VOLUME 7

AGENDA FOR RESEARCH

ON WOMEN’S HEALTH

FOR THE 21ST CENTURY

NEW FRONTIERS IN 

WOMEN’S HEALTH

NATIONAL INSTITUTES 

OF HEALTH

Office of the Director
AGENDA FOR RESEARCH

ON WOMEN’S HEALTH

FOR THE 21ST CENTURY

NATIONAL INSTITUTES 

OF HEALTH

Office of the Director

Office of Research 

on Women’s Health

VOLUME 7

NEW FRONTIERS IN 

WOMEN’S HEALTH
U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health. 

Agenda for Research on Women’s Health for the 21st Century, Volume 7. New Frontiers in Women’s Health. 

Bethesda, MD. NIH Publication No. 01-4391.
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

MAJOR DISEASES, Conditions, AND 

HEALTH RISKS AMONG WOMEN . . . . . . . . . . . . . . . . . . . .3

Heart Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

Mental Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

Bone and Musculoskeletal Diseases . . . . . . . . . . . . . . . . . . . . . . . . .9

Immunity and Autoimmune Diseases . . . . . . . . . . . . . . . . . . . . . . .10

Kidney and Urologic Conditions . . . . . . . . . . . . . . . . . . . . . . . . . .12

Digestive Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

Alcohol, Tobacco, and Illicit Drug Use . . . . . . . . . . . . . . . . . . . . . .15

ADDITIONAL CRITICaL ISSUES 

IN WOMEN’S HEALTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

Reproductive Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

Oral Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

Drug Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

EMERGING DIRECTIONS FOR IMPROVING 

WOMEN’S HEALTH IN THE 21ST CENTURY . . . . . . . . . . .23

Understanding Sex and Gender Differences in 

Health/Disease and Prevention/Treatment . . . . . . . . . . . . . . . . . .23

Enhancing Women’s Health across the Life Span . . . . . . . . . . . . . .24

Emphasizing Prevention in Women’s Health . . . . . . . . . . . . . . . . . .26

Recognizing the Impact of Behavior on Women’s Health 

and Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

Employing a Multidisciplinary (Team) Approach to Fully Understand

Women’s Health and Provide Women’s Health Care . . . . . . . . . .29

Examining Health Disparities among Diverse Groups of Women . .30

Exploring the Role of Genetics in Women’s Health and Disease . . .31

THE ROAD AHEAD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35

CONTENTS

VOLUME 7

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“The extensive focus on

women’s health has brought 

forward new concepts 

and scientific questions.”

Vivian W. Pinn, M.D.

Associate Director for 

Research on Women’s Health

Director, Office of Research 

on Women’s Health

National Institutes of Health

Women live an average of 7 years longer than men and make

up the majority of the population over 65. They suffer from

different diseases, disorders, and conditions than men and,

even when they have the same diseases, women often experience different

symptoms and responses to treatment than do their male counterparts. 

There is ample evidence of variations in health and disease between

women and men. Research shows, for example, that more women than

men are diagnosed with arthritis, depression, type 2 diabetes, osteoporosis, gallstone disease, and eating disorders. Women have a higher 

rate of lung cancer and spend twice as many years disabled. They suffer

more serious consequences from drinking less alcohol; have a 2 to 3 

times higher occurrence of irritable bowel syndrome and functional 

bowel disease; and are 9 times more likely to contract certain liver 

diseases. Older women tend to experience more reactions to medications than older men, and women of all ages have a higher prevalence 

of urinary incontinence. And, while women account for 52 percent of 

all deaths due to heart disease and 61 percent of all deaths due to stroke

in the United States, they are less likely to have been treated by a doctor

for heart problems prior to their deaths. 

Sex and gender differences in disease rates, symptoms, and treatment 

outcomes have been recognized only recently. Earlier scientific studies

sometimes excluded women for various reasons, including the desire to

protect reproductive-age women from the unknown effects of unproven

treatments, and the commonly held belief that what was true for men 

was also true for women. 

INTRODUCTION

Sex refers to the classification of living things, generally

as male or female, according to their reproductive organs

and functions assigned by their biological make-up.

Gender refers to a person’s self-representation as male or

female, or how society responds to that person based on

the individual’s gender presentation. Gender is rooted in

biology and shaped by environment and experience.
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A GENDA FOR R ESEARCH ON W OMEN ’ S H EALTH FOR THE 2 1 S T C ENTURY

Fortunately, in the last decade of the 20th century, science has made 

substantial progress in understanding the differences between women 

and men in health and disease. Supported by a federal mandate, women’s

health research is now an integral part of the fabric of research at the

National Institutes of Health and in programs nationwide. Yet progress

gives rise to new questions—critical questions that point the way into

uncharted territory.

This report summarizes thousands of issues and questions raised by 

more than 1,500 women’s health professionals and advocates throughout the United States. Their recommendations for addressing the major 

diseases and health risks affecting women create a comprehensive map 

for scientific inquiry in the 21st century. Their common concerns reflect

emerging directions for women’s health research as it explores new 

frontiers in women’s unique experience of health and disease.

Creating a National Agenda 

In 1996-1997, more than 1,500 scientists, public policy makers,

clinicians, advocates, and members of the general public came

together at a series of meetings held across the United States to

discuss the state of women’s health research at the end of the 20th

century. Their task was to contribute to a 21st century national

research agenda that would address the changing requirements 

and opportunities for women’s health. Meetings were sponsored 

by the Office of Research on Women’s Health, National Institutes 

of Health (NIH), with the assistance of the Task Force on the NIH

Women’s Health Research Agenda for the 21st Century and the 

NIH Advisory Committee on Research on Women’s Health. 
Major Diseases, Conditions, and

Health risks among women

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Women are at risk for numerous life-threatening diseases 

and chronic conditions that impact the length and quality 

of their lives. By addressing critical questions about each 

of these health risks, research can help improve the lives of generations 

of women.

HEART DISEASE

More than 960,000 Americans die each year from cardiovascular 

disease (CVD), about one person every 33 seconds. CVD, which 

includes heart and coronary artery diseases, congestive heart failure, 

and stroke, kills almost twice as many American women as all cancers

combined, and more than 11 times as many women as does breast 

cancer. In fact, a postmenopausal woman is 10 times more likely to 

die from coronary artery disease than she is from breast cancer. 

Although women develop heart disease later in life than men do, heart

attacks are more deadly for women. For example, older women who have

heart attacks are nearly twice as likely as men to die from those attacks

within a few weeks (about 44 percent of women compared to 27 percent 

of men). And, among the women who die suddenly of coronary heart 

disease, 64 percent have had no previous symptoms. 

While dramatic progress has been achieved against heart disease in recent

decades, the frequency of heart attacks and other cardiovascular diseases

remains disturbingly high. Even though risk factors for heart disease in

women and men have been known for years, heart attack, stroke, and

Heart disease has been the number one killer 

of women for nearly a century and accounts 

for 43 percent of all deaths among women.
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A GENDA FOR R ESEARCH ON W OMEN ’ S H EALTH FOR THE 2 1 S T C ENTURY

other cardiovascular diseases in women have not been recognized 

as serious problems until recently, especially by women themselves.

Recent scientific achievements include increased funding for cardiovascular research, including research into women’s health services, the 

cost effectiveness of treatments, and the study of diverse populations 

and communities; greater participation of women in clinical studies; 

and new cardiovascular disease treatment regimens for women.

Continued research in the 21st century will help save women’s lives 

with answers to critical questions related to heart disease, such as:

• How do hormones affect the cardiovascular system in women 

versus men? In premenopausal versus postmenopausal women?

With or without hormone replacement therapy?

• What effects do diabetes and obesity have on the cardiovascular

system? Why is obesity a greater problem for women than for 

men and what factors contribute to this difference?

• What differences in cardiovascular disease exist among elderly 

and disabled women, as well as racial and ethnic minorities?

Among women living in different locations?

• How can cardiovascular disease in high-risk populations be 

prevented, detected, and managed?

CANCER 

Cancer is the leading cause of death for American women aged 35 to 74. 

It is only after age 75 that heart disease claims the lives of women in sufficient numbers to become their number one killer. In 1997, an estimated

596,000 women were diagnosed with cancer, while 265,900 women died

from the disease. 

Breast cancer is the most common form of cancer in women, yet lung 

cancer is the leading cause of cancer deaths in women, followed by breast

and colorectal (colon and rectal) cancers. The number of lung cancer

TABLE 1. Women’s Perceived and Real Health Risks

Perception Percent Cause of Death Percent

Breast cancer 46 Heart disease 34

Other cancer 19 Other cancer 21

Heart disease 4 Stroke 8

Breast cancer 4

“As obesity is becoming 

more prevalent, particularly

among women, and affects 

a number of risk factors, 

as well as risk for coronary 

heart disease itself, further

research into its causes and 

treatment are needed.”

Marian C. Limacher, M.D.

American College 

of Cardiology
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“The tragic and 

commanding fact 

about ovarian cancer 

is that more than 

50 percent of the 

women who have 

it die within 5 years 

of diagnosis.”

Ann Kolker

Ovarian Cancer National Alliance

“Ovar’coming Together”

deaths in 1997 represented 25 percent of all cancer deaths among 

women, and an increase of more than 16,000 deaths since 1991.

While lung cancer among all women continues to rise (it is decreasing

among men), scientific progress in the last decade has helped decrease the

death rate from breast and colorectal cancers among white women. Fiftysix new drugs for treating breast cancer are now in various stages of development and factors decreasing the risk of colon and rectal cancers have

been identified. In addition, major advances in genetics are improving the

scientific understanding of cancer, although little progress has been made

to improve women’s survival from ovarian, cervical, and uterine cancers.

Cancer researchers have observed differences in metabolism between

women and men, between different racial and ethnic groups, and between

older and younger persons; these differences influence individual responses

to carcinogens (cancer-producing substances) and treatments. As a result 

of these findings, studies are now underway to investigate how factors 

such as age, ethnicity, genetics, the environment, and social and economic

variables interact to determine whether an individual will develop cancer

and whether that cancer will respond to treatment. Researchers hope to

develop prevention strategies, diagnostic tests, and education and treatment programs that are effective, inexpensive, acceptable, and available 

to women of all income levels and cultural backgrounds.

Perhaps one of the most promising discoveries to date is that cancer may

be a preventable disease. Diet, cigarette smoking, hormones, and the environment have been found to be potential contributing factors to various

cancers. Decreased tobacco use has been shown to lower the occurrence 

of lung cancer, and some studies have shown that hormone replacement

therapy may decrease the risk of colon cancer, although it may also

increase the risk of breast and endometrial cancers. 

TABLE 2. Estimated 1997 Prevalence of Cancer in Women

Type of Cancer Number of Diagnoses Number of Deaths

Lung 83,200 67,430

Breast 180,200 43,900

Colorectal 65,900 24,300

Ovarian 26,800 14,200

Cervical 14,500 8,000

Uterine 34,900 6,000
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A GENDA FOR R ESEARCH ON W OMEN ’ S H EALTH FOR THE 2 1 S T C ENTURY

“Battered women are 

consistently found to 

have more depressive 

symptoms and significantly

higher diagnoses of 

major depression than 

other women.”

Jacquelyn Campbell, Ph.D., R.N.,

F.A.A.N.

The Johns Hopkins University 

School of Nursing

The women’s health agenda for the 21st century contains important 

recommendations and leading questions for cancer research, such as 

those stated below.

• What are the long-term effects of different forms of estrogen 

on cancer risk?

• How does cancer start, grow, and spread?

• What medications are effective for various cancers, with minimal

side effects?

• What are the effects of exercise and weight control on cancer risk?

• What strategies and methods help people quit smoking or refuse 

to start? 

MENTAL DISORDERS 

Mental disorders include anxiety disorders (panic disorder, posttraumatic

stress syndrome, obsessive compulsive disorder, and phobias), depressive

disorders, schizophrenia and other psychoses, and the eating disorders of

anorexia and bulimia. Anxiety disorders are the most widespread forms 

of mental illness in the United States, affecting more than 20 million 

individuals. By comparison, an estimated 18.4 million Americans suffer

each year from some form of depression, while another 2.3 million are 

considered manic depressive (experiencing alternating cycles of excessive

excitement and depression). 

Major mental disorders impact women and men to almost the same extent,

although certain conditions are more common in women. Anxiety disorders, for example, are diagnosed approximately 2 to 3 times as often in

women as in men. Major depression is diagnosed in about twice as many

women as in men, while eating disorders occur 8 to 10 times more frequently in women. Plus, there is growing evidence that depression may

express itself differently in women than in men. 

Research over the past decade has led to a new understanding of the 

burden of mental illness in women. Because women are often caregivers 

for both parents and children, their mental problems can influence two 

or three generations of family members. At the same time, women may

Depression is becoming a global epidemic. 

At its current rate of increase, depression will 

be second only to heart disease as the reason 

people lose healthy years of life by the year 2020. 
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“HIV infection is the 

third leading cause of 

death among women 

ages 25 to 44, and the 

leading cause of death 

among black women 

in this age group.”

Betty B. Hambleton

Health Resources and 

Services Administration

have multiple responsibilities creating stresses that amplify their mental 

illnesses. Women are also more likely to be the victims of violence, an

experience that has been linked to the onset of various mental disorders.

Most mental disorders can be treated successfully. Nearly 85 percent 

of people with depression respond positively to one or more types of 

treatment, while recent therapies have provided relief to women with 

anxiety disorders. Progress is also being made in how to educate and 

help women and young girls suffering from eating disorders. 

In addition to conducting research on the role of sex and gender in 

mental disorders, researchers are currently exploring how age, physical

health, ethnicity and race, marital status, parental status, education, occupation, income, sexual orientation, geographic location, and work status

influence the appearance, symptoms, and treatment of mental illnesses. 

As science enters the new century, it aims to answer additional questions

about mental health in women, including those listed below. 

• What factors contribute to the development of mental disorders in

women across the life span? What makes some women susceptible

and others resistant to mental disorders?

• What are the causes of depression in all its forms? What individual

and interactive roles do genetics and environment play? How can

depression be prevented and treated effectively in women?

• What are the long-term mental and physical consequences of 

sexual assault and domestic violence?

• What are the impacts of hormones on brain development, aging,

behavior, and sex and gender differences in mental disorders? What are

the long-term interactive effects of mood-altering drugs and hormones?

INFECTIOUS DISEASES

Sexually transmitted diseases (STDs), including human immunodeficiency

virus/acquired immunodeficiency syndrome (HIV/AIDS), are often the 

focus of discussions on infectious diseases in women, primarily because 

of their long-term potential for harm. Many STDs are more difficult to

detect in women, often due to a lack of noticeable symptoms. Even so,

these diseases tend to affect women, including a disproportionate number 

of minorities, more severely than they do men. An estimated 8 to 10 

million women suffer from the chlamydia infection, while millions more

live with genital herpes and human papilloma virus infections. As a result

of sexually transmitted diseases, women often experience infertility, 

miscarriages, and genital cancer. In addition, STD infections have 

been shown to increase the risk of contracting or transmitting HIV.
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A GENDA FOR R ESEARCH ON W OMEN ’ S H EALTH FOR THE 2 1 S T C ENTURY

“The need for womancontrolled methods of 

STD and HIV prevention 

has only recently been 

recognized as a priority, 

and much remains to be 

done to move this issue 

to the forefront of the 

women’s health agenda.”

Amy Allina

Reproductive Health 

Technologies Project

Scientific studies of infectious diseases have led to new diagnostic tests and

drugs for treating HIV/AIDS and other sexually transmitted diseases, and

have reduced the spread of HIV to newborn infants. Research has also

revealed a strong causal link between human papilloma virus (HPV) and

cervical cancer, resulting in the consideration of cervical cancer as an STD.

Additional findings have increased sensitivity to the importance of behavioral changes in preventing sexually transmitted diseases and HIV/AIDS,

raised awareness about women’s risk of HIV infection, and shown that the

diagnosis and treatment of STDs can decrease the risk of HIV transmission.

Ongoing investigations of infectious diseases seek to (a) understand 

the development and natural history of STDs, including the influence 

of genetics; (b) develop and test methods for preventing infections and 

treating diseases and complications; (c) consider the impact of women’s 

life cycle changes on the progression and treatment of infectious diseases;

and (d) determine the range of related health issues important to women

and their families and communities. For example, researchers hope to

develop a catalog of sexual behaviors across the life span, and within and

across communities, as a step toward preventing and treating STDs. They

are studying the impact of popular culture and social standards on individual and group behavioral change, to guide the creation and use of public

health messages. And they are creating new methods to diagnose and treat

STDs that are reliable, inexpensive, rapid acting, accurate, and easy to use.

Leading questions for infectious disease and STD research in the 21st 

century include the following:

• How do environmental factors, genetics, and the immune system

influence women’s susceptibility to sexually transmitted diseases, 

including HIV?

• What are the potential effects of hormonal birth control methods 

on women’s vulnerability to infections? 

• What methods are effective in preventing STDs, including HIV, 

in women? In babies born to infected mothers? 

• What are the long-term effects of vaccines, disease progression, 

and treatments for all sexually transmitted diseases and HIV?

• What factors influence women’s incidence of urinary tract 

infections, tuberculosis, group B strep, and hepatitis B and C?

Adolescents are at high risk of contracting sexually

transmitted diseases, including HIV. An estimated 

3 million STD cases occurred in teenagers in 1994.
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“Today, no national 

system exists which 

can provide comprehensive information 

about injury and illness 

patterns in physically 

active women.”

Marjorie J. Albohm,

M.D., A.T.C.

The National Athletic 

Trainers Association

BONE AND MUSCULOSKELETAL

DISEASES

Many bone and musculoskeletal conditions appear more often in women

than in men, and have different causes, symptoms, effects, and treatment

outcomes. Arthritis, which refers to more than 100 illnesses and conditions,

is the most common chronic condition reported by American women 

(23 million in 1990). About 16 million Americans suffer from osteoarthritis,

which affect 2 times as many women as it does men, while rheumatoid

arthritis afflicts 2.1 million Americans, occurring in 3 times as many women

as men. In all its forms, arthritis is the third leading cause of bed disability

in the United States and contributes to individuals’ inability to work or

perform daily activities, as well as to adverse psychological effects. 

Osteoporosis involves low bone mass, with continued bone loss leading 

to an increased risk of fracture. Low bone mass, or density, is found more

often in women than men because women build up less bone as they

mature and have increased bone loss at menopause, due to a drop off 

of estrogen. An estimated 4 to 6 million women over age 50 suffer from

osteoporosis, while an additional 13 to 17 million have osteopenia (less

severe bone loss). The percentage of women with osteoporosis increases

with each decade of life after age 50. 

Orthopedic problems, such as fractures, foot problems, shoulder instability, scoliosis (curvature of the spine), and carpal tunnel syndrome

(severe wrist pain) are the primary causes of bed disability in the United

States. Women made an estimated 20 million visits to their physicians 

for these conditions in 1995. Although the lack of appropriate exercise

throughout life may contribute to some of the physical impairments 

occurring in some women as they age, the increased participation of 

many women in sports and fitness activities makes the prevention 

of orthopedic sports injuries a high priority. In some cases, extreme 

physical activity can play a part in eating disorders and lead to 

amenorrhea (the absence of menstrual cycles) and osteoporosis. 

Progress over the last few years in the science, treatment, and management of bone and musculoskeletal disorders has been remarkable. 

Arthritis research has led to improvements in joint replacement surgery,

the discovery that self care works and enhances self-sufficiency, and 

an understanding of the benefits of exercise for pain relief. Studies of

The combination of arthritis and orthopedic 

impairments limits the physical activity of 

4.5 times as many people as do heart conditions. 
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osteoporosis have resulted in revised dietary guidelines for calcium 

intake, new ways to measure bone mass, and new drugs for disease 

prevention and treatment. In the field of orthopedics, scientists have

improved techniques for treating fractures and soft tissue injuries, 

as well as for performing total joint replacements; developed less 

invasive surgery procedures; and identified factors that may make 

some women prone to carpal tunnel syndrome.

Research in the next century promises to improve the bone and musculoskeletal health of women by addressing questions like those below. 

• What factors influence the progression of arthritis and why do 

more women than men suffer from this disease?

• What factors contribute to the development of peak bone mass?

What contributes to bone loss?

• What causes stress fractures?

• What is the role of physical activity in developing bones, tendons,

ligaments, and muscles? In preserving muscular strength, balance,

and coordination as a means of preventing falls in the elderly? 

IMMUNITY AND AUTOIMMUNE

DISEASES

The immune system protects the body from viruses, bacteria, and 

other health threats by identifying and destroying these foreign intruders.

Autoimmune diseases, in which the immune response begins to attack 

the body’s own tissues, affect three times as many women as men. 

Autoimmunity is the root cause of more than 80 serious, chronic diseases,

including rheumatoid arthritis, type 1 diabetes, lupus (destructive tissue

inflammation), multiple sclerosis, Graves’ disease (hyperthyroidism), 

and scleroderma (thickening and hardening of the skin).

The most common autoimmune disease is arthritis, which currently 

afflicts 23 million women in the United States and is expected to afflict 

36 million by the year 2020. A leading cause of disability in women, 

arthritis has also been linked to anxiety, depression, and changes in 

cognitive abilities (perception, memory, judgment, and reasoning). 

Asthma and chronic allergies, also immune-related diseases, account 

Over a 10-year period, a 65-year-old woman 

has a 40 percent chance of being hospitalized 

for a musculoskeletal condition.
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for considerable illness among women, while atherosclerosis (hardening 

of the arteries) and Alzheimer’s disease are complicated by an immune 

or inflammatory component. 

Notable scientific progress over recent years has expanded understanding

of the immune system and its related diseases. For example, researchers

have discovered that the immune function may be altered by external 

factors such as diet, vitamins, stress, infections, indoor and outdoor allergens, physical activity and exercise, sexual orientation, implants, hormone

replacement therapy, and birth control pills. Study results have helped 

doctors improve bone marrow transplants and the rebuilding of the

immune system after chemotherapy and radiation treatments. 

At present, new research tools involving DNA are allowing researchers 

to conduct studies that were previously impossible, while important 

interactions between the immune system and the nervous and endocrine

systems, as well as with hormones, are being studied and documented.

These and other advances offer hope that autoimmune and allergic diseases

can be prevented and effectively treated. 

The women’s health agenda for the 21st century includes the following

questions concerning immunity and autoimmune diseases.

• What genes are involved in autoimmune and allergic diseases?

• What are the specific effects of environmental factors, such as 

diet, stress, and allergen exposure on immune function?

• What are the effects of age and sex on normal and abnormal

immune function?

• How do hormones affect the immune response? Is there a 

difference in effect between the body’s natural hormones and 

the hormones contained in birth control pills and hormone 

replacement therapy? Do women’s cyclical changes in hormones

affect the immune response?

• What differences exist in various organs associated with 

inflammatory diseases—the brain in multiple sclerosis, the 

joints in rheumatoid arthritis, the beta cells in diabetes, the 

kidney and vasculature (blood vessels and lymph ducts) in 

lupus, the lung in asthma, and the skin in scleroderma?

“Basic research will 

yield information that 

benefits the treatment 

and diagnosis of all 

autoimmune diseases 

and represents the most 

promising approach to 

finding a cure.”

Virginia T. Ladd, R.T.

American Autoimmune 

Related Diseases Association

Many autoimmune diseases are considered rare, affecting fewer

than 200,000 people. Taken together, however, they afflict 50

million Americans, including 3 times more women than men.
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KIDNEY AND UROLOGIC 

CONDITIONS

Diseases of the kidney and urinary system have a major impact on

women’s health. Permanent kidney failure, called end-stage renal disease,

affects more than 120,000 women in the United States. And although

treatment with dialysis or transplantation is necessary to sustain life, 

neither of these options restores normal, or even near-normal, 

life expectancy. 

Kidney disease is on the rise among both men and women. The number of

new patients requiring dialysis or a transplant nearly doubled from 1985

to 1995. Women, however, are more likely to suffer from renal failure as a

result of type 2 diabetes or lupus (a type of autoimmune disease characterized

by a destructive inflammation of connective tissue), or from the long-term

use of painkillers; many also experience pregnancy-related kidney disorders.

Women’s urological disorders, which afflict all women at some point in

their lives, include urinary incontinence (uncontrollable urine flow), pelvic

floor disorders, urinary tract infections, and interstitial cystitis (chronic

bladder inflammation). Generally less serious than renal failure, these conditions still have a profound effect on women’s quality of life. They are

often chronic, misdiagnosed, and inadequately treated. Many women are

too embarrassed to report these conditions to their doctors, often waiting

years before getting treatment. Of the estimated 50 percent of childbearing

women who lose pelvic floor support, resulting in urinary incontinence

and severe pelvic pain, only 10 to 20 percent seek medical care.

Progress in renal health in recent years, which benefits many women, has

included the development of new drugs for preventing organ rejection in

kidney transplant patients. Advances in diabetes research have produced

better ways to attempt to prevent and manage diabetic renal failure. In 

the field of urology, scientists have improved the design and increased 

the availability of adult continence products, while emphasizing patient

training for the self-management of uncontrolled urine flow. Researchers

have also enhanced their understanding of the link between childbirth 

and pelvic floor disorders, the use of folate supplements before and during pregnancy to help prevent bladder dysfunction, and the behavioral 

risk factors associated with urinary tract infections. And new drugs for

treating interstitial cystitis now offer relief to millions of women.

“Interstitial cystitis (IC) 

was considered, and 

still is considered by 

some urologists, as 

an ‘hysterical female 

condition.’ Unfortunately, this blatantly 

incorrect label still 

haunts IC victims with 

the sufferer taking, on 

average, 4.5 years to 

get a correct diagnosis 

and often having to 

see an average of 

five physicians before 

IC is diagnosed.”

Vicki Ratner, M.D.

Interstitial Cystitis 

Association

A person developing end-stage renal disease at age 50

has only a 20 percent chance of surviving for 10 years.
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Further progress in the prevention, diagnosis, and treatment of kidney and

urologic conditions will come from answers to questions like those below.

• What are the effects of the chronic use of pain relief medication 

on kidney function?

• In women with kidney disorders, what is the impact of 

pregnancy on renal function? The best approach to hormone

replacement therapy?

• What strategies are effective in preventing kidney diseases 

among women with type 2 diabetes?

• What are the impacts of childbearing and aging on urinary 

incontinence, pelvic floor disorders, and urinary tract infections among diverse populations? Over long periods of time?

DIGESTIVE DISEASES

Women are at high risk for many digestive diseases. For example, 

2 to 3 times more women than men are diagnosed with irritable bowel 

syndrome and functional bowel diseases, conditions that affect 15 to 

20 percent of the U.S. population. Women also comprise two-thirds 

of the estimated 20 million Americans suffering from gallstones. More

women than men develop peptic ulcers from high doses of nonsteroidal

anti-inflammatory drugs, such as aspirin and ibuprofen. Nine times as

many women suffer from biliary cirrhosis and 3 to 4 times as many 

women have autoimmune hepatitis (progressive inflammation of the 

liver). In addition, women with inflammatory bowel or chronic liver 

diseases have an increased chance of developing osteoporosis, while

women diagnosed with colorectal cancer (also considered as a digestive 

disease) have a higher risk of experiencing cancer of the pancreas, small

bowel, or endometrium. 

TABLE 3. Frequency of Kidney and Urologic Conditions 

Condition Frequency

Urinary Incontinence 10-30 percent of women aged 15 to 64 and 10.4 million women

over 65 (80 percent of all cases) 

Pelvic Floor Disorder 400,000 related surgeries each year

Urinary Tract Infection Half of all women have at least one infection by age 30

Interstitial Cystitis 405,000 women (90 percent of all cases) 

“Approximately 75 percent 

of individuals with irritable

bowel syndrome (IBS) in 

the community are female, 

with the incidence being

reported as high as 90 percent in some medical centers.”

Nancy Norton

International Foundation 

for Functional 

Gastrointestinal Disorders
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A GENDA FOR R ESEARCH ON W OMEN ’ S H EALTH FOR THE 2 1 S T C ENTURY

Digestive problems during pregnancy include (a) chronic conditions present

prior to pregnancy, such as ulcerative colitis, Crohn’s disease, and biliary

disease; and (b) symptoms and conditions generally associated with pregnancy, such as nausea, vomiting, and heartburn. Acute fatty liver disease

can also occur during pregnancy and, although very rare, can be fatal.

Scientific advances over the past 10 to 15 years have expanded the 

understanding of gastrointestinal functions and diseases. For example, 

factors such as stress, physical and sexual abuse, and mental health have

been shown to play important roles in the onset and treatment of irritable

bowel syndrome, changes in the motility (ability to move) of the small

intestines or colon, and an increased sensitivity to pain. The newly 

identified nonalcoholic liver disease, steatohepatitis, has been linked to

obesity and non-insulin dependent diabetes. Plus, the development of 

less invasive surgical techniques now permit more rapid recovery rates 

for gallbladder patients, while recent genetic discoveries offer great 

promise for reducing the incidence of colorectal cancer and gallstone 

and acute fatty liver diseases.

The agenda for research on digestive diseases in women includes finding

answers to questions such as:

• Why do irritable bowel syndrome and functional bowel diseases

affect more women than men?

• What cost-effective methods are there for the early detection of 

colorectal cancer? How can women and health care providers be

made more aware of the importance of screening for this disease?

• What causes gallstones during pregnancy and periods of rapid

weight loss?

• What are safe and effective therapies for treating liver diseases 

in women? For treating chronic gastrointestinal conditions in 

pregnant women?

• How does calcium absorption in the intestines affect health 

and disease, and how does this change with age? 

Early screening for colorectal cancer is highly effective in 

preventing new cases of colon cancer because growths can be

discovered and removed before they become cancerous.

Gallbladder removal is one of the most 

common surgeries performed on women.
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VOLUME 7

“Women have a 1.4 

to 2.9 times higher risk 

of developing lung 

cancer than men when 

the amount of tobacco 

exposure is controlled.”

Carolyn M. Dresler, M.D.

Thoracic Surgical Oncologist

American College of 

Chest Physicians

ALCOHOL, TOBACCO, AND 

ILLICIT DRUG USE 

Women make up one-third of the estimated 14 million Americans who

abuse or are dependent upon alcohol. While men drink alcohol in larger

amounts than women do, alcohol-dependent women often experience

greater psychological impairment sooner once they begin to drink heavily.

Women alcoholics also develop alcohol-related liver disease, heart disease,

and brain disorders earlier in their drinking careers than do men.

About half of the 48 million smokers in the United States are women, 

as are nearly a third of the 500,000 people who die from tobacco use 

each year. Even though tobacco is the most preventable cause of death 

in this country, smoking rates among women have declined only 21 percent in the past 30 years, compared to an 84 percent decline among men.

In addition to risking lung cancer, women who smoke often experience

early menopause, which may increase their risk for coronary artery disease. 

A study conducted in 1990-1992 found that about 6 percent of American

women between the ages of 15 and 54 met the criteria for lifetime drug

dependence. In another study, more than 221,000 women admitted using

drugs while pregnant. Such illicit drug use (as well as alcohol abuse) 

has been linked to mental disorders, especially depression; violence and

sexual abuse; eating disorders; low self-esteem; and exposure to sexually

transmitted diseases, including HIV/AIDS. 

Recent scientific studies have demonstrated that (a) alcoholism risk can 

be transferred genetically from generation to generation; (b) women are

more likely to begin or maintain cocaine use in order to develop more 

intimate relationships, while men are more likely to use the drug with 

TABLE 4. Women’s Alcohol, Tobacco, and Illicit Drug Use 

Condition Prevalence

Alcohol abuse and/or dependence 4.0 million

Alcohol use in past year of ≥ 12 drinks 32.7 million

Tobacco use at some time in life 73.6 million

Tobacco use in past year 32.5 million

Tobacco use in past month 29.5 million 

Illicit drug use in past month among 4.3 million

women of childbearing age

Cigarette ads have been linked to an increase 

in smoking rates among teenage girls. 
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A GENDA FOR R ESEARCH ON W OMEN ’ S H EALTH FOR THE 2 1 S T C ENTURY

male friends and in relation to the drug trade; and (c) the presence 

of their children in residential treatment facilities increases women’s 

length of time in treatment. 

The following questions will help guide future research into alcohol, 

tobacco, and illicit drug use among women.

• What are the effects of a mother’s alcohol and drug use 

on her children’s use of alcohol and drugs?

• How is women’s alcohol and drug use influenced by 

the presence of anxiety disorders? Eating disorders? 

Depression? Childhood sexual abuse? 

Violent victimization as an adult? 

• How do the media and advertisements influence women’s 

use of alcohol, tobacco, and illicit drugs?

• How do hormones and alcohol interact?

• What can be learned about effective treatment for alcohol 

and drug addictions from women who successfully recover?
ADDITIONAL CRITICAL ISSUES

IN WOMEN’S HEALTH 

“One of the greatest 

and most unfortunate 

gaps in the public’s 

knowledge about 

women’s health is a 

lack of understanding 

about human reproduction.”

Mary Hammond, M.D.

American Society for 

Reproductive Medicine

I

n addition to the major diseases and health risks just described, women

face unique issues related to their reproductive and oral health. They also

respond differently to medications and drug treatments than do men.

REPRODUCTIVE HEALTH 

Historically, the term “women’s health” has meant “reproductive health,”

with research in women’s health generally limited to the study of obstetrics

and gynecology. In the late 1970s, however, social pressures, especially

feminist concerns about women’s interactions with the medical system,

resulted in a broader definition of women’s health that included the treatment of all diseases and conditions in women. As the concept of women’s

health expanded, reproductive health research remained focused on issues

related to pregnancy, fertility and infertility, contraception, benign reproductive tract diseases and disorders, and menopause. 

In recent years, results from reproductive research have contributed to 

an increased knowledge of pregnancy, including the effects of infection 

and other external factors, such as diet, exercise, smoking, violence, and

medications. In addition, physicians now have access to new birth control

methods and more effective treatments for infertility, along with genetic 

and other diagnostic tests to help prevent birth defects. They also have 

a greater awareness of the occurrence and treatment of abnormal uterine

bleeding, premenstrual syndrome, leiomyoma (uterine fibroids), pelvic

pain, endometriosis, and pelvic floor relaxation. 

Scientific studies are now underway to address gaps in our understanding

of normal and problem pregnancy. Hopefully, biological and behavioral

research can come together to (a) identify contraceptives that are effective 

and acceptable to use and (b) improve the safety and cost-effectiveness 

of fertility treatments, while addressing ethical concerns in reproductive

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A GENDA FOR R ESEARCH ON W OMEN ’ S H EALTH FOR THE 2 1 S T C ENTURY

medicine. Scientists can also explore the long-term effects of gynecological diseases and treatments, as well as the effects of hormonal

changes over the life span, on fertility, behavior, menopause, and 

hormone-dependent diseases.

Reproductive health research in the 21st century will keep two considerations in mind: (a) educating health professionals and the general

public on risk factors, diagnostic tests, and the pros and cons of available treatment options; and (b) attending to the individualized needs 

of specific populations, including the medically underserved, women 

of color, women with disabilities, adolescents, postmenopausal and 

elderly women, and lesbians. Within this context, some key research 

questions are stated below.

• What genetic tests, medical and surgical options, and other 

treatment alternatives can improve the monitoring and outcomes of pregnancy? 

• How can contraceptives help prevent sexually transmitted 

diseases?

• Which infertility treatments are best for specific populations? 

How can the negative medical, social, and economic effects of 

multiple pregnancy and births be reduced?

• What are the critical factors in the development of gynecological

diseases and disorders? How can these diseases be identified?

What are the safe, effective, and less invasive treatment options?

• What are the effects of hormone changes at menopause? What 

is the safety and usefulness of hormone replacement therapy

(HRT)? How can problems be detected and reduced? What 

effects does HRT have on the start-up, growth, or return of 

hormone-dependent diseases?

ORAL HEALTH

Most oral problems are complex diseases involving genetic, behavioral,

social, economic, and environmental factors. They affect women of all

ages. Young women who smoke, engage in unprotected sexual activity, 

or suffer from eating disorders in which they invoke frequent vomiting 

are at risk for mouth and throat cancers, AIDS-related oral problems, 
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VOLUME 7

“Dental and oral 

diseases affect most 

older Americans; 99.5 

percent of Americans 

65 years and older 

have had cavities and 

40 percent of these 

elderly Americans have 

lost all their teeth...

46 percent of women 

over 75 years of age 

have lost all their teeth.”

Susan Silverton, M.D., Ph.D.

American Association of 

Dental Schools

and tooth erosion and decay. Uninsured single mothers living in 

poverty and many mothers, in general, who defer their own dental 

care in favor of other family members are susceptible to oral problems 

that repeat and multiply over time. Older women who have multiple

chronic conditions, take numerous medicines, or experience reduced 

physical functioning and/or mental capacity encouter many disabling 

problems from oral diseases, disorders, and conditions.

In addition to providing new materials for dental and facial implants 

and jaw replacements, oral health advances in the latter part of the 

20th century offer hope to women suffering from a variety of diseases. 

For example, oral health studies confirming differences in pain sensitivity

between men and women may help to explain and treat women’s more 

frequent experience of migraine headaches, fibromyalgia, and temporomandibular joint (TMJ), or jaw, pain. Preliminary data pointing to links

between oral and hipbone mineral densities, periodontal (gum) disease 

and diabetes, and gum disease and heart attacks may lead to new strategies

for reducing these major health risks. Emerging evidence showing that

poor maternal periodontal health increases a newborn infant’s potential 

for low birth weight, and for preterm or premature birth, may be an 

important key to effective prenatal care. And saliva, which is already 

being used to monitor levels of hormones and prescription drugs, as 

well as the presence of illicit drugs, may prove to be an effective diagnostic aid in diseases such as Alzheimer’s, cystic fibrosis, and diabetes.

Oral health refers to the status of the 

teeth, gums, salivary glands, bone and 

facial structures, nerves, taste buds, 

and mucous membranes (inner 

lining of the mouth). 

Severe periodontal disease in pregnant 

women is linked to a sevenfold increase 

in the risk of delivering preterm, 

low-birthweight babies.
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A GENDA FOR R ESEARCH ON W OMEN ’ S H EALTH FOR THE 2 1 S T C ENTURY

Additional research topics offering promise in the control of oral diseases

and the improvement of the general health and quality of life for women 

in the 21st century are stated below.

• What is the relationship between variations in reproductive 

hormone levels and women’s experience of pain? How do social 

and cultural factors influence women’s responses to pain across 

the life span? In different cultural environments?

• What is the relationship between oral diseases in HIV-infected

women and their children? 

• How do stress, coping behaviors, and depression affect the 

relationship among oral bone loss, osteopenia, and osteoporosis?

What are the effects of hormones and hormone replacement 

therapy on oral bone loss and tooth retention?

• What is the role of periodontal infection in diabetes? 

In cardiovascular disease? In premature birth?

DRUG THERAPY

Women’s bodies absorb and respond to therapeutic drugs differently 

than men’s bodies do. As a result, women often experience negative 

side effects from drug doses established for men, and require higher or

lower dosages to reap the same benefits. In addition, women’s reactions 

to medications vary over the life span and may be influenced by hormonal

changes during pregnancy and by hormone replacement therapy. There

may also be differences in women’s responses to medications or drug 

therapies across different racial and ethnic groups.

Therapeutic drugs are called “pharmacologic agents,” as are dietary 

supplements (vitamins and minerals), and complementary and alternative medicines. Understanding how these therapies work in women, 

individually and in combination, can help doctors prescribe the correct

amounts of the right medications and advise women on possible therapeutic drug interactions.

The most important advancement in drug therapy research in recent 

years is the progress made in promoting women’s participation, including

women of childbearing potential, in all phases of clinical trials. Results 

have contributed to an increased awareness of differences in medicationinduced responses between men and women; the impact of hormones 
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VOLUME 7

“To provide optimal 

pharmaceutical care, 

pharmacists should be 

aware of the ethnic and 

racial composition of their

patient population, and the 

distinctive characteristics that

may elicit ethnic and racial 

differences in pharmacologic

responses to medicines as 

well as the psychosocial 

and economic parameters 

that influence drug use 

or misuse.”

Gloria J. Nichols, M.Ed., Ph.D.

Catherine A. White, Ph.D.

University of Georgia 

College of Pharmacy

and various enzymes on drug effectiveness; and the occurrence of 

problem side effects experienced by women during drug therapy 

and/or after taking dietary supplements. 

While these and other findings will help ensure the safety and effectiveness of medications for women, complicated issues remain in the study of

therapeutic drugs in women. Testing new medications on women of childbearing age raises concerns about the potential harm to unborn infants.

Not testing new medications on pregnant women leaves unanswered questions about the safety of the drugs, once they are approved, for the pregnant

women themselves, as well as for their unborn and newborn children 

(who might take in the medication through a mother’s breast milk). 

With these issues in mind, the agenda for research on women and drug

therapy in the next century includes important questions, such as:

• What are the differences in how medications work in women 

and men? In women from different racial and ethnic groups?

• How do therapeutic drugs affect women across the life span? 

During pregnancy? During and after menopause?

• What therapeutic drug-to-drug interactions are important 

for women’s health? Drug-to-supplement interactions? 

Drug-to-food interactions?

• How can the effects of medications on pregnant women and their 

children be evaluated without risking the health of the women 

or the children? What effect will drug therapies, especially antidepressants, taken by a pregnant mother have on the development

of her unborn child? What are the effects of a mother’s medications 

on her breast-feeding infant?

In 1994, the National Institutes of Health 

published the NIH Guidelines on Inclusion of Women

and Minorities as Subjects in Clinical Research.

EMERGING DIRECTIONS FOR

IMPROVING WOMEN’S HEALTH

IN THE 21ST CENTURY

“Gender differences 

of significant clinical 

relevance have already 

been discovered in the 

immune system, susceptibility 

to lung cancer, use of 

pain-killing drugs, and 

treatment of angina.”

John C. Fletcher, Ph.D.

Professor of Biomedical Ethics 

University of Virginia

Answers to critical questions in all areas of women’s health 

research will pave the way for improvements in disease prevention, diagnosis, and treatment. Scientists can gain further

ground, and enhance the quality of life for both women and men in 

the 21st century, by following the seven emerging directions in women’s

health research listed below and described on the following pages.

• Understanding sex and gender differences in health/diseases and 

prevention/treatment

• Enhancing women’s health across the life span

• Emphasizing prevention in women’s health

• Recognizing the impact of behavior on women’s health and diseases

• Employing a multidisciplinary (team) approach to fully understand

women’s health and provide women’s health care

• Examining health disparities among diverse groups of women

• Exploring the role of genetics in women’s health and disease

UNDERSTANDING SEX AND 

GENDER DIFFERENCES IN 

HEALTH/DI SEASE AND 

PREVENTION/TREATMENT 

Women and men differ in their physiology and their behavior. While they

suffer from diseases that are unique to their sex, they may also develop 

the same diseases at different rates with different symptoms. Variations in

lifestyle choices (cigarette smoking, alcohol consumption, and exercising)

often affect their health directly, while their distinct roles in society can

contribute to their risk of disease. Their hormones, which affect many of

their sex- and gender-dependent physical traits, have been shown to modify

their ability to absorb and respond to certain medications; their biological

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A GENDA FOR R ESEARCH ON W OMEN ’ S H EALTH FOR THE 2 1 S T C ENTURY

“Research on women’s 

health must include the full 

biological life cycle of the

woman and the concomitant

(related) physical, mental, 

and emotional changes 

that occur.”

Marianne Legato, M.D. 

Donna Dean, Ph.D.

Task Force on the NIH Women’s

Health Research Agenda 

for the 21st Century

differences in body composition, size, and metabolism may influence 

the required amount and effectiveness of therapeutic drugs. In addition,

women go through hormonal stages that influence the development of diseases such as heart disease and osteoporosis, are more often the victims of

domestic violence, and have higher rates of depression and eating disorders.

It is only in the last 10 years that the National Institutes of Health 

has implemented a policy requiring that women be included routinely 

in medical and behavioral research. Within NIH, the Office of Research 

on Women’s Health was establish in 1990 to ensure the inclusion of

women in clinical trials, as well as to ensure and enhance research on

women’s health. Fortunately, such research is now providing information

about sex and gender differences that can address the dangers of assuming that women and men are identical.

While the past decade of research into women’s health has raised awareness

of sex and gender differences in diseases and treatments, there is more to be

done. For example, the continued examination of differences in brain and

nervous system development (neuroscience) between women and men, including sex- or gender-specific symptoms and treatment responses, can increase

the scientific understanding of how diseases in women start, progress, and

improve with treatment. Results of such research can hopefully shed light

on conditions such as Alzheimer’s disease, chronic pain, anxiety disorders,

depression, multiple sclerosis, Parkinson’s disease, stroke, schizophrenia, and

epilepsy. Studies to determine the behavioral, social, cultural, and environmental factors that contribute to these diseases can round out the picture. 

Additional areas of investigation offer considerable promise. Of special

interest to women are studies on the role of hypertension (high blood 

pressure) in women’s heart disease; new and advanced technologies 

for the early diagnosis of lung and reproductive cancers; effective 

approaches for the treatment of infectious diseases in women; new 

categories of therapeutic drugs for depression; links between nutrition,

obesity, and diabetes; gene studies related to heart disease, osteoporosis, 

and other conditions; and outreach to special populations of women 

(racial and ethnic minorities, women with disabilities, lesbians, and 

women living in poverty). 

ENHANCING WOMEN’S HEALTH

ACROSS THE LIFE SPAN 

A woman faces specific health risks at each stage of her life. Studying 

these risks, along with other issues relevant to each stage of women’s 

development, is essential to understanding and improving women’s 

health in the 21st century.
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VOLUME 7

“Issues for women who are 

65 or 70 and 85 or 90 

years of age are enormously

different. Since this is the

fastest-growing segment of 

our population, it can only 

be ignored at the peril of 

society as well as of the

women whose problems 

we hope to address.”

Jeanne Carritt, M.A., M.Ed.

Lois Grey Long, R.N., M.S.N.

Research on the prenatal, infancy, and childhood years can focus on 

identifying the short- and long-term effects of drugs on unborn infants 

and young children; and normal physical, behavioral, and psychological 

development, including the influence of genes and the environment. Studies

can also determine sex and gender differences in response to stress and

nutrition, critical stress points, and the development of coping behaviors.

When studying the adolescent years, scientists can consider how girls develop

physically, socially, emotionally, and mentally, as well as how the environment affects their physical growth. They can look at risk-taking behaviors

related to sexual activity, substance use and abuse, violence, injury, runaways,

suicide, homelessness, and girls in gangs. Other areas of focus include how

teens learn to cope with chronic illness, family problems, life events, violence, and troubling emotions. In this area of research, investigators can

also search for effective ways to promote healthy behaviors, such as good

nutrition, physical activity, sexual health and hygiene, and oral health.

For women in their reproductive years, researchers in the new millennium

can concentrate on issues related to contraception, pregnancy, and the prevention, diagnosis, and treatment of sexually transmitted diseases, including

HIV/AIDS. They can investigate the effects of physical, chemical, atmospheric,

and social exposures on women; and make an effort to reach special populations like minorities, prisoners, and the homeless. To study this stage in

women’s lives, scientists can also conduct tests to determine the effectiveness,

safety, and possible complications and side effects of alternative therapies.

Research into women’s health during the perimenopausal and postmenopausal years can aim to clarify the menopausal process and explore

environmental, cultural, and lifestyle influences on menopause, including

what comprises the best health care for women in this stage of life. Other

studies can focus on the effects of hormones, including hormone replacement therapy, on the body; the psychological aspects of menopause,

including possible links between menopause, care giving responsibilities,

and the loss of loved ones; and the attitudes of women, doctors, and 

society toward menopause and aging.

Diseases and conditions for which reproductive-age

women are at risk include heart disease, autoimmune

disorders, female cancers, infertility, endometriosis,

uterine fibroids, mental health disorders, substance

abuse, stress-related digestive disorders, and obesity.
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A GENDA FOR R ESEARCH ON W OMEN ’ S H EALTH FOR THE 2 1 S T C ENTURY

“Prevention can add more 

to the quality and length of 

life than the best treatment.”

William R. Harlan, M.D. 

Director, Disease Prevention

National Institutes of Health

Scientific studies of the elderly and frail elderly years can examine how

changes in family and social structures, caregiving roles, and new workforce services affect women’s well being; and how managed health care, 

living arrangements, and fear of death and dying impact women’s mental

and physical health. Research can also determine what empowers older

women to use available health care, including mammograms, second 

opinions, and clinical breast exams. 

EMPHASIZING PREVENTION 

IN WOMEN’S HEALTH

Until recently, most doctors and researchers were more concerned with

detecting and treating illnesses than they were on maintaining overall

health or preventing disease; many still are. Prevention involves limiting

the actual occurrence of diseases and supporting the body’s systems for

maintaining health. It relies on an understanding of how illnesses start,

grow, and spread, as well as what biological, psychological, social, cultural,

and environmental factors contribute to diseases. Prevention depends on

individuals avoiding the identified risk factors, while making healthy

lifestyle choices.

Preventive health measures, which often involve recommended behavioral

changes related to diet, exercise, and routine health examinations, are

meant to promote wellness, a concept that has gained acceptance over the

past 10 years. Even so, significant numbers of Americans continue to lead

unhealthy lives, including many women who seem to be ignoring life-saving information on how to prevent diseases.

Hopefully, research in the 21st century can help doctors focus on 

prevention, while encouraging women to act in their own best interests, 

by answering the following: Why do women resist life-preserving change?

Why do young women continue to smoke and engage in unsafe sex? Why

Lung cancer is the most rapidly increasing cancer in U.S. women,

despite the fact that it can be reduced or prevented in women 

who voluntarily quit smoking or never start. 

Diseases and issues often affecting elderly women include 

heart disease and stroke, osteoporosis and osteoarthritis,

impaired vision, and urinary incontinence, along with chronic

pain, physical fitness, surgery options and recovery times, 

and toxic drug reactions.
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VOLUME 7

“Areas that significantly 

impact women’s health, their

family, and the economy all

deserve greater attention 

as we work to help prevent

many of the conditions 

that today we can only 

incompletely treat.”

Mary Lynn Newport, M.D.

American Society for Surgery 

of the Hand

"Research has not adequately

addressed psychosocial 

and behavioral factors that 

contribute to health status."

Gwendolyn Puryear Keita, Ph.D.

American Psychological Association

do older women fail to get mammograms and Pap smears? Why do so

many women lead inactive lives? What methods are effective in helping

young girls, teens, and adult women adopt healthy lifestyles? 

Prevention is the best strategy for avoiding a lifetime of medical treatments and financial burdens. Fortunately, research in many critical areas 

of scientific inquiry promises to provide the information necessary to 

develop effective prevention measures. For example, researchers can 

determine (a) how hormones, diet, and exercise can prevent various 

cancers; (b) what early childhood developmental factors can point to the

possible onset of mental illness; (c) which methods and vaccines are effective in preventing sexually transmitted diseases, including HIV; (d) what

women can do to prevent osteoporosis and hip fractures; and (e) what 

medical options prevent or delay kidney failure in women with diabetes.

Scientists can also help prevent many cancers, reproductive disorders, 

and infertility, as well as some chronic diseases in women, by understanding the risks of environmental exposures. 

Prevention is both simple and complex. Finding ways to prevent diseases

across the life span of women requires that women of all ages participate 

in clinical research trials. Once results are known, informing the general

public, as well as doctors and other health care professionals, requires

effective public service messages and educational programs. Physicians 

can play an important role in helping prevent diseases and promoting

healthy behaviors in women. Yet, for this to occur, women of all ethnic 

and cultural backgrounds and income levels must have equal access to

health care, especially to culturally appropriate preventive services. 

RECOGNIZING THE IMPACT 

OF BEHAVIOR ON WOMEN’S

HEALTH AND DISEASES

As noted in the discussion on prevention, a woman’s health depends 

on her behavior as well as on the condition of her body. In fact, her 

individual experience of health and disease involves her attitudes, beliefs,

emotions, and lifestyle choices and actions—all influenced, in turn, 

by her race, ethnicity, age, education, employment status, income level, 

social roles and support system, and sexual preference. Her health is also

affected by where she lives, her access to quality healthcare, and whether 

or not she is the victim of violence or physical/sexual abuse. The combination of these factors, and their interaction with her genetic makeup and

current physical condition, contribute to a woman’s overall health and 

her susceptibility to disease. 
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A GENDA FOR R ESEARCH ON W OMEN ’ S H EALTH FOR THE 2 1 S T C ENTURY

“Behavioral research is 

important for it enables 

us to use effectively the 

continually emerging 

research knowledge—

as individuals and 

as a nation.”

Judith H. LaRosa, Ph.D., 

R.N., F.A.A.N.

Professor and Chair 

Tulane University School of Public

Health and Tropical Medicine

Studies that explore how these elements impact women’s health are 

referred to as behavioral research or social science. Discoveries in these

fields complement the results of biomedical research, which investigates 

the physical causes, progression, and treatment of specific diseases. 

Biomedical research, for example, seeks to understand the benefits of 

physical activity in reducing the risk of heart disease, while behavioral

research focuses on the factors that motivate women to exercise.

To help translate the results of biomedical research into improvements 

in women’s health, behavioral science in the 21st century can answer 

questions such as, "How do women make decisions about their health,

including whether to adopt or maintain healthy behaviors? More specifically, investigators can look at the social influences on women’s 

reproductive and oral health choices and at the cultural factors, including race and ethnicity, that contribute to women’s behavior regarding 

alcohol, tobacco, and illegal drugs. They can explore the effects of 

income, housing, employment, education, and self-esteem on women’s

choices related to nutrition, exercise, and sexual activity; investigate 

possible links between poverty, stress, and heart disease; and clarify 

the relationship between violence and depression. Social scientists can

identify which specific medical, behavioral, and social interventions 

work, with whom, and why—to prevent and treat illnesses as diverse as

cancer, infectious diseases, mental disorders, digestive and autoimmune

diseases, and osteoporosis. They can also determine who benefits the 

most from genetic testing and counseling; and what factors are involved 

in assuring that women will follow medical advice, including taking 

prescribed medications. And, perhaps most importantly, behavioral

researchers can address how the knowledge gained about women’s 

health choices and actions can be used to encourage women to make

health-promoting changes. 

Together, biomedical and social sciences can offer guidance to women 

of all ages on how to prevent disease and maintain wellness. Equipped 

with this information, women can make positive lifestyle choices and 

take charge of their own health.

The results of behavioral research can be especially effective 

in helping young girls adopt healthy behaviors related 

to nutrition, exercise, and sexual activities.
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VOLUME 7

Research teams might often include members from the basic

sciences, nursing, psychology, sociology, pharmacology,

anthropology, health education, social work, or economics.

EMPLOYING A MULTIDISCIPLINARY

(TEAM) APPROACH TO FULLY

UNDERSTAND WOMEN’S HEALTH

AND PROVIDE WOMEN’S 

HEALTH CARE

Each field of scientific inquiry captures key information on important

aspects of women’s health. Psychosocial research, including behavioral

studies, explores how culture, lifestyle, personality, motivation, and 

social support affect women’s choices related to health. Socioeconomic

research examines the links between women’s health, employment status,

and income. Biomedical research, which is the most common type of

women’s health research, focuses on the physical causes of diseases and

how they develop in women. Yet each of these focal points, by its very

nature, provides just a single snapshot of the bigger picture that includes

all three views. 

Some scientists recognize that women’s health is a unique, multidisciplinary

research realm. It offers opportunities to supplement discipline-specific

research by combining biomedical, psychosocial, and socioeconomic 

points of view and/or collaborating across various disciplines within biomedical research. Current research on chronic fatigue syndrome, for example, involves scientists from different biomedical and behavioral disciplines

who are examining (a) a wide range of infectious agents as possible causal

factors, (b) the roles played in the disease by the neuroendocrine function

and the immune system, and (c) the use of antidepressants to relieve 

symptoms of fatigue, sleep disturbance, and chronic aches and pains.

At the beginning of the new century, scientists who collaborate or weave

multiple views together can contribute significantly to the overall knowledge of women’s health, especially with regard to prevention and treatment.

For instance, they can determine the psychological, social, and cultural 

factors that influence women’s and doctor’s attitudes about the risks of 

cancer and the benefits of prevention and routine screening. They can

explore the importance of developmental influences, environmental 

stressors, and biological, psychological, and social factors in digestive 

and autoimmune diseases, heart disease, and mental disorders.

Multidisciplinary research can be especially helpful in the investigation 

of HIV/AIDS, physical and sexual abuse, posttraumatic stress disorder, 

and depression. By conducting community-based studies of the risk 

“True multidisciplinary 

research will bring together

professionals involved in 

all levels of care, from 

prevention to diagnosis 

to treatment to education, 

to ensure a whole-person 

exploration of women’s health.”

Charlotte (Barney) Sanborne, Ph.D.

Texas Women’s University
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A GENDA FOR R ESEARCH ON W OMEN ’ S H EALTH FOR THE 2 1 S T C ENTURY

factors for these conditions, along with the impact of popular culture 

on individual and group behavioral changes, scienctists can design 

effective and culturally appropriate interventions and treatments.

EXAMINING HEALTH DISPARITIES

AMONG DIVERSE GROUPS OF WOMEN

A woman’s health may hinge upon the groups or subgroups to which she

belongs. Her risk of getting and surviving certain diseases may depend 

on where she lives, how much money she has, and whether or not she is

disabled, an immigrant, or a lesbian. A woman may face higher or lower

risks of illness, and better or worse medical treatment, based on whether

she is a black, white, Hispanic, American Indian, Asian, Pacific Islander, 

or Alaskan Native woman. 

Health disparities abound in the United States. For example, while heart

disease is the leading cause of death for all American women, cancer is 

the number one killer of Asian-American women. Black women, who 

have a lower frequency of breast cancer, are more likely than other 

women to die from the disease. The death rate due to all cancers among

black women is more than 3 times higher than it is for American Indian

women in New Mexico. High blood pressure, diabetes, and obesity are

more common among black women than white women, while women 

of all races living below the poverty line are more likely to be obese 

than their higher income counterparts.

Differences in health status and health outcomes among these special 

populations relate to cultural, educational, and behavioral variables, as 

well as the availability of services, individual preferences, and differences 

in supplementary services and the treatment of diseases. Physiological 

differences, including predispositions to certain disorders and different

rates of drug absorption may also contribute to some variations. 

“It is really important that 

the affected population 

be part of all phases 

of research.”

Byllye Avery, M.Ed.

Founder, National Black 

Women’s Health Project

“We want to be assured 

that diseases and ailments 

that so disproportionately 

affect minorities and 

women—diabetes, hypertension, teenage pregnancy,

low-birthweight babies, heart

attacks, strokes, sickle cell 

anemia, kidney failure—

are given adequate 

attention and funding.”

Jann Primus, Ph.D.

Spelman College

In 1993, a white woman was expected to reach

79.5 years of age; a black woman, 73.7 years.

To become more widely practiced, this relatively new

approach to scientific study requires new and appropriate

funding mechanisms, incentives and rewards, and training

for researchers, as well as advocates who can develop 

multidisciplinary research opportunities.
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VOLUME 7

“Genomic technology, 

in particular, holds the 

potential for uncovering 

the mechanisms of disease 

that underlie many women’s

health disorders.”

Michael J. Gast, M.D., Ph.D.

Vice President for Women’s 

Healthcare

Clinical Research and Development 

Wyeth-Ayerst Research

We are engaged in a genetic revolution.

In addition, physicians’ attitudes and practices have been shown to 

influence women’s health outcomes. Lesbians, women of color, and 

women with disabilities, for instance, are more likely to avoid routine 

medical care and screening procedures due to their fear of discrimination and the cultural insensitivity of health care professionals.

Despite the evidence of health disparities among various subgroups of

women, most clinical research that has included women has focused on

white, middle-class, heterosexual, able-bodied women. This attention 

to the majority group limits scientific understanding of the biomedical,

behavioral, and cultural factors operating in the minority groups that 

make up more than 25 percent of the U.S. population. 

To develop the knowledge base that will benefit all women, 21st century

researchers can explore the reasons for existing disparities. They can also

ensure diversity in all aspects of research, by (a) designing studies that

include minority women and that accurately evaluate differences among

population groups; (b) training minority researchers; (c) working with

minority communities to define research goals, gather data, and analyze

results; (d) making sure findings reach and help people in affected 

neighborhoods; and (e) widely disseminating results to health care 

professionals and the general public. 

EXPLORING THE ROLE OF 

GENETICS IN WOMEN’S 

HEALTH AND DISEASE

Not long ago, most people viewed the study of human genetics (DNA

codes that determine physical traits) as a way of dealing only with rare 

diseases. Now, with the growing evidence of genetic influences in diseases

as common as heart disease, cancer, osteoporosis, diabetes, manic depression, alcoholism, and some forms of mental retardation, genetic testing 

is becoming a routine part of mainstream medicine.

Advances in genetics have improved doctors’ ability to diagnose many 

diseases, through the widespread use of screening procedures and the 

specific testing of high-risk individuals. Prenatal genetic tests, for 

example, already help to prevent birth defects; ongoing genetic research

will likely lead to new treatment options for many diseases, even helping 

to determine the drugs that work best for each patient, thus eliminating

negative drug reactions.
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A GENDA FOR R ESEARCH ON W OMEN ’ S H EALTH FOR THE 2 1 S T C ENTURY

“Bipartisan efforts are currently

underway on issues such

as...banning discrimination

based on genetic testing.”

Constance A. Morella, M.A.

Representative 

U.S. House of Representatives

As research continues to identify the genes that predispose individuals to

certain illnesses, many scientists suspect that most diseases, even those

with proven genetic links, also involve environmental and socioeconomic

risk factors. Therefore, scientific studies like the human genome project,

which is mapping the genetic code for all three billion pairs of the human

genome (the full set of inheritable human traits), can be balanced by 

studies of the social, cultural, familial, chemical, behavioral, and other 

factors that contribute to diseases. After all, explaining everything in 

terms of genetics would take away individuals’ personal choices. 

The primary purposes of genetic research are first, to understand 

diseases and second, to use the information to develop better diagnostic methods and treatment options. In some cases, genetic research 

may also lead to strategies for preventing disease. To this end, every 

area of medical research in the 21st century can focus on genetic factors to some degree. Scientists, for example, can (a) define the role of

genetics in the onset, progression, and spread of cancer; (b) find ways 

to reduce the influence of genes on alcohol and drug use, abuse, and

dependence; (c) identify the genes that cause or resist multiple sclerosis,

lupus, rheumatoid arthritis, type 1 diabetes, scleroderma, and asthma; 

and (d) develop genetic-based methods for the improved monitoring 

of pregnancy.

The study of human genes raises many ethical, legal, and social 

questions: How can genetic tests be made available to everyone? 

What should doctors do with the information gained from genetic 

testing? If medical science offers a genetic test for an incurable disease, 

does a patient have meaningful reasons for undergoing that test? 

How can patient privacy and confidentiality be assured? How might 

genetic information change family relationships? Could the misuse 

of information result in discrimination against the carriers of genes 

for specific diseases? Hopefully, science in the 21st century will 

provide insight into these issues.
THE ROAD AHEAD

“The women’s health 

movement is a movement 

that I think can and will 

bring benefits to all 

members of our society.”

Vivian W. Pinn, M.D. 

Associate Director for Research 

on Women’s Health

Director, Office of Research 

on Women’s Health

National Institutes of Health

There is no doubt that research provides the scientific foundation for making positive changes in women’s health practices 

and policies. The enhanced understanding of normal and 

abnormal biologic processes and behavior contributes significantly 

to the improved prevention, diagnosis, and treatment of diseases, 

disabilities, and other conditions that affect the health of women 

and their families and communities.

The women’s health research agenda for the 21st century sets the 

course for the further understanding of sex and gender differences 

in health and disease. It also seeks to learn more about disparities 

in the health needs and healthcare of diverse populations of women. 

The agenda emphasizes prevention, patient education, and the role of

women in maintaining their own wellness. Encompassing behavioral 

and social research, as well as biomedical studies, this comprehensive 

plan calls for multidisciplinary collaboration to address relevant health

issues across women’s life span—from the prenatal stage to the frail 

elderly. And it highlights the importance of both genetics and the 

environment in determining how diseases start, grow, and spread.

At the dawn of the new millennium, women’s health research offers 

hope to millions of women suffering from heart disease, cancer, 

mental disorders, infectious and autoimmune diseases, bone and 

musculoskeletal diseases, kidney and urologic conditions, digestive 

33

VOLUME 7

Women’s health is not just about 

the health of one woman. 

It is about the health of our families 

and the health of this country.
34

A GENDA FOR R ESEARCH ON W OMEN ’ S H EALTH FOR THE 2 1 S T C ENTURY

“We want our daughters 

and their daughters to 

travel a different road 

than we have.”

Laura Tosi, M.D.

American Academy 

of Orthopedic Surgeons

diseases, and alcohol, tobacco, and illicit drug abuse or dependence.

Results can also enhance women’s reproductive and oral health and 

ensure the benefits of drug therapies. Yet, beyond improving the 

length and quality of women’s lives, such research promises to expand 

and enrich the practice of medicine to the benefit of all. As a result 

of scientific exploration, doctors will be better able to prevent, diagnose,

and treat diseases in both women and men based on differences in 

biology, genetics, ethnicity, psychological make-up, cultural influences,

social and environmental conditions, and economic status.

To reach this desired end, the Office of Research on Women’s Health 

will continue to maintain its close collaboration with scientists, health 

care providers, policy makers, and women’s health advocates across the

United States and beyond. Together, they will lead the way for scientific

advances into the ever-expanding frontier of women’s health.

Office of Research on Women’s Health 

Established in 1990, ORWH is the focal point for women’s health research at the National Institutes 

of Health. The office has a threefold mandate to 

• Strengthen and enhance biomedical research related to diseases, disorders, and conditions 

that affect women; ensure that research conducted and supported by NIH adequately 

addresses issues regarding women’s health; and establish a national research agenda for 

future directions in women’s health;

• Ensure that women are appropriately represented in biomedical and behavioral research 

studies supported by NIH; and

• Develop opportunities and support for the recruitment, retention, re-entry, and advancement 

of women in biomedical careers.
Resources

For additional information, contact the 

appropriate National Institutes of Health 

office(s) shown below.

National Institutes of Health (NIH)

9000 Rockville Pike

Bethesda, MD 20892

http://www.nih.gov/

Clinical Center (CC) (301) 496-2563

6100 Executive Boulevard, Room 3C01

Bethesda, MD 20892

http://www.cc.nih.gov/

National Cancer Institute (NCI) (301) 435-3848

31 Center Drive, Room 10A03 (800) 422-6237

Bethesda, MD 20892

http://www.nci.nih.gov/

National Eye Institute (NEI) (301) 496-5248

31 Center Drive, Room 6A32

Bethesda, MD 20892

http://www.nei.nih.gov/

National Heart, Lung, and (301) 496-4236 

Blood Institute (NHLBI) Publications: (301) 251-1222

31 Center Drive, Room 4A03

Bethesda, MD 20892

http://www.nhlbi.nih.gov/index.htm

National Human Genome Research (301) 402-0911

Institute (NHGRI)

31 Center Drive, Room 4B09

Bethesda, MD 20892

http://www.nhgri.nih.gov/

National Institute on Aging (NIA) (301) 496-1752

31 Center Drive, Room 5C27 (800) 222-2225

Bethesda, MD 20892

http://www.nih.gov/nia/

National Institute on Alcohol Abuse (301) 433-3860

and Alcoholism (NIAAA)

6000 Executive Boulevard, Room 409

Bethesda, MD 20892

http://www.niaaa.nih.gov/

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VOLUME 7
36

A GENDA FOR R ESEARCH ON W OMEN ’ S H EALTH FOR THE 2 1 S T C ENTURY

National Institute of Allergy and (301) 496-5717

Infectious Diseases (NIAID)

31 Center Drive, Room 7A50

Bethesda, MD 20892

http://www.niaid.nih.gov/

National Institute of Arthritis and (301) 496-8188

Musculoskeletal and Skin Diseases (NIAMS)

31 Center Drive, Room 4C05

Bethesda, MD 20892

http://www.nih.gov/niams/

National Institute of Child Health and (301) 496-5133

Human Development (NICHD)

31 Center Drive, Room 2A32

Bethesda, MD 20892

http://www.nichd.nih.gov/

National Institute on Deafness and Other (301) 496-7243

Communication Disorders (NIDCD) TTD: (301) 402-0018

31 Center Drive, Room 3C35

Bethesda, MD 20892

http://www.nidcd.nih.gov/

National Institute of Dental and (301) 496-4261

Craniofacial Research (NIDCR)

31 Center Drive, Room 5B49

Bethesda, MD 20892

http://www.ndir.nih.gov/

National Institute of Diabetes and Digestive (301) 496-3583

and Kidney Diseases (NIDDK)

31 Center Drive, Room 9A04

Bethesda, MD 20892

http://www.niddk.nih.gov/

National Institute on Drug Abuse (NIDA) (301) 443-1124

6001 Executive Boulevard, Room 5213

Bethesda, MD 20892

http://www.nida.nih.gov/

National Institute of Environmental (919) 541-3345

Health Sciences (NIEHS)

P.O. Box 12233

Research Triangle Park, North Carolina 27709

http://www.niehs.nih.gov/

National Institute of General Medical (301) 496-7301

Sciences (NIGMS)

45 Center Drive, Room 1AS25H

Bethesda, MD 20892

http://www.nigms.nih.gov/
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VOLUME 7

National Institute of Mental Health (NIMH) (301) 443-4513

6001 Executive Boulevard, Room 8184

Bethesda, MD 20892

http://www.nimh.nih.gov/

National Institute of Neurological Disorders (301) 496-5751

and Stroke (NINDS)

31 Center Drive, Room 8A06

Bethesda, MD 20892

http://www.ninds.nih.gov/

National Institute of Nursing Research (NINR) (301) 496-0207

31 Center Drive, Room 5B10

Bethesda, MD 20892

http://www.nih.gov/ninr

National Library of Medicine (NLM) 24-hour information:

38 Center Drive, Room 2S10 (800) 272-4787

Bethesda, MD 20892

http://nlm.nih.gov/ Outside U.S.: (301) 496-6095

National Center for Complementary and (301) 435-5042

Alternative Medicine (NCCAM)

31 Center Drive, Room 5B37

Bethesda, MD 20892

http://nccam.nih.gov/

National Center for Research Resources (NCRR) (301) 435-0888

12 South Drive, Room 4007

Bethesda, MD 20892

http://www.ncrr.nih.gov/

Office of AIDS Research (OAR) (301) 496-0357

2 Center Drive, Room 4E10

Bethesda, MD 20892

http://www.nih.gov/od/oar/

Office of Research on Minority Health (ORMH) (301) 402-1366

1 Center Drive, Room 250

Bethesda, MD 20892

http://www1.od.nih.gov/ORMH/

Office of Research on Women’s Health (ORWH) (301) 402-1770 

1 Center Drive, Room 201

Bethesda, MD 20892

http://www4.od.nih.gov/orwh/

Agenda for Research on Women’s Health for the 21st Century is an 8-volume report from four scientific 

meetings and public hearings to establish an agenda for women’s health research for the 21st century. 

Volume 1 contains the executive summary and volume 2 is a composite report containing recommendations from all four meetings. Volume 3 contains public testimony from the Bethesda, Maryland meeting, and

volumes 4, 5, and 6 are reports and public testimony from the three regional meetings and public hearings. 

Volume 7 summarizes emerging directions for women’s health research, and volume 8 is the Spanish version 

of volume 7. To order a single, free copy of each volume, please indicate which publication(s) you would 

like to receive.

Volume 1 — Agenda for Research on Women’s Health for the 21st Century, A Report of the Task Force on the NIH

Women’s Health Research Agenda for the 21st Century, Executive Summary; NIH Publication No. 99-4385.

Volume 2 — Agenda for Research on Women’s Health for the 21st Century, A Report of the Task Force on the NIH

Women’s Health Research Agenda for the 21st Century; NIH Publication No. 99-4386.

Volume 3 — Agenda for Research on Women’s Health for the 21st Century, Public Testimony; Bethesda, Maryland:

November 1997; NIH Publication No. 99-4387.

Volume 4 — Agenda for Research on Women’s Health for the 21st Century, Influences of Sex and Gender on

Health; Philadelphia Scientific Meeting and Public Hearing, September 1996; NIH Publication No. 99-4388.

Volume 5 — Agenda for Research on Women’s Health for the 21st Century, Sex and Gender Perspectives for

Women’s Health Research; New Orleans Scientific Meeting and Public Hearing, June 1997; NIH Publication 

No. 99-4389.

Volume 6 — Agenda for Research on Women’s Health for the 21st Century, Differences Among Populations of

Women; Santa Fe, New Mexico, Scientific Meeting and Public Hearing, July 1997; NIH Publication No. 99-4390.

Volume 7 — Agenda for Research on Women’s Health for the 21st Century, New Frontiers in Women’s Health;

NIH Publication No. 01-4391.

El volumen 8 — Orden del día para la Investigación en Mujeres’la Salud des para el Siglo vigésimo primero, 

Las Fronteras Nuevas en Mujeres’ la Salud des; La Publicación de NIH No. 01-4392. (Spanish)

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Please mail or fax this completed form to: Office of Research on Women’s Health, Office of the Director, National

Institutes of Health, 1 Center Drive, Room 201, MSC 0161, Bethesda, Maryland 20892-0161; fax: 301-402-1798.

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NIH Publication No. 01-4391