Why don’t we know much about periods, menopause and heart disease in women? A gender gap exists in healthcare

Have you ever wondered why there’s no targeted medication for menstrual cramps and women are instead given generic painkillers? Why are conditions like endometriosis or polycystic ovary syndrome frequently diagnosed later?  And why are women told that their joint pain, body aches and urinary problems are just part of going through menopause? 

After receiving the COVID-19 vaccine, you may have noticed changes to your periods: More intense cramps, a shorter cycle, and heavier bleeding. Doctors said it was all in our minds and that the disruption to our menstrual cycles would go away eventually – only for some women, it didn’t.

The Singapore Heart Foundation, in its Women’s Heart Health Survey this year, said heart disease claims the lives of about one in three women annually. Yet, more than 80 per cent of women are unaware of its severity or its symptoms – which often present very differently in females compared with males.

There’s a common thread to all these anecdotes. Associate Professor Sophia Archuleta calls it the gender gap in healthcare and health research.

The head of the National University Hospital’s (NUH) infectious diseases division said the gap refers to insufficient research on women’s health, barriers to women having access to care, and poorer health outcomes for women compared with men.

WHAT THE HEALTHCARE GENDER GAP IN SINGAPORE LOOKS LIKE

The healthcare gender gap affects women everywhere, said Assoc Prof Archuleta. On a day-to-day level, it often means that women’s health concerns are dismissed or minimised.

It makes visiting a doctor a nerve-wracking experience for many women, Assoc Prof Archuleta said. Doctor appointments are marked by anxiety about having their concerns dismissed or being uncertain about the outcome of their consultation. 

Professor Yan Li, from the Department of Information Systems at ESSEC Business School and an expert in femtech, products that use technology to improve women's health, said the dismissal is wide-ranging.  

“It took considerable advocacy before large-scale studies were initiated to investigate the effects of COVID-19 vaccinations on women,” she said. “Conditions like postpartum depression are often viewed as ingratitude after having children or weakness, leading to long-term harm for both mother and child.”

Prof Li added: “Similarly, women with chronic pain conditions like fibromyalgia or endometriosis are frequently told their pain is ‘all in their heads’, causing significant delays in diagnosis and treatment.”

In Singapore, Prof Li said the gender gap manifests in late diagnosis, medical research with a “lack of focus” on women, and “insufficient public awareness campaigns targeting women for early screening”. 

As a result, women in Singapore are diagnosed with diseases such as cancer later, as early symptoms go unchecked and the disease becomes apparent only after it has progressed. Mental health disorders are also worse in women because they go unaddressed. 

The numbers are staggering. A report by McKinsey Health Institute estimates that the women’s health gap in Singapore collectively amounts to roughly 40,000 Disability-Adjusted Life Years (DALYs). DALYs measure the years we spend living in poor health or losing to early death – on an individual level, this translates to each woman losing about three and a half days of her life to inadequate healthcare.

If a woman is unable to work, care for her family, or enjoy her usual activities for a year due to chronic pain from, say, untreated endometriosis, she loses one DALY.  And if another woman dies from a preventable condition 10 years earlier than expected, those 10 years are 10 DALYs. 

Megan Ann Greenfield, a partner at McKinsey and co-leader of McKinsey’s women’s health programme, said there is also a significant economic impact. 

“Over two-thirds of the health gap occurs during women’s prime working years,” she said, highlighting that when women are not healthy enough to work, there is substantial economic loss for the country.

She added that addressing the top 10 health conditions in women – which include gynaecological conditions, heart disease, mental health disorders, breast cancer and migraines – could boost Singapore’s gross domestic product (GDP) by approximately US$3 billion (S$4.05 billion).

However, since these conditions are not given enough attention, Greenfield said that Singapore foregoes this economic gain instead. 

So why does the gap exist? Here are three factors, as well as what’s being done – and needs to be done – to tackle them:

MEN’S BODIES ARE THE DEFAULT IN HEALTH RESEARCH  

Much of our understanding of the human body is based on male physiology, despite women experiencing many health issues differently, Prof Li said.

McKinsey’s Greenfield added: “Questions around sex-based differences were rarely investigated or recorded. It was falsely assumed that men’s and women’s organs and systems functioned similarly, except for reproductive organs.

“Women have also been underrepresented in clinical trials, making their experiences less researched and understood.

A study published this year by the Singapore medical journal The Annals revealed a significant gender disparity in local clinical trials. 

The study found that females were significantly underrepresented, making up only 40 per cent of participants in nearly two-thirds of trials focused on infectious diseases, cardiology, endocrinology and psychiatry.

The scarcity of studies on women’s health and their historical exclusion from research cannot be overlooked, said Assoc Prof Archuleta.

She highlighted the impact of this disparity: For instance, while COVID-19 vaccines affect women’s periods, little research exists due to the lack of focus on women and infectious diseases. Similarly, despite women’s higher risk for dementia, studies on the condition are relatively recent, likely due to underrepresentation.

In this regard, Prof Li advocates for policymakers in Singapore and worldwide to mandate the inclusion of women in clinical trials and research projects. More resources should also be allocated to women’s health research to address gender disparity.

The Association of American Medical Colleges reported that it was only in the 1990s – barely three decades ago – that the United States Food and Drug Administration mandated the inclusion of women in research unless there is a justification for exclusion (for example, if the disease only affects men). 

However, the report found that even as of 2019, despite strides in medical research, women were still significantly underrepresented in clinical trials for leading diseases.

It’s why experts need to continue pushing for better representation to close the gap that widened due to the late start, Assoc Prof Archuleta said. 

In Singapore, the Global Centre for Asian Women’s Health at NUS Yong Loo Lin School of Medicine was established in 2023 to advance women’s health. Its goals include increasing women’s representation in local clinical research, addressing common women’s health issues and turning research into practical steps for earlier prediction, prevention, and treatment of various health conditions.

TABOOS SURROUNDING WOMEN’S HEALTH 

Prof Li noted that topics surrounding women’s health have traditionally been seen as taboo.

“In Southeast Asia, including Singapore, it remains culturally taboo to openly discuss women’s sexual well-being and infertility issues,” she said. 

“There’s also a stigma associated with vaginal diseases and breast issues due to deeply rooted social norms regarding women’s bodies.”

When women feel that talking about their health and well-being is embarrassing or inappropriate, they may keep concerns to themselves when they experience something amiss, leading to delayed diagnosis. 

Assoc Prof Archuleta said to battle cultural issues, public education plays a crucial role. 

“Mainstream media should publish more health news from credible and reputable sources to help everyday women better understand their bodies and the symptoms they go through for different health conditions,” she said. “That way, issues like stigma and taboo can be addressed, too.”

UNDERREPRESENTATION OF WOMEN IN SENIOR HEALTHCARE ROLES

Having fewer women in senior roles in healthcare and health research leads to a diminished focus on women’s health issues, said Prof Li.

“The underrepresentation directly impacts the attention given to advancing women’s health, as it affects policies and research priorities,” Assoc Prof Archuleta added.

Assoc Prof Archuleta added that underrepresentation is partly driven by intense work cultures in healthcare and academia that don’t accommodate women’s needs, particularly for those balancing roles like caregiving.

“It becomes difficult for them to meet the rigorous demands of medical and research fields, despite their capability to do so,” she said. “And when fewer women are involved in the top roles of healthcare and academia, the effects will be adverse downstream.

“Fewer journal topics on women’s health will be approved, less priority is given to secure the fair representation of women in research projects, and policies in the workplace and when treating patients may not consider women’s needs.” 

Efforts to close the gap include policy changes to improve the representation of women in health and research.

At NUH, for example, there is an emphasis on having diverse representation in decision-making bodies. Assoc Prof Archuleta stressed that it’s not enough to have just one token woman in committees; these bodies must include women who are literate in women’s health issues.

Another key aspect that Assoc Prof Archuleta noted is the need to build a culture of male allies in the workplace and at home. 

For many women, balancing a career with caregiving responsibilities – what Assoc Prof Archuleta called the “second shift” – can be overwhelming, especially for academic physicians juggling clinical work, teaching, research, and studies. 

In 2019, the Equal Opportunities & Career Development was set up at the NUS Yong Loo Lin School of Medicine. It aims to make the medical workplace more inclusive for women, including setting up comfortable nursing rooms for working mums in hospitals and clinics, and pushing for more flexible hours for women with other caregiving duties. 

“Providing more support for women in these fields is essential to help them navigate the demands of both work and life,” Assoc Prof Archuleta said. “When women feel more comfortable at work in hospitals, they will be better represented, leading to better health outcomes for women.”