Concealed Pains Revealed Through Time: The Changing Landscape of Women’s Health 

Nithikka Senthil Kumar, Second Year Medicine

“Women are born with pain built in. It’s our physical destiny… We carry it with us throughout our lives” ⁱ.

Crafted by Phoebe Waller-Bridge for the television series ‘Fleabag’, this candid monologue helps to express the maze-like journey of navigating women’s health. In a wider context, these words provide social commentary, shedding light on the complexity of a subject that is intrinsically connected with social dogma, politics and evolving medicine.  

Historically, influences of war, fluctuating economics and societal ideologies have dictated medical discourse. The inherent mechanisms created have persisted, and continue to impact scientific knowledge and quality of life for many. Today’s evolving field of women’s health can be traced back to (arguably unsteady) foundations laid down at the beginnings of western medical history.  

From the birth of Hippocratic Corpus, medical ‘fact’ and social attitudes were contextual extensions of one another. Medical understanding of this time encircled the fundamental difference between male and female anatomy: the possession of an organ absent in a man.  This conveniently reduced a woman’s purpose in society to solely her reproductive ability. Notably, Plato’s theory of the “wandering womb”, likened the uterus to an “irrational animal” in a woman’s body, inflicting disease within those who strayed from acceptable social behaviours.ⁱⁱ Limited scientific knowledge legitimised growing social hierarchies, and vice-versa, with the fog of misinformation that then began to settle only growing thicker through time. 

The consensus that female biology was a deviant of the male form (evidenced by inferences from mythology and religion – Pandora, Eve) continued to shape ideas through to the Middle Ages.ⁱⁱⁱ Medical handbooks conveyed the idea that women were vessels, their personhood collateral to their reproductive organs. Advice to sufferers of gynaecological problems was to “not dare to reveal the anguish of their diseases… to a physician”.^iv Against a 14^th century backdrop of Plague pandemics, inherently flawed information heightened fears and shrouded women further in shame.  

In 1542, the passing of the Witchcraft Act in England inflamed medical superstitions further, finding natural physiological changes of menopause indistinguishable from pathological states, and now pursuits of magic.² Religious fervour saw the promotion of the diagnosis of “hysteria”, an all-encompassing explanation for any health concerns afflicting women. The etymology of ‘hysteria’ (Ancient Greek – “hystera”, meaning uterus^v) reflects the belief that conditions of the uterus manifested in the mind, a misinterpretation of the interconnectedness of biological systems in the body. Real health concerns were reduced to hysterical passions, or worse, grounds for conviction. Amongst much uncertainty, women existed as a contradiction: the paradoxical perception of the womb suspending them in social limbo.  

Only in the 18^th century, opposition against harmful medical attitudes began to gain motion, pursued by individuals like Mary Wollstonecraft. Successes were few and far between, however, as progress through this period was haunted by countless cases of mistreatment. This was highlighted by playwright Frances Burney’s 1812 account of her mastectomy, performed without anaesthesia. ^vi 

Social inequalities further infiltrated medicine, with effects experienced more intensely felt, and continuing to be felt, by marginalised groups. Fundamentally, incorrect concepts of black women’s insensitivity to pain, and the generalised misunderstanding of labour pain, may continue to impact women’s healthcare for many years to come.^vii 

The Victorian era saw the infectious spread of contagious diseases and beliefs, where the legally justified, yet inappropriate, use of speculums incited shame and dangerous ovariotomy surgeries entered the limelight. Continual resistance against regurgitations of older theories persisted; Florence Nightingale, Josephine Butler and Putnam Jacobi notably strived to return autonomy to women’s healthcare. Parallel to the 20^th century suffrage movement, medical myths met scrutiny, the concept of hysteria loosened its clutch on practice, and birth control was invented. Conversely, over-medicalisation was prevalent, particularly with menstruation which was viewed in relation to pathological states.  

Growing knowledge of physiology & reproductive endocrinology in the 1920s built more accurate disease profiles of gynaecological cancers, fibroids, endometriosis and other prevalent conditions. New avenues of biomedical research aided the dwindling of false conjectures, but this was not without setbacks. The 1962 Thalidomide tragedy prompted policy changes excluding large cohorts of female participants in clinical research for almost a decade. ^viii 

Nevertheless, efforts from physicians like Clelia Duel Mosher gradually shifted focus to understanding patient experiences. Although the aftertaste of older ideologies still lingered, rapid advancements following the birth of the NHS excited with improved patient outcomes.  

Change had not been radical, rather a slow-burning struggle to untangle healthcare from the knotted social and political influences which strangled its progress.   

While a condensed overview of a geographically localised history, it is evidentiary that the attitudes of today have travelled far from its progenitors. Even the existence of the recent parliamentary review of ‘Women’s reproductive health conditions’ ^ix demonstrates the time and space now given for reflection. This does not diminish ongoing issues; the contents of the report reveal concerns in a similar vein to issues of the past, but under a modern context.  

Endometriosis received particular focus in the parliamentary review. Characterised by the growth of endometrial tissue outside the uterus and often causing severe pelvic pain, this condition affects 1 in 10 women in the UK. Despite its prevalence, on average it takes around 8-10 years to be diagnosed.⁴ Reasons for diagnostic delays are multifaceted: vague symptomatic presentation, healthcare system pressures, lacking research, insufficient awareness, and entrenched inequities are contributors, and each is compounded by stigma.  

Among the public women’s health conditions are “woefully misunderstood”⁴, stemming from gaps in health education and awareness. A difficulty in quantifying pain, characterising highly variable symptoms, and individual reluctance to seek help means that conditions such as endometriosis can be a life-long burden, the weight of which is often silently carried. Even in this digital era, only 8% of women said they felt they had enough knowledge about gynaecological conditions⁴, highlighting the need for trustworthy, intersectional information resources.  

For endometriosis, definitive diagnosis can only be ascertained through laparoscopy. Until then, many patients unfortunately have to endure a pursuit of convincing clinicians of their pain.^x The enquiry reports that 80% of women feel dismissed throughout their health care journey, suggesting greater attention is needed towards understanding lived experiences. Biases in healthcare, both conscious and unconscious,to the greater detriment of certain populations, particularly black women and gender-diverse individuals.^xi Furthermore, pressures following the pandemic have exacerbated waiting times in gynaecology, lags in research endeavours and development of treatment options. ^xii  

For the person seeking help, a disconnect is formed to one’s own health.  Suppressing internalised fears through flimsy self-reassurances: “It’s probably nothing” is often a crutch for women to manage uncertainty.  

While there are intricacies to the broader issues, the problems are not insurmountable. In a recent interview with Dr Shazia Khan, a GP with special interests in women’s health based in Leeds, she expressed that improving public awareness is at the crux of the matter. She highlighted the potential of using social media platforms for greater outreach to initiate open conversations. In addition to emphasising the importance of addressing one’s own biases, her practical advice for medical students regards approaching history-taking with a wider focus. Being more conscientious with social history, learning how the patient’s symptoms may limit their daily life are pivotal to understanding with empathy. “Women all too often suffer in silence”, she says, and being more inquisitive to ask questions can provide space for people to be more forthcoming with their struggles.  

Through time, the knowledge of women’s health has grown through phases of evolving attitudes, pressures and competencies. In today’s practice, balancing celebrations of scientific accomplishment with acknowledging frustrating realities may pave the way for lasting change.  

Paraphrasing a comment from the conversation in ‘Fleabag’, future progress is “something to look forward to”.  

Thanks to Dr Khan for her time & thoughts for the article.  

References

(i) Waller-Bridge, P. and Bradbeer, H. 2019. Fleabag.  

(ii) Adair, M.J. 1995. Plato’s View of the ‘Wandering Uterus’. The Classical Journal. 91(2), pp.153–163. 

(iii) Cleghorn, E. 2021. Unwell women : a journey of medicine and myth in a man-made world. London: Weidenfeld & Nicolson. 

(iv) Green, M.H. 2001. The Trotula A Medieval Compendium of Women’s Medicine. Philadelphia University Of Pennsylvania Press. 

(v) Last, J.M., Dunea, G. and Lock, S. 2006. The Oxford companion to medicine. Oxford: Oxford University Press. 

(vi)Epstein, J.L. 1986. Writing the Unspeakable: Fanny Burney’s Mastectomy and the Fictive Body. Representations. (16), pp.131–166. 

(vii) Rao, V. 2020. Implicit bias in medicine: How it hurts Black women. TODAY.com. [Online]. Available from: https://www.today.com/health/implicit-bias-medicine-how-it-hurts-black-women-t187866.  

(viii) Balch, B. 2024. Why we know so little about women’s health. Association of American Medical Colleges. [Online]. Available from: https://www.aamc.org/news/why-we-know-so-little-about-women-s-health.  

(ix) Women and Equalities Committee 2024. Women and Equalities Committee Women’s reproductive health conditions First Report of Session 2024-25 HC 337 [Online]. Available from: https://committees.parliament.uk/publications/45909/documents/228040/default/.  

(x)Endometriosis UK 2024. Years of being ‘dismissed, ignored and belittled’: Endometriosis UK urges improvement to deteriorating diagnosis times  | Endometriosis UK. http://www.endometriosis-uk.org. [Online]. Available from: https://www.endometriosis-uk.org/diagnosis-report.  

(xi) Nuffield Department Women’s & Reproductive Health 2023. Endometriosis: black women continue to receive poorer care for the condition — Nuffield Department of Women’s & Reproductive Health. http://www.wrh.ox.ac.uk. [Online]. Available from: https://www.wrh.ox.ac.uk/news/endometriosis-black-women-continue-to-receive-poorer-care-for-the-condition.  

(xii) Smitha Mundasad and Burns, C. 2024. Gynaecology waiting lists in UK double, leaving women in pain. BBC News. [Online]. Available from: https://www.bbc.co.uk/news/articles/clyvg2157mvo.