Health Plan for the Adult Woman
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Child marriage including union or cohabitation  is defined as marriage under the age of eighteen and is an ancient custom. In it was estimated that 67 million women, then, in their twenties had been married before they turned eighteen, and that million would be in the next decade, equivalent to 15 million per year.
This number had increased to 70 million by In developing countries one third of girls are married under age, and before The highest prevalence is in Western and Sub-Saharan Africa. For instance in Mali the ratio of girls to boys is , while in countries such as the United States the ratio is Marriage may occur as early as birth, with the girl being sent to her husbands home as early as age seven. There are a number of cultural factors that reinforce this practice. These include the child's financial future, her dowry , social ties and social status, prevention of premarital sex , extramarital pregnancy and STIs.
The arguments against it include interruption of education and loss of employment prospects, and hence economic status, as well as loss of normal childhood and its emotional maturation and social isolation. Child marriage places the girl in a relationship where she is in a major imbalance of power and perpetuates the gender inequality that contributed to the practice in the first place.
Girls married under age are also more likely to be the victims of domestic violence. There has been an international effort to reduce this practice, and in many countries eighteen is the legal age of marriage. Urges all States to enact, enforce and uphold laws and policies aimed at preventing and ending child, early and forced marriage and protecting those at risk, and ensure that marriage is entered into only with the informed, free and full consent of the intending spouses 5 September Efforts to end child marriage include legislation and ensuring enforcement together with empowering women and girls.
Women's menstrual cycles, the approximately monthly cycle of changes in the reproductive system, can pose significant challenges for women in their reproductive years the early teens to about 50 years of age. These include the physiological changes that can effect physical and mental health, symptoms of ovulation and the regular shedding of the inner lining of the uterus endometrium accompanied by vaginal bleeding menses or menstruation.
The onset of menstruation menarche may be alarming to unprepared girls and mistaken for illness. Menstruation can place undue burdens on women in terms of their ability to participate in activities, and access to menstrual aids such as tampons and " sanitary pads ".
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This is particularly acute amongst poorer socioeconomic groups where they may represent a financial burden and in developing countries where menstruation can be an impediment to a girl's education. Equally challenging for women are the physiological and emotional changes associated with the cessation of menses menopause or climacteric. While typically occurring gradually towards the end of the fifth decade in life marked by irregular bleeding the cessation of ovulation and menstruation is accompanied by marked changes in hormonal activity, both by the ovary itself oestrogen and progesterone and the pituitary gland follicle stimulating hormone or FSH and luteinizing hormone or LH.
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These hormonal changes may be associated with both systemic sensations such as hot flashes and local changes to the reproductive tract such as reduced vaginal secretions and lubrication. While menopause may bring relief from symptoms of menstruation and fear of pregnancy it may also be accompanied by emotional and psychological changes associated with the symbolism of the loss of fertility and a reminder of aging and possible loss of desirability. While menopause generally occurs naturally as a physiological process it may occur earlier premature menopause as a result of disease or from medical or surgical intervention.
When menopause occurs prematurely the adverse consequences may be more severe. Other reproductive and sexual health issues include sex education , puberty , sexuality and sexual function. Women and men have different experiences of the same illnesses, especially cardiovascular disease, cancer, depression and dementia,  and are more prone to urinary tract infections than men.
For instance the incidence of stroke in women under the age of 80 is less than that in men, but higher in those aged over Overall the lifetime risk of stroke in women exceeds that in men. Women and men have approximately equal risk of dying from cancer , which accounts for about a quarter of all deaths, and is the second leading cause of death.
However the relative incidence of different cancers varies between women and men. In the United States the three commonest types of cancer of women in were lung , breast and colorectal cancers. In addition other important cancers in women, in order of importance, are ovarian , uterine including endometrial and cervical cancers Gronowski and Schindler, Table III.
More recently cancer death rates have started to decline as the use of tobacco becomes less common. In the early twentieth century death from uterine uterine body and cervix cancers was the leading cause of cancer death in women, who had a higher cancer mortality than men. From the s onwards, uterine cancer deaths declined, primarily due to lower death rates from cervical cancer following the availability of the Papanicolaou Pap screening test.
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This resulted in an overall reduction of cancer deaths in women between the s and s, when rising rates of lung cancer led to an overall increase. By the s the decline in uterine cancer left breast cancer as the leading cause of cancer death till it was overtaken by lung cancer in the s. All three cancers lung, breast, uterus are now declining in cancer death rates Siegel et al. Figure 8 ,  but more women die from lung cancer every year than from breast, ovarian, and uterine cancers combined.
In addition to mortality, cancer is a cause of considerable morbidity in women. Breast cancer is the second most common cancer in the world and the most common among women. It is also among the ten most common chronic diseases of women, and a substantial contributor to loss of quality of life Gronowski and Schindler, Table IV.
Globally, cervical cancer is the fourth commonest cancer amongst women, particularly those of lower socioeconomic status. Women in this group have reduced access to health care, high rates of child and forced marriage, parity , polygamy and exposure to STIs from multiple sexual contacts of male partners.
All of these factors place them at higher risk.
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The highest incidence occurs in Eastern Africa , where with Middle Africa , cervical cancer is the commonest cancer in women. Cervical cancer is associated with human papillomavirus HPV , which has also been implicated in cancers of the vulva , vagina , anus , and oropharynx. Also an HPV vaccine programme is available in 45 countries.
Screening and prevention programmes have limited availability in developing countries although inexpensive low technology programmes are being developed,  but access to treatment is also limited. By contrast, ovarian cancer, the leading cause of reproductive organ cancer deaths, and the fifth commonest cause of cancer deaths in women in the United States, lacks an effective screening programme, and is predominantly a disease of women in industrialised countries.
In the United States, women have depression twice as often as men. The risks of depression in women have been linked to changing hormonal environment that women experience, including puberty, menstruation, pregnancy, childbirth and the menopause. The prevalence of Alzheimer's disease in the United States is estimated at 5.
Furthermore, women are far more likely to be the primary caregivers of adult family members with depression, so that they bear both the risks and burdens of this disease. The lifetime risk for a woman of developing Alzheimer's disease is twice that of men. Part of this difference may be due to life expectancy, but changing hormonal status over their lifetime may also play a par as may differences in gene expression.
Anaemia is a major global health problem for women. Anaemia is linked to a number of adverse health outcomes including a poor pregnancy outcome and impaired cognitive function decreased concentration and attention. IDA starts in adolescence, from excess menstrual blood loss, compounded by the increased demand for iron in growth and suboptimal dietary intake. In the adult woman, pregnancy leads to further iron depletion. Women experience structural and personal violence differently than men. The United Nations has defined violence against women as; . Violence against women may take many forms, including physical, sexual , emotional and psychological and may occur throughout the life-course.
Structural violence may be embedded in legislation or policy, or be systematic misogyny by organisations against groups of women. Perpetrators of personal violence include state actors, strangers, acquaintances, relatives and intimate partners and manifests itself across a spectrum from discrimination , through harassment , sexual assault and rape , and physical harm to murder femicide.
It may also include cultural practices such as female genital cutting. Violence was declared a global health priority by the WHO at its assembly in , drawing on both the United Nations Declaration on the elimination of violence against women  and the recommendations of both the International Conference on Population and Development Cairo, and the Fourth World Conference on Women Beijing,  This was followed by its World Report on Violence and Health, which focusses on intimate partner and sexual violence.
However it was later criticised for not including violence as an explicit target, the "missing target". UN Women believe that violence against women "is rooted in gender-based discrimination and social norms and gender stereotypes that perpetuate such violence", and advocate moving from supporting victims to prevention, through addressing root and structural causes. They recommend programmes that start early in life and are directed towards both genders to promote respect and equality, an area often overlooked in public policy.
This strategy, which involves broad educational and cultural change, also involves implementing the recommendations of the 57th session of the UN Commission on the Status of Women  Changes in the way research ethics was visualised in the wake of the Nuremberg Trials , led to an atmosphere of protectionism of groups deemed to be vulnerable that was often legislated or regulated.
This resulted in the relative underrepresentation of women in clinical trials. The position of women in research was further compromised in , when in response to the tragedies resulting from thalidomide and diethylstilbestrol DES , the United States Food and Drug Administration FDA prohibited women of child-bearing years from participation in early stage clinical trials.
In practice this ban was often applied very widely to exclude all women. However, research has demonstrated significant biological differences between the sexes in rates of susceptibility, symptoms and response to treatment in many major areas of health, including heart disease and some cancers. These exclusions pose a threat to the application of evidence-based medicine to women, and compromise to care offered to both women and men. The increasing focus on Women's Rights in the United States during the s focused attention on the fact that many drugs being prescribed for women had never actually been tested in women of child-bearing potential, and that there was a relative paucity of basic research into women's health.
The next phase was the specific funding of large scale epidemiology studies and clinical trials focussing on women's health such as the Women's Health Initiative , the largest disease prevention study conducted in the US. Its role was to study the major causes of death, disability and frailty in older women. One of the challenges in assessing progress in this area is the number of clinical studies that either do not report the gender of the subjects or lack the statistical power to detect gender differences.
A related issue is the inclusion of pregnant women in clinical studies. Since other illnesses can exist concurrently with pregnancy, information is needed on the response to and efficacy of interventions during pregnancy, but ethical issues relative to the fetus, make this more complex.
This gender bias is partly offset by the initiation of large scale epidemiology studies of women, such as the Nurses' Health Study ,  Women's Health Initiative  and Black Women's Health Study. Women have also been the subject of abuse in health care research, such as the situation revealed in the Cartwright Inquiry in New Zealand , in which research by two feminist journalists  revealed that women with cervical abnormalities were not receiving treatment, as part of an experiment.
The women were not told of the abnormalities and several later died. In addition to addressing gender inequity in research, a number of countries have made women's health the subject of national initiatives. For instance in in the United States, the Department of Health and Human Services established an Office on Women's Health OWH with the goal of improving the health of women in America, through coordinating the women's health agenda throughout the Department, and other agencies.
In the twenty first century the Office has focussed on underserviced women. Research is a priority in terms of improving women's health. Research needs include diseases unique to women, more serious in women and those that differ in risk factors between women and men.
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The balance of gender in research studies needs to be balanced appropriately to allow analysis that will detect interactions between gender and other factors. They also suggest it is the role of health organisations to encourage women to enroll in clinical research. However, there has been progress in terms of large scale studies such as the WHI, and in the Society for Women's Health Research founded the Organization for the Study of Sex Differences and the journal Biology of Sex Differences to further the study of sex differences.
Research findings can take some time before becoming routinely implemented into clinical practice. Clinical medicine needs to incorporate the information already available from research studies as to the different ways in which diseases affect women and men. Many "normal" laboratory values have not been properly established for the female population separately, and similarly the "normal" criteria for growth and development. Drug dosing needs to take gender differences in drug metabolism into account. Globally, women's access to health care remains a challenge, both in developing and developed countries.
The situation is aggravated by the fact that women living below the poverty line are at greater risk of unplanned pregnancy , unplanned delivery and elective abortion. Added to the financial burden in this group are poor educational achievement, lack of transportation, inflexible work schedules and difficulty obtaining child care, all of which function to create barriers to accessing health care.