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by Ruaraidh Gilmour
12 March 2024
Women's health: An equal playing field

Women's health: An equal playing field

Leah has been searching for a diagnosis to explain her pelvic pain for over a decade. And throughout that time, she feels her symptoms have been, at times, dismissed by doctors.    

She says doctors have told her the excruciating pain is being caused by heavy periods, or premenstrual syndrome (PMS), and have opted to change her contraception many times to try to relieve things. Now in her late 20s and living in East Lothian, she is still in pain but says medics are beginning to listen after she “started advocating” for herself.   

Persistence was her only option. After repeated requests to test her, doctors finally tested for endometriosis and, after initial tests showed no signs, she was referred to a gynaecologist who told her “they may have seen something but were still unsure”.   

Her pain became so severe that she was taken to hospital by ambulance after GPs deemed it to be an emergency. But still tests offered no definitive answer and she was placed on the waiting list for a laparoscopy – an operation where a surgeon passes a thin tube through a small cut in the abdomen to look for patches of endometriosis tissue. It is currently the only way to be certain of endometriosis and it comes with the risk of causing a hernia or damage to a blood vessel or an organ, such as the bladder.  

Leah speaks to Holyrood the day before her surgery and says she feels “in the dark”. She still has not been told what endometriosis is or what is going to happen in the surgery. “They haven’t told me what will happen if I have it, and what happens if I don’t,” she says.  

After hours of waiting post-operation, she is told by her consultant that she does not have endometriosis, and while the next steps are unclear, she will continue to struggle with pelvic pain and heavy periods without a diagnosis or an effective way to tackle it.  

As her search for an explanation for her pain continues, her experience of the endometriosis diagnosis path is all too common for the one in 10 women who suffer from it. But it also highlights a wider issue in that women often feel unlistened to, not taken seriously or even dismissed by the health service, meaning their symptoms go undiagnosed.

In August 2021, the Scottish Government launched its Women’s Health Plan: A plan for 2021-2024, which aims to reduce avoidable health inequalities for women and girls across the course of their lives – from puberty to the later years – focusing on the areas that are stigmatised, disregarded or dismissed as ‘women’s problems’. It also called for the appointment of Scotland’s first women’s health champion, a role that clinical scientist Professor Anna Glasier – emeritus professor in the Centre for Reproductive Health at the University of Edinburgh – was appointed to last year.   

Then in October 2023, at the SNP’s autumn party conference, a resolution was unanimously passed calling on the government to launch a nationwide awareness campaign aimed at promoting early recognition of endometriosis symptoms. In December last year, the Scottish Government did just that, setting out steps to reduce diagnosis times and offer all women access to the right support and effective treatment for endometriosis, as well as access to a specialist endometriosis centre.  

It came after the trade union BMA Scotland noted in August 2023 that while the Women’s Health Plan had made some progress, “there’s a great deal more to be done before women and girls in this country feel that things have substantially changed”. Similarly, while some positive steps have been made towards achieving more efficient endometriosis health outcomes, Endometriosis UK says a lot of women have to wait around eight years for a diagnosis and it tends to be a “postcode lottery” when it comes to effective treatment, even in Scotland despite “doing slightly better than the rest of the UK”.  

Emma Cox, chief executive of Endometriosis UK, says: “Scotland has at least had a conversation about where you need specialist [endometriosis] centres related to the volume of cases you would be seeing, but they aren’t all yet up to that capacity. Since Covid, we have seen that the gynaecologist waiting lists increased by the highest percentage of all the specialities and people in Scotland are some of the people waiting really long lengths of time for surgeries – we are talking a couple of years.”  

She adds: “In an ideal world, at the first point of contact, you would go to your GP and describe your symptoms. They should be saying we know about 10 per cent of women have endometriosis. So, while they rule things out, they should give information on endometriosis and encourage patients to keep a pain and symptoms diary. In the meantime, they could be giving hormones, which manage endometriosis, and if they do manage the symptoms, it could give patients a working diagnosis.”  

Menopause is another example of something that affects hundreds of thousands of women in Scotland every year. And like endometriosis, it has been targeted by the Scottish Government’s Women’s Health Plan for improved health outcomes, though treatments have hit some roadblocks in the last few years.   

Last year the menopause pill Utrogestan, which is used to treat the symptoms of menopause, was restricted due to shortages. The drug had only become widely available to Scots in 2022 after TV personality and menopause champion Davina McCall highlighted that GPs were being warned against prescribing it on cost grounds. For a few months in 2023, pharmacists were expected to use their judgment to decide whether it was reasonable and appropriate to substitute a person’s prescribed medicine.  

Addressing the new challenges menopause creates for women as well as the stigma it still carries for some, community and transparency can be at the heart of tackling the condition.   

Norma is one of the 400,000 Scots who are of menopausal age. It left her feeling alone, a symptom that is reported to be common among menopausal women. Experiencing hot and cold flushes, brain fog, bladder weakness issues, chin hair, irritable itches and sleep deprivation, she put it all down to old age.  

She joined a pilot programme, run in collaboration between the Scottish FA, St Mirren FC Charitable Foundation, the University of Glasgow, and menopause expert Maria Anderson. The 12-week course saw 25 local women, who each had to address several issues brought on by menopause. They reported improvements in symptoms, a greater sense of empowerment and, overall, better mental health.  

Norma told the SFA: “We have a chat and a cup of tea. The room is full of love, laughter and learning. Topics have included hormones, nutrition, gut health, brain health and general exercise. All things that benefit us and help deal with our own various stages of the same journey.  

“Even the communal WhatsApp chat helps. If we’re ever feeling down or lost – or even if we’re full of joy and happiness – that group is there for you to share. We all bounce off each other and it’s another safe space. You can talk about anything, and you know everyone can relate to you. If it wasn’t for this group, I’d be jogging on the spot with no sense of direction and a lot more duvet days. Menopause is an issue that has probably not been taken seriously enough given how debilitating it can be.”  

Dr Nóra Murray-Cavanagh, the NHS Lothian GP lead for health inequalities, a member of the BMA Scottish Council and a GP, acknowledges that there is a “huge wait” for women even before they get referred to specialists, which is made worse by having “often carried these issues by themselves” for years in some cases. She says women will often be on waiting lists for months or years, and then wait for a follow-up appointment.  

“Everybody’s in a tricky position because clearly there are lots of things that can be managed in general practice and lots that used to sit there that now have been squeezed out because of the workload pressures,” she says. “Many GPs used to have women’s health as a special interest, but now as we have become really pressed, the fittings for coils for example, some of those appointments that were available in primary care don’t exist any more because everybody’s firefighting.”  

But there is another level to health inequality some women experience says Murray-Cavanagh. She tells Holyrood that one of the biggest challenges in providing equitable healthcare for all women in Scotland is improving access for women living in lower socio-economic areas. She is clear that the challenges in providing women from such backgrounds with primary care are “really seen in general practice”. She says there is less access to GPs generally in these areas and suggests there can be staffing, skill mix and training issues in some of these practices.   

“If we don’t understand that general practices are the basic unit of our NHS and how it functions, and how it has functioned very successfully historically, then we are down a blind alley,” she says.  

Murray-Cavanagh talks about a holistic approach being needed, one that deals with improving better health outcomes for women while also tackling issues like extreme poverty, which she says in turn exacerbates poor health. Poverty statistics released by the Scottish Government measured from 2019 to 2022 show that one in five Scots – more than one million people – live in poverty and face the same challenges she is warning are causing health inequality. Murray-Cavanagh says that women, particularly mothers, are often worst affected.  

“Often, mums are feeding their kids or partners first. And there is a real penalty that we see around not being exposed to cooking with fresh ingredients that are being sacrificed to pay things like high utility bills,” she explains.  

Much has been made about what the NHS will look like in the next few years as budgetary constraints continue to squeeze healthcare professionals’ capacity. Murray-Cavanagh says there needs to be a national conversation about what should be expected from the NHS. She says that until the public is involved in that, there will continue to be “animosity” towards the NHS.   

“There has to be a conversation about what we can fund and provide care for,” she notes, “and that has to be an ethical, equitable approach.”  
She continues: “This year I think we are going to see some brave changes being made because we must. We have run out of time on the system as was.”  

As policymakers search for answers on how to create a more equitable health service, Leah is an example of why improvement must be swift, effective and accessible for all women. While dealing with the pain, she was also diagnosed with attention-deficit/hyperactivity disorder (ADHD), a condition that, according to the Journal of Attention Disorders 2023, in childhood, the ratio of boys to girls with ADHD is about 3:1, whereas in adulthood it is closer to 1:1. This has led many doctors to believe it is another condition where girls are underdiagnosed.    

“Basically, for both issues for a long time, it was ‘here’s a pill’. And every time I would go back, they would just put me on another one,” Leah says.

“In my experience, they didn’t listen, it was like they were making assumptions based on what they had seen a million times in others, so their response was ‘here’s a pill’. It’s scary going to the doctor, they’re the experts and they can sometimes make you feel like you’re wrong – especially if you lack confidence.”   

She continues: “All of this has caused me to have so much anxiety and a real lack of confidence. I feel as if had I been diagnosed a long time ago, it would have helped in so many aspects of my life, and I wouldn’t have missed out on a lot of things. It is so frustrating, that in my late teens, I couldn’t explain how I felt and maybe I would have been diagnosed earlier. I might have done better in life; I might have gone to university or had a better career.” 

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