Reviewing 50 years of progress on medical issues relevant to women can be a daunting and sometimes exacting task. But as we learned while writing about milestones in women’s health, it can also be a personal journey, having both come of age around the same year our review began.
As academic physicians specializing in women’s health, we were writing a Perspective piece for the New England Journal of Medicine’s yearlong series of articles celebrating the 50-year anniversary of the National Academy of Medicine. Our essay focused on medical advances and public policy during an initially tumultuous — then progressive — time for women’s health.
We were asked to craft a timeline to accompany the article. We included two columns: One chronicled scientific advances in prevention, early detection, and treatments relevant to women’s health. The other included key public policy milestones. Putting the two together was exciting and challenged our memories and our resources. It was surprising to see how a number of the entries brought flooding back not just professional memories but personal ones as well.
The first policy milestone we included was the 1972 U.S. Supreme Court ruling that a state cannot prevent distribution of birth control to unmarried persons. To young women today, this ruling may be difficult to comprehend. A restriction on birth control unless you are married? Seriously? Yet we both could recall the era when young women seeking contraception were routinely turned away because they lacked a gold band on their left fourth finger, and wondered if we might ever go back to such times.
The second entry in the policy milestone column was the 1973 U.S. Supreme Court ruling in Roe v. Wade that established a woman’s right to reproductive choice and legalized abortion. For both of us, this entry triggered flashbacks to horrific images of desperate women attempting to disrupt unwanted pregnancies with disastrous and often fatal results, a specter raised again by current challenges to the ruling.
These two decisions unequivocally opened the door to a new era for women, an opportunity for self-determination, autonomy in reproductive choices and, as a result, unimaginably expanded opportunities in society. New methods for long-acting contraceptives followed in 1990, with the FDA approval of Norplant. By 1998, the first emergency contraceptive pill was approved and, by 2006, it was available over the counter. The passage of the Affordable Care Act in 2010 covered contraceptives as a no-cost preventive health benefit and removed the financial barrier to contraceptive access. By 2013, the Centers for Disease Control and Prevention reported that teen pregnancy rates had dropped to the lowest point since 1946.
The skies have darkened during the past decade as state-led legislation has increasingly moved to curb women’s reproductive health options. Laws were passed that targeted regulation of abortion providers. Companies were allowed to conscientiously object to providing contraception as a health benefit. The composition of the Supreme Court changed dramatically.
Our concerns grew as we completed the timeline, so we decided to include a caution in the review that the new conservative Supreme Court could overturn Roe v. Wade and imperil the progress we had just acknowledged and celebrated.
The day we signed off on our review, the Supreme Court agreed to hear a case concerning a Mississippi law passed in 2018 seeking to ban most abortions after 15 weeks of pregnancy — two months earlier than currently allowed by Roe. According to the New York Times, “the precise question the justices agreed to decide was whether all pre-viability prohibitions on elective abortion are unconstitutional.” Two days later, the governor of Texas signed into law a prohibition on abortion as early as six weeks. More than 20 states have provisions in place that would outlaw abortion completely if Roe is overturned.
Reproductive justice — equity and accessibility of reproductive health care — was another topic we explored. It is unconscionable that despite advances in reproductive health care, maternal deaths have been on the rise in the U.S. over the past two decades and now our country has the highest rate of maternal death among industrialized countries. Black women are three times more likely to die during and after childbirth than white women. Not all states are equal in this regard. California, for example, instituted measures to curb the risks of preeclampsia (signaled by high blood pressure and protein in the urine) and continued bleeding after delivery, with a 57% drop in maternal mortality rates since 2006. A national research agenda to better prevent, identify early, and manage pregnancy complications is underway. It will also be important to move beyond medical measures and consider social, structural, and environmental determinants of maternal health.
In 1985, the Public Health Service Task Force on Women’s Health Issues shifted the focus from reproductive health to conditions relevant to women throughout the life course, with the understanding that health conditions such as heart disease can manifest and progress differently in women than in men. As a result, in 1986, the National Institutes of Health encouraged participation of women in clinical trials of new drugs or devices. In 1990, the Office of Research on Women’s Health was established and briskly moved to start a number of clinical trials specific to women’s health on topics such as hormone therapy and menopause.
In 2001, the Institute of Medicine posed the question that would alter all medical research going forward. It asked, “Does sex matter?” when it comes to biological contributions to human health. The answer: a resounding “Yes!”
As just one example, coronary heart disease has sex-specific differences in symptoms, prognosis, and response to therapies. It also has a number of women-specific risk factors, such as recurrent miscarriage, preeclampsia, gestational diabetes, preterm delivery, and early menopause, for starters. A woman’s reproductive history is now accepted as providing a window into her future risk of heart attack, stroke, and heart failure. Cardio-obstetrics has been established as a new sub-specialty. This is progress.
Since 1970, cancer medicine has also scored many successes. Mammography was established as an important way to detect breast cancer early. The discovery of breast cancer hormone receptors, along with the development of targeted therapies, the identification of genetic risk factors such as BRCA and other genes, and refinements in surgery have yielded a five-year survival rate of 90% and enhanced quality of life for survivors. Cervical cancer screening and the human papilloma virus vaccine, the latter introduced in 2006, have contributed to a 50% reduction in deaths from cervical cancer. More progress.
Moving forward, incorporating sex as a biologic variable in all research designs, from the cellular level to the personal, is a top priority. The 2019-2023 Strategic Plan for Women’s Health Research at the NIH has set a vision for every woman to receive evidence-based disease prevention and treatment tailored to her needs, circumstances, and goals. Recognition and study of intersectional health disparities based on sex, race, ethnicity, gender identity, sexual orientation, income, and disability status will be essential because social and economic inequities contribute to compromised care. Overcoming structural issues within our medical systems, including implicit racial bias, will contribute to improved care for everyone. Finally, championing the role of science as the route to better health remains essential.
To continue and even accelerate the pace of progress achieved over the past 50 years, advocacy for women’s health is vital — from physicians, scientists, patients, the general public, journalists, legislators, and policy experts. We’ll also need public policy decisions that are just and forward thinking. On to the next 50 years!
Cynthia A. Stuenkel is an endocrinologist and clinical professor of medicine at the University of California, San Diego, School of Medicine. JoAnn E. Manson is an endocrinologist and epidemiologist at Brigham and Women’s Hospital in Boston and professor of medicine at Harvard Medical School.
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