Women's health and primary care: time to get it right for the life course.

Evidence and resources that understand the role of primary care in women’s health and recognise the complexity of what primary care can and does do, are needed in order to optimise this capability and potential. Women’s health is often narrowly focused on reproductive health but, in primary care, GPs care for all of women’s health needs throughout the whole life course. Evidence and resources that can inform and support holistic and longitudinal care are needed yet currently lacking in many areas of women’s health. In our work on endometriosis 12 and female genital mutilation (FGM), 13 – 14 we found that the majority of evidence deployed in primary care is derived from specialist settings and then extrapolated back to the primary care setting, where the populations and needs may significantly differ. Most women across the spectrum of women’s health (before adolescence to menopause and beyond) are cared for exclusively in primary care, with a relatively small number of women referred for specialist care. Those who are referred are more likely to have symptoms that are difficult to understand or manage, or more complex health needs. Using evidence and guidance predominantly derived from specialist settings presents a denominator problem for primary care clinicians trying to determine risk, share decisions, or advise on management options, where the knowledge and evidence relates to a different population from the one they are working with. For example, the National Institute for Health and Care Excellence guidance on endometriosis suggests that referral for specialist care is considered if symptoms are not controlled with first-line therapies such as hormonal treatment or non-steroidal anti-inflammatory drugs. 15 This leaves GPs facing uncertainty about how to support women with impactful period pain, whose symptoms are well controlled with first-line therapies, against the backdrop of widespread reporting of delayed referrals to specialist endometriosis clinics. 12 Another example is the predominance of FGM research in obstetric and midwifery settings resulting in a lack of evidence or resources for how GPs might support women with FGM beyond their reproductive years and through the menopause. 14 Where potential gaps in care are identified, all too often the conclusion is that GPs lack knowledge and awareness, and that increasing these would improve care. 12 However, our work on endometriosis demonstrates GPs are rarely working with a lack of knowledge, but rather engage with complex and nuanced considerations. They are already balancing multiple possibilities and involved in complex shared decision making with women based on knowledge about known uncertainties and the challenges at the primary to secondary care interfaces.

These new Women’s Health Strategies offer opportunities to put primary care at the heart of enhancing women’s health throughout the life course. But to achieve this we need evidence and knowledge developed with, from, and for primary care. We need to ensure that the services and resources developed in response to these strategies do not become too symptom or condition specific, risking compartmentalising women’s lives and bodies into organs, conditions, and phases of life. Instead, this is an opportunity to call for primary care focused resources, education, and services that will enable GPs to support patients throughout the life course, and across their physical, psychological, and social wellbeing needs. Within primary care, there are opportunities to identify and mitigate against health inequalities in women’s health, which would benefit all of society. Primary care’s huge strength is being there for the journey. It would be a missed opportunity if the conclusion and outcome of these consultations defaulted to an explanation of ignorance and to pillorying GPs to simply know more. Instead, we urge policymakers to positively utilise the wisdom and experience of GPs and patients, in research and consultation, to support an effective and meaningful women’s health strategy inclusive of primary care.