Despite considerable progress in the past decades, societies continue to fail to meet
the healthcare needs of women at key moments of their lives, particularly in their
adolescent years and older age. Global Strategy for Women’s and Children’s Health
was launched by the UN’s Secretary General in 2010, and then renewed in 2015 to focus
worldwide attention and ensure international commitments and contributions toward
improving the existing situation worldwide 1,2.
Especially in low-income and medium-income countries, the challenges exist in female
health not only in terms of diseases or conditions specifically affecting the female
sex but also general access to healthcare and proper diagnostic imaging. Several key
issues justify the importance of imaging in disease management, the influence of sex
on the practice of imaging, the importance of women in societies and the continuing
efforts of global international organizations, such as the International Atomic Energy
Agency and the WHO, geared toward capacity-building in low-income and middle-income
countries.
The current status
Multiple international programmes and activities, such as the UN Millennium Development
Goals (MDGs) 3, Global Strategy for Women’s, Children’s and Adolescents’ Health 2
or WHO Global Action Plan 4, have been launched with the goal of impacting significantly
toward improving womens’ health worldwide. Although the overall pattern is improving,
female life expectancy at birth still markedly varies in different regions of the
world, reaching 80 years and above in 46 high-income countries, but only averaging
less than 58 years in the African region 5. Furthermore, a disproportionately large
number of deaths occur in low-income countries for women in the younger age groups
versus the high-income countries.
Shifts in population dynamics towards a more ageing population create new challenges
and greater complexities in the global burden of ill health, including an increase
in noncommunicable diseases 6. Combined cardiovascular disease and stroke, often considered
to be a ‘male’ problem, is the number one killer in women globally, with over 7.5
million deaths reported in 2010 for women older than 60 years of age and cardiovascular
diseases accounting for 46% of older women’s health issues 5.
The normal life cycle exposes women to multiple risk factors associated with diseases
or to socioeconomic conditions leading to diseases later in life. Indeed, many health
problems faced by women in their older age are the result of exposure to risk factors
in adolescence and adulthood, such as smoking, sedentary lifestyles and unhealthy
or insufficient diets.
Maternal health
Despite international efforts and implementation of MDGs 4 (reduction in child mortality)
and 5 (improving the maternal health), maternal and antenatal death rates are still
high, with more than 360 000 maternal and three million estimated annual neonatal
deaths worldwide 7–9.
Nearly 800 women died every day in 2013 because of complications during pregnancy
and childbirth, 99% of all maternal deaths occurring in developing countries. The
global maternal mortality ratio has decreased by almost 50% worldwide between 1990
and 2013 3,10, however, without reaching the target of MDG 5, that is, 75% reduction
in maternal mortality by 2015.
The WHO Millennium Goals Progress Report showed that 36 of 40 countries with the highest
maternal mortality rates are in Africa. In sub-Saharan Africa, the maternal mortality
risk is 1 : 30 compared with 1 : 5600 in the developed countries 3. Lack of education
and inadequate maternal care are major factors related to poor pregnancy outcomes
and high maternal and antenatal mortality 11,12. Although these causes are, in principle,
fully preventable, and reversible, 45–50% of women in Africa do not even have basic
antenatal care and 60 million of births occur without any skilled birth attendants
3,10.
Adolescent pregnancy is the leading cause of death in young women (15–19 years old)
in low-income countries, contributing towards 15% of total maternal deaths worldwide,
but 26% in Africa. Adolescent pregnancy is also linked to unsafe abortion, leads to
low weight at birth and to poor health during infancy. Over 2.65 million stillbirths
occur per year, many from preventable causes related to poor maternal health and care
12.
The main leading factors for maternal mortality include unsafe abortion, severe bleeding,
infections, eclampsia/pre-eclampsia, complications from delivery and, above all, lack
of access to healthcare facilities. The WHO Focused Antenatal Care model recommends
at least four antenatal care visits for uncomplicated pregnancies, with the first
visit starting before 16 weeks of gestation 13,14. The first visit should take place
in the early weeks of pregnancy to confirm the pregnancy and expected delivery time,
classify woman for basic antenatal care or care in more specialized centres, and develop
a birth and emergency plan. Further visits are centred on assessing the maternal well-being
and foetal development.
During pregnancy, ultrasound (US) imaging plays a crucial role in detecting several
conditions potentially to life-threatening complications, for example, ectopic pregnancy,
multiple gestations, placenta previa, abnormal foetal growth and malposition; these
conditions may thus be identified early and appropriately managed. Coupled with accurate
gestational dating, US can assist in the management of pregnancies and allow the mother
to reach appropriate obstetric care before delivery if a high-risk pregnancy is identified.
Congenital anomalies (2–4% of all births) cause 20–25% of all perinatal deaths and
even higher percentages of perinatal morbidity. Routine US provides crucial information
for decisions during pregnancy and appropriate treatment at birth, thus reducing perinatal
mortality and morbidity.
Abnormal foetal growth is a leading cause of perinatal morbidity and mortality in
both developed and developing countries. Growth parameters measured by US early in
pregnancy serve as a baseline against which later scans may be compared for foetal
growth and health, and facilitate the management of problems arising later in pregnancy.
The Cochrane Library reviewed 11 randomized-controlled trials including 37 505 women
for outcome after routine early pregnancy US (before 24 weeks) versus selective US
15. Routine US improved the early detection of multiple pregnancies and improved gestational
dating, thus resulting in fewer inductions for postmaturity.
Whereas in most developed countries US is part of the standard obstetric and gynaecological
care that every woman receives to diagnose high-risk conditions (thus allowing for
timely treatment/intervention), in developing countries, the availability of US is
very limited because of lack of the necessary training and restricted access to expensive
equipment.
Introducing US technology to prenatal care should be the main priority of all governments
and healthcare organizations worldwide. It is an easy-to-deliver, portable diagnostic
examination, which can help to identify pregnancies at risk of adverse outcomes and
plan adequate antenatal care and deliveries in hospital settings. It is recommended
by the WHO as an optimal way to determine the well-being and development of the baby
13,14.
Reproductive health
Providing universal access to reproductive healthcare has been recognized by the UN
as a priority global health area, included in the MDGs. Women’s access to reproductive
healthcare is well established in the developed countries. However, in the developing
countries, women’s health services, particularly sexual and reproductive health services,
are often not provided at a level of quality that meets human rights standards 16.
Infertility, or the inability to conceive after a prolonged period of unprotected
intercourse, is a critical, but much neglected aspect of reproductive health. This
condition affects couples worldwide and causes emotional and psychological distress
in both men and women. Many factors – physiological, genetic, environmental and social
factors – contribute towards infertility. According to the WHO 5,6,17, infertility
resulting from sexually transmitted diseases or reproductive tract infections is particularly
high in developing countries in Africa and Latin America. These causes are fully preventable
and treatable.
Untreated sexually transmitted infections cause not only infertility and severe complications
of pregnancies but also significant morbidity and mortality among young women. In
2013, 60% of new HIV infections in population younger than 25 years occurred in girls
and young women 18. About 70% of cases of cervical cancers worldwide are caused by
the human papillomavirus (HPV) and untreated syphilis still causes over 200 000 deaths
every year 19.
Clinical history, medical examination, laboratory tests and diagnostic imaging all
play a significant role in improving the delivery of sexual and reproductive health.
US examinations enable the assessment of ovaries and the uterine cavity, help to exclude
structural and congenital abnormalities and enable monitoring of changes in the ovaries
and endometrium during the normal cycle. Hysterosalpingiography aids assessment of
the fallopian tubes and the uterine cavity, their structure and patency, which plays
an important role in the investigation of infertility and recurrent miscarriages.
Noncommunicable diseases
Wide disparities exist in the three leading causes of death for women of varying age
among countries with differing income levels. In the low-income and middle-income
countries, infectious diseases are the prevalent cause for children and young adult
women, but the prevalence of noncommunicable diseases as leading causes of death in
the more advanced age groups is also increasing, related directly to the change in
global dynamics and ageing of the human population 6. On a global scale, ischaemic
heart disease, stroke and chronic obstructive pulmonary disease account for 45% of
deaths in women older than 60 years old versus 15% caused by cancer in the same age
group.
Cardiopulmonary diseases
Cardiovascular disease was traditionally considered to be a ‘male’ disease, but recent
data show that women are affected in the same or even higher proportion than the male
population, and noncommunicable disease causes significant mortality and morbidity
in the overall population older than 60 years of age. In 2008, 7.5 million women older
than 60 years of age died from cardiovascular disease versus 6.6 million men 6.
The situation is also changing in the younger population, with most visible effects
in unprivileged countries. In 2012, the most premature deaths from noncommunicable
diseases among women aged 30–70 years occurred in low-income and middle-income countries
20.
Other non-sex-specific medical conditions impact significantly on women’s health,
for example, infectious diseases, chronic obstructive pulmonary disease and mental
problems among others. Although diabetes mellitus, a multifaceted disease, is not
formally listed among those directly causing most of the deaths in the global statistics,
its complications are especially important for infection and cardiovascular disease,
therefore being at the base of a non-negligible fraction of the main causes of death
listed above.
Diagnostic imaging in general plays some well-defined roles in certain phases of all
these conditions, its impact on clinical management being especially important in
the case of, for example, ischaemic heart disease. However, the type and modality
of application of imaging techniques in women for these diseases do not differ markedly
from those utilized generally in men.
Osteoporosis
Poor nutrition in the younger age groups (child and adolescent girls) and during pregnancy
leads to a decrease in bone mineral density (BMD) and osteoporosis in older age. Osteoporosis
affects an estimated 200 million women worldwide, with approximately one in three
women older than 50 years old experiencing an osteoporotic fracture 21. Especially
in low-income and middle-income countries, the consequences of osteoporosis (hip fracture
and vertebral fractures) disrupt the woman’s ability to maintain well-being from both
medical and social points of view. Traditionally, women have provided most of the
care in the families; therefore, the consequences and complications of osteoporosis
will often increase poverty and decrease the socioeconomic status of the whole family.
Although the causes of osteoporosis vary from country to country and from region to
region, India is a paradigmatic example for other sociopolitical scenarios as well.
Over 61 million Indians (90% of whom are women) have osteoporosis; globally, Indians
have the highest prevalence of osteopenia and, compared with Whites, osteoporotic
fractures in the Indian population occur 10–12 years earlier.
In Europe, disability because of osteoporosis is higher than that caused by malignant
disease and is comparable to or higher than a variety of noncommunicable diseases,
such as rheumatoid arthritis, asthma or heart disease 22. It constitutes an even more
severe problem in low-income and middle-income countries because of the lack of education,
poor nutrition and very limited access to treatment and prevention.
BMD is the single best factor for the diagnosis of osteoporosis and for the assessment
of potential risk factors for developing osteoporosis, as well as to predict fracture
risk and to monitor the efficacy of therapy. Noninvasive tests for measurement of
BMD include dual-energy X-ray absorptiometry (DEXA), quantitative ultrasound (QUS)
and quantitative computed tomography (CT) at different skeletal sites.
DEXA currently constitutes the ‘gold standard’ for measuring BMD, most commonly at
‘central’ or ‘axial’ skeletal sites (spine and hip); BMD can also be measured by DEXA
at the forearm and in the total body.
Dedicated machines for peripheral quantitative CT at selected skeletal sites provide
accurate data on total, cortical and cancellous BMD, thus investigating the architecture/microstructure
of bone. In contrast to DEXA, peripheral quantitative CT measures a volumetric density,
and is therefore not affected by bone size.
QUS is performed with equipment that can be transported at distant locations and operated
by skilled, but not highly specialized personnel; this is an advantage for implementing
screening programmes for women living in remote, rural areas. Although QUS has a high
negative predictive value for osteopenia/osteoporosis, reduced BMD values at QUS require
confirmation with DEXA. Thus, QUS (a cheaper and more accessible technique) would
be useful for mass screening to identify individuals with possible osteopenia/osteoporosis,
to be further evaluated with DEXA.
Cancers
Women’s cancers result in high rates of mortality and morbidity, especially in low-income
and middle-income countries. The most frequent cancers affect the breast and cervix
for women living in low-income countries; the breast, the cervix and lungs (including
the trachea and bronchus) in middle-income countries, and the breast and lungs in
high-income countries. Major inequalities in access to early detection and screening
lead to large variations in clinical outcomes and survival after treatment 23.
Breast cancer
Breast cancer, the leading cause of deaths from cancer in women (1.7 million new cases
and 0.5 million deaths in 2012), is diagnosed in low-income and middle-income countries
mostly at advanced stages, when palliative care is the only option 24,25. Therefore,
the 5-year survival differs markedly in different regions of the world, declining
from more than 80% in North America and Sweden to ~60% in middle-income countries,
and less than 40% in low-income countries 26.
The incidence of breast cancer increases with age, affecting one in every 2525 women
at the age of 30 years, but one every 10 women at the age of 80 years. There is an
alarming increase in incidence worldwide not only because of increased detection/reporting,
but because of an actual increase in incidence (by about 30–40% from the 1970s to
the 1990s), including more advanced stages. In the USA, breast cancer incidence (97/100 000
in white women) is over three-fold higher than that in Asian countries (27/100 000).
The imaging modalities available for screening purposes (i.e. for examining ‘apparently’
healthy individuals in certain risk groups to identify a disease in an early, asymptomatic
stage) or for diagnostic purposes (i.e. patients with symptoms or individuals with
some abnormality detected during screening) include X-ray mammography (digital mammography
in most instances, in some cases complemented by computer-aided diagnosis), US, mammoscintigraphy,
MRI, CT and galactography. The subsequent step towards correctly diagnosing a breast
lesion is usually cytology or biopsy, generally aided by imaging as in US-guided fine-needle
cytology, US-guided core biopsy, stereotactic core biopsy and needle placement for
excisional biopsy. An efficient breast-screening unit cannot rely on a single imaging
modality, but rather on the possibility of integrating during a single session the
basic procedure (e.g. mammography) with other complementary procedures (e.g. US).
Gynaecological cancers
Approximately 85% of deaths because of cervical cancer occur in low-income and middle-income
countries, where women have limited access to screening and treatment of premalignant
lesions, which results in diagnosis at very late, advanced stages 25,26.
Cervical cancer is the second most common cancer in women, with ~530 000 new cases
and more than 270 000 deaths every year 26. The marked prevalence of cervical cancer
(with the associated deaths) in low-income and middle-income countries can be explained
by considering that in most instances, cervical cancer is linked to HPV infection,
highly transmissible through sexual intercourse. Challenges to be faced to improve
the current situation in low-income countries include very limited access to screening,
inadequate education and a high rate of sexually transmitted diseases. In developed
countries, the prevention procedures and vaccination against HPV infection play a
crucial role in reducing the incidence of cervical cancer in the long term 27.
The impact of imaging on the clinical management of these malignancies varies according
to the specific type of cancer and the stage at which cancer is diagnosed. When cervical
and uterine cancers are detected at a relatively early stage, surgery is potentially
curative and minor impact is expected from imaging. Ovarian cancer is usually detected
in more advanced stages, when imaging has a major impact on risk stratification and
choice of treatment.
The first-line approach to diagnosing gynaecological cancer is clinical examination,
with colposcopy in selected cases, generally associated with cytological/histological
and laboratory tests. Pelvic and abdominal lesions are often diagnosed by either transabdominal
and/or transvaginal US. Local and general staging is usually based on CT and MRI.
Conclusion
Medical imaging plays a crucial role in all aspects of women’s healthcare – preventive,
promotive, curative and palliative, with special reference to maternal well-being,
reproductive health and noncommunicable diseases.
Providing universal access to affordable, appropriate and quality imaging services
with an understanding of the challenges and variety of available resources should
become a priority in providing female healthcare in all different Member States.
The International Atomic Energy Agency and other international professional organizations
and societies should define guidelines and recommendations to standardize and harmonize
the practice of clinical imaging in female healthcare; they should also provide advice
on comprehensive education and training programmes, capacity-building, audit, quality
control and continuous professional development.