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Research on Women's Health: Ready for the Future

Regine douthard.

1 Office of Research on Women's Health, National Institutes of Health, Bethesda, Maryland, USA.

Lori A. Whitten

2 Synergy Enterprises, Inc., North Bethesda, Maryland, USA.

Janine Austin Clayton

The National Institutes of Health (NIH) Office of Research on Women's Health (ORWH) was established in 1990. With the completion of the office's 30th anniversary year, we look back and recount some of the key events and overall zeitgeist that led to ORWH's formation, and how it became the focal point at the nation's primary biomedical research agency for coordinating research on science to improve the health of women. We discuss ORWH's mission and signature programs and the bold vision that drives the NIH-wide strategic, interdisciplinary, and collaborative approach to research on women's health and efforts to promote women in biomedical careers. Also discussed are several of the many scientific advances in research on the health of women, policy innovations and their effects, and career advancements made by women in medicine and related scientific fields. We also highlight key challenges for the health of women, the need to continue pushing for equity in biomedical research careers, and NIH's approach to addressing these problems to ensure progress for the next 30 years and beyond.

Introduction

In the 1970 s and 1980s, many became aware that women were not benefiting equally from the major advances in biomedical research and health care. One of the driving factors for this inequity was an astonishing lack of knowledge on conditions that are unique to or more prevalent among them. Society was changing rapidly, with the public demanding solutions to multiple inequities, chronic diseases, and emerging health problems. The National Institutes of Health (NIH) responded accordingly and grew in size, scope, and ambition. 1 Knowledge was also expanding, and as we learned more about human biology, fundamental sex differences in physiology not related to reproductive systems emerged. For example, research revealed that myocardial and vascular structure and function—and some important clinical outcomes ( e.g., the mortality rate after myocardial infarction)—differed between women and men. 2 In addition, studies documented more adverse drug reactions among women. 3 , 4

Despite the fact that women and men shared the top three causes of death (heart disease, cancer, and stroke), most knowledge on their etiology, progression, and treatment had been derived from all-male studies. 2 A vanguard of leaders at the U.S. Public Health Service established the Task Force on Women's Health Issues, and this group's report and recommendations charted a course for future research to remedy the inequity and improve the health of women. 5

Principal recommendations were the expansion of biomedical and biobehavioral research on conditions particularly affecting women of all ages and the development of guidelines to ensure adequate numbers of women in clinical trials of medications. 5 The Congressional Caucus for Women's Issues campaigned for implementing these recommendations, and one result of these efforts was the establishment of the NIH Office of Research on Women's Health (ORWH) in 1990. For more information on the history of the office's formation, see https://orwh.od.nih.gov/about/mission-history .

The landmark Report of the National Institutes of Health: Opportunities for Research on Women's Health (commonly referred to as the Hunt Valley report) in 1991 set out an agenda to address gaps in scientific knowledge about the health of women of all ages and to increase the use of research designs that would potentially identify sex and gender differences in outcomes. 2 Standing on the foundation that report helped build, we are now able to envision a world in which the biomedical research enterprise thoroughly integrates sex and gender influences across the life course, every woman receives evidence-based disease prevention and treatment tailored to her own needs and circumstances, and women in scientific careers reach their full potential.

That vision—set out in Advancing Science for the Health of Women: The Trans-NIH Strategic Plan for Women's Health Research 6 —is possible because there has been a congressionally mandated focal point for coordinating research on the health of women at NIH since ORWH was enshrined by statute in this role in the NIH Revitalization Act of 1993 (Public Law 103–43, section 486). 7

ORWH's core areas of focus dovetail with NIH's mission to seek fundamental knowledge about the nature and behavior of living systems and apply that knowledge to enhance health, lengthen life, and reduce illness and disability. The 27 constituent NIH Institutes and Centers (ICs) address women's health in their respective scientific areas. Part of the NIH Office of the Director, ORWH plays a vital coordinating role, collaborating with ICs to ensure that interdisciplinary research on women's health is part of the scientific framework at NIH and throughout the biomedical community—as reflected in the Trans-NIH Strategic Plan for Women's Health Research . Throughout its three decades, ORWH has acted on its mission and worked with its IC partners to build signature programs that advance research on sex and gender, and support women as biomedical scientists ( Table 1 ).

National Institutes of Health Office of Research on Women's Health Mission and Signature Programs

ORWH, Office of Research on Women's Health; NIH, National Institutes of Health.

ORWH's milestone 30th anniversary year caused us to reflect and focus on the future. This article will briefly review (1) a few of the many scientific advances in research on the health of women—some of which were highlighted at the ORWH 30th Anniversary Scientific Symposium (videocast available at https://videocast.nih.gov/watch=40060 ), (2) policy innovations and their effects, (3) the research career advancements made by women in science, technology, engineering, mathematics, and medicine (STEMM), and (4) prominent key challenges for the health of women and NIH's approaches to addressing them.

Thirty Years of Scientific Advances Result in Better Health for Women

Perhaps the most important advancement has been the paradigm shift in the way biomedical researchers conceptualize women's health, from a narrow focus on the reproductive system and maternity (women were viewed to be the same as men except for these functions) to a perspective that encompasses the health of the whole woman over the life course. ORWH has emphasized the life course perspective since its inception 2 and continues on this path in the Trans-NIH Strategic Plan for Women's Health Research .

ORWH champions the intentional integration of the multidimensional framework ( Fig. 1 ) in interdisciplinary multifactorial studies across the continuum of biomedical research to build a knowledge base for personalized medicine. 8–11 Achieving personalized medicine will be bolstered by the inclusion of sex and gender awareness in clinical care and the provision of evidence-based care tailored to every woman's needs, which requires embedding the concepts of sex and gender health into the educational curricula of all health professionals. 12

The multidimensional framework represents the intersection of multiple internal factors ( e.g., sex influences at genetic, molecular, cellular, and physiological levels) and external factors ( e.g., social determinants of health [including gender], behavior, and policies) that affect the health of women across the life course.

It is perhaps not surprising that major scientific advances stem from interdisciplinary research that applies the multidimensional framework. Such is the case with the second scientific accomplishment highlighted in this study: knowledge about the impact of environmental exposures on women of all ages. Exposures are conceptualized broadly and can include lifestyle factors (such as stress, local access to healthful food, substance use, and physical activity), as well as chemicals, radiation, infectious agents, and climate change. 13 Researchers now understand that across the life course, environmental exposures during windows of susceptibility contribute to the developmental origins of disease. 14 , 15

As early as the 1980s, scientists reported changes in human reproduction—such as declining sperm counts in males 16 and earlier puberty in females 17 —as well as deleterious genital and physical alterations among wildlife. 18–20 Since then, research has linked these changes to endocrine-disrupting chemicals (EDCs)—compounds that interfere with sex hormones' production and mechanisms of action. 21–24 EDCs warrant close attention because exposures to them are universal ( e.g., they are present in pesticides, plastics, and fuels). 21 In addition, scientists have established that environmental exposures can have transgenerational effects. 25

EDCs act at receptors, alter hormone synthesis, induce epigenetic changes, and disrupt hormone breakdown or clearance to have detrimental effects on health. Crucially, their effects depend on whether the exposure was before or after puberty. 26 It is important for researchers to pay special attention to the impacts of exposures to personal care, consumer, and occupation-related products—such as cosmetics, scented shampoos, hair sprays, lotions, and household deodorizers—which are affected by gender. For example, as alluded to earlier, the EDC compounds ( e.g., phthalates, parabens, and phenols) contained in these items have been linked with earlier pubertal timing—to a greater extent in girls than in boys, perhaps because of girls' greater use of these items. 27

Our colleagues at the National Institute of Environmental Health Sciences (NIEHS) lead efforts to understand the complex effects of potential exposures, the influence of timing and sensitive periods across the life course, and a multitude of individual and contextual factors. NIEHS supports an approach that incorporates the exposome—the totality of environmental exposures experienced over the life course, the individual biological responses to them, and how those exposures affect health. 14 For more information on NIEHS's efforts to ensure that researchers explicitly incorporate sex and social determinants of health into investigations of individual susceptibility and to advance our understanding of exposure burdens and health disparities, see www.niehs.nih.gov/research/supported/exposure/hhear/index.cfm 28 Importantly, NIEHS and colleagues have outlined the intersectionality of climate change, gender, geography, and socioeconomic status and proposed policy directions to address their negative effects on women's health. 29

Great progress in our understanding, detection, and treatment of postpartum depression (PPD) is the third scientific advancement in research on the health of women featured in this study. When ORWH was founded in 1990, PPD was not yet officially recognized by the Diagnostic and Statistical Manual of Mental Disorders. (That would occur in 1994, with the publication of DSM-4.) 30 Many researchers, clinicians, and members of the public now understand that many women do experience the “baby blues,” a temporary bout of worry, sadness, and fatigue after delivery that resolves without intervention. 31

In contrast, PPD—experienced by about 13% of women with a recent live birth in the United States in 2018 32 —is an intense persistent sadness that can interfere with a woman's ability to care for herself and the baby, 33 last for up to 3 years in some women, 34 and elevate depressive symptoms up to 11 years after childbirth. 35 Worryingly, the rate of women with a depression diagnosis at delivery increased sevenfold between 2000 and 2015. 36 Moreover, PPD is most likely underdiagnosed (because women may be reluctant to report symptoms), which highlights the need to integrate mood disorder screening and treatment services into standard prenatal and postnatal care. 37 The National Child and Maternal Health Education Program, sponsored by our colleagues at the Eunice Kennedy Shriver National Institute of Child Health and Human Development, aims to increase awareness of mental health around the time of pregnancy through science-based information and resources.

Brexanolone, the first medication specifically for persistent postpartum mood disruption, was approved by the Food and Drug Administration (FDA) in 2019. 38 Incorporating the multidimensional framework into research on women's mental health across the life course illuminated the risk factors for PPD—most notably, stress and adverse life events and subsequent neuroendocrine alterations and hormonal fluctuations—and then generated valuable knowledge about their underlying mechanisms. 39 Researchers identified sensitivity to the reproductive hormones estrogen and progesterone (rather than absolute levels), which modulate the neurotransmitter γ-aminobutyric acid (GABA), and dysfunction of GABA A receptors as contributing factors to PPD. 40 , 41

As a synthetic analog of allopregnanolone, brexanolone is thought to boost the ability of GABA A receptors to adapt, thereby improving symptoms. 41 , 42 Brexanolone is currently available as an injection for intravenous use in medical settings, offering effective and immediate relief from what can be a debilitating and potentially life-threatening mood disorder. 42 , 43 An oral version of brexanolone, zuranolone (SAGE-217), is in Phase III trials. 44 If shown to be safe and effective, this more accessible formulation might help many more women who experience PPD.

The fourth scientific advancement reflects a central tenet of NIH Innovative policies that change the way scientists conduct their investigations are crucial and potentially even more transformative than specific experimental findings. In 1986, NIH responded to the recommendation of the Public Health Service Task Force on Women's Health Issues to ensure adequate numbers of women in clinical trials by establishing a policy encouraging researchers to include women in studies. Subsequently, Congress passed the NIH Revitalization Act of 1993 (Public Law 103–43), which requires NIH to ensure that women and minorities are included in all clinical research (unless there is a compelling scientific reason for exclusion) and that trials are designed and conducted in a way that permits an analysis of outcomes by sex/gender, race, and ethnicity. 7

The full history of NIH's efforts to ensure that women and underrepresented minorities are included in the clinical research it supports are detailed on the ORWH website. ( https://orwh.od.nih.gov/toolkit/recruitment/history and https://orwh.od.nih.gov/womens-health-research/clinical-research-trials/nih-inclusion-policies/including-women-and ) Although movement in this area has not always been straightforward, the following examples show that progress has been made and that NIH's policy on inclusion continues to adapt to public health needs.

In 2018, more than half (52.4%) of participants in NIH-supported clinical research were women. 45 However, we recognize that the need to expand inclusion in NIH-sponsored clinical trials continues. For example, women's inclusion in clinical trials lags behind that of men in some important areas, 46 such as clinical trials on cardiovascular conditions. 47 In alignment with the 21st Century Cures Act (Public Law 114–255), the inclusion of pregnant women and lactating women in clinical trials is currently a focus at NIH, led by our colleagues at NICHD and the Task Force on Research Specific to Pregnant Women and Lactating Women (PRGLAC). (See www.nichd.nih.gov/about/advisory/PRGLAC ) NIH's view is that our clinical enterprise should change to protect pregnant people and lactating people through research, not from research. 48

By the 2000s, NIH had seen steady progress in implementation of its inclusion policy, but the consideration of both female and male animals and cells in preclinical research had generally not advanced at the same pace. 49 As part of broader efforts to improve scientific rigor, transparency, and reproducibility, 50 , 51 NIH set out to address the lack of attention to sex as a biological variable (SABV) 7 years ago by announcing its intention to require applicants to report plans for including male and female cells and animals in preclinical investigations. 52

ORWH then led an extensive process of internal and external consultation 53 and an in-depth exploration of methods, experimental designs, and approaches for statistical analysis that consider the incorporation of male and female animals, cells, and tissues in preclinical research. 54 The SABV policy (NOT-OD-15-102) went into effect January 25, 2016, and since then, NIH has expected that “sex as a biological variable will be factored into research designs, analyses, and reporting in vertebrate animal and human studies.” 55 NIH subsequently provided additional guidance for researchers and grant reviewers to facilitate implementation of the SABV policy. 56 , 57

There has been progress in SABV implementation, as the omission of sex has decreased and investigators are increasingly using both females and males in preclinical research. 58 , 59 More NIH grant applicants are appropriately addressing sex in their proposals, and grant reviewers report increased acceptance of the SABV policy. 60 However, basic research and preclinical research continue to over-rely on male cells and animals, 58 , 61 and there has been minimal progress in the disaggregation, analysis, and reporting of data by sex. 62 A detailed summary of NIH's multipronged efforts to increase SABV implementation was published last year. 63 Among the most important efforts to advance SABV implementation is the development of online educational modules (discussed in “The Next 30 Years: Facing Challenges to Improve Health for Everyone” hereunder).

The fifth advancement during the past three decades is the increase in the proportion of women working in laboratories, medical schools, and academic research centers across the nation. Building the participation of women in medical and biomedical research careers has been a core mission area for ORWH since its inception and is part of larger efforts by the NIH Scientific Workforce Diversity Office. NIH is committed to diversity because we need the brightest minds to contribute to the biomedical research enterprise, regardless of background. Workforce diversity is also a best practice backed by research—as heterogenous interdisciplinary teams make better decisions and outperform homogenous ones, particularly when addressing complex problems. 64 , 65

When ORWH was established in 1990, about one-third of medical school graduates and faculty members were women. 66 Now about half (48%) of medical school graduates and about three-fifths (58%) of graduate students enrolled in biomedical doctoral programs are women. The overall proportion of full-time medical school faculty members who are women is now at 41%. 67 Data from NIH also show some progress for women at various stages of their careers ( Fig. 2 ). 68–70 This progress reflects concerted efforts by NIH to improve biomedical workforce diversity, 71 including those focused on promoting the careers of women. 72

(A) The representation of women in positions as NIH postdoctoral fellows and postdoctoral trainees increased between 1990 and 2020. (B) The percentage of women earning NIH research grants and R01-equivalent grants increased between 1998 and 2020. Data sources: National Institutes of Health. 68–70 NIH, National Institutes of Health.

The most seminal moment in all of ORWH'S decades-long work in this crucial area was the 2008 release of the request for applications (RFA) titled “Research on Causal Factors and Interventions that Promote and Support the Careers of Women in Biomedical and Behavioral Science and Engineering” (RFA-GM-09-012). 73 NIH's unprecedented investment of $16 million resulted in an explosion of evidence contributing to our understanding of how individuals make career choices, how workplaces may inadvertently impede advancement, the existing barriers, and effective interventions. The research resulted in >100 publications, but the most profound contribution was the identification of best practices in the recruitment, retention, and advancement of women in academic medicine—with the ultimate effect of accelerating change and progress. 74 NIH is taking an innovative approach to improving women's representation in leadership, described in the next section.

The Next 30 Years: Facing Challenges to Improve Health for Everyone

The coronavirus disease 2019 (COVID-19) pandemic continues to cause widespread illness and deaths (254,215,816 cases and 5,112,710 deaths worldwide and 47,272,975 cases and 765,127 deaths in the United States as of November 16, 2021, according to the Johns Hopkins COVID-19 Dashboard). The FDA approval of one vaccine and authorization of two other vaccines for emergency use have brought some hope, and 58.9% of the U.S. population was fully vaccinated as of November 16, according to the Centers for Disease Control and Prevention. 75 Although COVID-19-related mortality seems to be lower for women, they have greater risk of exposure because of their overrepresentation among the frontline health care workforce and essential workers. 76 , 77

Much more research is needed to understand the effects of COVID-19 on all women. Specifically, rigorous research ( i.e., studies that are fully aligned with the NIH inclusion and SABV policies) is needed for all COVID-19-related areas ( e.g., immune responses, sex differences in risk profiles, mental health effects, vaccine efficacy, and novel therapeutics). Released in July 2020, the NIH-Wide Strategic Plan for COVID-19 Research outlines five strategic priorities for COVID-19 research and NIH's commitment to addressing the needs of health disparity populations and other vulnerable people—including research on COVID-19-related maternal health and pregnancy outcomes. 78

To complement the NIH-wide strategic plan and guide its COVID-19 response, ORWH developed Guiding Principles: Sex and gender influences in COVID-19 and the health of women . The principles promote rigorous research, advance health equity, and enhance the nation's response to the pandemic by laying out a systematic approach to incorporating sex and gender into research to inform and improve the health of women. 79 The document also addresses the disproportionate negative effects of the pandemic on the careers of women scientists, a topic that is discussed as follows. As in all research that includes both sexes, it is crucial to disaggregate data from COVID-19 studies by sex so they can be analyzed for potential differences. 80 A recent study found that although men have a higher COVID-19 mortality rate overall, black women had died at a higher rate than white men in Michigan and Georgia—illustrating the importance of disaggregating and analyzing data for sex, gender, and race interactions in COVID-19 outcomes. 81

Since the beginning of the pandemic, NIH has realized that reassignment to fight COVID-19 and restrictions on physical workspaces would have significant negative effects on the biomedical workforce. Sensitive to the notion that this situation would most likely have a greater effect on early-stage investigators (ESIs) and on scientists who are in populations that are underrepresented in medicine (URiM) 82 , 83 —including women scientists, who are disproportionately affected by additional caregiving and family responsibilities 84 —NIH objectively documented COVID-19's impact on the workforce through an online survey of extramural researchers in October 2020. 85 Some of those findings are shown in Figure 3 . NIH provides numerous flexibility options, offers an opportunity for scientists to apply for an extension of their ESI status because of COVID-19-related delays, and supports efforts to retain early-career biomedical investigators during critical life events (NOT-OD-20-054 and NOT-OD-20-055).

Reported effects of the COVID-19 pandemic among the NIH extramural scientific workforce: (A) lower productivity, (B) negative effect on career trajectory, and (C) more women than men with children under age 5 years saying caregiving made work completion more difficult. Data source: Bernard and Lauer. 85

The second major challenge to the health of women is the abysmal rates of maternal morbidity and mortality in the United States—the highest among wealthy nations 86 —and the marked racial disparities in these outcomes. In 2019, deaths from complications while pregnant or within 42 days of termination of pregnancy numbered 754. 87 About 60% of maternal deaths are considered to be preventable. 88 Black women and American Indian and Alaska Native (AI/AN) women have rates of maternal mortality that are about two to three times higher than those of white and Hispanic women. 89 Importantly, higher levels of education and income do not mitigate the risk for maternal deaths among black women. 89 , 90 A recent scoping review found that black mothers were particularly vulnerable to environmental exposures ( e.g., air pollution, ozone, and heat) that are exacerbated by climate change and their negative effects on pregnancy outcomes. 91

In addition, too many U.S. women—>50,000 annually and disproportionately black women—experience severe maternal morbidity ( e.g., requiring a transfusion, infection, or high blood pressure). 92 , 93 NIH has mounted a robust response to address the crisis—increasing research funding in this area from $334 million in fiscal year (FY) 2019 to $345 million in FY 2020—and makes information on these projects available to the public through the NIH Research Portfolio Online Reporting Tools (RePORT) website. 94 See Table 2 for selected NIH initiatives to address the maternal morbidity and mortality crisis in the United States.

Selected National Institutes of Health Initiatives to Address High Rates of Maternal Morbidity and Mortality in the United States

IC, Institutes and Centers.

The third challenge covered in this study is the furtherance of some aspects of NIH's SABV policy—particularly the analysis and reporting of sex-specific results in scientific articles, which has lagged despite guidance in the literature. 54 , 80 , 95–98 A study that examined SABV implementation across nine biomedical disciplines found that in eight of the disciplines, there was no change in the proportion of studies that included data analyzed by sex. 59 Analysis and reporting by sex—whether significant differences are found or not—is crucial for seeing patterns of results, accurately interpreting data, and guiding the next steps in the research. 95

A lack of analysis and reporting by sex is a lack of transparency that perpetuates an incomplete and possibly inaccurate knowledge base, as aggregated data may mask important sex differences—such as variance in treatment response, toxicity, symptoms, and adverse effects. In addition, analysis and reporting of results by sex facilitates meta-analysis, helps avoid duplication, guides sample size calculations for future studies, 95 improves the design of clinical trials, informs sex- and gender-aware diagnosis and treatment, facilitates personalized medicine, and advances a system-based understanding of sex and gender influences on health and disease. 80 , 96

ORWH and its partners have developed several educational modules on the influences of sex and gender on health—with SABV as a linchpin concept—for researchers and practitioners. Through its e-learning program (found at bit.ly/ORWHeLearning ), ORWH offers free online tools to help researchers apply a sex-and-gender lens (including analyzing and reporting data by sex) to their work ( Table 3 ). These courses would greatly benefit researchers who serve on NIH study sections, scientific peer reviewers, and journal editors. 60 , 98 Because of the myriad influences of sex on health and the impact of gender on how individuals are treated in the health care system, we believe that SABV and information on sex and gender should be included as part of the standard training of physicians, nurses, and other practitioners to advance precision medicine. 99 , 100

Recently Expanded Free Online Learning Modules That Cover Sex as a Biological Variable

The final challenge highlighted in this study is the need to increase the number of women in leadership roles in STEMM fields in academia, particularly women who are in URiM racial and ethnic groups. Inclusive and diverse leadership in academic medicine—the central driver of medical education, biomedical research, scientific training, and clinical care—is a crucial component of spurring innovation, attracting top scientists, and maximizing return on taxpayer investment. 101 Data indicate that the academic medicine workforce pipeline is not the problem. 67 However, women still only represent 18% of department chairs and 18% of deans. 67 A 17-year longitudinal cohort study indicates that women are half as likely to hold senior leadership positions at medical schools, even after controlling for publication productivity. 102

Moreover, URiM women were only 13% of faculty in 2018, and it seems that progress has stalled, as the figure was 12% in 2009. In addition, the majority of URiM women work at the rank of assistant professor. Among the already small proportion of women chairs in basic science and clinical science departments, only 15% were from URiM groups in the 2018–2019 academic year. 67 ORWH continues to support innovative collaborative programs to advance women's participation in biomedical careers and foster their leadership opportunities ( Table 4 )—particularly addressing the barriers identified by research. 74

Examples of National Institutes of Health's Efforts and Leadership to Advance the Careers of Women in Biomedicine

Reasons for Optimism: Responsiveness, Collaborations, and Strategic Thinking

Although these challenges are significant, NIH can leverage collective ability, experience, and infrastructure to solve these problems. We have a clear way forward, as Advancing Science for the Health of Women: The Trans-NIH Strategic Plan for Women's Health Research provides a solid framework for advancing strategic goals and improving the health of women. And we understand that the value of NIH investments in women's health research goes beyond the individual to have a significant impact on society, as demonstrated in recent microsimulation analyses that found large returns from very small health improvements among women. 103

ORWH knows that it cannot do it alone. At the 5th Annual Vivian W. Pinn Symposium, ORWH explicitly focused on building a broad-based network of government, nonprofit, academic, and business organizations to integrate sex and gender into biomedical research. ORWH's strong collaborative partnerships—so crucial to the progress achieved in its first three decades—ensure that the office will meet pressing needs, rise to future challenges, and catalyze the scientific breakthroughs, resulting in optimal health for all women during the next 30 years and beyond. 6 , 104

Acknowledgments

The authors thank all speakers and panelists at the ORWH 30th Anniversary Scientific Symposium. Special thanks to Dr. John Balbus (NIEHS), Dr. Pauline M. Maki (University of Illinois at Chicago), and Dr. Shaheen Lakhan (Virginia Tech University and Carilion Clinic), who inspired the inclusion of some topics discussed in this article.

Authors' Contribution

R.D. and J.A.C. conceived the structure of the information presented and provided references. L.A.W. searched for supporting references and wrote the article with support from R.D. and J.A.C.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding has been received for this article. Dr. Whitten performed her work as part of an ORWH contract with Synergy Enterprises, Inc.

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• 05 August 2024

Data reveal how doctors take women’s pain less seriously than men’s

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Physicians treat men and women differently when it comes to pain — women in hospital wait longer to be seen and are less likely to receive pain medication than men, finds a study comparing how pain is perceived and treated in male and female patients.

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Guzikevits, M. et al. Proc. Natl Acad. Sci. USA 121 , e2401331121 (2024).

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August 15, 2024

Health Care for Women: How the U.S. Compares Internationally

People navigate along a street in the Minami-Senju area of Arakawa Ward in Tokyo on September 12, 2023. Women in the U.S. have the highest rate of avoidable deaths: 270 of every 100,000 deaths in 2021 could have been prevented if the right prevention or treatment were provided at the right time. Women in Japan and Korea are the least likely to die from a preventable or treatable cause. Photo: Richard A. Brooks/AFP via Getty Images

U.S. women’s life expectancy and access to affordable health care trail far behind other countries in our analysis, with significant racial and ethnic disparities among Black and Hispanic women in some measures

U.S. women have the highest rate of avoidable deaths among 14 countries — more than triple the rate in Japan and Korea

• Chartpack (pdf) ↓
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• 2024 State Scorecard on Women’s Health and Reproductive Care
• Insights into the U.S. Maternal Mortality Crisis: An International Comparison
• U.S. Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening Outcomes
• Mirror, Mirror 2021: Reflecting Poorly — Health Care in the U.S. Compared to Other High-Income Countries

Recently released federal data once again show the United States with by far the highest rate of maternal deaths of any high-income nation, despite a decline since the COVID-19 pandemic. 1 Racial disparities are also extreme: Black women in the U.S. are nearly three times more likely to die from pregnancy-related complications than white women are. But maternal deaths and complications may be an indicator of the nation’s wider failures with respect to women’s health and health care.

Compared to women in other high-income countries, American women have long had worse access to the health care they need. While the U.S. spends more on health care than other countries do, surveys regularly find that Americans avoid seeking care because of costs at the highest rates, even as the U.S. continues to lead in the prevalence of chronic disease. 2 At the same time, limited access to primary care and inadequate coordination of health services are likely factors in the nation’s poor performance when it comes to the prevention, diagnosis, and management of diseases. 3

In this brief, we compare selected measures of health care access and outcomes for women in high-income countries. We drew upon data from four sources: the Commonwealth Fund’s 2023 International Health Policy Survey of Australia, Canada, France, Germany, the Netherlands, New Zealand, Switzerland, the United Kingdom, and the United States, which allowed us to analyze responses by race and ethnicity; 4 the Centers for Disease Control and Prevention National Vital Statistics System; the Organisation for Economic Co-operation and Development (OECD); and the Institute for Health Metrics and Evaluation Global Burden of Disease. The latter two data sets permitted us to show results on selected measures for five additional countries — Chile, Japan, Korea, Norway, and Sweden. (See “ How We Conducted This Survey ” for more details.)

• Mortality : As of 2022, women in the U.S. had the lowest life expectancy of 80 years compared to women in other high-income countries. As of 2021, women in the U.S. had the highest rate of avoidable deaths (270 per 100,000).
• Health status : Women in the U.S. are more likely to take multiple prescriptions regularly, and they have among the highest rates of mental health needs and social needs compared to women in other countries.
• Access to care : The U.S. is the only nation in the analysis where a considerable percentage of women are uninsured. Women in the U.S. have among the lowest rates of access to a regular doctor or place of care and among the highest rates of unnecessary emergency room visits. Black women are more likely to visit ERs for unnecessary care than white women.
• Affordability of care : Women in the U.S. have among the highest rates, and in some cases the highest rate, of skipping or delaying needed care because of the cost and having medical bill problems.

Health Status and Outcomes

High life expectancy can be attributed to a number of factors, including high living standards, a healthy lifestyle, quality education, access to comprehensive health services, and superior health outcomes. 5 Life expectancy at birth in the U.S. was 80 years in 2022, at least two years lower than in all the other countries we examined. Within the U.S., American Indian, Alaska Native, and Black women have lower life expectancy compared to white, Asian, and Hispanic women (data not shown). 6

A high rate of avoidable deaths — deaths before age 75 from conditions that can be prevented or treated — often indicate shortcomings in public health and care delivery systems. 7 In the U.S., the leading causes of mortality, including heart disease, cancer, and stroke, are considered avoidable. 8 Broad use of primary and preventive health care services, including cancer screenings and immunizations, can limit the number of premature and unnecessary deaths. 9

Women in the U.S. have the highest rate of avoidable deaths: 270 of every 100,000 deaths could have been prevented if the right prevention or treatment were provided at the right time. Women in Japan and Korea are the least likely to die from a preventable or treatable cause.

Cardiovascular disease is the leading cause of death for women in the U.S., killing over 300,000 women in 2021 alone. 10 U.S. women are more likely to die from heart disease than women in other high-income countries — compared to some countries, the U.S. rate is more than double.

More research on gender differences in risk factors is necessary to drive the effective diagnosis, management, and treatment of cardiovascular disease. Expanded insurance coverage and access to preventive screening are also critical to improving diagnosis and treatment.

Breast cancer deaths have been declining in the U.S., mainly owing to advancements in early detection and treatment. 11 Still, the U.S. mortality rate, about 17 per 100,000 women, exceeds rates in some peer nations.

In 2021, the U.K., Germany, and the Netherlands had the highest rates of breast cancer–related deaths. Korea had the lowest rate.

The rate of cervical cancer deaths has decreased by more than half over the past five decades with the advent of better prevention, including the HPV vaccine, and increased screening. 12 In 2021, between two and three women per 100,000 died from cervical cancer in all countries except Chile, where there with six deaths per 100,000 women.

Women in the U.S. are more likely to have multiple chronic conditions than women in most peer nations (data not shown). 13 They are also the most likely to take multiple prescription drugs on a regular basis to treat underlying health conditions, with a quarter or more taking at least four prescription drugs. Nearly two of five Black women in the U.S. take four or more prescription medications regularly. In Germany, fewer than one in 10 women take multiple prescription drugs.

The high and rising use of prescription drugs in the U.S. is related to a multitude of factors, including longer survival times for people with chronic conditions. 14

The Commonwealth Fund’s 2023 International Health Policy Survey asked respondents whether they had ever been told they had depression, anxiety, or other mental health conditions, or whether, in the past 12 months, they received mental health counseling or treatment. Mental health needs were greatest among women in the U.S. and Australia. White women in the U.S. were more likely than Black and Hispanic women to report having a mental health need.

The Commonwealth Fund survey also asked women if they were always or usually worried about at least one of the following in the past 12 months: having enough food, having enough money to pay rent or mortgage, having a clean and safe place to sleep, or having a stable job or source of income.

More women in Canada, the U.S., and France reported having at least one unmet social need. In the U.S., Black and Hispanic women were more likely than white women to report this. Only about one in 10 women in Germany and the Netherlands reported having one social need.

People with unmet social needs are more likely to require intensive and expensive medical interventions, make frequent trips to the emergency room, and face financial barriers to getting care. 15

Access to Care

All countries in this analysis, except the U.S., guarantee government-provided health care coverage to all their residents. In addition to this public coverage, women in other countries also have the option to purchase additional, private coverage. In France, nearly all women have private coverage on top of their public plan.

In the U.S., 14 percent of women ages 19–64 in 2023 reported being uninsured, including over a quarter of Hispanic women. Although substantial progress has been made since the enactment of the Affordable Care Act in 2010, many women under age 65 remain ineligible for public overage or cannot access affordable private coverage.

Having a regular doctor or place of care, such as a primary care physician or a medical home, is important for getting screenings, vaccinations, and other preventive services needed to ensure good health outcomes. Having a usual source care is also essential to minimizing health disparities and improving population health. 16 In the U.S. and Canada, women were the least likely to report having this. In New Zealand, the U.K., and the Netherlands, nearly all women said they have a regular doctor or place of care.

Among women in the U.S., the Commonwealth Fund survey found no racial or ethnic disparities in regular access to care.

Overuse and avoidable use of emergency departments has been a concern in the U.S. for many years. 17 Not only are these facilities often functioning at high capacity or overcapacity, but the care they deliver is expensive relative to care offered in many other health care settings. Among women who either did not have a regular doctor or did not use their regular doctor for routine care, Black women in the U.S. reported the highest usage of emergency departments, followed by Hispanic women in the U.S.

Affordability of Care

The Commonwealth Fund survey asked women about times when cost prevented them from getting health care in the past year, including when they had a medical problem but did not visit a doctor; skipped a needed test, treatment, or follow-up visit; did not fill a prescription for medicine; or skipped medication doses. Half of women in the U.S. reported skipping or delaying needed care for cost reasons. Hispanic women were more likely to skip needed care than Black women and women in all the other countries. In the Netherlands, only 15 percent of women said they had forgone care for cost reasons.

America’s outlier status on this measure likely stems from the large number of working-age women who lack health insurance — nearly 10 million — as well as the high copayments, coinsurance, and deductibles that many U.S. women enrolled in commercial health plans face when seeking care. 18

Women in the U.S. and Australia — the two countries where women most often reported having a mental health care need — are the most likely to skip getting needed mental health services because of the cost. One of four women overall in the U.S. and Australia reported skipping mental health care. Our survey found no statistically significant differences between surveyed racial and ethnic groups in the U.S.

Women in Germany and the Netherlands were the least likely to report skipping mental health services because of the cost.

The Commonwealth Fund survey asked women whether they’d had at least one medical bill problem in the past year, including: having serious difficulty paying for care they’d received or being unable to pay a medical bill; spending a lot of time on paperwork or disputes related to medical bills; or having their insurer deny payment or pay less than expected for a claim.

Compared to their counterparts in the other eight countries, women in the U.S. were significantly more likely to report one or more of these medical bill problems, with over half saying they had experienced one or more. Only one in 10 women in the U.K., which provides free care to all residents through the country’s National Health Service, reported a medical bill problem. There were no racial and ethnic disparities in the U.S.

Research shows that investing in women’s health results in a healthier overall population, healthier future generations, and greater social and economic benefits. 19 While there is much variation across states on access to care, quality of care, and health outcomes, the United States remains the only wealthy country without universal health care. 20

Other countries have made substantial efforts to ensure women are able to get needed health care, which includes primary, mental, maternal, and social care. In addition to ensuring coverage for all, the other nations in this analysis generally cap annual out-of-pocket costs for covered benefits, provide cost-sharing exemptions for primary care and certain other services, and offer additional safety nets based on income and health status. 21 For example, Canada, Germany, the Netherlands, and the U.K. impose no cost sharing for primary care visits, and France waives all copayments for care related to long-term chronic mental illnesses. Maternal care, including postpartum care, is free in most of the countries we studied and includes home visits by a nurse. 22

While the Affordable Care Act (ACA) did away with cost sharing for preventive services like wellness visits, immunizations, and cancer screenings, U.S. women still can face high out-of-pocket costs for other care. Moreover, although a recent circuit court ruling has preserved this ACA provision in Braidwood Management v. Becerra — a case that challenges the guarantee of free preventive services for privately insured individuals — that could change as the case winds its way through the courts. 23 With a future ruling in the plaintiffs’ favor, we could see less use of these services, especially among women with lower income, and worsening health outcomes. 24

U.S. policymakers could expand on the ACA’s reforms to allow all women to get comprehensive and affordable health care. For example, by enhancing marketplace plan subsidies and covering those low-income individuals who fall into Medicaid’s coverage gap, they could allow all women to receive primary care services without cost barriers. While the enhanced premium subsidies under the Inflation Reduction Act have led to historic gains in coverage in the marketplaces, the subsidies expire at the end of 2025; Congress will need to make those permanent to keep marketplace plans affordable. 25 U.S. policymakers also could extend the ACA’s requirement to cover essential health benefits, including mental health care, to the large-group employer plans that cover most Americans.

In terms of maternity care, the ACA’s expansion of eligibility for Medicaid coverage has been associated with better health outcomes in the states that have opted in, particularly lower rates of maternal mortality for Black and Latina mothers. 26 Yet 10 states have opted not to expand their Medicaid programs, leaving 800,000 low-income women, who are disproportionately Black or Latina, in the Medicaid coverage gap. 27 The 2022 U.S. Supreme Court case overturning Roe v. Wade has also threatened women’s access to reproductive care. Twenty-two states have so far imposed bans or restrictions on abortions. Additional bans and tighter restrictions may further limit women’s health care access. 28

The U.S. health care system too often fails women. American women face increasing threats to reproductive health care access, including abortion services, that could have a lifelong impact on physical and mental health. While the nation awaits the outcomes of legal challenges to state restrictions on these services, U.S. policymakers have a number of options to improve health and health care for women.

2023 Commonwealth Fund International Health Policy Survey

The Commonwealth Fund 2023 International Health Policy Survey collected data from nationally representative samples of noninstitutionalized adults age 18 and older in Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, Switzerland, the United Kingdom, and the United States.

Samples were generated using probability-based overlapping landline and mobile phone sampling designs in Australia, Canada, France, Germany, the Netherlands, New Zealand, and the U.K. In the U.K., additional online interviews were completed via a nationally representative probabilistic panel. In Sweden and Switzerland, respondents were randomly selected from listed or nationwide population registries, and surveys were completed via landline and mobile phones, as well as online. In the U.S., three probability-based sample frames were used. Most of the interviews were conducted from address-based sample (ABS). Additional interviews were completed via a nationally representative probabilistic panel and from a sample of cell phone numbers connected to prepaid cellphones to reach populations who are typically underrepresented in ABS samples, including low-income and non-white adults. Respondents in the U.S. completed surveys via mobile phones as well as online.

International partners cosponsored surveys, and some supported expanded samples to enable within-country analyses. Final country samples ranged from 750 to 4,820 participants. For this analysis, final country samples ranged from from 232 to 1,680 women ages 19–64. The survey research firm SSRS was contracted to field the survey in the U.S. and six additional countries, as well as collaborate with fieldwork partners and oversee survey administration in the other three countries, from March to August 2023, though the field period for each country varied. SSRS also provided methodological oversight for the study as a whole, including supporting questionnaire development, consultation and design of sampling protocols, and managing the statistical weighting across countries. Response rates varied from 6 percent to 49 percent. Data were weighted using country-specific demographic variables to account for differences in sample design and probability of selection.

Because of data protection and privacy laws, data could not be provided on average annual household income in Sweden. Respondents from Sweden, therefore, were not included in this analysis.

CDC Data Analysis, National Vital Statistics System

For U.S. life expectancy data, we used the latest data from the U.S. Centers for Disease Control and Prevention (CDC) National Vital Statistics Systems, 2022 mortality data file. The data shown in their report reflect information collected by the National Center for Health Statistics for 2021 and 2022 from death certificates filed in all 50 states and the District of Columbia. Life expectancy is defined as: the expected average number of years of life remaining at a given age. Life expectancy estimates for 2022 are based on a methodology first implemented with 2008 final mortality data.

OECD Data Analysis

This analysis used data from the 2023 release of health statistics compiled by the Organisation for Economic Co-operation and Development (OECD), which tracks and reports on a wide range of health system measures across 38 high-income countries.

Data on life expectancy and avoidable mortality were extracted in August 2024. While the information collected by the OECD reflect the gold standard in international comparisons, it may mask differences in how countries collect their health data. Full details on how indicators were defined, as well as country-level differences in definitions, are available from the OECD.

Institute for Health Metrics and Evaluation, Global Burden of Disease

The 2021 Global Burden of Disease study from the Institute for Health Metrics and Evaluation (IHME) provides a comprehensive picture of mortality and disability across countries, time, age, and sex. It quantifies health loss from hundreds of diseases, injuries, and risk factors. The study calculated cardiovascular-related deaths, breast cancer deaths, and cervical cancer deaths. Data were extracted in May 2024. Details on their methods are available here: https://www.healthdata.org/research-analysis/about-gbd#methods .

The authors thank Robyn Rapoport, Rob Manley, Molly Fisch-Friedman, and Christian Kline of SSRS; and Chris Hollander, Melinda Abrams, Reggie Williams, Faith Leonard, Arnav Shah, Sara Collins, Kristen Kolb, Paul Frame, Jen Wilson, and Sam Chase of the Commonwealth Fund.

• Munira Gunja et al., Insights into the U.S. Maternal Mortality Crisis: An International Comparison (Commonwealth Fund, June 2024). ↩
• Munira Z. Gunja, Evan D. Gumas, and Reginald D. Williams II, U.S. Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening Outcomes (Commonwealth Fund, Jan. 2023). ↩
• Eric C. Schneider et al., Mirror, Mirror 2021: Reflecting Poorly — Health Care in the U.S. Compared to Other High-Income Countries (Commonwealth Fund, Aug. 2021); and Evan D. Gumas et al., Finger on the Pulse: The State of Primary Care in the U.S. and Nine Other Countries (Commonwealth Fund, Mar. 2024). ↩
• Because of national data protection and privacy laws, data pertaining to age could not be provided for Sweden. Respondents from Sweden, therefore, were not included in measures taken from the 2023 Commonwealth International Health Policy Survey. ↩
• Organisation for Economic Co-operation and Development, “ Life Expectancy at Birth ,” OECD Data, Nov. 2023. ↩
• Elizabeth Arias et al., Provisional Life Expectancy Estimates for 2022 , NVSS Vital Statistics Rapid Release no. 31 (Centers for Disease Control and Prevention, Nov. 2023) ↩
• Organisation for Economic Co-operation and Development, Avoidable Mortality: OECD/Eurostat Lists of Preventable and Treatable Causes of Death (January 2022 Version) (OECD, Jan. 2022). ↩
• National Center for Health Statistics, “ Leading Causes of Death ,” Centers for Disease Control and Prevention, last updated May 2, 2024. ↩
• HealthyPeople.gov, “ Clinical Preventive Services ,” Dec. 2021. ↩
• Centers for Disease Control and Prevention, Women’s Health, “ Lower Your Risk for the Number 1 Killer of Women ,” Feb. 22, 2024. ↩
• American Cancer Society, “ Key Statistics for Breast Cancer ,” Jan. 2024. ↩
• American Cancer Society, “ Key Statistics for Cervical Cancer ,” Jan. 2024. ↩
• Commonwealth Fund analysis of the Commonwealth Fund International Health Policy Survey, 2023 . ↩
• Jessica Y. Ho, “ Life Course Patterns of Prescription Drug Use in the United States ,” Demography 60, no. 5 (Oct. 2023): 1549–79. ↩
• Seth A. Berkowitz, Travis P. Baggett, and Samuel T. Edwards, “ Addressing Health-Related Social Needs: Value-Based Care or Values-Based Care? ,” Journal of General Internal Medicine 34, no. 9 (Sept. 2019): 1916–18. ↩
• Office of Disease Prevention and Health Promotion, “ Access to Primary Care ,” Healthy People 2030, n.d. ↩
• Assistant Secretary for Planning and Evaluation, Office of Health Policy, Report to Congress: Trends in the Utilization of Emergency Department Services, 2009–2018 (U.S. Department of Health and Human Services, Mar. 2, 2021); and “ 18 Million Avoidable Hospital Emergency Department Visits Add $32 Billion in Costs to the Health Care System Each Year ,” UnitedHealth Group, July 2019. ↩
• Women’s Health Insurance Coverage (KFF, Dec. 2023). ↩
• Michelle Remme et al., “ Investing in the Health of Girls and Women: A Best Buy for Sustainable Development ,” BMJ 369 (June 2020): m1175. ↩
• Sara R. Collins et al., 2024 State Scorecard on Women’s Health and Reproductive Care (Commonwealth Fund, July 2024). ↩
• Roosa Tikkanen et al. (eds.), International Profiles of Health Care Systems (Commonwealth Fund, June 2020). ↩
• Sara Rosenbaum and MaryBeth Musumeci, “ What the Latest Decision in the Braidwood Case Could Mean for Preventive Care? ,” To the Point (blog), Commonwealth Fund, July 19, 2024. ↩
• “ Braidwood Management v. Becerra Puts Over a Decade of Progress in Preventive Health Care at Risk ,” George Washington University, Milken Institute School of Public Health, Oct. 17, 2023. ↩
• David C. Radley et al., 2023 Scorecard on State Health System Performance: Americans’ Health Declines and Access to Reproductive Care Shrinks, But States Have Options (Commonwealth Fund, June 2023). ↩
• Erica L. Eliason, “ Adoption of Medicaid Expansion Is Associated with Lower Maternal Mortality ,” Women’s Health 30, no. 3 (May 2020): 147–52. ↩

Publication Details

Munira Z. Gunja, Senior Researcher, International Program in Health Policy and Practice Innovations, The Commonwealth Fund

Munira Z. Gunja, Relebohile Masitha, and Laurie C. Zephyrin, Health Care for Women: How the U.S. Compares Internationally (Commonwealth Fund, Aug. 2024). https://doi.org/10.26099/7322-n764

• Advancing Health Equity

Women's Health , International , International Surveys , Access to Care , Coverage and Access , Costs and Spending , Affordability , Health Equity , Maternal Health , Behavioral Health

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The White   House Initiative on Women's Health   Research

We have a clear goal: to fundamentally change how our nation approaches and funds women’s health research. First Lady Jill Biden, at an event announcing funding for women’s health research on february 21, 2024.

The President and First Lady launched the White House Initiative on Women’s Health Research in November of 2023 with a clear goal:  to fundamentally change how our country approaches and funds research on women’s health.

Women are over half the population, but research on women’s health has ALWAYS been underfunded and under-studied.

TOO MANY medical studies have focused on men and left women out.

TOO MANY of the medicine dosages, treatments, medical school text books, are based on men and their bodies – and that information doesn’t always apply to women.

That means there are BIG GAPS in medical research on:

• Diseases and conditions that only affect women (e.g., menopause, endometriosis)
• Diseases and conditions that disproportionately affect women (e.g., Alzheimer’s)
• Diseases and conditions that affect women and men differently (e.g., heart disease)

These gaps in research mean we know far too little about women’s health – and those gaps are bigger for women of color and women with disabilities.

We are going to change that.

Together, we will build a health care system that puts women and their lived experiences at its center. Where no woman or girl has to hear that “it’s all in your head,” or, “it’s just stress.” Where women aren’t just an after-thought, but a first-thought. Where women don’t just survive with chronic conditions, but lead long and healthy lives. First Lady of the United States on February 21, 2024. 

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A Call for Government Agencies to Fill Research Gaps on Women’s Health 

While women represent 50.4% of the US population, the costs of chronic conditions on women are likely underestimated due to underrepresentation of women in medical research.  

To date, much of what is known about chronic disease is based on the bodies and health of men, which disservices women by resulting in inaccurate diagnoses, resulting in poorer health outcomes. And, although women live longer than men on average, women also have more years of disability or lowered quality of life due to disease years.  

A new report by the National Academies of Sciences, Engineering, and Medicine (NASEM) reviews public health research related to many specific debilitating disorders including cardiovascular disease, depression, and metabolic disorders. It provides additional evidence that current efforts to understand women’s health for regulatory science are incomplete—yet they are still used for policy decisionmaking. 

NASEM is the nation’s highest independent scientific body and is charged with providing objective analysis and advice to the US government so that policy can be guided by the best scientific expertise. US government agencies and departments will reach out to NASEM and ask it to investigate topics of interest. If it accepts, NASEM will assemble a committee of experts to investigate and create a publicly available report. NASEM reports can lead to many changes for the better, such as new, scientifically backed government policies, increased federal funding for research on the topic, or additional research projects.  

NASEM report calls for a closer look at women’s chronic health issues

In July, NASEM released a preliminary report identifying gaps in what is known about chronic health conditions that are specific to women or that affect women differently. It outlines glaring gaps in scientific knowledge of women’s health and potential improvements to research methods, sheds more details on structural and social determinants of health, and provides a high-level description of differing impacts on women. The NASEM report recommends:  

• Addressing inequities and women-centered research to improve diagnostic tools for women as it pertains to debilitating chronic disease 
• Developing animal models that more closely resemble the human female 
• Striving to understand, better diagnose, and create improved treatments for women living with multiple chronic conditions 
• Seeking to better understand the mechanisms hormonal changes play in the development and outcomes of chronic conditions in women 
• Creating new and better approaches for addressing symptoms during perimenopause, menopause, and postmenopause for women with chronic conditions  
• Working to better understand the effects of structural and social determinants on chronic health conditions, by also focusing on the life experience of women and on trauma as a risk factor in the development of chronic conditions 
• Investigating the role lifestyle behaviors have on the development of chronic disorders  

Radiation exposure and women’s health is still understudied

Evidence that radiation exposure affects women (and infants, children, and pregnant people) differently has grown over the years and has been examined by NASEM.  

For example, NASEM has published landmark reports on the health effects of exposure to low levels of ionizing radiation. Two of these reports ( BEIR V , BEIR VII ) indicated that infants, children , pregnant people, and the female body are more susceptible than their adult, not pregnant, or male counterparts. This was proven by showing the health harms that can be caused by ionizing radiation disproportionately increased among these vulnerable groups after similar exposures in their counterpart peers.  

Additional studies have been done by international scientific bodies, such as the International Commission on Radiological Protection ( ICRP 84 ), to provide guidelines about using medical radiation during pregnancy, and the US Environmental Protection Agency Federal Guidelines Report examines cancer risk coefficients for environmental exposure to radionuclides ( EPA FGR ).  

Overall, female breasts and thyroids are more radiosensitive (sensitive to radiation) than male organs, which implies that women and girls are more susceptible to harm caused by radiation ( Makhijani et al. 2006 , NCI 1997 ). Children are much more radiosensitive than their adult counterparts due to differences in size and development of organs ( EPA’s 1999 FGR 13 and CD supplement from 2002) . For example, if an adult and infant drank milk contaminated with iodine-131 released by aboveground nuclear detonations, the infant would receive 13 times the radiation dose to its thyroid compared with the adult ( Makhijani et al. 2006 ). 

Unfortunately, the health harms of radiation for females and children are also often underreported when it comes to regulatory science. A briefing by the Nuclear Information and Resource Service (NIRS) explains this underreporting is due to only considering external exposures (gamma and X-rays) and not considering absorbed radiation , which the female body is much more prone to storing.   

Still, there is not enough research or data to support a full understanding of these issues.  

Organizations including the United Nation’s Treaty on the Prohibition of Nuclear Weapons Science Advisory Group (SAG) advocate for newer research on radiation exposure that is not based on location from a detonation (since these exposures are rare).  SAG also suggested further study on women’s radiosensitivity.  

When it comes to determining risks to the general population from harmful exposures to nuclear weapons materials, evidence-based research methods are a must to protect the public. 

Sex and gender have different definitions

Often, the first step in defining women’s health is in determining what defines a woman. Some gender rights problems in the regulatory science field are as fundamental as defining basic terminology. Inherent to this conversation is understanding the difference between sex and gender, and that currently regulatory science doesn’t account for either accurately.  

Within the NASEM report, the term “female” refers to biological sex (based on genetic coding or physical presentation) and “women” refers to the social construct of gender and how the person identifies. However, across the public health literature, these two concepts of sex and gender are conflated with each other, do not have inclusive gender categories, and rarely consider genetic aspects of sex to define biological sex.  

Due to oppressive systems such as sex, gender, and gender expression bias, many studies assume people who identify as women were born female and that those born female identify as girls or women. This is still something the fields of regulatory science and public health need to better consider within their analyses since both can be false assumptions.  

NASEM has also called for more study of low-dose ionizing radiation

There is also still far too little scientific knowledge about the effects of low-dose radiation on the human body in general. An earlier study by NASEM, published in 2022, highlighted the need for better understanding of low-dose radiation exposure (defined by NASEM as a single exposure of less than 100 mGy or 5 mGy/hour) on people across the United States.  

One reason it is more difficult to understand the effects of low levels of radiation on cancer risk is because of the often-long latency from exposure to cancer development, but there is also a lack of research on chronic low-dose exposure and its association with health outcomes.  

This report suggested creating tools for sensitive detection of radiation and precise characterization of cell and tissue changes, harmonizing across national health research databases, and ensuring access to research on low-dose radiation health effects. The recommended program is estimated to cost $100 million annually for its first 15 years of operation. Affected communities reported being excited about the following proposals:  

• more research into non-cancer health outcomes 
• additional focus on differential impacts (how exposure might differ based on gender, age, lifestyle, ethnicity, etc.)  
• the importance of community involvement in research, including appropriate collaboration with Indigenous nations 

More recently, research on low-dose radiation has been associated with increased cancer deaths as well. More specifically, mortality due to solid cancers among workers exposed to ionizing radiation increased with cumulative dose over time by 52% per Gy , when choosing a lag time of 10 years for cancer development. This lag time means that cancers that developed prior to 10 years after exposure are not included, since the science suggests the exposure would require at least 10 years to develop associated cancers.  

“Regulatory scientists can protect all vulnerable people within the United States population by focusing regulations on the needs of those most at risk.” Dr. Chanese Forté, Union of Concerned Scientists

Current models used by regulatory scientists disservice women and children

These two NASEM efforts together highlight a key challenge in addressing low-dose radiation exposure in women and children. The “Reference Man” concept was developed by the International Commission on Radiological Protection ( ICRP ) and is used to estimate radiation doses and assess potential health risks. In a 1975 ICRP repor t, Reference Man is defined as a hypothetical individual with specific characteristics: he is an adult male, aged 20 to 30, weighing roughly 70 kg (154 lb), measuring 170 cm (5 feet 7 inches) in height, and lives in a climate with an average temperature from 10 to 20°C. Reference Man is also Caucasian and a Western European or North American in habitat and custom.  

This model assumes specific anatomical and physiological traits that are considered average for the adult male population. It serves as a standard for designing radiation protection measures and for regulatory purposes. However, it has limitations because it does not account for differences in radiation sensitivity due to age, gender, or individual biological variability. 

It is important to keep in mind the average modern male body is also very different from people who lived in 1975, especially by body mass index (height and weight). 

Alternate models of a reference person exist and should be considered

More recently, regulatory scientists have chosen to average men and women’s health risk estimates, but this overestimates men’s risks and underestimates the risk to women. Regulatory scientists can protect all vulnerable people within the United States population by focusing regulations on the needs of those most at risk: women or children with increased radiosensitivity, and “frontline” communities (those with increased radiation exposure burdens due to their proximity to nuclear weapons testing, production, or waste). There are alternative models to Reference Man that could be employed, and you can learn more about centering women in regulatory science here . 

Many community-led organizations have also called for a better understanding of women’s health and exposure to radiation as well as a more protective standard for women. For example, Tewa Women’s United (TWU), an Indigenous women’s reproductive health and justice organization with a focus on the Pueblos (and a collaborator of UCS), has proposed a reference person called Nava To’I Jiya (Tewa for “Land Worker Mother Model”). The Land Worker Mother is a pregnant person who works and lives off of the land. As a universal environmental protection standard, this model would better protect the general public and the most marginalized in society.  

Additionally, the Gender + Radiation Impact Project suggests “Radiation Girl,” using a girl (15 years and younger) as the radiation model, which would also be more sensitive than current regulatory science methods for understanding women and children’s health.  

Nuclear weapons policy will benefit from more inclusive human health research

There are multiple aspects of the nuclear materials process such as uranium mining and plutonium processing that have harmed, and continue to harm, human health through intentional and accidental releases of toxic materials. Many people are still experiencing the health impacts of past exposures to the more than 500 atmospheric nuclear weapons tests conducted globally before such tests were banned in 1963. A study by the Centers for Disease Control and the National Cancer Institute concluded that any person living in the contiguous United States since 1951 has been exposed to some radioactive fallout. 

Both nuclear policy and regulatory policy would be significantly improved by interrogating biased models of radiation exposure, improving our overall understanding of low-dose radiation, and increasing our sensitivity to the unique ways that women and female-identifying individuals experience chronic health issues.  

Get involved with UCS and learn more about public health and nuclear weapons

The Union of Concerned Scientists is committed to creating more public health research and awareness of the risks to nuclear frontline communities. We would love to have more experts advocating for important changes to US nuclear policy in the name of public health—to join us in our fight against nuclear weapons, sign up here .  

For additional reading on community health, see these previous blog posts:  

• Nuclear Weapons Justice  
• What are Nuclear Frontline Communities?  
• Nuclear Frontline Communities Understand Cumulative Burdens—Let’s Get Policymakers On The Same Page  
• Senate Passes Bill to Help Nuclear Testing Victims, But The Fight for Nuclear Justice Isn’t Over Yet  
• The Global South is Leading the Way in Being A Nuclear Weapon Free Zone  
• Cold War Nuclear Weapons Put St. Louis Community At Risk—in 2023  
• Anti-Blackness in Europe Creates Vulnerability During War  
• Missouri Community and Its Children Grappling With Conflicting Nuclear Waste Exposure Reports  
• The House Has Less Than Two Weeks to Save RECA  
• For People Who Have Been Poisoned by Radiation, the Fight Continues in 2024  
• Why Nuclear Justice for the Marshall Islands is the Biggest US-China Issue You’ve Never Heard Of  
• Why a National Day of Remembrance for Downwinders is Not Enough  
• Resuming Nuclear Testing a Slap in the Face to Survivors  

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Ten top issues for women's health

Dr flavia bustreo, assistant director general for family, women’s and children’s health through the life-course, world health organization.

We've come a long way since 1995--and it is time to celebrate women and their achievements. But it is also time to take stock of how women’s rights are fulfilled in the world --especially the right to health. Twenty years after countries signed pledges in the 1995 Beijing Declaration and Platform of Action, women still face many health problems and we must re-commit to addressing them.

Here are ten of the main issues regarding women's health that keep me awake at night:

Cancer : Two of the most common cancers affecting women are breast and cervical cancers. Detecting both these cancers early is key to keeping women alive and healthy. The latest global figures show that around half a million women die from cervical cancer and half a million from breast cancer each year. The vast majority of these deaths occur in low and middle income countries where screening, prevention and treatment are almost non-existent, and where vaccination against human papilloma virus needs to take hold. 

Reproductive health : Sexual and reproductive health problems are responsible for one third of health issues for women between the ages of 15 and 44 years. Unsafe sex is a major risk factor – particularly among women and girls in developing countries. This is why it is so important to get services to the 222 million women who aren’t getting the contraception services they need.

Maternal health : Many women are now benefitting from massive improvements in care during pregnancy and childbirth introduced in the last century. But those benefits do not extend everywhere and in 2013, almost 300 000 women died from complications in pregnancy and childbirth. Most of these deaths could have been prevented, had access to family planning and to some quite basic services been in place.

HIV : Three decades into the AIDS epidemic, it is young women who bear the brunt of new HIV infections. Too many young women still struggle to protect themselves against sexual transmission of HIV and to get the treatment they require. This also leaves them particularly vulnerable to tuberculosis - one of the leading causes of death in low-income countries of women 20–59 years.

Sexually transmitted infections : I’ve already mentioned the importance of protecting against HIV and human papillomavirus (HPV) infection (the world’s most common STI). But it is also vital to do a better job of preventing and treating diseases like gonorrhoea, chlamydia and syphilis. Untreated syphilis is responsible for more than 200,000 stillbirths and early foetal deaths every year, and for the deaths of over 90 000 newborns.

Violence against women : Women can be subject to a range of different forms of violence, but physical and sexual violence – either by a partner or someone else – is particularly invidious. Today, one in three women under 50 has experienced physical and/or sexual violence by a partner, or non-partner sexual violence – violence which affects their physical and mental health in the short and long-term. It’s important for health workers to be alert to violence so they can help prevent it, as well as provide support to people who experience it.

Mental health : Evidence suggests that women are more prone than men to experience anxiety, depression, and somatic complaints – physical symptoms that cannot be explained medically. Depression is the most common mental health problem for women and suicide a leading cause of death for women under 60. Helping sensitise women to mental health issues, and giving them the confidence to seek assistance, is vital.

Noncommunicable diseases : In 2012, some 4.7 million women died from noncommunicable diseases before they reached the age of 70 —most of them in low- and middle-income countries. They died as a result of road traffic accidents, harmful use of tobacco, abuse of alcohol, drugs and substances, and obesity -- more than 50% of women are overweight in Europe and the Americas. Helping girls and women adopt healthy lifestyles early on is key to a long and healthy life.

Being young : Adolescent girls face a number of sexual and reproductive health challenges: STIs, HIV, and pregnancy. About 13 million adolescent girls (under 20) give birth every year. Complications from those pregnancies and childbirth are a leading cause of death for those young mothers. Many suffer the consequences of unsafe abortion.

Getting older : Having often worked in the home, older women may have fewer pensions and benefits, less access to health care and social services than their male counterparts. Combine the greater risk of poverty with other conditions of old age, like dementia, and older women also have a higher risk of abuse and generally, poor health.

When I lie awake thinking of women and their health globally, I remind myself: the world has made a lot of progress in recent years. We know more, and we are getting better at applying our knowledge. At providing young girls a good start in life.

And there has been an upsurge in high-level political will – evidenced most recently in the United Nations Secretary-General’s Global Strategy for Women’s and Children’s Health. Use of services, especially those for sexual and reproductive health, has increased in some countries. Two important factors that influence women’s health – namely, school enrolment rates for girls and greater political participation of women - have risen in many parts of the world.

But we are not there yet. In 2015, in too many countries, “women’s empowerment” remains a pipedream - little more than a rhetorical flourish added to a politician’s speech. Too many women are still missing out on the opportunity to get educated, support themselves, and obtain the health services they need, when they need them.

That’s why WHO is working so hard to strengthen health systems and ensure that countries have robust financing systems and sufficient numbers of well-trained, motivated health workers. That’s why WHO, with UN and world partners, are coming together at the UN Commission on Status of Women from 9-20 March 2015 in New York. We will look again at pledges made in the 1995 Beijing Declaration and Platform of Action with a view to renewing the global effort to remove the inequalities that put decent health services beyond so many women’s reach.

And that is why WHO and its partners are developing a new global strategy for women’s, children’s and adolescents’ health, and working to enshrine the health of women in the post 2015 United Nations’ Sustainable Development Goals. This means not only setting targets and indicators, but catalysing commitments in terms of policy, financing and action, to ensure that the future will bring health to all women and girls – whoever they are, wherever they live.

Dr Flavia Bustreo

Former Assistant Director-General, Family, Women's and Children's Health WHO

Gender bias in medical research: how women are still overlooked

Clinical trials have historically been male-centric, but they are leaving the medical community in the dark about women and girls

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Medical research has been disproportionately focused on male subjects for years, creating a deficit of data about women's health. Even in the preclinical stage, test animals and cells tend to be male. Scientists say that despite decades of alarm-ringing over the exclusion of women from clinical trials, they continue to be underrepresented. And evidence shows that women suffer because of it.

A history of excluding women from medical research

Women have historically been overlooked in medical research , but intentionally excluding them was cemented into policy in the 1970s. In 1977, the Food and Drug Administration created a guideline that recommended excluding women of childbearing age from Phase I and early Phase II drug trials in response to a widespread tragedy linked to the drug thalidomide, according to the National Institutes of Health (NIH) Office of Research on Women's Health (ORWH) . 

The anti-morning sickness drug was used in Europe and Australia and caused more than 10,000 deaths and congenital disabilities in babies in the 1960s. While the drug was not approved for use in the U.S., the incident caused researchers to be more cautious about including women in studies. The FDA's policy was broad and included "women who used contraception, who were single or whose husbands were vasectomized."

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The policy was a major setback for the inclusion of women in medical research, but almost a decade later, after protests and pushback, the NIH revisited the decision. In 1986, the NIH established a policy that encouraged researchers to include women in their studies, and three years later, it released a Memorandum on Inclusion that said research solicitations should encourage the inclusion of women and minorities. Still, the shift in policy was not enough to turn the tide of decades of exclusion.

In 1990, the Congressional Caucus for Women's Issues asked the General Accounting Office (GAO) to investigate the implementation of the NIH's guidelines for including women and people of color in studies that it funded. The GAO reported that the policy had been "poorly communicated and inconsistently applied" and "only pertained to extramural research," said the NIH Office of Research on Women's Health. It also found that the NIH "had done little to encourage researchers to analyze study results by gender." Two months later, the NIH established the ORWH to oversee the policy implementation. Only in 1993 did Congress write the policy into law in a section of the NIH Revitalization Act of 1993 .

The impact of overlooking women in clinical trials

Despite the changes in the law, progress during the last 30 years has been slow. Bias against female subjects starts to "creep in at the development stage, years before drugs reach patients," said the Financial Times . Scientists say that preclinical testing has, at times, focused disproportionately on male animals and male cells. When medicine reaches the human trials stage, women are still underrepresented. Part of that persistent exclusion stems from the thalidomide scandal, which "casts a long shadow," the outlet said. "More prosaically, caring responsibilities may make it harder for women to carve out the time commitment a study often demands."

As a result, women are being prescribed drugs that are sometimes less safe and less effective than they are for men, researchers say. By focusing on male bodies for safety and tolerability studies, "you're creating doses of these drugs that are based on the male body," which are "generally speaking, larger, heavier bodies, but also bodies that have different fat content," Jill Fisher, professor of social medicine at the University of North Carolina's center for bioethics, said to the Financial Times.

Research reinforces the idea that women suffer from this male-centric approach to developing medicine. Since 2000, women in the U.S. have reported "total adverse events," defined as "any untoward medical occurrence," 52% more frequently than men, and severe or fatal events 36% percent more frequently, according to Food and Drug Administration data gathered by the McKinsey Health Institute.

"Historically the white male body has been seen as the scientific norm, so there's a sense that 'whatever we find in men will apply to women'," Fisher said. This assumption, which is also evident in the lack of racial diversity, has been "very difficult to change in the culture of science."

The underrepresentation becomes "particularly glaring" when compared to the "proportion of women with the condition that a particular medicine is designed to address," said the Financial Times. A 2022 study by researchers at Harvard Medical School found that women accounted for about 40% of clinical trials for three diseases that most affect women despite representing 51% of the U.S. population. 

Researchers and clinicians are including both men and women in clinical trials but not in a "manner which is balanced or reflective of the prevalence of the disease," Melina Kibbe, surgeon and dean of the University of Virginia's School of Medicine and a longtime advocate of gender-inclusive research said to the outlet.

Trying to reverse the trend

The White House has taken notice of the lack of attention to women's health in medical research. In November 2023, the president and the first lady launched the White House initiative on women's health research, with first lady Jill Biden taking the lead. "Research on women's health has been underfunded for decades, and many conditions that mostly or only affect women, or affect women differently, have received little to no attention," the first lady said when she announced the initiative. The gaps are "even greater for communities that have historically been excluded from research – including women of color and women with disabilities." In February, she announced $100 million in funding for research and development in women's health as a part of the initiative, and the president signed an executive order in March that included an additional $200 million for research at the NIH.

Despite having policies in place to encourage more inclusive research, the NIH has struggled to enforce them thus far. "We know less about female biology and we are struggling to catch up," Janine Clayton, the director of the NIH's Office of Research on Women's Health, said to The Guardian . Breaking that pattern to increase enrollment of excluded populations would require better enforcement of federal guidelines and hiring more female scientists to conduct research, especially in higher positions. "Women, people from diverse backgrounds, ask different questions," Clayton said.

Diversifying medical research will require researchers to rethink how they recruit and retain participants and potential employees. At medical clinics, people often "don't see anyone who looks like them," Danielle Mitchell, CEO and founder of Black Women in Clinical Research, said to the Association of American Medical Colleges . This is a lost opportunity to build trust, especially in communities who have historically faced health care disparities , she argued. "From my perspective, we need to have those tough conversations with people about what happened in the past for people to consider clinical trials as a health care option."

Progress has been slow, but in the meantime underrepresented communities should continue to ask questions and put pressure on the whole drug development pipeline. "Drug companies — and all of us — need to see that the group most at risk for adverse outcomes is going to be the sex that's often left out," Teresa Woodruff, president emerita and MSU Foundation professor at Michigan State University, said to the Financial Times. "And that, right now, is women."

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Theara Coleman has worked as a staff writer at The Week since September 2022. She frequently writes about technology, education, literature and general news. She was previously a contributing writer and assistant editor at Honeysuckle Magazine, where she covered racial politics and cannabis industry news. 

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Work-related stress a clear risk factor for sick leave, study finds

Middle-aged women who experience work-related stress have a significantly increased risk of future sick leave, a University of Gothenburg study shows. Lack of influence and conflicts at work are clear stress factors.

The aim of the current study, published in the Scandinavian Journal of Primary Health Care , was to investigate whether work-related mental stress can be linked to sick leave among middle-aged women in the labor market.

The data used in the study consists of information about 573 women of two different ages, 38 and 50, taken from the comprehensive Population Study of Women in Gothenburg, PSWG, at the University of Gothenburg. This was combined with register data on the women's sick leave from the Swedish Social Insurance Agency.

Job conflicts are a significant risk factor

When the study began, the majority of the participants (504 women) were employed and in work. Three out of four experienced work-related or general mental stress, or both. During the following year, 16% had at least one instance of sick leave lasting for two weeks or more, and the sick leave patterns were clear.

Of 21 specific work-related problems, job conflicts and a lack of influence over decisions at work were most clearly associated with sick leave. In terms of job conflicts, this applied whether or not the women themselves were involved.

Women who had reported job conflicts were more than twice as likely (a factor of 2.31) to take sick leave during the follow-up year. After adjusting for general stress, previous sick leave, age, sleep quality, wellbeing, and physical activity, the risk remained twice as high (a factor of 1.98). A lack of empowerment was also accompanied by a significantly greater risk of sick leave (a factor of 1.71 after adjustments).

The importance of a better work environment

One of the main authors in the study is Kirsten Mehlig, Associate Professor of Epidemiology and Senior Lecturer in Health Science Statistics at Sahlgrenska Academy at the University of Gothenburg.

"Little scope for decision-making and conflicts in the work environment can predict sick leave, independent of general mental stress and previous periods of sick leave," she explains. "Improving the work environment is therefore important in order to reduce sick leave among women in the labor market."

The research team behind the study was led by Dominique Hange, Associate Professor and Senior Lecturer in General Medicine, and general practitioner at Närhälsan's Tidan primary care center in Skövde.

"Regardless of women's own involvement, the effects of conflicts at work may also suggest a specific vulnerability among women that may be interesting to address in the future," she notes.

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Materials provided by University of Gothenburg . Note: Content may be edited for style and length.

Journal Reference :

• Kirsten Mehlig, Amanda von Below, Kristina Holmgren, Cecilia Björkelund, Lauren Lissner, Ingmarie Skoglund, Magnus Hakeberg, Dominique Hange. Exploring the impact of mental and work-related stress on sick leave among middle-aged women: observations from the population study of women in Gothenburg, Sweden . Scandinavian Journal of Primary Health Care , 2024; 1 DOI: 10.1080/02813432.2024.2380925

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Underfunding of Research in Women's Health Issues Is the Biggest Missed Opportunity in Health Care

Feb 11, 2022

Photo by Drouk/Getty Images

By Chloe E. Bird

For far too long, the medical sciences have treated men and women as interchangeable subjects, favoring men's health for funding and the male body for study. This approach creates a problem, not just for women but everyone. Not only are we missing a large and critical slice of the population, we are leaving an unknown amount of science unexplored.

What's more, by underfunding the study of women's health issues, we've left a tremendous amount of money on the table. In fact, in nearly three-quarters of cases where a disease primarily affects one gender, the so-called “men's diseases” are overfunded, while the “women's diseases” are dramatically underfunded . Even a slight increase in capital invested in basic research into women's health would unleash staggering returns that would capture the attention of anyone on Wall Street or in Silicon Valley.

Women, after all, make up more than half the U.S. population and about half the workforce. Women are more likely than men to be caregivers , and make 80 percent of all health care decisions . Yet the medical sciences continue to underfund studies focused on women, even among diseases that affect women most of all. This is, quite simply, inefficient science .

Even a slight increase in capital invested in basic research into women's health would unleash staggering returns.

Cardiovascular disease, for example, is the number one killer of women in the United States, but only about a third of participants in clinical trials for new treatments for cardiovascular disease are female. Almost two-thirds ( PDF ) of the 6.2 million people suffering with Alzheimer's are women, but in most animal studies of the disease, researchers haven't reported the sex of the animal they're studying.

We can't know what we're missing if we aren't even paying attention to it—so how might things look different if we were to start improving funding for research into women's health, even slightly more than we currently fund it?

I recently helped oversee a study —commissioned by Women's Health Access Matters , a nonprofit advocacy organization that works to increase awareness of and funding for women's health issues—that ran a series of simulations looking at the return on investment we might expect if the National Institutes of Health budget for studies specifically assessing the health of women were doubled. For example, we examined what might happen if the budget for Alzheimer's research into women specifically went from $288 million to $576 million. In these simulations, we conservatively assumed that this budgetary increase would deliver merely the slightest of health improvements, just 0.01 percent for Alzheimer's and coronary artery disease, and 0.1 percent for rheumatoid arthritis, over 30 years.

Even these slivers of improvement produced a shockingly high return on investment. By doubling the NIH budget for research on coronary artery disease in women from its current $20 million, we could expect an ROI of 9,500 percent. Studies focused on rheumatoid arthritis in women receive just $6 million a year. Doubling that would deliver an ROI of 174,000 percent and add $10.5 billion to our economy over the 30-year timespan.

Rheumatoid arthritis might seem like an outlier, but it's a telling case: a disease that forces millions of women out of the workforce, resulting in not just lost earnings potential but a more difficult-to-measure loss of support at home. So many women provide unpaid care for their families that the impacts of these diseases, and the potential upside of increased investment in research, are likely even larger than what our conservative simulation landed on.

This, in a strange way, is very good news. There's a huge opportunity here, among the biggest opportunities in health care in generations. Invest in women's health and be lavishly rewarded. The upside is simply too great to continue ignoring.

Chloe E. Bird is a senior sociologist at the nonprofit, nonpartisan RAND Corporation, where she studies women's health and determinants of sex/gender differences in health and health care .

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Commentary gives RAND researchers a platform to convey insights based on their professional expertise and often on their peer-reviewed research and analysis.

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Massive biomolecular shifts occur in our 40s and 60s, Stanford Medicine researchers find

Time marches on predictably, but biological aging is anything but constant, according to a new Stanford Medicine study.

August 14, 2024 - By Rachel Tompa

We undergo two periods of rapid change, averaging around age 44 and age 60, according to a Stanford Medicine study. Ratana21 /Shutterstock.com

If it’s ever felt like everything in your body is breaking down at once, that might not be your imagination. A new Stanford Medicine study shows that many of our molecules and microorganisms dramatically rise or fall in number during our 40s and 60s.

Researchers assessed many thousands of different molecules in people from age 25 to 75, as well as their microbiomes — the bacteria, viruses and fungi that live inside us and on our skin — and found that the abundance of most molecules and microbes do not shift in a gradual, chronological fashion. Rather, we undergo two periods of rapid change during our life span, averaging around age 44 and age 60. A paper describing these findings was published in the journal Nature Aging Aug. 14.

“We’re not just changing gradually over time; there are some really dramatic changes,” said Michael Snyder , PhD, professor of genetics and the study’s senior author. “It turns out the mid-40s is a time of dramatic change, as is the early 60s. And that’s true no matter what class of molecules you look at.”

Xiaotao Shen, PhD, a former Stanford Medicine postdoctoral scholar, was the first author of the study. Shen is now an assistant professor at Nanyang Technological University Singapore.

These big changes likely impact our health — the number of molecules related to cardiovascular disease showed significant changes at both time points, and those related to immune function changed in people in their early 60s.

Abrupt changes in number

Snyder, the Stanford W. Ascherman, MD, FACS Professor in Genetics, and his colleagues were inspired to look at the rate of molecular and microbial shifts by the observation that the risk of developing many age-linked diseases does not rise incrementally along with years. For example, risks for Alzheimer’s disease and cardiovascular disease rise sharply in older age, compared with a gradual increase in risk for those under 60.

The researchers used data from 108 people they’ve been following to better understand the biology of aging. Past insights from this same group of study volunteers include the discovery of four distinct “ ageotypes ,” showing that people’s kidneys, livers, metabolism and immune system age at different rates in different people.

Michael Snyder

The new study analyzed participants who donated blood and other biological samples every few months over the span of several years; the scientists tracked many different kinds of molecules in these samples, including RNA, proteins and metabolites, as well as shifts in the participants’ microbiomes. The researchers tracked age-related changes in more than 135,000 different molecules and microbes, for a total of nearly 250 billion distinct data points.

They found that thousands of molecules and microbes undergo shifts in their abundance, either increasing or decreasing — around 81% of all the molecules they studied showed non-linear fluctuations in number, meaning that they changed more at certain ages than other times. When they looked for clusters of molecules with the largest changes in amount, they found these transformations occurred the most in two time periods: when people were in their mid-40s, and when they were in their early 60s.

Although much research has focused on how different molecules increase or decrease as we age and how biological age may differ from chronological age, very few have looked at the rate of biological aging. That so many dramatic changes happen in the early 60s is perhaps not surprising, Snyder said, as many age-related disease risks and other age-related phenomena are known to increase at that point in life.

The large cluster of changes in the mid-40s was somewhat surprising to the scientists. At first, they assumed that menopause or perimenopause was driving large changes in the women in their study, skewing the whole group. But when they broke out the study group by sex, they found the shift was happening in men in their mid-40s, too.

“This suggests that while menopause or perimenopause may contribute to the changes observed in women in their mid-40s, there are likely other, more significant factors influencing these changes in both men and women. Identifying and studying these factors should be a priority for future research,” Shen said.

Changes may influence health and disease risk

In people in their 40s, significant changes were seen in the number of molecules related to alcohol, caffeine and lipid metabolism; cardiovascular disease; and skin and muscle. In those in their 60s, changes were related to carbohydrate and caffeine metabolism, immune regulation, kidney function, cardiovascular disease, and skin and muscle.

It’s possible some of these changes could be tied to lifestyle or behavioral factors that cluster at these age groups, rather than being driven by biological factors, Snyder said. For example, dysfunction in alcohol metabolism could result from an uptick in alcohol consumption in people’s mid-40s, often a stressful period of life.

The team plans to explore the drivers of these clusters of change. But whatever their causes, the existence of these clusters points to the need for people to pay attention to their health, especially in their 40s and 60s, the researchers said. That could look like increasing exercise to protect your heart and maintain muscle mass at both ages or decreasing alcohol consumption in your 40s as your ability to metabolize alcohol slows.

“I’m a big believer that we should try to adjust our lifestyles while we’re still healthy,” Snyder said.

The study was funded by the National Institutes of Health (grants U54DK102556, R01 DK110186-03, R01HG008164, NIH S10OD020141, UL1 TR001085 and P30DK116074) and the Stanford Data Science Initiative.

• Rachel Tompa Rachel Tompa is a freelance science writer.

About Stanford Medicine

Stanford Medicine is an integrated academic health system comprising the Stanford School of Medicine and adult and pediatric health care delivery systems. Together, they harness the full potential of biomedicine through collaborative research, education and clinical care for patients. For more information, please visit med.stanford.edu .

Hope amid crisis

Psychiatry’s new frontiers

Issues in Women’s Health: Global Lessons, Opportunities, and Challenges

Women are currently facing a number of important issues in mental health. How can clinicians improve this situation?

VectorMine/AdobeStock

SPECIAL REPORT: GLOBAL PSYCHIATRY

Sex-specific differences in various biological functions as well as in brain neuroanatomy and circuits may result in different prevalence, symptomatology, treatment responses, and outcomes in neuropsychiatric and many other disorders. 1-4 In addition, men and women are not equally exposed to psychosocial stressors such as violence , among many others. 5 How many sex/gender differences in health are due to biology or to the consequences of behavioral and sociological factors remains to be sorted out. This article will detail how women’s mental health is in need of improvement, and how the COVID-19 pandemic has highlighted a number of preexisting difficulties.

Also In This Special Report

Social Determinants and Clinical Realities

Renato D. Alarcón, MD, MPH

Moving Beyond the Enormity Problem: Tackling the Global Refugee Crisis

Richard F. Mollica, MD, MAR

Challenges and Opportunities Beyond COVID-19

Milton L. Wainberg, MD

Exploring the Consequences of the COVID-19 Pandemic

Professor Sir Graham Thornicroft, PhD, MSc

Inspiring Collaboration in Cardiovascular Health

The recent mobilization of cardiologists is a perfect example of how we could advance women’s health, especially mental health. In women, cardiovascular disease is the leading cause of death, causing 35% of all deaths worldwide. Yet it remains underdiagnosed and undertreated, and women remain underrepresented in clinical trials. Apart from common risk factors that are shared by males and females, sex-specific factors such as premature menopause, gestational diabetes, hypertension during pregnancy , preterm delivery, polycystic ovary syndrome, systemic inflammatory and autoimmune disorders may play a specific role in women . Other important and underrecognized risk factors (abuse and intimate partner violence, socioeconomic deprivation), most frequently observed in women, may also play an additional role. 4

Risk factors that were observed more traditionally in men have increased in women. For example, historically, women have used tobacco, alcohol, or illicit drugs less often than men, and they have consumed alcohol in lower amounts than men. However, over time, the gradual change in the societal role of women and the lessening of social taboos have led to a rise in both the frequency and level of alcohol, tobacco, and illicit drug consumption among women . 6

Women usually start using psychoactive substances, including alcohol, as coping strategies to face depression, anxiety, and negative feelings, whereas men usually are more influenced by peers or sensation seeking. Consequently, the greater exposure of women to negative life events such as trauma and violence is a major contributing factor to the narrowing gap between rates of psychoactive drug use among men and women. Sex hormones and differences in pharmacokinetics and neurobiological circuits may also contribute to differences in susceptibility to dependence.

Moreover, men and women are differentially affected by triggers for relapse to drug taking. Potenza et al 7 have studied neural correlates of cue-induced craving states in women and men addicted to cocaine and reported sex differences in cue-induced craving, with corticostriatal-limbic hyperactivity being linked to stress cues in women but to drug cues in men. In addition, women suffer more severe consequences of alcohol , tobacco, and drug use with lower doses than men; they also suffer from pregnancy complications (for review see Fonseca et al, 2021; Thibaut et al, 2019). 8,9 Finally, women have a higher risk of relapse but achieve better results than men when they adhere to specialized treatment. Gender-oriented treatment is needed to take into account gender-related vulnerabilities.

In partnership with the Icahn School of Medicine at Mount Sinai, the journal The Lancet has convened a cardiovascular disease commission, including experts from 11 countries. 4 The commission proposed 10 recommendations to reduce this global burden by 2030, including educating health care providers and patients on early detection; using heart health programs in highly populated and underdeveloped regions; and prioritizing sex-specific research in women on heart disease and intervention strategies. 4 We should be inspired by this interesting collaboration in women’s health and create a similar list of recommendations, focusing on prevention, early detection, and treatment, to reduce the global burden of mental illness in women .

Lessons Learned From the Pandemic

The COVID-19 pandemic highlighted the urgent need for sex-specific clinical and pharmacological studies. The fatality rate with COVID-19 and the severity of the disease were higher in men than in women; for every 10 females, there were 15 confirmed cases in males who have died and 18 male intensive care unit admissions. 10 The higher death ratio reported in men may be partly explained by more preexisting cardiovascular or metabolic diseases, as well as higher risk-associated behaviors such as alcohol abuse, tobacco smoking , and less compliance with sanitation measures. 11 Hormonal (eg, estrogens) and genetic differences in the immune response may protect women against infectious diseases, but, at the same time, put them at higher risk of autoimmune disorders and inflammatory diseases. 12-15 Yet the COVID-19 pandemic has affected women more than men, both as frontline workers and at home due to lockdown and quarantine measures.

Worldwide, 70% of the frontline health workforce (nurses, midwives, and community health workers) and facility service staff (cleaners, laundry, catering) is made up of women. 16 As a consequence, women were more likely to be exposed to the virus. 17 For example, in Italy and Spain, 66% and 72% of infected health workers were females, compared with only 34% and 28% of males, respectively ( Figure 1 ). 16 Moreover, the severity of COVID-19 was higher in pregnant women, with a higher risk of intensive care unit admission and potential risks for the fetus and/or the baby . 18-20

Figure 1 . Global Perspective: Sex Differences in Health Care Workers Infected With Coronavirus 2019 13

In addition, psychological consequences of the COVID-19 pandemic were more often observed in women, both in the general population and in COVID-19 positive patients, compared with prepandemic data. 21 The mean rate of depressive disorders for females is approximately twice that of males (1.63-3.89), and anxiety disorders are more common in women than in men, increasing two- to threefold in the occurrence of generalized anxiety disorder and personality disorders. 22,23 These preexisting sex differences were even greater after the pandemic, as females were more affected by the pandemic than males for major depressive disorders (B=0.1 [0.1-0.2; P <.001]) and for anxiety disorders (B=0.1 [0.1-0.2; P <.001]), especially in the younger age group.

In the same way, in Japan, Tanaka and Okamoto 24 reported that, following a decrease by 14% during the first 5 months of the pandemic (February to June 2020), suicide rates increased by 16% (between July and October 2020), with a larger increase among females and younger populations, compared to males and older populations.

In post-illness stage, posttraumatic stress disorder (PTSD) was reported in one-third of 381 patients who initially sought treatment at the emergency department in Rome (Italy) for severe SARS-CoV-2. Sex (being a female), delirium or agitation, and persistent medical symptoms were associated with PTSD. 25

Overall, women were more likely to be affected by the economic and social consequences of the COVID-19 pandemic. 16 Additional household tasks, lower salaries, and less secure employments were more likely to occur in women compared to men. Riley et al26 have conducted a cross-sectional study in 2020 among 152 women experiencing homelessness and unstable housing in San Francisco. Half of these women experienced moderate-to-severe depressive and anxiety symptoms during the pandemic; these symptoms were associated with increased challenges accessing non–COVID-19 care and managing symptoms for chronic medical conditions.

Women were also at higher risk of domestic violence during the pandemic, with increases found internationally, which may, in turn, induce or aggravate psychiatric symptoms ( Figure 2 ). 16,27

Figure 2. International Increases in Violence Against Women Since the Pandemic 13

Understudied Sex/Gender Effects

Finally, despite different pharmacokinetic and pharmacodynamic properties of many compounds according to sex, medications have been studied essentially in men, and the data obtained about the clinical efficacy and potential adverse effects have been extrapolated to women. In addition, women of childbearing age were often excluded from clinical trials. Furthermore, in several cases, adverse events of medications during pregnancy became apparent only after many reports of toxicity to the fetus and/or the newborn (eg, sodium valproate, lithium).

Yet despite known sex-specific differences, sex/gender effects remain largely under-studied in clinical and pharmaceutical trials. For example, 10 prescription drugs were withdrawn from the US market between 1997 and 2000. Eight of these 10 compounds showed higher health risks for women than for men. In 4 cases, they were prescribed more often to women, while the other 4 had more adverse events in women even though they were widely prescribed to both. 28  Moreover, of the 350 cases of anaphylaxis after vaccination in adults, reported to the Vaccine Adverse Event Reporting System in the US between 1990 and 2016, 80% were observed in females, with influenza vaccines being most frequently reported. 29

In the United States, of the 300 new drug applications received by the FDA (1995-2000), only 163 included sex-based pharmacodynamic analysis, and 11 drugs showed a 40% or greater sex difference in pharmacokinetics. This information was listed on the drug label, yet no differences in dosing between males and females were recommended. 1 The European Association of Science Editors reported that sex was not reported for 22% to 60% of animals used in biological and immunological preclinical studies. In a study based on 768 trials, 89% reported recruitment of males and females, but less than 1% reported that they analyzed gender effects. 30

Howard et al 2 analyzed 728 papers published in JAMA Psychiatry and The British Journal of Psychiatry . Among them, 16% stratified analyses by sex, but no studies reported a calculation powered for the analysis of its primary outcome by sex. In fact, a gender-sensitive perspective is urgently needed.

In 2016, the Cochrane Sex/Gender Methods Group published a paper entitled, “Why sex and gender matter in health research synthesis.” 31 Clinical and pharmacological research reflects a mostly male perspective, assimilating women to men despite known biological and pharmacological differences. Participation of women of reproductive age in clinical trials is necessary, provided that there is adequate risk protection in case of pregnancy . In the near future, every pharmaceutical compound should clearly mention whether trials were conducted in women or not, and whether different adverse effects might be expected in women. For this purpose, the US National Institutes of Health, the Canadian Institutes of Health Research, and the European Commission have called for sex/gender analyses in all clinical trials. Heidari et al 32 have published a procedure for reporting sex and gender information in study design, analysis, and interpretation of the data.

Concluding Thoughts

According to a recent statement from Phumzile Mlambo-Ngcuka, former executive director of United Nations (UN) Women, “This is a moment for governments to recognize both the enormity of the contribution women make and the precarity of so many.” 16

Women are currently facing a number of important issues: financial crisis is gradually developing in this post–COVID-19 period and, as a consequence, mental health issues are likely to grow exponentially. According to the UN, women aged 24 to 34 years are already 25% more likely than men to face extreme poverty. 16 As such, the UN recommends allocating additional resources to protect women, putting women at the center of policy changes, and collecting more sex-disaggregated data to analyze the impact of pandemics on women. 16 Moreover, the 17 Sustainable Development Goals proposed by the UN offer a unique opportunity to achieve gender equality before 2030, 33 which is a key element in sustaining women’s health.

Dr Thibaut is professor of psychiatry at the University of Paris and University Hospital Cochin-Tarnier, and president of the International Association of Women's Mental Health.

1. Anderson GD. Sex and racial differences in pharmacological response: where is the evidence? Pharmacogenetics, pharmacokinetics, and pharmacodynamics. J Women’s Health (Larchmt). 2005;14(1):19-29.

2. Howard LM, Ehrlich AM, Garnlen F, Oram S. Gender-neutral mental health research is sex and gender biased. Lancet Psychiatry . 2017;4(1):9-11.

3. McCarthy MM. Sex differences in the developing brain as a source of inherent risk. Dialogues Clin Neurosci . 2016;18(4):361-372.

4. Vogel B, Acevedo M, Appelman Y, et al. The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030. Lancet. 2021;397(10292):2385-2438.

5. García-Moreno C, Riecher-Rössler A, eds. Violence against Women and Mental Health . Karger; 2013:1-11.

6. Thibaut F. Overview of women and addiction. In: Chandra PS, Herrman H, Fisher J, Riecher-Rössler A, eds. Mental Health and Illness Worldwide, Mental Health and Illness of Women . Springer; 2020:423-442.

7. Potenza MN, Hong KI, Lacadie CM, et al. Neural correlates of stress-induced and cue-induced drug craving: influences of sex and cocaine dependence. Am J Psychiatry. 2012;169(4):406-414.

8. Fonseca F, Robles-Martínez M, Tirado-Muñoz J, et al. A gender perspective of addictive disorders. (Gender, F Thibaut and J Labad Arias, Section Editors). Current Addiction Reports . 2021;8:89-99.

9. Thibaut F, Chagraoui A, Buckley L, et al. WFSBP * and IAWMH ** Guidelines for the treatment of alcohol use disorders in pregnant women. World J Biol Psychiatry. 2019;20(1):17-50.

10. The Sex, Gender and COVID-19 Project. The COVID-19 sex-disaggragated data tracker. Updated October 27, 2021. Accessed November 3, 2021. https://globalhealth5050.org/the-sex-gender-and-covid-19-project/the-data-tracker/

11. Johnson HD, Sholcosky D, Gabello K, et al. Sex differences in public restroom handwashing behavior associated with visual behavior prompts. Percept Mot Skills . 2003;97(3 Pt 1):805-810.

12. Klein SL, Flanagan KL. Sex differences in immune responses. Nat Rev Immunol . 2016;16(10):626-638.

13. Zhang Q, Bastard P, Liu Z, et al. Inborn errors of type I IFN immunity in patients with life-threatening COVID-19. Science . 2020;370(6515):eabd4570.

14. Bastard P, Rosen LB, Zhang Q, et al. Autoantibodies against type I IFNs in patients with life-threatening COVID-19. Science . 2020;370(6515):eabd4585.

15. Tsiambas E, Chrysovergis A, Papanikolaou V, et al. Chromosome X riddle in SARS-CoV-2 (COVID-19) - related lung pathology.   Pathol Oncol Res . 2020;26(4):2839-2841.

16. United Nations. Policy brief: the impact of COVID-19 on women. April 9, 2020. Accessed November 3, 2021. https://www.unwomen.org/-/media/headquarters/attachments/sections/library/publications/2020/policy-brief-the-impact-of-covid-19-on-women-en.pdf?la=en&vs=1406

17. Boniol M, McIsaac M, Xu L, et al. Gender equity in the health workforce: analysis of 104 countries. World Health Organization. March 2019. Accessed November 3, 2021. https://apps.who.int/iris/bitstream/handle/10665/311314/WHO-HIS-HWF-Gender-WP1-2019.1-eng.pdf

18. Capobianco G, Saderi L, Aliberti S, et al. COVID-19 in pregnant women: a systematic review and meta-analysis. Eur J Obstetr Gynecol Reprod Biol . 2020;252:543-558.

19. Della Gatta AN, Rizzo R, Pilu G, Simonazzi G. Coronavirus disease 2019 during pregnancy: a systematic review of reported cases. Am J Obstet Gynecol . 2020;223(1):36-41.

20. Vivanti AJ, Vauloup-Fellous C, Prevot S, et al. Transplacental transmission of SARS-CoV-2 infection. Nat Commun . 2020;11(1):3572.

21. COVID-19 Mental Disorders Collaborators. Global prevalence and burden of depressive and anxiety disorders in 204 countries and territories in 2020 due to the COVID-19 pandemic. Lancet. 2021;398(10312):1700-1712.

22. Yu S. Uncovering the hidden impacts of inequality on mental health: a global study. Transl Psychiatry . 2018;8(1):98.

23. Jalnapurkar I, Allen M, Pigott AT. Sex differences in anxiety disorders: a review. J Psychiatry Depress Anxiety . 2018;4:11.

24. Tanaka T, Okamoto S. Increase in suicide following an initial decline during the COVID-19 pandemic in Japan. Nat Hum Behav . 2021;5(2):229-238.

25. Janiri D, Carfi A, Kotzalidis GD, et al. Posttraumatic stress disorder in patients after severe COVID-19 infection. JAMA Psychiatry . 2021;78(5):567-569.

26. Riley ED, Dilworth SE, Satre DD, et al. Factors associated with symptoms of depression and anxiety among women experiencing homelessness and unstable housing during the COVID-19 pandemic. JAMA Netw Open . 2021;4(7):e2117035.

27. UN Women. COVID-19 and ending violence against women and girls. April 6, 2020. Accessed November 3, 2021. https://www.unwomen.org/-/media/headquarters/attachments/sections/library/publications/2020/issue-brief-covid-19-and-ending-violence-against-women-and-girls-en.pdf?la=en&vs=5006

28. United States Government Accountability Office. Drug safety: most drugs withdrawn in recent years had greater health risks for women. January 19, 2001. Accessed November 3, 2021. https://www.gao.gov/assets/gao-01-286r.pdf

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• Health and social care
• National Health Service

Health Secretary announces new women's health priorities for 2024

Problem periods, women’s health research and support for domestic and sexual abuse victims are among the government’s priorities.

• Top priorities to be tackled under the Women’s Health Strategy in 2024 include menstrual problems and menopause, maternity care and birth trauma support
• Support for domestic and sexual abuse victims and women in the criminal justice system will also be improved
• Health Secretary addresses women’s health champions at major London event to outline plans for coming year and celebrate successes of strategy’s first year
• Successes since the launch include reducing the cost of hormone replacement therapy ( HRT ) and the rollout of women’s health hubs
• £50 million for research to tackle maternity disparities

The Health and Social Care Secretary has named problem periods, women’s health research and support for domestic and sexual abuse victims among the government’s priorities for women’s health in 2024. 

Speaking at the Women’s Health Summit in central London to mark the second year of the landmark Women’s Health Strategy for England , Victoria Atkins said it would also prioritise improving maternity care and support for mothers who suffer birth trauma.

This follows a raft of successes over the strategy’s first 12 months, including reducing the cost of HRT for nearly half a million women, and the rollout of specialist women’s health hubs in every local health area. The strategy also championed the creation of a new dedicated women’s health section of the NHS website , providing updated information, advice and practical resources for women’s health across the life course.

Health and Social Care Secretary, Victoria Atkins, said:  

We’re breaking historical barriers that prevent women getting the care they need, building greater understanding of women’s healthcare issues and ensuring their voices and choices are listened to.  We’ve made huge progress - enabling almost half a million women access to cheaper HRT , supporting women through the agony of pregnancy loss and opening new women’s health hubs - but I absolutely recognise there is more to do.  We’re ensuring these changes benefit all women, regardless of socioeconomic background or ethnicity, because our Women’s Health Strategy is only a success if it works for all women.

The 2024 priorities were developed from responses to the government’s call for evidence from over 100,000 healthcare professionals, women’s health champions, members of the public and other stakeholders across the health sector. They are:

better care for menstrual and gynaecological conditions - by rolling out women’s health hubs, producing new guidance for healthcare professionals, continuing to improve information and support for women suffering from painful heavy periods and endometriosis, and promoting easier access to contraception - which often plays a vital role in managing menstrual problems. The Office for National Statistics will investigate the impact of period problems and endometriosis on women’s participation and progress at work, improving our understanding to achieve reductions in diagnosis times

expanding women’s health hubs - by delivering through our £25 million investment, the hubs will improve women’s access to care, improve health outcomes and reduce health inequalities. We are working towards the aim of establishing one fully functioning hub in every local area this year, enabling better access and quality of care in services for menstrual problems, contraception, pelvic pain, menopause care and more

tackling disparities and improving support for vulnerable women including victims of sexual abuse and violence by ensuring training and support systems are working collaboratively and efficiently. This will include creating new models within the NHS to protect its staff. We will focus on improving the health of women in the justice system, by implementing the recommendations set out in the National Women’s Prison Health and Social Care Review

bolstering maternity care, before during and after pregnancy - by continuing to deliver on NHS England’s 3-year delivery plan for maternity and neonatal services and ensuring women understand the care they can expect from the NHS during pregnancy and after giving birth. We will also be supporting women who suffer with birth trauma and ensure both mental and physical health are prioritised. A greater focus will be placed on preconception and postnatal care for women, raising awareness of pregnancy sickness and actioning the recommendations set out in the Pregnancy Loss Review . Through the first ever National Institute for Health and Care Research ( NIHR ) ‘challenge’, backed by £50 million, researchers, policymakers and women will be tasked with finding new ways to tackle maternity disparities

more research - a vital component to levelling up the playing field for women’s health. In addition to the NIHR challenge, we are building on the £53 million invested via the NIHR programmes and will continue to improve how women are represented in medical research through the NIHR research inclusion strategy

Minister for Women’s Health, Maria Caulfield, said:  

Helping women and girls who suffer from bad periods can make a huge difference to their lives, education and careers. And any woman who has experienced trauma after giving birth - either mentally or physically - will know the impact it can have on all aspects of her life.  These are issues that impact women but they should not be seen as ‘women’s problems’ - it is an everyone problem. We are doing more to put these issues on the agenda and keep them there, to close the gender health gap once and for all. We’ve made enormous strides in the first year of the strategy and I’m excited to see what 2024 will bring.

As well as announcing its new priorities, the government announced the reappointment of Professor Dame Lesley Regan as Women’s Health Ambassador for England for a further 2 years, to December 2025.   

Professor Dame Lesley was appointed as the Women’s Health Ambassador in 2022 and brings a raft of expertise spanning a 44-year career in women’s health as a practising clinician. She has specialised in core areas including miscarriage, period problems, gynaecological surgery and menopause. 

Professor Dame Lesley Regan, Women’s Health Ambassador, said:  

Our Women’s Health Strategy is ambitious. It was created to ensure our healthcare system places women’s health on an equal footing to men.  I want women everywhere to feel confident that when they seek advice from their healthcare professional, whether it’s for heavy or painful periods or issues following birth, they know they are going to receive world-class treatment. This is the ultimate goal of the strategy, and I am delighted that we have made such positive progress in the first year and generated so much enthusiastic help to succeed. This coming year offers us the opportunity of taking further steps forward in delivering better healthcare outcomes for every woman in our society.

Chief Nursing Officer for England, Ruth May, said:

The NHS is committed to ensuring women’s individual healthcare needs are met, which is why every area of England is being supported to develop a women’s health hub alongside the rollout of a network of Women’s Health Champions, who will use their leadership and experience to drive forward work to improve women’s health. The NHS is also rolling out dedicated pelvic health clinics, and every local health system now has a specialist community perinatal mental health team and we have also made it easier to access contraception through local pharmacies. But there is clearly more to do which is why it is brilliant to see the publication of the women’s health priorities for 2024.

CEO of Endometriosis UK, Emma Cox, said:

Women’s health has long been an underfunded and under-researched area. Implementing the aspirations in the Women’s Health Strategy will provide a much needed boost to turning this around, improving treatment and the lives of those suffering from endometriosis and menstrual health conditions. At Endometriosis UK, we know that many women face an unacceptable delay in securing a diagnosis and appropriate care. With sufficient funding and support, women’s health hubs could offer a real opportunity to drive down diagnosis times and support women to access the support they need. We’re delighted Professor Dame Lesley Regan has been reappointed and we look forward to continuing to support her vital and much needed work to deliver the key priorities outlined within the Women’s Health Strategy.

Dr Ranee Thakar, President of the Royal College of Obstetricians and Gynaecologists, said:

We are pleased to see the government launching their 2024 priorities for the women’s health strategy at our Union Street home, also the location of 15 other women’s health organisations. The focus on improving care and treatment for women with gynaecological conditions such as endometriosis and fibroids, which are often progressive, and have a huge impact on a woman’s quality of life, is hugely welcome. We have continually called for action to improve waiting lists in gynaecology services and know that women’s health hubs present a real opportunity to improve women’s health outcomes, and reduce inequalities in access and outcomes for women across the country. I am also glad to see that ensuring high quality care following birth trauma, an area of care which has long been a professional and personal passion of mine, has been recognised as a key focus for government. We also want to congratulate our former president, Professor Dame Lesley Regan, for her excellent leadership of the women’s health agenda at a national level and her well-deserved reappointment as Women’s Health Ambassador. As a dedicated advocate for a life course approach to women’s health, we have every faith she will continue to provide excellent leadership to drive the strategy forward.

Background information

Over the past year, a range of new actions have begun to make England one of the best places to be for women’s health: 

• between launch on 1 April and 31 December, 484,082 HRT prescription prepayment certificates were purchased, saving women millions of pounds in ongoing prescription charges
• NHS England announced its ambition to eliminate cervical cancer by 2040 by making it as easy as possible for women to get the lifesaving human papillomavirus (HPV) vaccination and increasing cervical screening uptake
• the NHS England Pharmacy Contraception Service relaunched to enable community pharmacies to initiate oral contraception. Almost 3,000 pharmacies have already signed, making access to contraception easier
• between launch in July 2023 and early January, there were 102,872 visits to the new women’s health area on the NHS website and 1.26 million visits to its new hormone replacement therapy area
• in September last year, we improved  IVF  transparency through an accessible new tool on GOV.UK to allow people to look up information about  NHS-funded  IVF  treatment  in their area

There have been various cross-government initiatives to support women in the workplace, including: 

• appointing recruitment and employability expert Helen Tomlinson as the government’s  Menopause Employment Champion to improve support for menopause in the workplace
• the government announced £12.4 million to help change choices about work , which included 6 ground-breaking projects including an investigation looking at how endometriosis impacts women in the workplace

Read the government’s response to the independent Pregnancy Loss Review . The government will continue to involve the Pregnancy Loss Review leads Zoe Clark-Coates and Samantha Collinge in rolling out the recommendations. 

Read details on the  £25 million investment in women’s health hubs  and cost-benefit analysis.

The NIHR , alongside other organisations, recently published a statement of intent for developing policy and practice which sees sex and gender fully accounted for in research .

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