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The way we talk about and value women’s health needs to change because too many women have painful periods and experience awful side effects from contraception, writes Dr Aajuli Shukla.
As a female GP in an area of high socio-economic disadvantage with burgeoning and impossible to get into gynaecological clinics, my scope of practice includes a lot of women’s health. This comprises gynaecological issues, screening, sexual health, contraception, menopause, and the management of common issues such as vaginal discharge and abnormal menstrual cycles. The breadth of women’s health can be intimidating. In one of the textbooks on general practice, the women’s health section covers ten chapters, whereas men’s health takes up about three.
I have been reflecting on my practice recently, as most of us do when we replay the consults of the day or to review our continuing professional development (CPD) points (do internal conversations count?). If you get a group of women in a circle and ask them if they’ve ever had abnormal, “funny” or painful periods, a majority are likely to raise their hand (here).
A dear friend has ironically nicknamed her uterus “cuterus” for how unpredictable and difficult it can be. Menstrual irregularities affect approximately 14–25% of women of childbearing age and yet we struggle to manage this common symptom in general practice (here and here). Similarly, women with endometriosis still struggle to get diagnosed, with some taking several years to be diagnosed with their condition which can be an incredibly invalidating experience(here and here).
Two cases stood out to me recently.
One was a woman who had been struggling for several months with vaginal discharge, which had been attributed to various things. Several swabs, creams and treatments later, she was no better. She had queried other health professionals on whether her recently inserted intrauterine device (IUD) could be the cause and was told that it was unlikely. Twice the importance of reliable contraception had been emphasised to her. Of course, her IUD was the cause. It’s a side effect that’s listed in the product information leaflet. Removing it and asking her to use condoms in the interim solved the problem. Although validating in the end, it has probably instilled in her a distrust in the medical system in general, and can anyone blame her?
I have wondered if the way we measure endpoints and outcomes in women’s health is flawed. Despite mood disorders being now recognised as a common side effect when using the contraceptive pill, the discourse around this is still flawed. A comprehensive review published in 2002 included 13 controlled studies investigating the relationship between mood and oral contraceptive pill use. All but one study found differences in affect between oral contraceptive pill users and non-users. Another pilot study involving 58 women found that current oral contraceptive pill users or recent users had higher subjective and objective depression rates than those of non-users. I see several women in my practice who are managed for depression and anxiety without exploring the link this might have with recently initiated contraception. Furthermore, most studies examining the safety and effectiveness of contraceptives seem to focus solely on the effectiveness of the contraceptive rather than the quality of functioning and side effects affecting a woman (here and here).
Cost is another issue that significantly affects managing women’s health in general practice. The second case that came to mind was one of a young woman who had already had several surgeries for endometriosis. An IUD was not an option and a progesterone-only pill that has specifically shown to have therapeutic benefits for women with endometriosis was prescribed. This medication is not listed on the Pharmaceutical Benefits Scheme (PBS) and the cost to this single mother with three children was exorbitant. She struggled to continue taking a tablet that significantly improved her quality of functioning.
Most doctors in other fields are still surprised to hear that a majority of contraceptive pills are not listed on the PBS. The Australian Medical Association has said the Pharmaceutical Benefits Advisory Committee, which recommends items for the PBS, needed to receive applications from pharmaceutical companies before their products could be listed on the PBS (here).
Quite a few of the newer types have significant benefits for a woman in terms of their side-effect profile and concurrent treatment of acne and menstrual issues. Yet they remain elusive for women with limited means (see this list of contraceptive prices). It’s the same for hormonal replacement therapy for menopause, with a significant proportion not on the PBS. If it’s not supply issues, then it’s high costs for treatments that significantly benefit a woman’s quality of functioning and symptom profile from menopausal symptoms. I struggle to think of any other conditions in medicine that are as common and yet as poorly funded in terms of therapeutic options.
Although women have several more therapeutic options for common menstrual issues that don’t go straight to a hysterectomy, it seems that vulnerable women are still missing out on treatment that suits them best. I find it incredibly difficult trying to explain exactly why the only contraceptive pill that works for them isn’t funded, or the combination hormone replacement therapy that’s worked wonders for them isn’t available any cheaper. Most of these women who cannot afford it continue to suffer with their symptoms. The way we talk about and value women’s health needs to change to make it more equitable.
Dr Aajuli Shukla is a Sydney GP and a Deputy Medical Editor at the Medical Journal of Australia.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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Dear Dr Shukla,
You show a couple of cases, which show just a tip of a mountain or iceberg of issues. Reflection is great, but it really needs education, education which enriches us in the real knowledge, not the most common. We need health workers who are compassionate, and practice in a culturally safe way, especially for women from other cultural backgrounds or CALD issues. And lastly, we need to realize that Australian Healthcare is still patriarchal in a lot of ways. I saw the BIRADS statement of “women may not cope” as a reason not to use it in reports on MMGs. I can, however, state, that we are lucky to have Prof Dorothy Keefe in Cancer Australia, who has followed her fair, holistic way of managing cancer in leading Cancer Care around our country. It beholds all of us to stop, think, and improve care of all our patients.