Women’s gynaecological health in Northern Ireland

Women’s gynaecological health refers to, menstruation, sexual health, fertility and menopause. Health inequalities experienced by women have long been apparent, often described by campaigners as the ‘gender-health gap’. Evidence has shown that a lack of research into conditions specifically affecting women can lead to poor health advice, misdiagnosis, delayed or ineffective treatment and overall worse outcomes for women. This blog post examines gynaecological health and the inequalities experienced by women across Northern Ireland (NI). Women’s health strategies across the other jurisdictions are explored, with a focus on gynaecological health.

Gynaecological health and associated disorders

Reproductive health is defined by The World Health Organisation (WHO) as a:

State of physical, mental and social well-being in all matters relating to the reproductive system. It addresses the reproductive processes, functions and system at all stages of life and implies that people are able to have a satisfying and safe sex life, and that they have the capability to reproduce and the freedom to decide if, when, and how often to do so.

Gynaecology specifically refers to the reproductive health of the vagina, uterus and ovaries. Although most women, or people with a uterus, will experience menstruation on a monthly basis from adolescence for up to 40 years of their lives, many remain unaware of menstrual and/or gynaecological health disorders. These include, but are not limited to:

• Ovarian cysts
• Pelvic pain
• Endometriosis
• Fibroids
• Heavy menstrual bleeding
• Menopause
• Polycystic ovary syndrome
• Pelvic organ prolapse
• Gynaecological cancers
• Termination of pregnancy care

Gynaecological health in NI

Recently published waiting times from the Department of Health have shown the total number of women waiting for a gynaecology outpatient appointment has more than doubled in seven years, with 28,511 patients waiting as of September 2021 (Figure 1). Over 10,000 of these patients have been waiting for more than 52 weeks. For gynaecology inpatient care, 7,363 patients were waiting with 4,245 waiting more than 52 weeks (Figure 2).

The full scope of women’s gynaecological health in NI is beyond the scope of this blog; however, focus will be given to endometriosis, menstrual and menopausal health and gynaecological cancers.

Endometriosis in NI

Endometriosis affects 1.5 million women in the UK accounting for 10-15% of reproductive women. Waiting times for endometriosis treatment in NI have been labelled ‘shocking’ by Endometriosis UK; in some cases women are waiting two years for an appointment with a consultant. Across the UK the average time for endometriosis diagnosis is seven and a half years.

380 women in NI shared their experiences of endometriosis with the BBC:

• Nearly all stated it had affected their mental health, career, opportunities, sexual relationships and education.
• Most stated it had badly affected their fertility.
• Around half stated it had led to suicidal thoughts.

In their report on endometriosis and fibroids in the UK, the All Party Parliamentary Group on Women’s Health (WHAPPG) found, out of 2600 women, 42% were not treated with dignity and respect, 62% were not satisfied with the information received regarding treatment options and nearly 50% were not told about short term or long term complications. In addition to the personal cost and debilitating nature of endometriosis, the socioeconomic burden of endometriosis in the UK equates to £8.2 billion, amounting to around £8,500 per woman per year.

Although the Department of Health endorsed NICE guidelines for treatment and diagnosis of endometriosis in October 2017, information on the number of people diagnosed with endometriosis is not collected centrally in NI. However, the Department of Health provided the number of people admitted to hospital with a diagnosis of endometriosis from 2016-2021 (Figure 3).

Belfast Health and Social Care (HSC) Trust is an accredited British Society for Gynaecological Endoscopy Endometriosis Centre and the Western Trust is working towards accreditation. No information on the accreditation of other HSC Trusts is available. Although these centres surgically treat endometriosis, in response to an MLA question regarding availability of excision surgery for endometriosis patients, the Department of Health responded:

Covid-19 has fundamentally affected the work undertaken by Trusts for the past 18 months and will continue to do so for some time. As such, there are currently no plans in place to specifically deal with those patients who are waiting on the gynaecology waiting list to have excision surgery relating to endometriosis, as the focus and priority remains on addressing red flags and cancers.

Information on waiting times for urgent endometriosis surgery in each HSC Trust is not available.

Disparity in expertise of medical professionals across NI is apparent. As of March 2021 only one endometriosis specialist surgeon is based in NI, in the Belfast HSC Trust. Fifteen obstetrics and gynaecology consultants are employed by the Western HSC Trust, to treat women with stage 1/2 endometriosis; stage 3/4 are referred to an obstetrics and gynaecology consultant with an interest in endometriosis. The remaining HSC trusts do not employ consultants or specialists for endometriosis.

Menstrual health and menopause in NI

Menstrual related problems affect a significant proportion of the female population in the UK, with associated stigma often preventing women and girls from discussing these issues. Endometriosis UK have called for the NI education system to implement ‘age appropriate menstrual wellbeing’, after it was successfully introduced in England in September 2020, to educate children and young people about what is and isn’t normal for a menstrual cycle and prevent suffering throughout their schooling.

The majority of women will experience at least one menopausal symptom with around a third of women experiencing severe symptoms. The Royal College of Obstetricians and Gynaecologists (RCOG) found that 58% of women in the UK could not access menopause services locally. In response to a query to create more menopause-specific treatment clinics in NI, the Minister for Health responded:

Women who require advice or treatment for menopausal conditions are generally managed by their GP or at general gynaecology clinics within their local Trust. Those identified as having a complex case can also be referred by their local clinician to the Regional Menopausal Clinic in Belfast. In addition to the Regional Clinic, the Northern HSC Trust has advised that it aims to establish a menopause-specific treatment clinic in the future, subject to the completion of ongoing training of a consultant who has developed a specialist clinical interest in menopause care.

However, menopause specialists employed by HSC Trusts varies considerably by the number employed and level of expertise (See Table 1).

Table 1: Menopause Specialists employed by HSC Trust   

Gynaecological cancers in NI

In 2019, 560 women were diagnosed with gynaecological cancers (ovarian, uterine, and cervical). Sadly 214 women passed away from these cancers in the same year. A further 1479 women were diagnosed with breast cancer in 2019, with 310 women passing away that year. In 2015 the charity Target Ovarian Cancer found women in NI had the worst ovarian cancer survival rates in the UK and the worst chance of having access to clinical trials, with only 30% of those diagnosed with the disease surviving for five years or more.

As early diagnosis is key to survival for gynaecological cancers, RCOG has recommend that the Public Health Agency NI prioritise campaigns targeting public and healthcare professionals to increase awareness of symptoms including post-menopausal bleeding. As only 46% of women are diagnosed with ovarian cancer at an early stage, Target Ovarian Cancer has recommended shortening diagnostic times in NI by carrying out diagnostic tests (CA125 blood test and transvaginal ultrasound) at the same time. This isn’t the standard procedure currently. A consultation for the proposed Cancer Strategy NI has recently closed. The Strategy aims to achieve ‘person-centred cancer care’ and has been welcomed by charities, although recommendations targeting specific cancers are not present.

Inequalities in women’s health

Inequalities in women’s health exist in a number of ways. Women’s health disorders are more likely to be under-funded and under-researched and women are less likely to be invited to participate in medical trials and research. These inequalities go further than women-specific conditions; research by the British Heart Foundation reported that 8,200 women in England and Wales died over a 10-year period because they did not receive equal treatment to men with regard to diagnosis and treatment of heart attacks. The research highlights the need to guard against unconscious biases that could contribute to gender-based inequalities in heart attacks as well as other diseases. Recently, there have been renewed calls to close the ‘gender data gap’ to eliminate the gender bias that has been identified in diagnosis, treatment and medical research.

Inequalities also exist amongst women. Racial disparity is stark in women’s health. Black, Asian, and minority ethnic women are more likely to experience a lower quality of healthcare compared to white women. This is evident in the disparity in endometriosis diagnosis and increased incidence and mortality of cervical cancer. Minority groups are less likely to be represented in medical research via clinical trials, further amplifying inequalities. Deprivation also contributes to disparity; the most socio-economically deprived areas of NI had a 64.1% higher incidence of cervical cancer compared to the national average.

Women’s health strategies in other jurisdictions

A series of reports concerning women’s health inequalities across the UK have been published in recent years, including the RCOG ‘Better for Women’. Primary recommendations focused on the creation of Women’s Strategies across each jurisdiction in the UK. Addressing the following areas of unmet need for women’s health has been advised:

• Access to reliable information on women’s health;
• Easy access to contraception, abortion and fertility services;
• Learning from indicators in the reproductive years to influence future health; and
• Prevention and early diagnoses of gynaecological cancers across the life course.

Aside from health, violence against girls and women and keeping women in the workforce were also areas of concern to be addressed by future strategies.

Scotland

Scotland is the first jurisdiction in the UK to create a Women’s Strategy. In August 2021 Scotland announced their Women’s Health Plan 2021-2024 including 66 actions to ensure women have the best possible health throughout their lifetime. The Scottish Government has committed to publishing an implementation report in 2024-25 to capture progress made, analyse the impact of the Plan and consider lessons learned.

England

Over the spring and summer 2021 it was announced that there would be a call for evidence in England to develop a Women’s Health Strategy. They sought evidence on 6 core themes that connect different areas of women’s health. Following the close of consultation in June 2021, the RCOG published their key recommendations for the Women’s Health Strategy, calling on a cross-government effort and close alignment with the Violence against Women and Girls strategy within the Home Office, the upcoming national sexual health strategy and the NHS COVID-19 recovery plan.

Wales

Wales does not currently have a Women’s Strategy in place. However, a Women’s Health Implementation Group (WHIG) has been in place since May 2018 to address specific areas of women’s health that require urgent attention and improvement. Across a 5-year programme of work the group was directed by the Health Minister to report on the following:

• The use of vaginal synthetic mesh tape and sheets for stress urinary incontinence and pelvic organ prolapse.
• Endometriosis care in Wales: Provision, care pathway, workforce planning and quality and outcome measures.
• Report of the Welsh task and finish group for faecal incontinence.

The Welsh Government committed £1m in funding to the WHIG per year of operation. Following these reports, the group made a series of recommendations for pelvic floor dysfunction and endometriosis. A recent petition called for increased spending on women’s health services, education and awareness in Wales.

Republic of Ireland

A report on the evidence base for the development of a women’s health action plan was published in August 2019 in the Republic of Ireland (ROI). A Women’s Health Taskforce was then established by the Department of Health in September 2019 to improve women’s health outcomes and experience of healthcare.

Funding for women’s health in the 2021 ROI Budget includes a dedicated €5m Women’s Health Fund to implement actions from the taskforce including a national awareness campaign ‘Let’s talk about women’s health’. A further €157,000 has been allocated to develop specialist menopause clinics to aid a new approach to menopause care for women. A further €12m has been allocated to develop maternity, gynaecology and fertility services, including two community-based ambulatory gynaecology services and the expansion and development of a specialist endometriosis centre at Tallaght University Hospital. €10 million has also been allocated to fund screening services including (BreastCheck and CervicalCheck).

A report on women’s views, experience and priorities for women’s health in ROI was published in September 2021 to help inform a proposed 2022 plan for women’s health, intended to be brought to Government in the ROI and published later this year. In anticipation of this, the 2022 Budget for the ROI intends to provide €31 million for specific women’s health measures to underpin the Action Plan in Women’s Health. A further €16 million has been allocated to support women’s health within other measures such as cancer, mental health and social inclusion budgets.

A women’s health strategy for NI is not currently available.

Conclusion

The United Nation’s Sustainable Development Goal 5 is to ‘achieve gender equality and empower all girls and women by 2030’, yet inequality in women’s health still prevails. The strategies put in place, or under review, in Scotland, the ROI and England are a pivotal first-step in addressing women’s health and the inequalities they face. Gynaecological hospital waiting times in NI have doubled in the last seven years, further exacerbated by the pandemic. A disparity in availability of gynaecological services and expertise of medical staff across NI is also apparent. NI is lagging behind other UK regions and ROI with regard to funding and planning for women’s gynaecological health services. The development of a comprehensive women’s health strategy would bring NI into line with other UK regions and could support much needed improvements to existing services.