Women's Health Review
Women make up more than half of the population (~50.5%) in countries like the USA or UK. While living longer than men, women have unique health issues that men do not, from reproduction to certain cancers. Women also experience marked biological changes in their lives, from their first period to living with menopause. And for those who get pregnant, many questions arise.
Misinformation is everywhere on the internet with regards to women’s health. From jade eggs to labiaplasty, women get targeted by wellness brands and the cosmetic industry, so they need to be better informed so they can make evidence-based decisions around their health.
Are psychological problems more common in women? Are menstrual cups safe? Does menopause have knock-on effects on your day-to-day life? Have there been improvements in breast cancer diagnosis?
This month, we have asked our experts to share all the facts on women’s health, and here is what we have learned.
5 billion: Estimate of the global market value of tampons in US dollars
35%: Percentage of women who have experienced physical or sexual violence at the hands of a partner
200 million: Number of girls and women alive today that have suffered genital mutilation
87%: Reduction in cancer rate in 12-13 year-old girls after HPV vaccination
1 in 10: Reproductive-age women who experience endometriosis worldwide
8 million: Number of babies born through the use of IVF
1 in 2: Premature births associated with microbial causes
59%: Pregnant women who have anemia in Mali (vs 16% in Australia)
2.3 million: Number of women diagnosed with breast cancer in 2020
How a vaccine is turning the tide of cervical cancer
Cervical cancer, which develops in the cervix (that’s the neck of the uterus), is the 4th most common cancer in women. According to WHO statistics from 2018, 570,000 women were diagnosed with this cancer and 311,000 died of it that year. However, some countries have been able to slowly reduce the number of cases. Two developments are behind such improvement: routine tests like the Pep test, and the Human papillomavirus (HPV) vaccine.
You may or may not be surprised that a vaccine can help us against a type of cancer, but there is no debate among our experts: almost every case of cervical cancer (99.7% of them) is caused by the HPV. As it turns out, this virus affects both sexes and is the most frequent sexually transmitted disease (STD). It’s estimated that up to 80% of sexually active woman will catch it at some point during their lives. The HPV virus can infect our skin and mucous membranes and, while most of the infections resolve by themselves, others may progress to genital warts or cancerous lesions that could lead to cervical cancer. Plus, the same virus can also trigger anal and vaginal cancers, as well as penis, vulva and oropharingeal tumoral processes.
In 2006, there was a turning point. An HPV vaccine was approved, which has since been included in the vaccination plan in at least 68 countries. Although the HPV vaccination was initially devised for 12- and 13-year-old teenage girls, boys and men have also become eligible as HPV can cause cancer in males. The truth is, HPV vaccination found an important opposition for a few years following its authorisation, as some groups falsely claimed that severe adverse effects were taking place after the jabs. However, many different scientific societies and associations, and the WHO themselves, have proved that it is a safe vaccine. Recent studies revealed that the HPV vaccine is not only safe, but also a huge success — the rate of cervical cancer dropped by almost 90% in vaccinated women.
Despite the success of the HPV vaccine, some issues remain. Worldwide, dramatic regional differences exist in vaccination coverage (this may ring a bell). HPV vaccines have only reached 3.5% of women, and the situation is particularly worrying in Africa, where cervical cancer rates are soaring and the incidence is still extremely high. Universal vaccination helps to reduce overall transmission, and experts call for greater vaccination coverage to reduce the presence of the virus across the population, but getting the jabs into as many arms as possible remains a logistical and political challenge.
Are women more anxious than men?
Symptoms of anxiety include tension, worried thoughts and physical changes like increased blood pressure. Although such feelings are normal, they may get exacerbated in some people and can even lead to panic attacks. These scenarios are not uncommon in patients with anxiety disorders, which dramatically interfere with their daily activities. Some say that women are more likely to suffer from these, so we have asked our experts about the truth behind this belief. Prof Amy Yee from Tufts University warns that we do not know the answer to this question, claiming that this “is a subjective question that does not lend to generalizations,” and Cara A Davidson from Western University also cautions against the “oversimplification of a nuanced condition.”
That said, Dr Julie Ji from University of Western Australia writes that “it is well established that more females are diagnosed with anxiety disorders than males,” according to a recent WHO mental health survey. In this line, Dr Sophia Yen from Pandia Health also notes that “The National Comorbidity Survey [...] found that lifetime prevalence rates for any anxiety disorder were 30.5% for women and 19.2% for men.” Dr Marianne Etherson from York St John’s University agrees, quoting data suggesting that these rates “are reported to be 1.5 to 2 times higher in women than men.” This is far from anecdotal. Dr Yen points out that “prevalence rates were also higher in women than men for each anxiety disorder examined,” including panic disorder, agoraphobia, specific phobia, social anxiety disorder, generalised anxiety disorder and posttraumatic stress disorder. She also includes information about obsessive compulsive disorder (OCD) for which “lifetime prevalence estimates [...] based on the Epidemiological Catchment Area study were also higher in women than in men.”
What’s causing this? Dr Sara Nowakowski from Baylor College of Medicine explains that whereas “men with anxiety report higher rates of alcohol, nicotine, and drug use,” in the case of women they found that anxiety was instead more frequently linked to “comorbid depression and a family history [of] depression.” Depression is not inheritable, but she explains that “female reproductive hormones, especially estrogen and progesterone, may play a critical role” in the development of anxiety disorders in women.
Does menopause impact sleep?
Menopause is a natural biological process that marks the end of the menstrual cycle of a woman. You are experiencing it if you have gone for 12 months without a menstrual period, which usually occurs between 45 and 55 years of age. Common symptoms are irregular periods, vaginal dryness, hot flashes or chills. However, sleep problems are sometimes reported as well. We have asked our experts about the menopause effect on a woman’s sleep.
Dr Sara Nowakowski confirms that “menopause does impact sleep.” Indeed, “menopausal women are twice as likely to report dissatisfaction with their sleep compared with premenopausal women,” she writes. If you are curious about what causes this, Dr Nowakowski explains that, among other factors “insomnia and poor sleep [are] likely related to factors such as aging, hormone fluctuation and hot flashes.” Prof Amy Yee writes that it is unknown whether menopause itself alters sleep, although she admits that “hormonal fluctuations can influence sleep.”
Such hormonal fluctuations during menopause may not affect just sleep, but other body functions as well. For example, Cara A Davidson from Western University explains that “hormonal changes during menopause have been known to impact metabolism.” Dr Yen agrees, saying that “women find they gain weight and the hormonal changes affect where fat is stored.” Plus, it is possible that these changes are connected. According to Prof Susan Davis from Monash University, "sleep disturbance [...] results in desynchronisation of clock genes in peripheral tissues (liver, gut, etc) and further contributes to metabolic disturbance."
Interestingly, menopause might affect the brain, too. Dr Yen reports that “many women have seen improvement of their memory once they start Hormonal Replacement Treatment (a common treatment to reduce menopause symptoms),” although she acknowledges that “it’s hard to separate if it is age or menopause (the change in hormones) that causes the memory change” in the first place. Prof Yee shares this view. For her, “it is known that hormonal fluctuations can influence memory and function in different areas of the brain, including the hippocampus,” but it remains unclear whether menopause directly affects memory. And yet, this hypothesis does pave “a new field” of study, says Prof Yee.
Do routine mammograms save lives?
Breast cancer is the most common malignancy not just specifically in women but overall - in 2020, it surpassed lung cancer with 2.3 million cases. Yet, it comes 5th in terms of mortality. The link between both is broken thanks to both improved treatments and early detection.
As for the latter, Prof Nancy Keating from Harvard University writes that mammograms probably decrease “the risk of dying of breast cancer.” She explains that “clinical trials […] suggest a relative risk reduction of breast cancer mortality of about 19%.” Dr Peter Eby from Virginia Mason Medical Center also argues that “regular mammography cut breast cancer deaths by roughly a third in all women [above] 40,” and cites the largest and longest running randomized breast cancer screening studies in history.” “Deaths from breast cancer have dropped by 35-40% per year since screening mammography became widespread in the United States,” says Dr Eby. If you look for even more recent evidence, a 2020 study shows that the risk of dying from breast cancer dropped by 41% in 10 years in women who had mammography screenings.
As compelling as all those numbers might be, however, a number of experts stress the need to be very cautious with overscreening. In the words of Prof Keating, negative knock-on effects could “include false positive mammograms, unnecessary biopsies, and overdiagnosis.” Prof Anthony B Miller from University of Toronto even thinks that the benefit of mammography screening might be negligible for women at average risk of breast cancer, considering our increasing knowledge about cancer biology and treatments.
“We have many tools for treating breast cancer,” writes Prof Amy Yee when asked if breast cancer can be cured. New treatments are indeed being developed as we learn more about its underlying causes, she says. Still, experts stress the importance of catching tumours early. Dr Harmen Bijwaard from Netherlands National Institute for Public Health and the Environment argues that, while some of the reduction in breast cancer rates might come down to improved therapy, “for a large part it is the earlier detection that allows for better treatment options and hence the decrease in mortality.”
Can excessive menstrual pain be eased?
Period pain in the tummy, which may spread to the back and thighs, occurs because of strong muscular contractions that compress the blood vessels lining the womb. Although it is a normal part of the menstrual cycle, not all women experience period pain the same way and it can get excruciating for some. Is there a way to keep this pain at bay?
Dr Sara Nowakowski writes that period pain shouldn’t always be dismissed as ‘normal’. In her words, “experiencing excessive bleeding (such as soaking 6+ tampons or pads per day and/or needing to change their tampon or pad during middle of night)”, or suffering from pain that greatly impacts everyday life, are not normal. If that sounds like you, Dr Nowakowski recommends “to speak to your healthcare provider about these abnormal menstrual symptoms.” This view is shared by many of our experts, like Prof Amy Yee from Tufts University, who stresses that “it is important to consult the expert gynecologists to ensure that there is not an underlying cause.”
This said, for normal menstrual pain, Dr Nowakowski advises “heat pad on their abdomen, stretching, staying hydrated, and avoiding/limiting alcohol, caffeine, and salty food.” She warns that “stress can also make menstrual cramps worse” so she proposes “stress relief techniques such as deep breathing, meditation, or yoga” to mitigate pain. In particular, Dr Nowakowski highlights the importance of sleep, as “obtaining adequate sleep can also improve pain severity”. In her view, “women of menstrual age should aim for 7-9 hours sleep and maintain a consistent sleep-wake schedule.”
Finally, Felicity Roux from Curtin University highlights the importance of the literacy of women on the menstrual cycle. She refers to My Vital Cycles, “an award-winning research project which is currently being trialled on the WHO's Health Promoting School framework” and that “aims to give young women life-long skills to understand and manage their cycles as a "Vital Sign" [...], and to communicate their cycle health accurately and confidently.”
Do phytoestrogens increase risk of ER cancers? Signalling via estrogen receptors is involved in breast or ovarian cancers, but there is no evidence that the estrogens in plant foods (like soy) increase your chances of getting cancer. In fact, the opposite might be true - high consumption of vegetables, fruits and fibers has been linked to reduced risk of cancer.
Can you take morning-after pills regularly? They are not intended to be used as a regular form of contraception, but you can use emergency contraception more than once in a menstrual cycle if you need to.
Does IVF impact the outcomes of children? IVF-conceived babies are more likely to be born pre-term and to have a low birth weight. While some developmental or respiratory problems may be more frequent among IVF-conceived children who are born prematurely, no major differences have been detected in their physical or mental health.
Is light drinking safe for pregnant women? No. Alcohol can cross the placenta and damage embryos. The effects of light drinking are hard to prove, as they are expected to be subtle and therefore easier to miss, but experts argue that zero alcohol is the only safe amount.
Are menstrual cups safe? Yes. According to a recent study, vaginal flora is not affected by the use of menstrual cups, and pain or allergies are extremely rare. They’re also effective, as menstrual cups leak the same or less than tampons or pads. That said, you do need to adapt to them when first using them.
Is Vitamin D helpful during pregnancy? The jury is still out on this topic, but current evidence suggests that a vitamin D may help skeletal and neurological development of the fetus.
Do covid vaccines cause infertility? No. RNAs are rapidly degraded (and our cells are full of their own RNAs anyway), and the spike protein the vaccine carries the instructions to make is nowhere near similar enough to any placental proteins to cause auto-immunity.
Do sexual minority women face barriers to healthcare?
Stigma and discrimination are common experiences that people who identify as LGBT or sexual minority face when accessing health services. One report found that one in seven LGBT people in the UK avoided seeking healthcare for fear of discrimination from staff. As many as one in four also experienced negative remarks against LGBT people from healthcare staff.
My colleagues and I recently conducted a systematic review which looked at the experiences of sexual minority women who had accessed UK health services. We defined “sexual minority” women as those who identified as lesbian or bisexual, women who have sex with other women, or live with or are married to another woman. This includes transgender women who identify as sexual minority as well as cisgender women.
We overwhelmingly found that women who identify as sexual minority experienced worse treatment in the healthcare system. We also found evidence that sexual minority women had worse health and well-being than heterosexual women, and tend to have worse health behaviours such as higher rates of smoking and drinking alcohol.
Professor Catherine Meads
An expert from Anglia Ruskin University in Health
Don’t hesitate to seek help if you’re having symptoms of depression or anxiety — which are more common among women.
Severe menstrual pain should also be discussed with a medical professional, but a healthy lifestyle (avoid alcohol/caffeine and stress, sleep well, etc.) may help to reduce it.
Morning pills can be used more than once in a menstrual cycle, but don’t rely on them as a regular form of contraception.
During pregnancy, Vitamin D may be important for the fetus, and remember that zero alcohol is the only safe amount.
Menopause comes, around 50 years of age, with hormonal shifts that lead to changes in sleep, metabolism or memory - but a causal link remains contentious, and they might be a knock-on effect of age.
Estrogens in plant foods aren’t linked to cancer (eating veggies may actually cut your risk of getting cancer). Enjoy your soy milk!
Some cancers can be prevented with a vaccine, like the HPV jab. For breast cancer, the combination of improved treatments and - especially - early detection remains the best shot to tackle it.
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