Dr Ciara McCarthy, a GP in Cork city, was appointed the first clinical lead in Women’s Health with the Irish College of GPs three years ago. In that time, there has been a gradual revolution in women’s healthcare in terms of increased awareness of women’s health needs, improved service provision, better access to some services and a significant expansion in education and training resources at College level.

“I’ve been clinical lead for Women’s Health now for three years, and in that time I’ve come to appreciate that GPs have a huge interest in and appetite for education and training in women’s health. Initially this was particularly notable in terms of menopause care. The Joe Duffy/Liveline effect led to a huge surge in the number of women attending for menopause advice and treatment. GPs expressed their need to keep up to date on this and engaged very strongly with the College’s educational resources. The Quick Reference Guide, ‘Diagnosis & Management of Menopause in General Practice’ is by far the most accessed guide on our website.

“It’s positive that the Government continues to recognise the financial burden women can face in availing of necessary healthcare. With HRT and menopause treatment, some women may need to be prescribed two or three items, and costs can quickly mount up. So we very much welcome the introduction of free, State-funded HRT from this month to reduce this burden on women, as we welcomed the provision of free contraception for women from age 17 to 35.

“The Government has given an assurance that the Free Contraception Scheme will be further expanded to cover all women of reproductive age who require contraception. We would feel this is a necessary move, as cost as a barrier to contraception access is not just limited to women up to the age of 35.”

Issues with access to care

Ciara says there are still issues with access to care in our health system and this is not just confined to women’s health services. “Access to GP care is multifactorial, with cost being just one of many factors at play. We have a GP workforce shortage and many practices are operating at capacity. While we know from College research that while the majority of practices maintain same day availability for acute and emergency care, patients may have to wait longer for non-acute or chronic care.”

One proposal to improve access has been to allow oral contraception to be available over the counter. Dr McCarthy says that while this is being considered by Government, there would not necessarily be a consensus that this is the best way forward. 

“While making the pill available OTC without a prescription would undoubtedly improve access to contraception for women who may be facing barriers, there are pitfalls which we would be concerned about. Oral contraceptives have a much higher failure rate than long-acting reversible contraceptives (LARCs), so there is a risk that in making the pill more accessible women might inadvertently choose a less effective form of contraception.

“In addition, medical eligibility for combined hormonal contraception can be complex, particularly with women who have risk factors for cardiovascular disease or venous thromboembolism. As GPs we have ready access to patients’ full medical histories, which enables us to counsel patients comprehensively and come to a shared decision on contraception that is both medically appropriate and in keeping with the individual woman’s personal preferences.”

In terms of improving women’s health services there is frequently a sense of having to fill a gender gap. “There is definitely a historic gender gap in terms of medical research, for example in terms of cardiovascular research. Many of the landmark clinical trials on primary and secondary prevention exclusively enrolled males but their findings have been extrapolated and used to guide treatment recommendations for both men and women. Dr Sarah McErlean discusses this in the College’s Gender and Health Outcomes course, and while 38% of participants in cardiovascular trials are now women, in specific areas like heart failure, female participation in clinical trials is quite a lot lower.”

Ciara says there are female-specific risk factors that impact on cardiovascular health, which can sometimes be overlooked. “These would include conditions such as gestational diabetes, pre-eclampsia, pre-term birth, PCOS and autoimmune disease. We really do need to highlight that these conditions confer a significant additional risk.

“The cardiovascular risk stratification systems that we regularly use don’t take these conditions into account, underestimating cardiovascular risk in these cohorts.”

Women overlooked

Does she believe that in general many women’s health conditions were until recently not taken seriously enough?

“Historically women’s health has been overlooked, not prioritised and under-invested in in terms of clinical research and clinical interventions. Obvious examples would include endometriosis and PCOS, both of which affect up to 10% of women yet many women are undiagnosed, or face significant barriers in obtaining a diagnosis. 

“In PCOS, for example, there are life-long sequelae in terms of metabolic and gynaecological health. We need to focus more research on a wide range of women’s health conditions right throughout the life cycle, recognising the impact of these conditions on both the individual and wider society.” 

“Particular focus needs to be given to women’s health provision in marginalised  and disadvantaged communities and also in more remote rural areas.”

Ciara welcomes the fact that the Government has been taking action on bridging the gender gap in healthcare access and provision. “Phase two of the Women’s Health Action Plan is aimed at building on what was implemented from the first plan, which included the introduction of free contraception and HRT, the setting up of endometriosis hubs, complex menopause clinics, public fertility clinics, postnatal hubs and a number of other initiatives.

“Phase two aims to build on that and expand these initiatives. It also has a particular focus on women who are in mid-life and beyond. There’s a specific emphasis on cardiovascular and bone health.”

Structured women’s healthcare programme

Ciara feels there is a need for a structured women’s healthcare programme for general practice. “I think the complexity and the breadth of women’s healthcare that GPs deliver is phenomenal and is delivered to a really high standard. A resourced, structured care programme for women’s health would enable and empower GPs to continue to provide that high standard of care and enhance it further, providing care right through the life course. This is in keeping with the central Slaintecare principle of ‘right care, right time, right place’.

The recent Programme for Government has committed to introducing a comprehensive women’s health programme in general practice, to include many areas such as advice on  contraception, STI screening, fertility and pre-conception care, and support for women experiencing menopause.

“If this wraparound care is introduced, and resourced appropriately, it would offer significant benefits to women. It would of course require careful logistical planning, taking into account the many pressures already facing Irish general practice”

Early medical abortion (EMA)  is now a routine part of care for around one-in-four GPs in Ireland. Ciara says as of March of this year there were 445 GP contract holders for EMA provision. “We know based on HSE research that there is an average of two GPs who provide care under each contract so we would estimate there are approximately 900 GP EMA providers, which represents 20-25% of GPs in active practice. There are new providers continually coming on board – about 70% of the attendees at the recent in-person training day in Portlaoise were new providers. We’ve seen an increase recently in the number of GP providers who have their names registered with MyOptions.

“For the most part, that level of participation is sufficient  for most women who need abortion care to obtain it in a manner that is timely and accessible. However, we do know there are a small number of counties which do not have  GP EMA providers listed on the MyOptions helpline. This undoubtedly means that women living in those areas need to travel some distance to access care. We hope to examine those geographical areas where there are fewer providers to see what supports can assist in embedding community EMA in these regions.”

Education and training

Ciara says as regards education and training resources in women’s health, the College is constantly looking at what it can improve upon, looking not only at women’s changing healthcare needs and best practice guidelines but also ensuring that resources are tailored to the set-up of Irish general practice.

“We’re currently working on a GP update on endometriosis and looking at delivering further in-person education. A lot of our education went virtual and online in the pandemic years and afterwards, and while this is a very positive, convenient and successful learning forum for busy GPs, there is still a desire among many GPs to have education delivered in a mix of virtual and in-person formats. Both in-person and online learning is very much here to stay.

“Recently we conducted a LARC training in-person update at the National Trainers Conference and an early medical abortion in-person update in Portlaoise. I think participants really benefit from attending in-person and meeting up with colleagues face-to-face to share experience and knowledge. 

“GPs are upskilling all the time in women’s health. Our community gynaecology course, for example, is now in its fourth year with a very high level of engagement.

“We must continue to advocate at Government level for improved access to and resources for women’s health, and as a College and a training body we must continue to ensure that we provide high-quality educational resources to ensure GPs can access education and continue to deliver evidence-based care in this vital area of healthcare.”