Historically, gynaecology and obstetrics occupied a marginalised position within healthcare specialties, often relegated to the status of a ‘Cinderella service’ (Royal College of Obstetrics and Gynaecologists, 2019; National Institute for Health and Care Excellence, 2021). This perception stemmed from societal attitudes and gender bias, which influenced how gynaecological and obstetric services were viewed in comparison to other specialties.

Nowadays, gynaecology is recognised as an essential specialism, employing a range of healthcare professionals, such as physiotherapists, specialist nurses and psychologists, to provide vital care to women of all ages, playing a crucial role in diagnosing and treating a broad range of women’s health issues. However, this historical context is important to consider when examining certain areas of practice, as unconscious bias can still exist and impact healthcare professionals’ decisions (Bourdieu, 2001; Chapman et al, 2013). Therefore, intuitive decision making in healthcare can act as a double-edged sword, where it can be helpful during emergencies but can also lead to discrimination and bias, especially in complex situations.

The vulva and sexual pleasure

The external female genitalia have several functions, including protection of the urethra, lubrication of the vagina and the production of sensual intensity upon stimulation because of an extensive nervous supply. However, until recently, the importance of the vulva in sexual pleasure has largely been underplayed, not encouraged or even discussed.

Female genital mutilation

The World Health Organization (2024a) recognises female genital mutilation as a violation of the human rights of women and girls, and suggests that the practice reflects deep-rooted gender inequalities.

• Female genital mutilation involves the partial or total removal of external female genitalia or other injury to the female genital organs for non-medical reasons
• It damages healthy genital tissue and interferes with the natural functions of girls’ and women’s bodies it has no health benefits and can also result in loss of life
• Female genital mutilation is mostly carried out on young girls between infancy and age 15 years
• More than 200 million girls and women have been subjected to female genital mutilation globally
• The practice violates a person’s rights to be free from torture and cruel, inhuman, or degrading treatment and a person’s rights to health, security and physical integrity (World Health Organization, 2024a)

Female genital mutilation is illegal in the UK and constitutes a form of child abuse. Therefore, it is imperative that healthcare professionals observe for signs of female genital mutilation and ask women about any possible alterations to their external genitalia, as these may increase the risk of reproductive complications, pain and normal vulval functioning. As female genital mutilation also constitutes an extreme form of discrimination, it may also alert healthcare professionals to possible safeguarding concerns for women and female infants.

Female genital mutilation and psychological support

Female genital mutilation can affect a woman’s mental health long after the physical trauma and can significantly impact all areas of her sexual, physiological and emotional wellbeing. It is often the case that the more extensive the physiological trauma, the higher the risk of developing mental health disorders (Köbach et al, 2018: World Health Organization, 2024a).

Signs of long- and short-term psychological trauma include:

• anxiety
• shock
• sadness
• somatisation
• depression
• post-traumatic stress disorder (Köbach et al, 2018; World Health Organisation, 2024a)

Women can also report feelings of anger, particularly at family members who have violated their trust, and isolation, as they do not feel they can talk to anyone about the issue. Midwives and specialist gynaecological nurses are well placed to recognise female genital mutilation, provide an outlet for the woman’s concerns and linking the woman to specialist support services such as NHS National FGM Support Clinics and The Dahlia Project also offer emotional support and counselling.

Vaginitis

Vaginitis refers to inflammation of the vagina that can be infectious or non-infectious, transmitted through sexual contact or resulting from an imbalance in natural flora and fauna caused by hormonal changes, personal hygiene or medications. It is one of the most common reasons for women to seek assistance from gynaecologists and there are many causes including bacteria, yeast, viruses, or even clothing, creams and soap (American College of Obstetricians, 2023).

Polycystic ovary syndrome

As the name suggests, polycystic ovary syndrome is a disorder that affects the ovaries and is linked to one or more cysts and/or elevated levels of androgens and few or anovulatory menstrual cycles. This is the most common female endocrine disorder and is a leading cause of infertility (Patton and Thibodeau, 2017). It is often diagnosed with other endocrine conditions, such as congenital adrenal hyperplasia, Cushing syndrome and thyroid disease. Symptoms are usually linked with obesity and include:

• acne
• hirsutism
• amenorrhoea
• hypertension
• dyslipidaemia (Ismayilova and Yaya, 2022)

Treatments and management strategies include promoting weight loss, healthy eating and oral contraceptives to help regulate menstrual cycles.

Ovarian cysts

Ovarian cysts are common in women of reproductive age, and can be separated into two main categories: functional and pathological ovarian cysts. The former is the most common type, subdivided into follicular and corpus luteum cysts, depending on whether they originate before or after the egg is released (NHS, 2023). Most functional cysts resolve on their own and women may not experience symptoms or even realise that they have a cyst. Pathological cysts arise as a result of abnormal cell growth, often occurring unilaterally, and can range from 5–10 cm in size, causing symptoms of pain within the pelvis, bloating or irregular menstruation (Ford, 2024). These cysts may become cancerous and need to be removed via surgery (Ford, 2024).

Ovarian cancer screening

Within the UK, ovarian cancer is the leading cause of death among gynaecological cancers and the incidence rate has risen significantly in the past few decades (Menon et al, 2021). Following extensive study within this area, the BRCA1 and BRCA2 (tumour suppressor) genes have been identified as increasing the risk of developing breast and ovarian cancer (Ford, 2024). Screening tests, such as transvaginal ultrasounds and serial CA125, have gone some way to help with the detection of this disease, but more still needs to be done to raise awareness of the signs and symptoms to assist with early detection (National Institute for Health and Care Excellence, 2023).

Endometriosis

Endometriosis is a disorder associated with the presence of functioning endometrial tissue outside of the uterus that respond to hormonal changes, proliferate and shed, bleeding into the surrounding area and causing inflammation and, for some women, significant pain. The most common affected sites are the ovaries, uterine ligaments and the pelvic peritoneum; however, endometrial tissue has also been found in the bowel, bladder, vulva, extremities and lungs (McCance and Huether, 2018).

Endometriosis affects approximately 190 million women of reproductive age globally, and is associated with severe dysmenorrhoea and chronic pelvic pain, which negatively impacts sexual intercourse, bowel movements and/or urination (World Health Organization, 2024b). Endometriosis can also cause nausea, fatigue, bloating and infertility (World Health Organization, 2024b). There is currently no cure, and treatments such as contraceptive steroids, non-steroidal anti-inflammatory drugs, analgesics, hormone therapy and surgery are pursued in order to control symptoms.

Surgery, pain management and treatment

Endometriosis is sometimes not considered a serious condition, as pelvic pain in women is often normalised in society. Consequently, women’s voices are often silenced or their symptoms minimised and not prioritised. This can have a devasting impact on their sexual and reproductive health, quality of life and overall wellbeing, as well as their psychological health and feelings of worth. When their complaint is taken seriously and surgery is required, these biases can continue.

Findings from a study by Ford (2020) highlighted that during preoperative interactions, healthcare professionals’ discussions about pain and decision making were influenced by their existing judgments and preconceptions. Day surgery and particularly gynaecological procedures were often minimised and downplayed, and patients were stereotyped in terms of the healthcare professionals’ perceptions of the level of pain that the surgery would evoke and thus were treated unequally (Ford, 2020). The preoperative information given to patients was at times inadequate, with dismissive language often being used. Female reproductive organs were not associated with high levels of pain, leading to less preparation preoperatively (Ford, 2020).

Aranda (2017) agreed that female reproductive organs are often unseen, rarely associated with death and infrequently talked about in society. Low prestige is also aligned with conditions that are not linked to specific major organs or are slow to develop, such as endometriosis. This may be a consequence of the additional cultural worth that is placed on different types of pain, as visceral pain is traditionally taken less seriously than somatic pain, and for many years was associated with being a hypochondriac (Maybin and Serpell, 2012). However, pain is uniquely experienced, so attempting to equate individuals’ specific pain to certain conditions and levels of tissue damage could be detrimental to a patient’s recovery.

Women-centred care

It is crucial to thoroughly investigate women’s reports of pain instead of dismissing them. Given the variety of symptoms, it may also be necessary to use a multidisciplinary and multimodal tailored approach to manage their symptoms effectively. This can include referrals to gynaecologists, pain specialists, pelvis physiotherapists, psychologists and alternative therapies as adjuncts to pharmacological management (World Health Organization, 2024b). It is essential to involve women (and their partners, if applicable) in their care and not to make decisions for women, but with them. Additionally, any decisions made must be tailored to the individual needs of the woman and must take into consideration their holistic picture.

The role of the nurse and bias

Healthcare providers’ stereotyped views of patients and their conditions can lead to repetitive practices that limit their ability to consider alternative options (Ford, 2020). Healthcare systems can be impacted by biases that affect decision making, especially when such biases are unconscious and not regularly checked through self-reflection. These biases can be particularly challenging for staff in day surgery, as their previously held perceptions of postoperative pain levels may be difficult to change if generated from a narrow viewpoint. Additionally, in busy areas such as perioperative departments, healthcare professionals may forget that while the surgery may be routine for them, it is a significant and non-routine event for the patient. It is therefore imperative that healthcare professionals who are caring for women adhere to the Nursing and Midwifery Council (2018) standards of proficiency by providing compassionate, person-centred care and using updated and evidence-based practices to improve safety and quality of care delivery.