Looking Beyond the Uterus
Author: Sarah Haynes, MD
Keywords: women’s health, bias, gender bias, uterus, bias, androcentric, medicine, research
Nothing instils more confidence in your patients than replying “uh 12 weeks” after they’ve asked how many years of experience you have as a doctor. With a mere 12 weeks under my belt, I make no diagnoses or decisions without the guidance of a more senior physician (thankfully).
My job as a first-year doctor is often to learn from the more experienced nurses and doctors that surround me and I’ve recently learnt a valuable lesson about medicine’s approach to women’s health.
I started my evening shift, opened the list of patients waiting to be seen and assigned myself first on the list. A young woman, around 20 weeks pregnant. I stepped into her room whilst my brain sorted through the collection of pregnancy related conditions for potential diagnoses.
She was nauseous, febrile, with abdominal pain. I examined her tummy, thrown by the 20cm of growing uterus, I tried to localise her pain. Pain worse on the upper right side?
As all juniors do, I went to relay my assessment to the senior doctor in the emergency department that day. “Call the obstetrics and gynaecology team”
An overworked and tired registrar answers the phone; “so you’ve got a patient with a fever and abdominal pain who happens to be pregnant and currently has no red flag symptoms of a pregnancy related emergency? Treat and examine this patient like any other non-pregnant patient that would present with these symptoms – call the surgeons”
I assumed that this woman’s pain was coming from her pregnant uterus and failed to consider other diagnoses. I shifted my thinking and considered what her collection of symptoms would make me concerned about in any non-pregnant patient. Gallstones?
Wrong again. She had appendicitis.
It hadn’t even crossed my mind, and yet it’s one of the first presentations of abdominal pain we are taught to identify in medical school. The most common identifying feature in appendicitis is pain in the right lower abdomen, and I missed that.
I’ve since learnt appendicitis can present ‘atypically’ in pregnant women. The right lower abdominal pain can often be felt higher in the abdomen, as the uterus grows and pushes the appendix higher.
I was disappointed I couldn’t look beyond the uterus to consider the whole patient. I had done what medicine has done to women for centuries; reduced their health to their reproductive organs. Something that is now coined as the “bikini approach” to women’s health.
A quantitative analysis published in 2021 compared the research published in various women’s health and general medical journals. It found that 49% of women’s health topics published in 2020 were on Reproductive Health.
Furthermore, reproductive health was primarily focused on a woman’s reproductive years. Women outside their reproductive years were significantly underrepresented in research. Only 2% of articles published were focussed on menopause.
After reproductive health, cancer was one of the most covered research topics. This was dominated by breast and cervical cancer with little focus on other significant cancers that disproportionately burden women, such as colorectal and lung cancer.
Once upon a time ‘reproductive and maternal’ medicine was one of the greatest burdens on women’s health but maternal and infant mortality has improved throughout the 20th century and the burden of disease has now shifted. The leading cause of death and disability for women is now non-communicable diseases such as heart disease, respiratory disease, stroke, and cancers.
Then there are the less common diseases that disproportionately affect women; women comprise 78% of people diagnosed with autoimmune diseases, around 66% of Alzheimer’s disease and are more likely to suffer from chronic pain.
Women may live longer than men on average, but they live fewer healthier years than men. We know that sex and gender can affect the diagnoses and treatment of medical conditions. This has been shown in the ‘atypical’ presentation of heart attacks in women and how this ultimately leads to poorer outcomes.
Whilst I am overjoyed to see more money and time spent on under researched reproductive health conditions such as endometriosis and polycystic ovarian syndrome, we must look beyond the uterus.
Medicine has spent centuries focussing on the 70kg white male and when it comes to the women, we’ve only been concerned about what lies beneath a bikini.
We must broaden the focus of what we consider to be ‘women’s health’ to adequately examine the role that sex, and gender really play in the burden of disease.
About the author: Dr Sarah Haynes is a PYG1 Intern working at Prince of Wales Hospital. Sarah found her passion for women’s health when she began training for ultramarathons during medical school. Through endurance running, Sarah discovered how unique female physiology can impact physical performance. Frustrated by the lack of medical education on women’s health outside of their reproductive organs, Sarah hopes to one day improve this. For now, Sarah is working out how to juggle internship and her love for running. (LinkedIn profile)
