry, and periods are messy. It doesn’t mean that you can’t manage it without feeling appalled by a normal physiological event.”

There has, however, been a recent positive shift towards putting an end to the stigma – even shame – which women and girls have carried around with them for far too long.

A ‘period poverty’ bill was lodged earlier this year in the Scottish Parliament which would ensure free access to sanitary products for all women, making Scotland a world leader in tackling the issue.

If passed, the bill would make it a statutory requirement for schools, colleges and universities to provide sanitary products, while the Scottish Government has pledged £4m to boost provision in public buildings.

Following a 2017 pilot in Aberdeen, which gave women and girls in low-income households free tampons and towels, the scheme was rolled out at the start of this year. Launching the rollout, Communities Secretary Aileen Campbell said: “In a society as rich as Scotland, no one should have to suffer the indignity of not having the means to meet their basic needs.

“We also want to continue to reduce the stigma and address the overarching gender equality and dignity issues that affect everyone who menstruates, regardless of their income.”

The Scottish Government has since gone even further by announcing its intention to put a women’s health plan in place within the next few months.

Announced by Nicola Sturgeon as part of this year’s Programme for Government, the plan will focus on a range of issues designed to help tackle women’s health inequalities.

These include ensuring rapid and easily-accessible postnatal contraception; improving access to abortion and contraception for young women and reducing inequalities in health outcomes which affect women, such as antenatal care and endometriosis.

Endometriosis – affecting one in ten women – recently hit the headlines after BBC research revealed the devastating impact it can have on women’s lives.

Those living with the condition – which can take years to diagnose – can experience heavy periods, fatigue, debilitating pain, depression and sometimes even infertility.

As a result of the BBC research, MPs are now launching an inquiry into women’s experience of living with endometriosis.

Politicians have also, in recent years, become involved in debating the issue of incontinence in women following the controversy surrounding vaginal mesh implants.

Often used to treat incontinence after childbirth, it emerged that the procedures have had a devasting impact on thousands of Scottish women, with almost 600 taking legal action.

The Scottish Government asked health boards in 2014 to consider suspending the use of mesh products, though it wasn’t until last October that the chief medical officer announced a halt to the procedures.

New figures, from October 2018 to March this year, show that over the past ten years, there has been a large decrease in the number of mesh procedures for stress urinary incontinence – particularly from 2014 onwards – and no mesh procedures have been carried out in Scotland since the halt was called.

The government’s women’s health plan also aims to improve services for women going through the menopause, including increasing the understanding and knowledge of women, families, healthcare professionals and employers.

Currently, there are very few specialists in Scotland – just five out of Scotland’s 14 regional health boards have a dedicated menopause clinic – and waiting lists are eye-watering.

And despite the fact that more and more women will still be employed as they enter the menopause, a survey conducted by the Scottish Trades Union Congress (STUC) found that 99 per cent of the 3,649 respondents either don’t have or don’t know if they have a workplace menopause policy.

I do feel for the women, and I feel kind of sad and a little bit frustrated. And we do regularly speak to GPs about the menopause but often the GPs who are not interested in it will not come to an update day about menopause.

The same survey also revealed that 32 per cent said menopause was treated negatively in the workplace and 63 per cent said it was treated as a joke at work, so it’s clear that the women’s health plan is much needed.

And with the current shortage of hormone replacement therapy (HRT) – which involves taking oestrogen to replace the decline in the body’s own levels around the time of the menopause, relieving many of the associated symptoms – it is perhaps more timely than ever before.

Gleser, who works in one of the specialist menopause clinics, says she feels “sad and a little bit frustrated” on behalf of women struggling with their menopause symptoms and admits there is a lack of specialist knowledge among GPs, which contributes to that.

She says GPs are under so much pressure already, but she would like to see more peer training or “hubs” where doctors could share their knowledge with others on the menopause.

“I don’t want to be a GP, I mean, it’s just crazy working as a GP because they have to know everything about everything,” she says.

“I do feel for the women, and I feel kind of sad and a little bit frustrated. And we do regularly speak to GPs about the menopause but often the GPs who are not interested in it will not come to an update day about menopause.

“Me, as a specialist, of course, I need to update on menopause, but if you’re a GP, nobody tells you that you have to update on menopause, so the people who come to our update days, or events are people who are interested already. So how do you get people engaged, to come along and get updated?”

It’s a fair question, and one which perhaps will only be answered through the introduction of more robust policies – and even legislation – to ensure the rights of women.

The Scottish Parliament, for example, introduced a period and menopause policy to “create a positive culture where staff experiencing problematic periods or menopausal symptoms get the support they need to manage their symptoms at work”.

Acknowledging the fact that there is a stigma attached to the menstrual cycle and menopause is key to normalising these natural physiological processes.

But Miller, a fellow of the Chartered Society of Physiotherapy, says that a lot of women’s health inequalities stem from the fact that many women are still unable to identify what is and isn’t normal regarding their own bodies, resulting in them putting up with abnormally painful periods or living with conditions like endometriosis without even knowing.

She believes there is a fundamental failing in the way these things are taught to young people in school.

“I would make sex education provide basic information about what you can reasonably expect from your genitals in boys and in girls, so I want young people to leave knowing what normal peeing, normal pooing and normal sexual function are, then they would be able to recognise when something is not right,” she says.

“I think part of the way they teach it in sex ed is problematic. A lot of schools still teach things separately and sometimes it’s better to teach these basic facts of life separately to reduce the embarrassment girls feel, but if men don’t have the information then it remains shameful.”

While both girls and boys are taught about contraception in schools, the likelihood is that when it comes to the time when they become sexually active, the burden of contraception – including the emotional, financial and health side-effects – will fall upon the woman.

According to a recent UN study of reproductive-age couples, when contraception is used, female contraceptives are by far the most common choice.

About 19 per cent of women who are married or in relationships rely on sterilisation, 14 per cent on the coil, nine per cent on the pill, and five per cent on injections, according to the research.

Contraceptives that directly involve men are much less common, with eight per cent relying on condoms and only two per cent on vasectomy.

These figures may not be particularly surprising – especially as the introduction of female contraceptives liberated women at the time – but there are many hidden health inequalities which are more startling.

Thanks to the work of writer and activist Caroline Criado Perez, who collated a mass of statistics highlighting a wide range of inequalities, we now know that there are real reasons why women take up to 2.3 times as long as men to use the toilet, and that women aren’t just complaining about being cold in the office for the sake of it – most offices are five degrees too cold for women because the formula to determine their temperature was developed in the 1960s based on the metabolic resting rate of a 40-year-old 70kg man.

The fascinating statistics also found that women involved in car crashes are nearly 50 per cent more likely to be seriously hurt – even though men are more likely to crash – because the crash test dummies are designed around the body of an average man.

And, as Criado Perez pointed out, women in Britain are 50 per cent more likely to be misdiagnosed following a heart attack, while heart failure trials generally use male participants.

A recent report – Bias and Biology – by the British Heart Foundation Scotland found that heart disease is killing nearly three times as many Scottish women as breast cancer, but gender disparity between men and women in recognising symptoms and receiving treatment means “too many women are not aware they are at risk”.

In short, the report found that too many women are dying “needlessly” from a heart attack because they “may not receive the same care as men”.

That statement seems almost impossible in Scotland in 2019, but the simple fact that the Scottish Government feels the need to introduce a women’s health plan shows not just how far we have come, but how far we still need to go.