Women in medicine on progress in women’s healthcare — and what still needs to be done

Significant improvements have occurred in health services for women over the past 25 years, thanks to advancements in medicine, progressive legislation, and targeted initiatives. Here, four leading women in medicine reflect on the progress made and the work still to be done

Dr Susan Smith: “Research tells us these women’s lifestyles are too busy for them even to think of going to the doctor. And this doesn’t only impact their health in menopause. It also negatively impacts other health outcomes." Picture: Moya Nolan.

Much has changed in women’s medicine over the past 25 years. Issues that were once spoken of in hushed tones are now openly discussed and receive the medical attention they deserve. However, further changes are necessary to ensure women receive the best possible care.

We talk to four leading doctors in the Irish healthcare system about significant developments in women’s healthcare and the changes they’d like the minister for health to introduce.

Much done, more to do

Dr Cliona Murphy is chair of the Institute of Obstetricians and Gynaecologists. She started working in this field 27 years ago and remembers it as a different time.

“Women’s health wasn’t even a phrase that was used then,” she says.

Women’s reproductive rights were strictly controlled. “If a woman became pregnant, she had to stay pregnant,” says Murphy.

“I saw how devastating this was for women carrying babies with foetal abnormalities, and I experienced how fraught it could be getting terminations for women whose pregnancies posed a risk to their life and health. I’d have to make sure another practitioner and the multi-disciplinary team agreed with my decision to avoid any legal implications afterwards, all while trying to look after my patient.”

She recalls women needing their husbands’ consent before they could get their tubes tied for sterilisation and adds how even then, the request had to be submitted to the hospital’s ethics committee.

Dr Cliona Murphy: “IVF has come on in leaps and bounds. Egg donation, for example, now enables women who have undergone premature menopause to carry children. And to see Ireland providing public funding for fertility treatment is fantastic.”

“It’s hard to believe a third party had a say when the decision should have been hers alone.”

The successful 2018 Repeal the Eighth campaign was pivotal. “So many women shared their stories of suffering due to not having the right to full reproductive healthcare during that campaign,” says Murphy. That led to a change in the law, and changes in healthcare followed.

Murphy cites improvements in fertility treatment as another significant change in women’s health.

“IVF has come on in leaps and bounds. Egg donation, for example, now enables women who have undergone premature menopause to carry children,” she says. “And to see Ireland providing public funding for fertility treatment is fantastic.”

However, she says there is still room for further progress, especially in paediatric and adolescent gynaecology. She explains how certain gynaecological conditions only show up when a girl’s periods don’t arrive as expected.

“These are mostly rare conditions. But there is also the issue of painful periods and girls developing problems like endometriosis. These can make school, sports, and exams extra challenging for girls.

“Just as we now have specialised menopause services, I’d like to see more specialised services aimed at supporting these girls and their parents in dealing with these problems.”

Taking women seriously

Dr Deirdre Lundy is the clinical lead of the complex menopause clinic in the National Maternity Hospital in Dublin. Thinking back 25 years, she recalls an era when “women’s health wasn’t taken seriously at all”.

However, three milestone developments highlight that the healthcare system was undergoing significant changes. She also remembers the repeal of the Eighth Amendment.

“It still amazes me how smoothly Ireland made that transition,” she says. “When you see places like the US rolling back on women’s reproductive rights while we’re moving forward, I feel proud of how Ireland has allowed women the autonomy to make decisions about their bodies.”

The establishment of the women’s health taskforce in 2019 marked another significant step forward. Set up following a recommendation from the Scoping Inquiry into the CervicalCheck screening programme, it allowed women’s voices to be heard through workshops, research, and outreach programmes.

“This has allowed women to tell the department of health what their needs are directly,” says Lundy.

Dr Deirdre Lundy: “When you see places like the US rolling back on women’s reproductive rights while we’re moving forward, I feel proud of how Ireland has allowed women the autonomy to make decisions about their bodies.”

The third pivotal development holds special significance in her area of medicine: the healthcare of women undergoing menopause.

“Sallyanne Brady contacted RTÉ’s Liveline, explaining how unhappy she was with the [menopause] treatment she had received from GPs and gynaecologists, and this led to an outcry from Irish women,” says Lundy. “There was so much correspondence that Joe Duffy devoted a whole week to the issue.”

According to Lundy, the taskforce had already identified menopause as an unmet need, but the public uproar precipitated their response. The taskforce set up six complex menopause clinics across Ireland — in Dublin, Cork, Galway, and Nenagh — to look after women who struggle during this stage of their lives.

Lundy’s advice for the minister for health, Jennifer Carroll MacNeill, is to “build on” these achievements.

“Throughout history, women’s lives have been affected by their ovaries, wombs, and hormones, but we’ve made such progress in overcoming problems associated with this,” she says. “Continue to expand the free contraception scheme. Fulfil the promise to provide free HRT. Remember that initiatives like these make a huge difference to women.”

Stop exporting problems

Dr Suzanne O’Sullivan is chair of the institute of obstetrics and gynaecology at the Royal College of Physicians of Ireland and clinical lead of the National Mesh and Complex Pelvic Floor Centre in Cork.

The death of Savita Halappanavar, who died from sepsis after being refused an abortion during a prolonged miscarriage in 2012, was a landmark for her in a career spanning more than 25 years.

“It prompted many healthcare professionals to speak up during the Repeal the Eighth campaign,” says O’Sullivan. “Our hands had been tied for so long by a law that prevented us from helping women who needed our help. We recognised that access to terminations had to be there for women who wanted and needed them.”

She also points to the development of the national maternity strategy in 2016 as a key moment that marked the first in a series of improvements in women’s healthcare.

“That strategy came about in response to several poor outcomes for mothers and babies in the maternity services,” she says. “It recognised the need to implement standardised maternity, gynaecology and neonatal services across the country. Resources and funding had to be provided to make sure there was good national distribution of these services.”

Dr Suzanne O'Sullivan: Savita's death prompted many healthcare professionals to speak up during the Repeal the Eighth campaign. Picture: Chani Anderson

O’Sullivan has a particular interest in pelvic floor dysfunction, a problem experienced by many women post-childbirth and wants them to know that physiotherapy can help. “It’s on offer in every maternity unit to anyone who needs it,” she says. “And your GP can also refer you if you have incontinence or other pelvic floor issues.”

She is also eager to see vaginal mesh implants reinstated as an option for women suffering from stress urinary incontinence, pointing out that they are a standard treatment for this issue everywhere except for Ireland and Britain.

The chief medical officer paused their use here in 2018 following complaints from women reporting post-surgical complications.

“That pause was to allow the medical system to tighten up procedures and governance,” she says.

O'Sullivan is the senior author of the National Guideline on the Management of Stress Urinary Incontinence, which was published in January 2023. She is adamant that all procedures and governance have been tightened.

 “However, the pause still hasn’t been lifted,” she says, despite evidence showing that these operations are safe. “They have high success rates, fast recovery times, and low complication rates.”

She says some 200 women in Cork alone need this surgery. “They cry in my clinic every week because they can’t play with their kids for fear of leaking.

“They’ve been waiting years for surgery. Some have travelled abroad to get it, in an example of Ireland once again exporting its women’s health problems.

“I’d love to see the minister for health show her support for ending the pause on vaginal mesh implant surgery.”

Removing barriers

Professor Susan Smith is a GP in Dublin, a professor of general practice at Trinity College and the chair of Deep End Ireland GPs, a group of doctors working in disadvantaged communities who are campaigning to end inequities in the Irish healthcare system.

When reflecting on how women’s healthcare has changed, she recalls a statistic she heard as a trainee doctor in the 1990s.

“Back then, some 30% of women had hysterectomies in their 40s due to heavy bleeding,” she says. “The Mirena coil brought an end to that. By delivering a small dose of progestogen, it reduces bleeding and serves as a form of contraception. It’s been a gamechanger for women.”

She also recalls the furore that surrounded the publication findings of the Women’s Health Initiative in the early 2000s. “Until then, hormone replacement therapy (HRT) had been prescribed as a way of managing menopause symptoms in women,” she says. “But overnight, that study’s suggestion that HRT increased their risk of breast cancer meant that all prescribing stopped.”

Dr Susan Smith: “Research tells us these women’s lifestyles are too busy for them even to think of going to the doctor. And this doesn’t only impact their health in menopause. It also negatively impacts other health outcomes."Picture: Moya Nolan.

It took more than a decade for scientists to show that this study was flawed and that HRT was safe.

“During that time, a lot of women suffered with debilitating symptoms that went untreated,” says Smith. “But now women have heard the message and more and more are asking about HRT.”

However, this is not necessarily the case for women from more disadvantaged areas. According to Smith, they are far less likely to be prescribed HRT than women from more affluent communities.

“Research tells us these women’s lifestyles are too busy for them even to think of going to the doctor,” she says. “And this doesn’t only impact their health in menopause. It also negatively impacts other health outcomes. These women have higher rates of heart disease, are less likely to attend cancer screenings, and are more likely to present later with cancer,” she says.

Smith would like to see targeted measures taken to improve these health outcomes. One is free GP visits for everyone to remove all financial barriers to accessing primary care.

Another is providing a level of care based on need. “Research shows that people living in disadvantaged areas develop multiple health conditions 11 years earlier than those living in more affluent areas,” she says.

“We would love for the capitation for medical card payments to be weighted more for doctors working in these areas.

“This change would allow them to spend more time with their patients, which would benefit the patients and the health system as a whole.

“It would result in better health outcomes for women, and ultimately, in better health outcomes for all.”