Women’s Health in Ireland

Women’s health is a broad category that includes health issues that are unique to women (e.g. menstruation, pregnancy and menopause), as well as conditions that affect both men and women, but that may affect women differently, such as heart disease. In Ireland, there are some indicators of women’s health that show an improvement over the last few decades: women’s life expectancy at birth in 2021 was 84.3, which is 1.4 years over the EU average, and 1.3 years over the OECD average. In terms of the number of years someone can live a healthy life, i.e. without serious or chronic illness from age 65, Irish women rank second highest in the EU with 13 years (1).

In 2019, a publication from the National Women’s Council of Ireland, Department of Health, and HSE (2) identified key health needs of women at different life stages (Table 1).

This was used to help develop The Women’s Health Action Plan, of which the first part was published in 2022. The Women’s Health Action Plan 2024-2025 (Phase 2: An Evolution in Women’s Health) was launched in Ireland in April of this year. The aim of this is to further develop women’s health services, and also establish the delivery of new services (3):

• In September 2022, the Free Contraception Scheme was launched, providing free contraception services to 17-25 year olds. This scheme is now extended to 35 years.
• There will be more focus on women at midlife and older – “living well and living longer”.
•  Further expansion of Termination of Pregnancy services.
• There will be continued implementation of period poverty measures.
• Expansion of screening services (Diabetic RetinaScreening and BreastCheck).
• A Patient Forum will be conducted to hear directly from women about their health experiences.
• The evidence base for women’s health will improve, through commissioned research and evidence reviews.
• The Cervical Cancer Elimination Partnership will develop a plan to eliminate cervical cancer by 2040, starting with a national public consultation in 2024.
• Support for women’s mental health will be developed.
• National fertility services have now been established (six Regional Fertility Hubs: The Coombe, National Maternity Hospital, Rotunda, Galway University Hospital, Cork University Maternity Hospital, Nenagh). Patients are referred by their GP, where an assessment will take place for both partners (e.g. ultrasounds, blood work and semen analysis). A plan of care is then put in place by the Reproductive Medical Specialist Consultant with the patients. For patients for whom assisted human reproduction treatment (AHR) is clinically indicated, where the national eligibility criteria is met, a referral can be made by the relevant regional fertility team to a HSE-approved private AHR provider of the couple’s choosing. Approximately 500 couples had been referred by a Reproductive Medical Specialist for AHR services by early April 2024.
• Five regional endometriosis hubs are operational, and service expansion is planned as full teams are recruited (Rotunda, Coombe, National Maternity Hospital, Limerick and Galway). Patients with complex needs are referred to one of two Specialist Endometriosis Centres for complex care in Tallaght and Cork.

Breast Cancer

As indicated in Table 1, the most common cancer in women is breast cancer: about 1 in 7 women are diagnosed in their lifetime (4). Most diagnoses are made over the age of 50, but it can still affect younger women and men. Breast cancer symptoms can include:

• A lump in either breast (most common symptom)
• Change in the size/shape of one or both breasts
• Dimpling on the skin
• A lump/swelling in the armpit
• Discharge from either nipple
• Rash on or around the nipple
• Change in the appearance of the nipple, e.g. becoming sunken into the breast (5).

There are many resources available for women that describe how to perform a self breast check, e.g. from the HSE (https://www2.hse.ie/conditions/how-to-check-your-breasts/), and through multiple phone apps, which can also send monthly reminders to check (e.g. the Breast Cancer Ireland app).

In Ireland, BreastCheck invites women for routine breast screening every two years. The age range for this has recently extended from 50-58 years to 50-69 years. Women should be automatically registered with the service, but if an eligible woman does not receive an appointment letter, she should check the breast screening register online.

Vasomotor Symptoms in Menopause

Management of menopause is important for women’s health and wellbeing. Symptoms of menopause negatively impact many women’s wellbeing and quality of life (6). Hormone therapy (combined oestrogen/progesterone, or oestrogen alone) is largely effective for symptom management (7), however, women experiencing symptoms during the menopause who have a history of vaginal bleeding, stroke, heart attack, liver disease or blood clots cannot take hormone therapy.

While there is a huge range of menopausal symptoms, one of the most common is vasomotor symptoms (VMS), i.e. hot flushes and night sweats. VMS affect about 80% of women during the perimenopause and menopause, and are attributed to a narrowing of the hypothalamic thermoneutral zone, caused by alterations downstream to the decline in oestrogen levels (8). Fezolinetant (Veoza) is a new oral medication available to treat moderate to severe VMS caused by the menopause. Because fezolinetant is not a hormone, it can be offered to women for whom hormone therapy is not appropriate. It targets neural activity that causes vasomotor symptoms (6). Fezolinetant is a neurokinin 3 receptor (NK3R) antagonist. This class of drugs was initially (but unsuccessfully) developed in the 1980s to treat schizophrenia. A network of CNS neurons (KNDy neurons, activated by peptides kisspeptin, neurokinin B, dynorphin), activates the NK3R in the thermoregulatory centre. In declining oestrogen, NK3R activation is unopposed, leading to hypertrophy of these neurons and altered activity on the thermoregulatory centre. Fezolinetant blocks NKB binding on the KNDy neuron, restoring normal thermoregulatory centre function (7,8).

A placebo-controlled RCT ( 9) found that doses of 30mg and 45 mg significantly reduced the frequency of VMS, compared to placebo, at week 4 (45 mg 51% reduction vs placebo 31%) and week 12 (45mg 61% vs placebo 35%). Severity of VMS were also reduced significantly. In further RCTs, improvement in hot flush frequency and severity was maintained for a year (10).

Prior to initiation of fezolinetant, and at appropriate intervals, patients require liver tests to monitor hepatic transaminase, or liver injury. As of now, it is not available on any of the government drug schemes, although a full Health Technology Assessment is recommended by the Centre for Pharmacoeconomics in Ireland to assess the clinical effectiveness and cost effectiveness of fezolinetant compared with the current standard of care (11).

Heart Health

As indicated in Table 2, more women die of diseases that affect the heart and blood vessels than men, but men are twice as likely to be hospitalised for heart diseases and heart attacks. 1 in 4 women – which is the same incidence as for men – die from heart disease and stroke, yet heart disease in women has been under-researched, under-diagnosed, and under-treated.

Ischaemic heart disease (IHD), for example, was previously thought to be similar among men and women, but occurring in women at a later stage of life (12). This oversimplifies the mechanisms and sex-specific differences. Due to IHD being considered mainly a man’s disease, models of the disease used in studies have traditionally been male, with women underrepresented.

On average, women have a higher pulse rate at rest than men, and lower haemoglobin levels. In response to stress, women’s pulse rate increases leading to increased cardiac output, whereas in men, response to stress more commonly leads to increased vascular resistance and increased blood pressure. Age related atrial fibrillation is more common in men, but has worse outcomes in women. In normal ageing, arteries lose elasticity, with changes less significant in premenopausal women compared to age matched men. However, postmenopausal women have more prominent arterial stiffness leading to hypertension.

The incidence of IHD is usually lower among women compared to men except in women aged 65 or older. Importantly, there is a difference in pain perception among sexes: acute coronary syndrome with atypical symptoms, e.g.abdominal discomfort, anxiety, neck pain, fatigue; is more common in women. Emotional distress, rather than physical exercise, may be a trigger for MI in older women. These atypical symptoms can delay diagnosis and treatment, and women are less likely to receive evidence based treatment than men.

The beneficial effect of oestrogen (which promotes vasodilation by nitric oxide and prostaglandin production, stabilisation of atherosclerotic plaques through anti-inflammatory mechanisms and preservation of endothelial function) is well established. The oestrogen withdrawal, change in body fat distribution, endothelial dysfunction, and increased sympathetic tone after menopause leads to a doubling of the risk of IHD in women compared to men.

Improvements in Women’s Health

Although women’s health in Ireland has seen some welcome improvements in recent times, there are areas that still require further research and focus. For many diseases, there is a need to strengthen the evidence base to identify sex related, clinically significant differences, in disease treatment and management. This is especially pertinent in these times where we have an increasing ageing population, and the government’s focus on “living well and living longer”.