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|WOMEN’S HEALTH ISSUES: AN OVERVIEW

**[Previous section]**

PRIORITY WOMEN’S HEALTH ISSUES

HEALTH CARE PRACTICES

Women often face a fragmentation in health care services to meet their reproductive and
other health needs8, and make more visits than men to the doctor1.
Women are also highly interested and informed about health care issues, but reliable
health information needed for informed choices about health care has not been widely
available. National studies have indicated that women may not be as satisfied as men with
the information they receive from their health care providers or the level of
communication with their provider9. Furthermore, several studies have found
that health care providers treat women differently from men. Compared with treatment given
to men, health providers may give women less thorough evaluations for similar complaints,
minimize their symptoms, provide fewer interventions for the same diagnoses, prescribe
some types of medications more often, or provide less explanation in response to
questions.

*ACCESS TO HEALTH INSURANCE*

Although the health of the American economy has never been better, more women than ever
lack health
insurance coverage. The proportion of uninsured women under age 65 rose from 14% in
1993 to 18% in 1998. More dramatic still, the proportion of women under 65 who lacked
health insurance for all or part of 1998 was a staggering 26%, according to the 1998
Commonwealth Fund Survey of Women’s Health10. The women most at risk of
going without health insurance are those who earn low or moderate incomes, women of color,
and women with health problems. More than 8 in 10 uninsured women are employed or married
to someone who is. Lack of insurance severely compromises both the accessibility and
quality of health care.

Seventy percent of women under age 65 had private health insurance in 1997, and 12
percent were covered by Medicaid1. Almost all Americans aged 65 and over are
covered by the Medicare program, including 92 percent of those who also have private
insurance1.
HEART DISEASE

Heart
disease is the number one killer of American women1. Although it is
typically viewed as a man’s disease, more women actually die of heart disease each
year than men. On average, women develop heart disease later in life than do men, and
women are more likely then men to have other co-existing, chronic conditions that may mask
their heart disease symptoms. Heart
attack symptoms in women may also differ from those in men, leading to misdiagnosis11.
Women who recover from a heart attack are more likely than men to have a stroke or to have
another heart attack12. In fact, 42 percent of women die within a year
following a heart attack compared to 24 percent of men13.
CANCER

Cancer
is the second leading killer of American women14. Since 1987, lung
cancer has been the leading cause of cancer death among women in the United
States, with an estimated 66,000 deaths in 199914. Over the past 10 years, the
mortality rate from lung cancer has declined in men but has continued to rise in women14.
These alarming trends are under-recognized by women and due almost exclusively to
increased rates of cigarette smoking in women.

At present, breast
cancer is the second leading cancer killer of American women, claiming the lives
of 43,300 women in 199914. The incidence of breast cancer rose steadily from
1940 to 1990, then stabilized at approximately 110 cases per 100,000 women14.
With the increased use of mammography screening, breast cancers have increasingly been
detected earlier in their development, when they are more treatable. This earlier
detection, coupled with improved treatment has led to a decline in breast cancer death
rates. Between 1990 and 1994, breast cancer mortality decreased by 5.6 percent. This
decline was more pronounced among white women (-6.1 percent) than among African American
women (-1 percent)1.


Colorectal cancer accounts for the third leading cause of cancer deaths in American
women14. Although many cases are preventable with regular screening, regular
exercise, and a diet low in fat and high in fruits, vegetables, and whole-grain foods,
colorectal cancer is expected to claim the lives of 28,800 women in 199914.

With the advent of the Pap
smear, the early detection and prevention of cervical
cancer has improved dramatically. Both the incidence and death rates from this
disease have declined by 40 percent since the early 1970s15. However, many
elderly, low-income, and rural women remain at high risk for this disease, because they
are not obtaining regular Pap screenings. Other major risk factors include cigarette
smoking and infection with certain types of the human papillomavirus (HPV)15.
An estimated 12,800 new cases of cervical cancer are expected to be diagnosed in 1999, and
an estimated 4,800 deaths14.

The Pap smear and pelvic examination are only partially successful at detecting endometrial
(uterine lining) cancer, which claimed an estimated 37,400 new cases in 1999,
and led to 6,400 deaths14. Although the incidence of ovarian
cancer is lower, ovarian cancer is the most deadly of all the cancers of the
female reproductive system. Symptoms often appear only in the very advanced stages of the
disease. In 1999, there were nearly 25,200 ovarian cancer cases with over 14,500 deaths14.


Melanoma—the
most serious form of skin
cancer—is the most frequent cancer in women 25 to 29 years of age and the second
most frequent (after breast cancer) in women ages 30 to 34. Although overall, men are more
likely than women to develop skin cancer, women under the age of 40 comprise the fastest
growing group of skin cancer patients and the rate of new melanoma cases is increasing.
Since 1973, it has doubled from 6 cases per 100,000 people to 13 per 100,000 in 199516.
STROKE

Stroke
is the third leading cause of death for American women, and it kills more than twice as
many women each year as breast cancer1. Stroke occurs at a higher rate among
African American and Hispanic women compared with white women1. Women account
for 43 percent (or 240,000) of the 550,000 strokes that occur each year and 61 percent of
stroke deaths (97,227 of 159,791 annual deaths)1. A stroke is usually caused
by a clot that stops the flow of blood to an area of the brain. Stroke can cause
paralysis, loss of speech, and poor memory and is the most common cause of adult
disability.

Taken together, stroke and heart disease kill nearly twice as many American women as do
all types of cancer combined. More than one woman in five has some form of major heart or
blood vessel (cardiovascular) disease in this country17. However, in a 1997
national survey, only 8 percent of American women recognized heart disease and stroke as
the leading cause of women’s deaths18.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

COPD
includes chronic bronchitis, emphysema,
and asthmatic bronchitis, all of which obstruct airflow from the lungs. In 1997, COPD was
the fourth leading cause of death among women, causing 53,045 deaths, for a rate of 17.7
deaths per 100,0001. While COPD death rates are much higher in men than in
women, the rates for women have nearly doubled since 1979, with the most rapid increases
occurring in women age 75 and older.
HIV/AIDS

Long considered a man’s disease, HIV/AIDS
is a public health problem among women, with 10,841 new AIDS cases among adult and
adolescent women between July 1998 and June 199919. From 1985 to 1999, the
proportion of AIDS cases reported among women increased from 7 percent to 23 percent.
Among 13 to 19 year olds, girls constituted 50 percent of all AIDS cases reported in 199820.

By June of 1999, a total 114,621 women were reported to have AIDS, and 77 percent of
women diagnosed with AIDS were African Americans and Latinas19. HIV/AIDS is the
fifth-leading cause of death among women ages 25 to 44 and the third leading cause of
death among African American women in this age group21. Fortunately, increased
screening for HIV among reproductive age women and more effective therapies to reduce
perinatal transmission of HIV, have contributed to the 75% decline in the proportion of
infants diagnosed with perinatally acquired AIDS since 199320.

The most common mode of HIV infection among adult and adolescent women is through
heterosexual contact, followed by intravenous drug use. Significant gender differences are
manifest throughout the course of the illness as well as in the mode of infection,
indicating the need for gender-sensitive treatment and prevention strategies to stem the
spread of AIDS.
AUTOIMMUNE DISEASES

Autoimmune
diseases arise when, for unknown reasons, a person’s body declares war on itself,
producing antibodies that attack healthy tissue. About 75 percent of autoimmune diseases
occur in women, including systemic lupus erythematosus (SLE), Sjögren’s syndrome,
rheumatoid arthritis, scleroderma, diabetes Type I, multiple sclerosis, and autoimmune
thyroid disease22,. Individually, autoimmune diseases are not very common;
however, taken together, they represent the fourth largest cause of disability among women
in the United States. These diseases remain misunderstood and misdiagnosed.
MENTAL ILLNESS

One in ten Americans experiences an episode of depression
each year23. Major depression and dysthymia (a less severe, more chronic form
of depression) affect approximately twice as many women as men24. An estimated
12 percent of women in the United States experience a major depression during their
lifetimes, compared with 7 percent of men; and 4.2 percent of women have dysthymia24.
Women are 2 to 3 times more likely to have certain types of anxiety
disorders, including anxiety, panic, and phobic disorders24. At least 90
percent of all cases of eating disorders occur in women and a high correlation appears to
exist between eating
disorders and depression, and eating disorders and substance abuse25.

Untreated mental illness can be fatal. Suicide
was the fifth leading cause of death among women ages 25 to 44 in 1994, and the fourth
leading cause for those ages 15 to 2426. Women are more likely than men to
attempt suicide, but are far less likely to die as a result, largely because men are more
likely to use a firearm1.
SUBSTANCE ABUSE

The abuse
of alcohol and other legal and illicit drugs is a serious and continuing problem among
American women. Approximately 120,000 deaths annually are attributed to alcohol and drug
use27. In 1998, the health and societal costs of alcohol and substance abuse
were estimated at $238 billion27.

Nearly 4.1 million women in this country currently use illicit
drugs, and over 1.2 million misuse prescription drugs for non-medical reasons28.
In 1997 and 1998, 4.5 million women ages 15 to 44 were current illicit drug users,
including 1.6 million who had children living with them28. Only 3.2 percent of
pregnant women were current drug users, but the rate increased to 6.2 percent among women
who had a child under age 2 and were not pregnant28. Altogether, women account
for an estimated 37 percent of illicit drug users in this country.

Women are less likely than men to use or abuse of alcohol,
however death rates among female alcoholics are 50 to 100 percent higher than those of
their male counterparts29. In 1998, 2.1 percent of American women were heavy
drinkers, 8.6 percent were binge drinkers (more than 5 drinks at one time), and 45.1
percent of women had at least 1 alcoholic drink in the past month1. Among
teenage girls in 1997, 40 percent reported some alcohol consumption in the past month and
29 percent reported binge drinking1.

Heavy drinking during pregnancy has been clearly associated with severe birth defects,
including mental retardation, nervous system disorders, abnormal features of the face and
head, and retarded growth30. The effects of moderate drinking (1-2 drinks per
day) are not well established, so the only known safe level of drinking in pregnancy is
total abstinence. In 1996, 16.1 percent of pregnant women reported any alcohol use; 1.3
percent reported binge drinking; and 0.5 percent reported heavy drinking (5 or more drinks
per day) in the past month28.

Many women who abuse drugs or alcohol have histories of mental illness. Seventy percent
report having been sexually abused before the age of 16, and more than 80 percent say they
have a family member addicted to drugs or alcohol31. These factors complicate
the course of their illness and treatment planning. Women who abuse alcohol or drugs are
also at higher risk for HIV/AIDS, tuberculosis, oral and pharyngeal cancer, injury, and
sexually transmitted diseases (STDs).
SMOKING

Cigarette smoking
is the leading preventable cause of death in this country, contributing substantially to
deaths from cancer, lung disease, heart disease, stroke, and other causes32.
Women’s smoking rates have decreased 35 percent since their peak in 1965. Yet, 22.3
million (22.1%) of adult women were still current smokers in 199733. Unlike
their adult counterparts, rates of teen girls who smoked in the past month have been
increasing their smoking rates, rising from 27 percent in 1991 to 37 percent in 1997. In
1997, 70% of highschool aged girls had ever tried cigarette smoking34.

Smoking in pregnancy substantially increases health risks to the developing fetus. It
is the leading cause of premature births, and greatly increases the risks of mental
retardation, miscarriage, low birth weight, and other serious health conditions in infants35.
The 1997 National Household Survey on Drug Abuse indicated that 19.9 percent of pregnant
women smoked cigarettes, with the highest rates among women in their first trimester of
pregnancy and lowest among those in their third trimester28. The smoking rate
among women with children under the age of 2 was 26.6 percent—indicating that some
women may abstain from smoking in pregnancy, but revert back after their child is born.

Children’s second-hand exposure to cigarette smoke has been shown to increase the
risk of Sudden
Infant Death Syndrome (SIDS), recurring ear infections, and severe respiratory
illnesses such as bronchitis,
pneumonia,
and asthma35.
VIOLENCE

Violence
is a major public health problem for American women. More than 4.5 million women are
victims of violence each year36. Of these, nearly two of every three are
attacked by a relative or someone they know. Women are 6-times more likely than men to be
abused by someone they know and 10-times more likely to be victims of sexual
assault36. It is estimated that 10 to 20 percent or 1-2 out of 10 young
women are the victims of sexual abuse37. In 1997, homicide was the second
leading cause of death among women ages 15 to 24 years and the sixth leading cause of
death among women ages 25 to 4438. It is the leading cause of occupational
deaths in women39, 40,. Researchers are increasingly concerned that violence
may also be an important hidden cause of maternal mortality. Prevalence of violence during
pregnancy appears to range from 4% to 8%41. Applying these percentages to the
3.9 million U.S. women who delivered live-born infants in 1995 yields the conclusion that
152,000 to 325,000 women experienced violence during their pregnancies. Thus, violence may
be a more common problem for pregnant women than preeclampsia,
gestational
diabetes, or placenta
previa41.
REPRODUCTIVE HEALTH

Women’s reproductive capacity plays an important role in shaping their lives and
health experiences. Over 80 percent of all American women have had a child by the age of
451, and the average woman has 2.2 children42.

While motherhood is a defining feature of adult life for many women, most spend the
greater part of their reproductive years trying to avoid pregnancy. Sixty-four percent of
women ages 15 to 44 use some form of contraception,
up from 56 percent in 1982 and 60 percent in 198843. Women’s use of
contraception at first intercourse has risen from 64 percent in the late 1980s to 76
percent in 19951. From 1987 to 1994, the rate of unintended pregnancy dropped
16 percent, due most likely to increased contraceptive use and improved effectiveness of
contraceptive methods44. Nonetheless, 49 percent of pregnancies in 1994 were
unintended, and nearly half of all women who experienced an unplanned pregnancy in 1994
had been using some form of contraception43.

The most commonly used contraceptive is female sterilization
(10.7 million women), followed by birth control pills (10.4 million), the male condom (7.9
million) and male sterilization (4.2 million). In 1995, 2 percent of women used hormone
injectable, 1 percent used hormonal implants, and less than 1 percent used the female
condom for contraception1.

Gynecological health is not only an important component of women’s health during
the reproductive years, but throughout the life course. The average woman spends a third
of her life beyond menopause.
While many older women mistakenly believe that regular gynecological exams are no longer
necessary, this is precisely the point in life when they are at higher risk for cancers of
the reproductive system, and other gynecological problems such as uterine prolapse.

Younger women are particularly at risk for reproductive health problems associated with
sexually
transmitted diseases (STD). Two-thirds of all STD cases occur among individuals
younger than 25 years, and 1 in 4 teenagers contracts an STD each year45. Women
are biologically more susceptible to STD infection than men, and younger women are more at
risk than their older counterparts due to differences in their cervical anatomy. Women are
less likely than men to experience symptoms of STD infection. For example, chlamydia—
the nation’s most prevalent curable infectious disease—produces symptoms in 50
percent of men compared to only 25 percent of women46. Left undetected, 20-40
percent of women infected with chlamydia and 10-40 percent of those infected with gonorrhea
develop pelvic
inflammatory disease (PID), which in turn leads to infertility in 20 percent of cases,
chronic pelvic pain in 18 percent, and ectopic
pregnancy in 9 percent of cases47. In addition to direct health problems
caused by STD infection, high rates of STD infection in adolescent women contribute to
increased susceptibility to HIV.

In 1998, there were 501,128 new cases of chlamydia in American women; 179,651 cases of
gonorrhea (with rates highest among young women ages 15 to 19); and 18,179 cases of
syphilis. Herpes simplex virus type 2 (HSV-2) infects about 1 in 4 women and 1 in 5 men47.

Gynecological problems are common among women of reproductive age. More than 4.5
million women ages 18 to 50 report at least one chronic gynecological condition each year48.
Half of all women who menstruate experience some pain during menstruation, and 10 percent
of them suffer from pain so severe (dysmenorrhea)
that it interferes with their daily routine49. Nearly 2 out of 5 women ages 14
to 50 experience some symptoms of premenstrual
syndrome (PMS) —10 percent with symptoms severe enough to disrupt their usual
activities50, 51,. As many as 10 percent of American women have endometriosis,
which can cause chronic pain and infertility52.
Between 10 and 20 percent of women have uterine fibroids (non-cancerous growths in
the uterus)53. Together, endometriosis and fibroids are associated with half of
the more than 580,000 hysterectomies
performed in the United States each year54. Other causes include cancer,
excessive bleeding or pain, and uterine prolapse. One woman in three over the age of 60
has had a hysterectomy, and it is the second most commonly performed surgical procedure in
the nation53.
FERTILITY AND INFERTILITY

In 1997, there were 3,880,894 million live births in the United States55.
From 1950 to 1997, the birth rate dropped from 24 to 14.5 live births per 1,000 population1.
The peak childbearing years remain the twenties, but the proportion of women in their
thirties and forties who are having babies has increased throughout this decade. There
were 483,220 births to teen girls in 1997 — representing a 16 percent drop since 199156.


Infertility
affected 6.1 million women in 1997, up from 4.6 million in 1988 — an increase due in
part to delayed childbearing and the aging of the baby boom generation57. The
causes of infertility are equally distributed among conditions affecting the man,
conditions affecting the woman, and conditions affecting both partners. Approximately 1 in
4 infertile couples are unable to conceive as a result of sexually transmitted diseases
according to the American Society for Reproductive Medicine.

Research has repeatedly indicated that timely and adequate prenatal
care greatly enhances the chances for positive pregnancy outcomes. In 1997, over
82.5 percent of all pregnant women received prenatal care in the first trimester of
pregnancy — reflecting a steady improvement since 19701. Still, 3.9
percent of pregnant women received prenatal care only in their third trimester or not at
all1.

Theinfant mortality rate reached a new low in 1997 of 7.2 deaths per 1,000 live
births1. Approximately one-third of that progress is associated with an
estimated 15 percent decline in Sudden Infant Death Syndrome (SIDS) between 1995 and 19961.
In spite of these improvements, the United States’ infant mortality rate remains one
of the highest in the industrialized world58.

The maternal mortality rate has decreased more than ten-fold since 1950. In
1997, there were 7.6 maternal deaths per 100,000 live births1. However new,
improved data collection techniques are suggesting that the rate of maternal mortality
associated with heart ailments, embolism, hemorrhage, high
blood pressure, domestic violence, and infection may be higher than current measures
indicate58.
ENVIRONMENTAL HEALTH

Environmental factors contribute substantially to the cause of many diseases in women.
Adverse environmental conditions range from water, air, and soil pollution to
contamination through the workplace. Occupational hazards include exposure to lead,
chemicals, pesticides, tobacco smoke, and continuous noise. Home and community
environmental factors—from radon, lead-based paints, electromagnetic fields, food,
and cosmetics to heatstroke, hypothermia, and violence—affect women’s health.
The ways in which environmental factors may disrupt women’s endocrine, reproductive,
central nervous, and immune systems and cause specific diseases such as cancer,
autoimmune
diseases, endometriosis,
and osteoporosis
are only beginning to be understood.
CHRONIC DISABLING CONDITIONS

In part because they live longer than men, women are more likely to be affected by such
chronic disabling conditions as diabetes, osteoporosis, osteoarthritis, obesity, urinary
incontinence, Alzheimer’s disease fibromyalgia, and chronic fatigue syndrome. These
conditions not only limit function but over time may be life-threatening. Each of these
disorders is characterized by a long trajectory of increasing impairment. Chronic
illnesses exert an untoward effect not only upon the person experiencing them but also
upon family members and other care givers. More research is needed to determine whether
specific gender-related factors contribute to the increased incidence of these illnesses
in women.


Diabetes mellitus. An estimated 16 million Americans have diabetes, but only 10.3
million cases are diagnosed, of which 8.1 million are women59. The prevalence
of diabetes is 2-4 times higher among Black, Hispanic, American Indian and Asian pacific
Islander women than among white women. Diabetes
is the fourth leading cause of death in African American, Native American, and Hispanic
women, the sixth leading cause in Asian American women, and the seventh cause in white
women59. Left untreated, diabetes can lead to severe vision loss, heart
disease, stroke, kidney disease, and amputation of the lower limbs. Diabetes can be
controlled through a proper diet, weight loss, exercise, or the use of medications.


Osteoporosis
is a disorder characterized by the thinning and increasing brittleness of the bones that
can lead to bone fracture. It afflicts more than 25 million Americans—80 percent of
whom are women60. More than half of all women over age 65 suffer from this
condition61. Each year, osteoporosis causes 1.5 million fractures of the hip,
wrist, vertebrae, and other bones, and it accounts for 70 percent of all the fractures
occurring annually in people over age 45. Twenty percent of the women who suffer a hip
fracture die within one year of that event. The annual costs associated with osteoporosis
are estimated at over $10 billion, and it is a major cause of admission to nursing homes61.
Although osteoporosis is typically viewed as a geriatric concern, the prevention of
osteoporosis spans the entire life course. Approximately 60 percent of a woman’s
final bone mass is acquired by the time she is 18, and peak bone density is achieved by
age 3560. To build and maintain healthy bones, girls and women of all ages need
to consume calcium-rich foods, get regular exercise, and avoid tobacco and the excessive
consumption of alcohol or caffeine. Further treatment strategies include calcium and
vitamin D supplementation, estrogen replacement therapy at menopause, and nonhormonal
medication to stem bone loss.

An estimated 4 million people in the United States suffer from Alzheimer’s
disease, and in 1995, there were over 13,600 women who died of this disease62.
It is the most common cause of dementia for individuals over age 65. Alzheimer’s
disease places a heavy burden on society — costing society an estimated $80 to $100
billion each year — and on the individuals (primarily women) who take care of people
with Alzheimer’s62.


Urinary
incontinence (the unintentional loss of urine) affects 13 million
Americans—11 million of them women. Although half of all elderly people experience
episodes of incontinence, it is not exclusively a problem among the elderly. In fact, 1 in
4 women ages 30 to 59 experiences urinary incontinence. Women are most likely to develop
this problem during pregnancy, childbirth, and physical activity, or after menopause, due
to weakened pelvic muscles, or pelvic trauma. Incontinence is treatable in 8 out of 10
cases, but fewer than half of the people who experience this problem discuss it with a
health care professional63.

Since the 1970s, female obesity
has risen more than a fourth to a rate of 36 percent1. The rate is particularly
high among African American women (52.3 percent) and Mexican-American women (50.1
percent). Much of the rising rate is attributed to increasing lack of physical activity
and overeating. Being overweight increases women’s risks of heart disease, diabetes,
high blood pressure, arthritis, and some types of cancer.

Nearly 26.4 million of the 42.7 million Americans with arthritis
are women64. It is the most common and disabling chronic condition reported by
women. An estimated 4.6 million (4.6 percent) of American women report that arthritis
limits their daily activities, with higher rates among African American (6.5 percent) and
Native American women (6.9 percent) than among white women (4.2 percent)1.
Although arthritis is more common among the elderly, half of all people affected by the
disease are under the age of 6565. There are over 100 different types of
arthritis ranging from mild to severe. It most commonly causes pain or stiffness in the
joints of the hands, feet, knees, and hips. Risk factors including increasing age, injury,
obesity, and genetic predisposition66. Treatment for arthritis includes
medication, exercise, use of heat or cold, weight control, and surgery.


Fibromyalgia.
The American College of Rheumatology reports fibromyalgia affects 3 to 6 million
Americans. An estimated 80% of sufferers are women— most of whom are of childbearing
age. Fibromyalgia is a common disorder characterized by widespread musculoskeletal pain,
fatigue, and multiple tender points in the neck, spine, shoulders, and hips. People with
fibromyalgia may also experience sleep disturbances, morning stiffness,irritable bowel syndrome, anxiety and other symptoms.


Chronic
Fatigue and Immune Dysfunction Syndrome (CFIDS) is characterized by persistent and
debilitating fatigue and additional nonspecific symptoms such as sore throat, headache,
tender muscles, joint pain difficulty thinking and loss of short term memory. It is
estimated to affect as many as a half a million people in the United States and
approximately 80 percent of those diagnosed with CFIDS are women.
DISEASE PREVENTION/HEALTH PROMOTION

Most of the health care burden in the United States stems from chronic illness, more
than half of which may be related to lifestyle and behavioral factors. An estimated 47
percent of premature deaths in the United States could be prevented by modifying lifestyle
behaviors (including tobacco use, diet, physical activity, use of helmets and seatbelts,
sexual behavior, and alcohol and drug abuse)1; 20 percent could be prevented
by reducing environmental risks67. The development of effective behavior change
strategies and health promotion programs directed toward women is critical to improving
the quality and length of life.

**[Next Section] [Endnotes]**

May 2000
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