Position Statement: Global gynaecological health

Globally, gynaecological health is one of the most neglected areas of health, despite its enormous burden on women.

Gynaecological health encompasses a broad range of issues that affect women’s reproductive organs, including gynaecological cancers such as cervical, ovarian and endometrial cancers and non-cancerous, so-called ‘benign’ gynaecological conditions.[a] ‘Benign’ gynaecological conditions – including urogynaecological problems, menstrual conditions, endometriosis, infertility and subfertility, fibroids, and menopause-related symptoms – are especially stigmatised and neglected.

Research commissioned by the Royal College of Obstetricians and Gynaecologists showed that in 2019, almost 8% of all years lived with disability (YLD) for women aged 15-49 in low- and middle-income countries (LMICs) were due to ‘benign’ gynaecological conditions. This was higher than the YLD due to malaria, TB and HIV/AIDS combined – diseases which receive far greater political prioritisation.[1]

The availability of high-quality gynaecology services is vastly insufficient, with long-term underfunding contributing to shortages of skilled healthcare professionals. This has led to a staggering unmet need for gynaecological healthcare, leaving millions of women and girls – predominantly in LMICs – suffering the life-changing and often life-limiting consequences of untreated or poorly managed gynaecological conditions.

This position statement sets out the urgent need to prioritise gynaecological health. Without intervention, women and girls around the world will continue to endure preventable suffering, hindering progress towards sustainable health and gender equality.

Gynaecological health covers a broad range of issues that affect women’s reproductive organs.
Examples of gynaecological conditions and current estimates of their global prevalence:

• Abnormal uterine bleeding (AUB) describes irregularities in the menstrual cycle, including heavy, irregular and intermenstrual bleeding. AUB is common, and often debilitating. While estimates suggest that one in three women experience AUB in their lifetime, this is likely an underestimation as heavy menstrual bleeding alone reportedly affects over 50% of women and girls of reproductive age globally.[2]
• Fibroids are the most common benign uterine tumours in women of reproductive age. Around 2 in 3 women will develop at least one fibroid in their lifetime, with around 1 in 3 women experiencing symptoms.[3]
• Endometriosis is a chronic disease in which tissue similar to the inner lining of the uterus grows elsewhere in the body, leading to inflammation and scar tissue. Globally, roughly 10% (190 million) of women and girls are affected by endometriosis.[4]
• Infertility affects a large proportion of the global population, with an estimated 1 in 6 people experiencing infertility in their lifetime.[5]
• Menopause is a normal part of biological ageing for most women. Symptoms are estimated to affect more than 75% of women, lasting on average for seven years.[6]  
• Obstetric fistula is a connection between the birth canal and bladder caused by prolonged, obstructed labour during childbirth. With early support from skilled healthcare professionals, obstetric fistula is largely preventable and treatable. However, there are stark global inequalities: while obstetric fistula has been almost entirely eradicated in high-income settings, at least two million women across Asia and Sub-Saharan Africa live with untreated obstetric fistula.[7]
• Cervical cancer is the fourth most common cancer among women, with around 90% of new cases and deaths worldwide in 2020 occurring in LMICs.[8]
• Ovarian cancer is the eighth most common cause of cancer death among women. The five-year survival rate for ovarian cancer is below 50%, even in high-income countries.[9]

The far-reaching consequences of gynaecological conditions affect women and girls from adolescence through to later life, exacerbating existing gender inequalities and restricting their full participation in society.

• Endometriosis symptoms commonly include chronic and severe pelvic pain, heavy and intermenstrual bleeding, fatigue, depression and anxiety.[10] Endometriosis is associated with infertility, with a prevalence of 25-40% in woman with infertility compared with 0.5-5% in women without infertility.[11]
• Infertility can have devastating impacts, with women frequently experiencing social stigma, ostracism, shame, emotional stress, anxiety, depression and low self-esteem. Infertility is an under-recognised risk factor for intimate partner violence.[12] In LMICs, women with infertility are more likely to suffer physical and sexual violence over their lifetime.[13]
• Heavy menstrual bleeding can significantly affect a woman’s ability to perform daily activities. In adolescents, heavy menstrual bleeding is strongly associated with girls’ absenteeism from school, exacerbating existing gender inequalities in educational attainment and reducing a woman’s opportunities for economic security and autonomy across her lifetime.[14] Heavy menstrual bleeding is also a major contributor to iron-deficiency anaemia, which increases the risk of life-threatening postpartum haemorrhage and is among the leading causes of YLD in LMICs.[15]
• Menopause affects women in various ways, with symptoms ranging from mild to severe. Menopause-related symptoms can include central nervous system-related disorders (including vasomotor symptoms and sleep disturbances), metabolic and weight changes, urogenital and skin disorders, and sexual dysfunction.[16] Musculoskeletal and cardiovascular health can also be affected by menopause, with perimenopausal and postmenopausal women at an increased risk of cardiovascular disease, the leading cause of death for women globally, as well as stroke, and osteoporosis and fracture.[17]
• Obstetric fistula causes chronic incontinence and can lead to frequent infections, kidney disease, painful sores, infertility and death if left untreated. Women and girls living with obstetric fistula often suffer social stigma and discrimination, ostracised by their families and communities.[18]

• Gynaecological conditions are underreported and underdiagnosed. Women often diminish and self-manage their symptoms, especially when this is normalised within their communities.[19] For example, almost half of women affected by heavy menstrual bleeding feel that their symptoms are ‘normal’ and unworthy of treatment.[20] At the same time, stigma and embarrassment can impact a woman’s ability to report her symptoms to healthcare professionals. Even when women contact the healthcare system, they experience poor care availability, and healthcare professionals may minimise their symptoms, compounding shame, self-doubt and symptom dismissal and inhibiting further seeking of care.[21] For example, worldwide, there is a seven year delay on average between symptom onset and diagnosis for women with endometriosis, driven in part by stigma and the normalisation of patient symptoms by healthcare professionals.[22]
• A large data gap exists for gynaecological conditions. The Global Burden of Diseases, Injuries and Risk Factors Study (GBD) is the most comprehensive effort to quantify trends in health. However, several important gynaecological conditions, including obstetric fistulae, are absent from the GBD database. There is also a lack of primary data for some regions, with data for LMICs mostly extrapolated from small-scale studies or models based on hospital statistics from high-income countries.[23] Outside of the GBD, data on gynaecological conditions is limited. For example, with just 21% of the world’s population covered by population-based cancer registries, there is limited data on the global burden of many gynaecological cancers.[24] While data is an important tool for improving health system functioning and population health, the capacity to collect and analyse data is limited in many LMICs.[25] Due to these limitations, the global burden of gynaecological conditions is likely to be significantly underestimated.
• Many national health policies, training programmes, and healthcare strategies neglect important areas of gynaecology, instead focusing largely on obstetrics. This neglect of comprehensive gynaecological health in national priorities creates harmful gaps in specialist knowledge and expertise on gynaecological health among healthcare professionals.
• The availability of respectful, high-quality gynaecology services is vastly insufficient. Shortages of skilled healthcare professionals and limited availability of equipment mean that millions of women are living with untreated or poorly managed gynaecological conditions. For example, obstetric fistula is surgically treatable in most cases yet only one in 50 women receive a fistula repair due to a shortage of skilled fistula surgeons.[26] The availability of obstetric fistula treatment is especially low in countries that have the highest levels of maternal mortality and fistulas.[27] In LMICs, fertility treatment is also very limited or unavailable, particularly in sub-Saharan Africa.[28] Additionally, resource constraints within healthcare systems mean that many women experience significant waiting times for gynaecology services. In England, almost 600,000 women are waiting for gynaecology care, with nearly half of women waiting over 18 weeks.[29] Long waiting times for gynaecology care are resulting in disease progression and an increase in complexity of symptoms, leaving women suffering with chronic and often avoidable pain.

• Develop and sensitise universally accepted definitions for gynaecological conditions to address data collection challenges resulting from the lack of specific and relatively non-invasive diagnostic criteria for gynaecological conditions.
• Establish international targets and indicators on gynaecological health to hold governments and donors accountable and systematically measure and track progress.
• Invest in large-scale, regionally representative research studies and improved data collection methodologies for gynaecological conditions to strengthen the evidence base on the burden of disease and to inform policy and programmatic responses.

• Invest in comprehensive, competency-based clinical training for frontline healthcare professionals to equip them with the knowledge and skills to recognise, prevent, manage, treat and refer gynaecological conditions at the earliest stage.
• Invest in task-shifting and task-sharing for health workers to support the delivery of integrated and decentralised sexual and reproductive health services, particularly in low-resource settings.

• Provide health services with the sustainable financial and logistical resources they need to strengthen and safeguard gynaecology services against operational pressures.
• Integrate gynaecology services into primary healthcare systems to improve women’s access to timely, quality, and respectful care at their first point of contact with a healthcare professional.
• Develop and implement evidence-based national policies and guidelines on gynaecological health, ensuring that they align with international best practices and frameworks.
• Improve communication with women waiting for gynaecology care, ensuring transparency on waiting times, service availability, and pathways for escalation of care.
• Expand accessible information and advice on gynaecological conditions, common symptoms, and when to seek further help.

• Champion gynaecological health as a political priority, ensuring that gynaecological health is integrated into broader gender equality, health equity, and sustainable development efforts.
• Ensure advocacy efforts focus on vulnerable and marginalised populations, who often face additional barriers to accessing timely, high-quality gynaecology care.
• Advocate for the removal of legal and policy barriers that restrict access to essential sexual and reproductive health services, including discrimination in healthcare settings.

• Establish dedicated funding streams for gynaecological health within national and global health budgets, ensuring that funding is proportional to the impact of these conditions on women and health systems.
• Ensure research funding mechanisms prioritise neglected gynaecological conditions to accelerate the development of more effective treatments and diagnostic tools.

• You can read more about the case for reinvestment in global SRHR in the RCOG report Getting Back on Track.
• The RCOG’s Gynaecological Health Matters programme aims to increase access to high-quality gynaecology care. Together with our partners, we deliver clinical training on Essential Gynaecological Skills (EGS) to frontline healthcare professionals, and advocate for the prioritisation of gynaecological health across all levels of the healthcare system. You can read about our Gynaecological Health Matters programme on our website.
• Climate change is a substantial and growing threat to women’s health, particularly for women living in countries most vulnerable to climate change. Climate change shapes women’s health outcomes throughout their lives, and climate-related disruption can seriously impact health services, preventing or delaying access to vital care. You can read our position statement to learn more about the impacts of climate change on women’s health, and the role of the UK governments and health services in creating a liveable, healthy future for women and girls.