Women's health plan

8 Context

This section provides a summary of the findings which informed this Plan and includes some of the things women have told us.

8.1 Access to information and services

A key theme which has been raised consistently in the development of this Plan, and which cuts across all of our priorities, is the importance of accessible health information and accessible services.

Women highlighted the importance of good communication by illustrating that they cannot take responsibility for their own health without enough information about it. Participants highlighted that those with low literacy or digital skills may not benefit from a website.

Lived Experience Engagement Report

There are many potential sources of information for women, including social media, but not all of these provide reliable information. Responses to our Lived Experience Survey suggest that women generally know where to access information about their health concerns, but information could be improved with the provision of a trustworthy comprehensive health website for women and girls and healthcare professionals.

Access to evidence-based information in a format that is user-friendly and accessible to all women is essential to empower women to take control of their own health and wellbeing. It must be recognised that not all women will have access to the internet, and so information must be presented in a variety of different formats, including alternative languages.

• 88% of households in Scotland have access to the internet.^[41]
• 21% of adults in social housing do not use the internet.^[42]
• 71% of adults who have some form of limiting long-term physical or mental health condition or illness reported using the internet.^[43]
• only half of those over 60 in the most deprived areas use the internet.^[44]
• in our Lived Experience Survey over 80% of respondents said they had accessed information through their GP, and just over 50% had used the internet to access information.^[45]

Poor access to basic women's health services leads to a rise in unplanned pregnancies, abortions, poor patient experiences and increases damaging postcode lotteries. It is essential that we develop a more integrated approach to the delivery of women's healthcare services.

RCOG, Better for Women Report

Additionally, one of the strongest themes from our lived experience engagement days was that many women experience difficulties in accessing services due to the challenge of getting an appointment that works around work commitments and caring responsibilities. There are additional difficulties for disabled women, women with visual impairments, those with learning disabilities and women who have experienced trauma or abuse.

• 61% of Scotland's 1.1 million unpaid carers are women.^[46]
• The vast majority, 92%, of lone parents in Scotland are women.^[47]
• Across the UK 37% of women cannot access contraception services locally.^[48]
• 42% of respondents to a survey conducted by the RCOG think that more flexible appointment times would improve their access to women's services, with 35% believing that more time with healthcare professionals would improve their use of services.^[49]

Women want to see a system which provides them flexibility around their lives, both when accessing appointments and for treatment and support options.

Lived Experience Engagement Report

8.2 Sexual health, contraception and abortion

Sexual health is an important aspect of our overall health. Good sexual health is an important part of a women's overall wellbeing, and can in addition reduce the risk of unintended pregnancies and sexually transmitted infections. The incidence and impact of poor sexual and reproductive health on women and girls varies between different groups and is influenced by factors such as age, geographic location, and socio-economic status.^[50]

'All the risks and responsibilities are on the girl.'

Young women expressed a strong sense of frustration that contraceptive work such as research, booking and attending appointments, navigating systems and services, using methods correctly and the management of side effects, falls to them.

CONUNDRUM Report, Understanding young people's use and non-use of condoms and contraception

Access to, and information on, contraception and abortion are key components of good sexual health and enable women to determine if and when they have children.

• Women aged under 25 are the group most at risk of being diagnosed with an STI.^[51]
• In 2019/20 around 54 per 1,000 women were prescribed long acting reversible contraceptive (LARC). The most common method of LARC is the contraceptive implant.^[52]
• 1 in 3 UK women will have an abortion by the time they are 45 years old.^[53]
• In 2020 13,815 terminations of pregnancy were recorded in Scotland (13.4 per 1000 women aged 15-44).^[54]
• In 2020 the abortion rate in Scotland was 2.2 times higher in the most deprived areas compared to least deprived areas.^[55]
• Termination rates in the 40-plus age group in Scotland have been steadily rising.^[56]
• In a recent survey, approximately 1 in 3 intercourse-experienced young people indicated difficulty getting an appointment for contraception or STI testing.^[57]
• Almost half (46.0%) of respondents to a recent survey of young people did not know or were unsure where to access free condoms in their local area.^[58]

I wanted to find out more about the options available, but was pretty much told to take the pill without any discussion as to side effects or current experiences with periods.

CONUNDRUM Report, Understanding young people's use and non-use of condoms and contraception

When it came to accessing information, participants spoke of the importance of understanding their options, particularly in relation to contraception… It was also highlighted during the conversation that in some cultures women will not raise topics such as contraception themselves, but would talk about it with a healthcare professional if asked.

Lived Experience Engagement Report

8.3 Menstrual health

A girl's periods usually begin at around the age of 12. Despite the fact that most girls and women will experience periods monthly for around 40 years of their lives, many remain unaware of just how common menstrual health disorders, or period problems, are or what options are available to control or stop the menstrual cycle and associated effects.

When discussing the stigma that exists around periods and menstrual health, the women in the events focussed on early and comprehensive education in schools.

Lived Experience Engagement Report

• In our lived experience survey, 70% of respondents told us that they had sought medical care or advice regarding their menstrual health. When asked where they accessed the service, 96% of those asked had accessed through their GP.^[59]
• 1 in 5 women of reproductive age suffer with heavy menstrual bleeding.^[60]
• The psychological impact of menstrual disorders is underestimated; a recent survey of women with heavy menstrual bleeding found that of 1000 surveyed:
  • 74% experienced anxiety;
  • 67% suffered with depression.^[61]
• As reported by the RCOG, 49% of girls say that they have missed an entire school day because of their periods, of whom 59% have made up a lie or an alternative excuse.^[62]
• The proportion of women reporting at least one PMS symptom ranges between 40–90%.^[63]
• The proportion of women reporting severe PMS symptoms or symptoms that interfere with daily activities ranges between 3–30%.^[64]

An understanding of what is, and is not, normal when it comes to the menstrual cycle is key to breaking down taboos around menstruation, and in equipping girls and women with the confidence to seek medical help when it is needed.

RCOG, Better for Women

8.4 Endometriosis

Endometriosis is a common long-term condition where tissue similar to the lining of the womb is found elsewhere in the body. While endometriosis is generally found within the pelvic cavity, it is sometimes found in other parts of the body, such as the lungs. The most common symptoms of endometriosis include: painful periods; pain in the lower abdomen, pelvis or lower back; pain during and after sex; difficulty getting pregnant and discomfort when going to the toilet. It can be difficult to diagnose because symptoms can vary considerably and many other conditions can cause similar symptoms.

Research is pivotal to understanding the cause of the disease, better treatment options, and one day a cure. Without research, people with endometriosis will continue to face huge barriers in accessing the right treatment.

Professor Andrew Horne, University of Edinburgh, APPG Endometriosis Report

The cause of endometriosis is unknown and there is no specific cure.

It is estimated that endometriosis affects around 1.5 million women in the UK.^[65] Most are diagnosed between the ages of 25 and 40^[66] .

On average in Scotland it takes 8.5 years from onset of symptoms to be given a diagnosis.^[67]

A survey by the All-Party Parliamentary Group (APPG) Inquiry into endometriosis found that 58% of respondents visited their GP 10 or more times due to their symptoms prior to diagnosis and 53% of respondents visited A&E prior to receiving a diagnosis.^[68]

Endometriosis costs the UK economy £8.2bn a year in treatment, loss of work and healthcare costs.^[69]

I missed school on a regular basis because of my periods… I was told by doctors, teachers and my family that this was normal and was what a period was like…I wish so much that we had been taught what was absolutely not a 'normal' period.

Endometriosis APPG Report

8.5 Menopause

The menopause is a natural part of ageing that usually occurs between 45 and 55 years of age, as a woman's oestrogen levels decline. In the UK, the average age for a woman to reach the menopause is 51.^[70] However, around 1 in 100 women experience the menopause before 40 years of age.^[71] This is known as premature menopause or premature ovarian insufficiency; it can happen naturally or as a side effect of some treatments, and this can increase the risk of osteoporosis.

The majority of women are able to manage menopause symptoms with lifestyle modifications and with support from their GP, therefore will not require specialist services. However, all women should have the ability to access specialist support should they need it.

Dr Heather Currie, Associate Medical Director, NHS Dumfries and Galloway

Menopause

• Mood swings
• Aches and pains
• Tiredness
• Recurrent UTI Symptoms
• Vaginal dryness
• Palpitations
• Anxiety
• Hot flushes
• Brain fog
• Loss of sex drive
• Night sweats
• Insomnia
• Lack of energy
• Memory loss
• Painful sex
• Weight gain

Most women will experience menopausal symptoms. Some of these can be severe and can have a significant impact on women's lives. The menopause is a key time to consider women's bone health because the oestrogen hormone that is important for keeping bone density stable decreases. As a result, bone density starts to decrease, which reduces bone strength and increases the risk of breaking bones. Menopausal symptoms can begin months or even years before periods stop and last for several years after periods stop.^[72]

The main thing women wanted from employers was flexibility to manage their own symptoms, such as being able to work from home or change hours slightly if needed.

Lived Experience Engagement Report

• Around 400,000 women in Scotland are of menopausal age (between 45 and 54).^[73]
• Women report feeling unprepared for the impact the menopause can have on their life and according to a 2019 survey conducted by the Scottish Women's Convention, with 1,000 respondents from Scottish Women, almost two thirds of women felt there was not enough information available at the beginning of their menopause.^[74]
• In a survey of 1,000 adults in the UK, the British Menopause Society found that 45% of women felt that menopausal symptoms had a negative impact on their work and 47% who needed to take a day off work due to menopause symptoms say they wouldn't tell their employer the real reason.^[75]
• 2,000 women members of the British Medical Association (BMA) were surveyed regarding their experience of menopause. 93% said that they had experienced symptoms such as insomnia, fatigue, loss of confidence, and debilitating hot flushes as a result of menopause, and 65% had experienced physical and mental symptoms. 90% said that these symptoms had impacted their working lives, with 38% saying that the impact was significant.^[76]

Respondents raised that improving the general knowledge and awareness among GPs of women's health and GPs being proactive in starting conversations around menstrual health would improve experiences of seeking help. Many respondents were made to feel dismissed or like they were 'wasting GPs' time' when presenting with symptoms, particularly of menopause or endometriosis.

Lived Experience Survey Report

8.6 Heart health

Ischaemic heart disease

Ischaemia occurs when blood flow to the heart is reduced, preventing the heart muscle from receiving enough oxygen. Heart attack and angina are symptoms of ischaemic heart disease.

BHF, Bias and Biology Report

Cardiovascular disease

Cardiovascular disease (CVD) is an umbrella term that describes a range of conditions that affect the heart, the blood vessels, or both.

CVD risk assessment and management – NICE Guidelines

Cardiovascular (CVD) diseases are the leading cause of death in the world^[77] and ischaemic heart disease (including heart attacks and angina) is a leading cause of death for women in Scotland.

Women have unique risk factors such as endometriosis, polycystic ovarian syndrome (PCOS) and pregnancy-associated complications that likely increase future risk of CVD. Women also have different manifestations of CVD, and studies have shown sex differences in their response to risk factors and treatments.

For many people heart disease simply means 'heart attack' when there are a range of cardiac conditions that the general population and women need to be aware of. Although risk factors for CVD such as smoking, diabetes and high blood pressure affect both men and women, the risk of CVD with the presence of these risk factors is greater for women.

There are a number of heart conditions that disproportionally affect women more than men, such as takotsubo cardiomyopathy, spontaneous coronary artery dissection (SCAD) and microvascular angina. A lack of awareness can lead to delayed presentation to healthcare systems for timely treatment which can have an impact on outcomes.

• Ischaemic heart disease kills nearly three times as many women as breast cancer in Scotland.^[78]
• Around 100,000 women in Scotland today are living with ischaemic heart disease.^[79]
• Seven women die every day in Scotland from ischaemic heart disease.^[80]
• Women are less likely to be prescribed drugs that help reduce the chance of a second heart attack.^[81]
• Women in Scotland have a worse rate of survival after a heart attack than men.^[82]
• Heart disease is the leading cause of maternal death in the U0K.^[83]
• It is estimated that information about risk in pregnancy is only provided to 10% of women attending cardiology appointments in Scotland.^[84]
• Women are under-represented in many cardiovascular clinical trials despite the fact that important sex and/or gender differences are present within most areas of heart disease.^[85]
• Pre-eclampsia is linked with a greater risk of heart disease in the future.^[86]
• Cardiac rehabilitation is associated with improved quality of life, however across the UK, the proportion of women recruited to cardiac rehabilitation programmes from those eligible is lower than expected. There is no easily accessible national data for cardiac rehabilitation currently available in Scotland.^[87]

Many women felt that messaging stereotypes around health issues partly contributed to the lack of awareness of health issues in women, particularly around heart health. For example, it was mentioned that messaging about heart attacks often feature an older man with a belt around his chest, showing that chest tightness is a symptom, but women do not relate to this.

Lived Experience Engagement Report