Pelvic health in female military personnel: Broadening the conversation

Pelvic health is an understudied area for female military personnel. This study aimed to explore the pelvic health concerns, prevalence rates, and co- existence of a wide range of pelvic health issues in Australian servicewomen. An online questionnaire was offered to adult females (sex-assigned at birth) who had completed a minimum of 6-month active-duty service in the Australian Defence Force (ADF). Data analyses were focused on calculating prevalence for the included female pelvic health issues and identifying trends within the data (frequencies, 95% CI). Of the 987 survey responses, 496 were excluded, leaving 491 responses (49.7%) to inform this study. Over two-thirds of servicewomen reported pelvic health concerns ( n = 350, 71%, 95% CI 67–75%), including sexual dysfunction (41%), gynecological surgery (34%), menstrual cycle manipulation (32%), frequent pelvic pain (20%), endometriosis (18%), irregular menstrual cycles (17%), pelvic organ prolapse (12%), pelvic injury (10%), and frequent episodes of fecal incontinence (2%). Coexistence of pelvic health issues were also reported by 24%. Pelvic health concerns, beyond lower urinary tract symptoms, are common and can co- exist in Australian servicewomen. Consideration of sex-responsive health services within military organizations may help to mitigate potential risks, enhancing wellbeing, operational readiness, and mission outcomes. ARTICLE HISTORY Received 27 March 2024 Revised 12 March 2025 Accepted 1 April 2025

Endometriosis; gynecological health; pelvic floor dysfunction (PFD); pelvic organ prolapse (POP); pelvic pain

Female personnel represent an expanding proportion of the military workforce internationally, necessitating an understanding of female-specific health requirements to optimize occupational health, safety, and performance (Iobst et al. 2023 ). Yet, it has been identified that many aspects of women’s health have not been well studied within the armed forces context, leading to a lack of evidence-based recommendations to inform policy and healthcare delivery (Iobst et al. 2023 ; Trego et al. 2022 ). Pelvic health (PH) is a key area where sex-specific health and support needs of military personnel diverges due to different pelvic anatomy and function. A recent gap analysis identified genitourinary health and menstrual research as key priorities for optimizing servicewomen’s health within the U.S. Armed Forces (Trego et al. 2022 ). It has been well-established that females (sex- assigned at birth) generally experience a higher prevalence of lower urinary tract symptoms, such as urinary incontinence (UI) and urinary tract infections (UTI), than their male counterparts (Hawthorne 2006 ; Maserejian et al. 2013 ), with a similar pattern and prevalence also identified in CONTACT Simone O’Shea [email protected] School of Allied Health, Exercise and Sport Sciences, Charles Sturt University, Elizabeth Mitchell Drive, PO Box 789, Albury, Australia. WOMEN & HEALTH 2025, VOL. 65, NO. 4, 314–327 https://doi.org/10.1080/03630242.2025.2489519 © 2025 The Author(s). Published with license by Taylor & Francis Group, LLC. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License ( http:// creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way. The terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent. military settings (AFHSC 2014 ). However, PH in servicewomen is broader than genitourinary or menstrual health. Little attention has focused upon other aspects of pelvic floor dysfunction (PFD) such as anal incontinence (AI), sexual dysfunction, pelvic organ prolapse (POP), and pelvic pain or conditions such as endometriosis. Challenges in understanding and supporting the PH of active-duty servicewomen (ADSW) include unclear definitions of PH, a variety of health disciplines that support pelvic health care, and the multitude of diagnoses that can be linked with PH issues (Toye et al. 2023 ). Similarly, female PH research has often focused on specific symptoms (e.g. UI), pathology (e.g. UTI), and physiological systems (e.g. urinary, gastrointestinal, or reproductive), with less consideration of factors that may influence PH or the interactions between different symptoms, conditions, and systems. A greater understanding of the range, extent, and impact of PH issues experienced by ADSW, and insights into what contributes to PH, will allow the development of effective policies, healthcare, and evidence- based recommendations for optimizing health and operational readiness. This study aimed to broaden understanding of PH in servicewomen by investigating the concerns, prevalence rates, and co-existence of PH symptoms and conditions of Australian servicewomen for a wider range of issues than have previously been investigated. We defined PH as the function of the bladder, bowel, and sexual and reproductive organs, including the supporting structures (i.e. muscles, joints, bones and connective tissue), and the influence of this on activity and participation of Australian servicewomen (Chalmers and Elkins 2022 ).

The PH of female Australian Defence Force (ADF) personnel and veterans was explored in a large cross- sectional online questionnaire conducted between October 2019 and June 2020. The following Human Research Ethics Committees provided approval: Australian Government Departments of Defence and Veterans’ Affairs (099–19), Charles Sturt University (H19271), and Bond University (TCO1733). A full description of the research methods and questionnaire development, together with the survey findings related to UI and UTI have previously been reported (O’Shea, Pope, Freire, and Orr 2023 ; O’Shea, Pope, Freire, Orr, and Gallagher 2023 ). Therefore, what follows is a summary of the methodology. To be included in the study, adult females (sex-assigned at birth) needed to have participated in active-duty service in the ADF for a period of at least six months. Participants were recruited through advertisements in Defence newspapers and Facebook pages for Australian servicewomen, which provided links and/or a QR code to the online survey information page. The information page provided access to a participant consent statement and subsequently the questionnaire, for those who wished to participate. This non-probability sampling method of recruitment was chosen to minimize risk of coercion to participate, and to promote respondent privacy and anonymity during participation (McManus et al. 2005 ). Data collected and reported in this paper include participant demographics, respondent-identified perspectives on their PH, and prevalence data related to bowel issues, POP, gynecological health, pelvic pain, pelvic injury, and endometriosis experienced during the respondents’ most recent, or last, period of active-duty service. The co-existence of PH issues (or presence of more than one) was also investigated. The methods employed for in-depth analysis of the questionnaire response rate and representa - tiveness of the sample have been previously reported (O’Shea, Pope, Freire, and Orr 2023 ). Data analyses aimed to calculate period prevalence rates and identify data trends (frequencies and 95% CI) for the female PH issues that were the focus of the current paper. Given the relatively small numbers of respondents within different demographic categories, sub-group comparisons were limited (Rea and Parker 2014 ). To minimize the risk of over-inflating prevalence estimates, missing responses were treated as though the PH issue being investigated was not a problem for the associated respondents. Content analysis was utilized to explore text-based responses to questions regarding the experiences of servicewomen related to the symptoms (Drisko and Maschi 2015 ). WOMEN & HEALTH 315

As previously reported, 491 of the 987 (49.7%) questionnaire responses were included in data analyses (496 responses removed for containing only limited or no demographic data), which equated to approximately 1% of the underlying population of servicewomen and female veterans, with a margin of error for population estimates of ± 4% (O’Shea, Pope, Freire, and Orr 2023 ; O’Shea, Pope, Freire, Orr, and Gallagher 2023 ). Limited data on eligible ADF servicewomen and veterans and the propor - tions reached by survey advertising meant it was not possible to accurately determine the question - naire response rate (O’Shea, Pope, Freire, and Orr 2023 ). Nevertheless, the sample was relatively well- matched to women serving in the ADF (O’Shea, Pope, Freire, and Orr 2023 ) when compared against the 2019 Defence Census (Department of Defence 2019 ) and Women in Defence 2017–2018 report (Defence People Group 2019 ). Table 1 provides an overview of key demographic data for survey respondents. Given the questionnaire breadth and limited sample size, the completion rate for Table 1. Participant attributes. Participant Attributes All respondents ( n = 491) Service Status Active Duty ( n = 299) Veteran ( n = 192) Mean (range) Age (years) 42 (19–78) 38 (19–63) 48 (20–78) Service Arm Navy 105 (22%) 62 (21%) 43 (22%) Army 258 (53%) 144 (48%) 114 (59%) Air Force 126 (26%) 91 (30%) 35 (18%) Service Years † 20 years 133 (27%) 93 (31%) 40 (21%) Rank Commissioned Officer 172 (35%) 138 (46%) 34 (18%) NCO/WO* 167 (34%) 98 (33%) 69 (36%) Other Rank 142 (29%) 59 (20%) 83 (43%) Trainee/Recruit 10 (2%) 4 (1%) 6 (3%) Occupational Category** Management/Administration 160 (28%) 99 (29%) 61 (27%) Communications/IT/Intelligence 80 (14%) 41 (12%) 39 (17%) Combat/Security 23 (4%) 12 (4%) 11 (5%) Technical/Engineering 43 (8%) 27 (8%) 16 (7%) Medical/Health/Science 108 (19%) 66 (19%) 42 (18%) Logistics/Hospitality 103 (18%) 67 (20%) 36 (16%) Aviation 23 (4%) 14 (4%) 9 (4%) Other 34 (6%) 18 (5%) 16 (7%) Obstetric History Gravidity ^ 282 (57%) 164 (55%) 118 (61.5%) Gravidity (range) ^^ 1–10 1–8 1–10 1–2 pregnancies 137 (49%) 79 (48%) 58 (49%) 3–4 pregnancies 99 (35%) 60 (37%) 39 (33%) 5 + pregnancies 46 (16%) 25 (15%) 21 (18%) No. births (range) + 0–9 0–7 0–9 0 births 26 (9%) 14 (8.5%) 12 (10%) 1–2 births 195 (69%) 119 (73%) 76 (64%) 3–4 births 53 (19%) 27 (16.5%) 26 (22%) 5 + births 7 (2.5%) 4 (2%) 3 (2.5%) Other Attributes (during service) Smoker BMI >25 61 (12%) 122 (25%) 26 (9%) 79 (26%) 35 (18%) 43 (22%) Notes: † Number of whole years of ADF service at time of completing survey (31% of veterans left service within 5 years of completing survey); **Respondents could nominate more than one occupational category ( n = 574 total responses, n = 344 active-duty, n = 230 veteran); ^ Gravidity, history of pregnancy; ^^ Gravidity (range), total number of pregnancies experienced regardless of outcome (including miscarriages/terminations/preg - nant at time of survey); + No. births (range), total number of births experienced (including stillbirths). Abbreviations: *NCO/WO, noncommissioned officer/warrant officer. 316 S. O’SHEA ET AL. individual questions was important when interpreting prevalence rates. Most data reported was provided by 80–85% respondents, ranging from 80.2% (pelvic pain, endometriosis, pelvic injury questions) to 99.8% (“do you have any concerns about your pelvic health?” ). At questionnaire commencement, respondents were asked whether they had any PH ‘ concerns’ . No definition was given for the term “concerns” , allowing servicewomen to self-determine what, if any - thing, concerned them about their PH. Over two thirds of participants reported PH concerns ( n = 350, 71%, 95% CI 67–75%), and when asked to describe these, 21 categories of “concern” were identified through open text responses. These could be divided into concerns linked with PH conditions ( Figure 1a ) and concerns about factors influencing PH or potential consequences ( Figure 1b ). Whilst lower urinary tract symptoms comprised the most frequently reported participant-identified concern, Figure 1 demonstrates the breadth of concerns expressed. Most servicewomen reported their “concerns” had developed during their ADF service ( n = 278/350, 79%, 95% CI 75–83%), compared with post-service ( n = 40, 11%, 95% CI 9–15%) or prior to service ( n = 11, 3%, 95% CI 2–6%). A moderate proportion of women ( n = 69, 24%, 95% CI 19–29%) also reported co-existing or multiple PH concerns. 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% P e r c e n t a g e o f e x p r e s s e d c o n c e r n s a) Pelvic health c onditions and symp toms 0% 5% 10% 15% 20% 25% 30% P e r c e n t a g e d o f e x p r e s s e d c o n c e r n s b) Pelvic heal th influe nces and co nsequence s Figure 1. Respondent-identified pelvic health concerns relating to (a) specific conditions and symptoms and (b) factors identified to influence PH or the consequences of PH conditions. Abbreviations: LUTS, lower urinary tract symptoms; Endo, endometriosis; POP, pelvic organ prolapse; IBS, irritable bowel syndrome; UTI, urinary tract infection; STD, sexually transmitted disease; ADF, Australian Defence Force WOMEN & HEALTH 317 Prevalence for the PH issues included in this report, are presented in Figure 2 , with the results broadly organized into four categories: pelvic pain, gynecological health, musculoskeletal health, and bowel health. The figure demonstrates that gynecological health symptoms and pelvic pain were commonly experienced. Similar patterns of prevalence were seen regardless of Service arm, rank, service status, or employment status; therefore, sub-group comparisons are not presented. The subsequent narrative synthesis contextualizes these findings. Less than one third of servicewomen ( n = 137, 28%, 95% CI 24–32%) reported they had ‘ never’ experienced pelvic pain (unrelated to menstruation) during their last period of active-duty service. Despite pelvic pain being a common experience, one fifth reported experiencing pelvic pain “ fre - quently” or “most of the time” ( n = 98, 20%, 95% CI 17–24%). Almost two thirds of women experien - cing frequent pain had done so for 10 or more years ( n = 60/98, 61%, 95% CI 51–70%), and most indicated their pain was a “current and ongoing issue ” ( n = 77, 79%, 95% CI 69–86%). Women experiencing frequent pelvic pain ( n = 98, 20%, 95% CI 17–24%) reported wide ranging impacts on their lives and service, particularly mood, physical activity, personal life, energy levels, and sleep ( Appendix Figure A1 ). A range of conditions fell under the umbrella of gynecological health. Of those, sexual dysfunction – encompassing dyspareunia, poor sensation, low libido, vaginal laxity or tightness, and/or poor lubrication – was the most reported ( n = 202, 41%, 95% CI 37–46%). However, no further sexual health data were collected, limiting analysis of the extents to which, and the ways these issues affect females and their service. There were 332 reports of urogynecology surgical procedures from 201 servicewomen, with most procedures occurring during ADF service ( n = 248, 75%, 95% CI 70–79%) ( Appendix Figure A2 ). Endometrial ablation ( n = 77, 38%, 95% CI 32–45%), hysterectomy ( n = 72, 36%, 95% CI 30–43%), abnormal cervical cell removal ( n = 35, 17%, 95% CI 13–23%), UI surgery ( n = 33, 16%, 95% CI 12–22%), and POP repair ( n = 24, 12%, 95% CI 8–17%) were the most frequently reported procedures. 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% Pelvic pain (frequent) Sexual dysfunction Menstrual pain* Urogynaecological Sx (ADF) Endometriosis Dx Pelvic injury (ADF) POP symptoms (any) POP symptoms (>1/wk) POP Dx Bowel strain (>1/wk) Incomplete bowel emptying Bowel urgency (>1/wk) AI (flatus) (>1/wk) AI (faecal) (>1/wk) Pain Gynaecological Health Musculoskeletal Health Bowel Health Proportion of respondents Figure 2. Prevalence rates for PH symptoms and conditions experienced by respondents during their most recent period of active- duty service in the ADF (excluding LUTS/UTI). Notes: Pelvic pain (frequent), regular or constant pelvic pain (unrelated to menses); *menstrual pain occurring most or all of the time during menses Abbreviations: LUTS, lower urinary tract symptoms; UTI, urinary tract infection; Sx, surgery; ADF, Australian Defence Force; Dx, diagnosis; >, greater than; wk, week; POP, pelvic organ prolapse; AI, anal incontinence 318 S. O’SHEA ET AL. Multiple and/or repeated urogynecology surgical procedures were not uncommon ( n = 83, 41%, 95% CI 35–48%). Complications affecting return to ADF work post-surgery were reported by 21% ( n = 41/ 201, 20%, 95% CI 15–27%), with delayed return to work ( n = 25/41, 61%, 46–74%) and modification of usual duties ( n = 19/41, 46%, 32–61%), the most frequently cited impacts. The high reported frequency of endometrial ablation procedures (for menorrhagia) is likely to have a relationship with the 18% of servicewomen reporting an endometriosis diagnosis ( n = 87, 95% CI 15–21%). Almost two thirds of servicewomen with endometriosis had been diagnosed 10 or more years ago ( n = 52, 60%, 95% CI 49–70%), compared with the past five years ( n = 21, 24%, 95% CI 16–34%), with nearly all diagnoses occurring during ADF service ( n = 83, 95%, 95% CI 88–98%). Servicewomen with endometriosis reported a variety of symptoms, most commonly dysmenorrhea, back and/or pelvic pain, menorrhagia, and abdominal pain ( Appendix Figure A3 ). Given this symptom profile, prevalence data obtained on menstrual pain and pelvic pain will have been influenced by those with endometriosis. Within questions related to gynecological and reproductive health, the menstrual cycles of service - women were briefly explored. During their most recent period of active-duty service, 26% reported regular periods (95% CI 22–30%, n = 126), 17% irregular menstrual cycles (95% CI 14–21%, n = 84), 32% manipulated their menstrual cycle through contraceptive methods (95% CI 28–37%, n = 159), and 7% (95% CI 5–10%, n = 34) reported their menstrual cycle had ceased, with medical reasons for cessation (such as surgery, medication, radiation, chemotherapy) more commonly reported than menopause ( n = 10) or excessive exercise ( n = 3). Reasons servicewomen manipulated their menstrual cycle are available in Appendix ( Figure A4 ). Both symptoms of POP (feelings of pressure, heaviness, dragging and/or a bulging sensation in the vagina) and a confirmed diagnosis of POP were explored within the questionnaire. Two thirds of servicewomen reported they never experienced any symptoms of POP during their most recent period of active-duty service ( n = 329, 67%, 95% CI 63–71%). Of the remaining third reporting POP symptoms ( n = 162, 33%, 95% CI 29–37%), over half experienced these symptoms less than once per week ( n = 87, 54%, 95% CI 46–61%), compared with frequently ( n = 36, 22%, 95% CI 17–29%), daily ( n = 25, 15%, 95% CI 11–22%), or during specific tasks only ( n = 14, 9%, 95% CI 5–14%). Over one third of women with symptoms of POP had experienced them for 10 or more years ( n = 60, 37%, 95% CI 30–45%), and half indicated their symptoms were a ‘ current and ongoing issue’ ( n = 83, 53%, 95% CI 44–59%). Lifting tasks were the main aggravating activity ( n = 43), followed by load carriage ( n = 19), running ( n = 17), physical training ( n = 16), menstruation ( n = 14), and gym activities ( n = 13). Only a small proportion of the entire cohort had been diagnosed with POP ( n = 61, 12%, 95% CI 10–16%), and one third with a diagnosis ( n = 21) did not specify the staging (or severity) of the condition. Where severity was known ( n = 40/61, 66%, 95% CI 53–76%), half had mild loss of pelvic organ support (stage 1, n = 21, 53%, 95% CI 38–67%), compared with moderate (stage 2, n = 15, 38%, 95% CI 24–53%) and severe (stage 3, n = 4, 10%, 95% CI 4–23%). Not all servicewomen with diagnosed POP reported symptoms during their most recent period of active-duty service ( n = 16, 26%, 95% CI 17–38%), which may be related to treatment received, as a similar proportion indicated the issue was not ‘current or ongoing’ ( n = 15, 25%, 95% CI 16–37%). Two thirds of servicewomen reporting POP symptoms more than once per week ( n = 42/61, 69%, 95% CI 56–79%) had not been diagnosed with the condition, but no data were available on whether they had accessed healthcare assessment. Management strategies utilized by women diagnosed with POP are shown in Appendix ( Figure A5 ). One third ( n = 20; 33%, 95% CI 22–45%) utilized one POP management approach, predominantly surgical repair ( n = 15). However, most servicewomen with POP utilized between one and four management strategies ( n = 50, 82%, 95% CI 71–90%). Injuries to the pelvic region were uncommon ( n = 62, 13%, 95% CI 10–16%), with most occurring during, and related to, ADF service ( n = 50, 81%, 95% CI 70–89%). The most common impacts of sustaining a pelvic injury at work were modification of usual duties ( n = 26/50, 52%, 95% CI 39–65%) and taking sick leave ( n = 12, 24%, 95% CI 14–37%). A smaller percentage reported no impact on ADF WOMEN & HEALTH 319 work ( n = 7, 14%, 95% CI 7–26%), whereas others needed to reduce their work fraction ( n = 6, 12%, 95% CI 6–24%), change roles ( n = 5, 10%, 95% CI 4–21%), leave service ( n = 5, 10%, 95% CI 4–21%), or ‘ soldier on’ ( n = 4, 8%, 3–19%). Frequent unpleasant bowel symptoms (>once per week) affected a small percentage of respondents (2–18%), with strain with elimination ( n = 86, 18%, 95% CI 14–21%) and incomplete bowel emptying ( n = 85, 17%, 95% CI 14–21%) the most common ( Figure 2 ). For most reporting bowel symptoms (range 77–100%), these were current and ongoing issues that had been present for 10 years or more. Parity may have a relationship with fecal incontinence (nulliparous n = 1, 0.9%; parous n = 8, 2.8%) but this cannot be verified due to the small number of women experiencing the symptom. Concurrent PH issues (UI, AI, UTI, pelvic pain, vulvovaginal irritation experienced more than once per week , and/or symptoms of sexual dysfunction, or a diagnosis of endometriosis or POP) during the most recent period of active-duty service was also investigated. Most servicewomen did not frequently experience PH issues ( n = 373, 76%, 95% CI 72–80%), and no servicewomen reported experiencing only one type of PH issue (> once per week). The remaining servicewomen frequently experienced two or more PH issues each week ( n = 118, 24%, 95% CI 20–28%, range 2–8). For servicewomen with co- existing PH issues, three quarters experienced between three and five issues once or more per week ( n = 89, 75%, 95% CI 67–82%).

This is the first known study to comprehensively explore numerous PH symptoms, conditions, and their co-existence in ADSW. The study found PH concerns were common for ADF servicewomen (71%), they experienced a variety of symptoms and conditions, and concurrent PH issues were not unusual (24%). These findings support recommendations for Defence organizations to consider PH when supporting the occupational health and wellbeing of servicewomen. However, given the poten - tial for bias from this small sample, there is a need for additional studies comprehensively investigating PH in servicewomen. Numerous studies have examined prevalence and incidence of lower urinary tract symptoms in ADSW (Greer et al. 2023 ; O’Shea, Pope, Freire, and Orr 2023 ; O’Shea, Pope, Freire, Orr, and Gallagher 2023 ; Puranda et al. 2023 ; Rogo-Gupta et al. 2021 ; Wheat et al. 2022 ), with less data available for other PH issues. Similar self-reported POP prevalence has been reported in Canadian (14.5%) (Puranda et al. 2023 ) and U.S. ADSW (16.3%) (Greer et al. 2023 ). Consistent with these findings, but also suggesting a possible role of military service in POP development, the proportion of U.S. Air Force recruits assessed to have a stage 2 POP (on pelvic examination) increased from 2% prior to initial training to 22% post-training (Larsen and Yavorek 2007 ). Hysterectomy prevalence in the current study (14.6%) was also similar to those in a sample of pre-menopausal U.S. military veterans (16.8%) (Ryan et al. 2016 ). One study of Canadian ADSW found 10.6% of their sample self-reported co- existing POP and UI (Puranda et al. 2023 ). These figures are lower than coexistence rate identified in this survey (24%) (more PH issues were included in our analysis). However, a supplementary analysis of data from this study identified a similar co-existence for UI symptoms and POP diagnosis (9.8%). The incidence rate for one or more types of female PFD (POP, bowel, bladder) in U.S. Army ADSW was found to be quite low (28.5 per 1000 person-years) from an audit of medical presentations between 2011–2014 (Rogo-Gupta et al. 2021 ). Similarly, another large audit of U.S. ADSW health data (2010–2019) found a low 10% prevalence of PFD diagnoses (Wheat et al. 2022 ). It is difficult to compare findings as no data on individual types or co-existence of different types of PFD is provided (Rogo-Gupta et al. 2021 ; Wheat et al. 2022 ). In addition, the data only included ADSW accessing military healthcare for PFD symptoms, and ADSW may choose not to seek or may not have access to appropriate military healthcare services for PH issues (Wilson and Nelson 2012 ). Higher self-reported fecal incontinence prevalence (73.6% versus <3% in this study) was found in a small sample ( n = 178) of U.S. Navy women attending a women’s health clinic (Greer et al. 2023 ). Definitions for frequency of leakage (monthly versus weekly) used in each study may contribute to some of the variation. Data on 320 S. O’SHEA ET AL. the prevalence of endometriosis in ADSW was not identified in previous studies; however, a rate of 30.8 new instances per 10,000 person-years was found during a five-year surveillance (2012–2016) of medical encounters in the U.S. Armed Forces (Stahlman, Williams, and Taubman 2017 ). In conclu - sion, a broader understanding of the PH issues experienced by ADSW is beginning to emerge, which can be used to prioritize future research, develop consistent terminology for the monitoring and reporting of PH, and guide health policies and service provision. When data from studies of military women are compared to the general female population, it is evident PH issues are not unique to ADSW. For example, 40–50% females experience one or more symptoms of sexual dysfunction (McCabe et al. 2016 ), 10–50% of women experience persistent pelvic pain (Righarts et al. 2018 ), approximately 10% of women have a diagnosis of endometriosis (Shafrir et al. 2018 ), and 5% experience symptoms of AI one or more times per week (Hawthorne 2006 ). It has been estimated that 20% of U.S. women will have at least one urogynecology surgical procedure for UI or POP in their lifetime (Wu et al. 2014 ), and 21% will have a hysterectomy (Harvey et al. 2022 ). A scoping review exploring the coexistence of PFD found the majority of studies in females focused on concurrent urinary and bowel symptoms, with relationships evident between symptoms (i.e. POP and defecation problems) (Knol-de Vries and Blanker 2022 ). Since PH issues are common in females, military healthcare services must monitor and be responsive to the diverse needs of servicewomen to support their occupational health and readiness. This represents a significant challenge for Defence organizations due to the diversity and coexistence of issues identified, the health specialties traversed, and the varied occupational settings in which military health services need to be delivered (i.e., garrison/barracks versus deployed healthcare). The findings of this study provide useful insights into the wide range of PH issues experienced by Australian servicewomen. However, the data presented does not address the impacts on female personnel and their work. The lived experiences and impacts of PH issues have been explored in a range of population groups, including females with lower urinary tract symptoms (Toye and Barker 2020 ; Toye et al. 2023 ), POP (Carroll et al. 2022 ; Toye et al. 2020 ), AI (Olsson and Berterö 2015 ), pelvic pain (Toye, Seers, and Barker 2014 ) and endometriosis (Young, Fisher, and Kirkman 2015 ). Despite the varied symptoms and diagnoses, common themes are evident in the experiences of females across studies, including the significant impact PH issues can have on all aspects of their lives and relation - ships (i.e., physical, psychological, cognitive, social, sexual, and vocational well-being and functioning) (Carroll et al. 2022 ; Toye and Barker 2020 ; Toye, Seers, and Barker 2014 ; Toye et al. 2020 , 2023 Young, Fisher, and Kirkman 2015 ). As such, females modify their behaviors in response to, or to control, their symptoms. For example, activity planning, social withdrawal, altered diet and hydration, toilet mapping and scheduling, avoidance and concealment behaviors (Carroll et al. 2022 ; Olsson and Berterö 2015 ; Toye et al. 2023 ). A ‘culture of secrecy’ (Toye, Seers, and Barker 2014 ) or a sense of taboo around PH issues, as well as trivialization of these were reported to contribute to feelings of embarrassment, guilt, and shame, which in turn may impact on help-seeking behaviors and healthcare access (Toye et al. 2020 , 2023 Young, Fisher, and Kirkman 2015 ). Negative healthcare interactions, including lack of validation, were also found to contribute to psychological distress, feelings of isolation, and disempowerment (Toye, Seers, and Barker 2014 ; Toye et al. 2023 ; Young, Fisher, and Kirkman 2015 ). Similar themes have been found in ADSW, where PH issues have been shown to impact occupa - tional performance and health behaviors. For example, in the current study, servicewomen with frequent pelvic pain reported wide ranging impacts on their life, including mood, energy levels, and physical activity. Higher levels of psychological stress (Greer et al. 2023 ), poorer fitness assessment scores (Greer et al. 2023 ; Rogo-Gupta et al. 2021 ), and greater risk of never deploying (Rogo-Gupta et al. 2021 ) have also been reported for ADSW experiencing PFD. Occupational factors such as mission requirements and permissions (Kostas-Polston et al. 2022 ), sanitation (Kostas-Polston et al. 2022 ; Wilson and Nelson 2012 ), lack of sex-sensitive or specialist healthcare options (Godier ‐ McBard, Gillin, and Fossey 2022 ; Kostas-Polston et al. 2022 ), stigma, and embarrassment (Wilson and Nelson 2012 ) have also been reported to influence PH behaviors of ADSW. For example, delaying healthcare WOMEN & HEALTH 321 access, intentionally reducing fluid intake, and altering toileting behaviors, particularly in austere field settings (Freire et al. 2023 ; Wilson and Nelson 2012 ) potentially increasing the risk of adverse health and mission outcomes. Despite increasing research, knowledge of military healthcare for servicewomen is still lagging and it is unclear how available evidence is being translated into appropriate military healthcare policies and practice initiatives. Developing female (sex-assigned at birth) responsive military health services requires more than an appreciation of the proportions of the workforce likely to be affected by PH issues. Understanding how women maintain their PH within the wide range of military occupational contexts, the services available to support PH at work, the accessibility and suitability of these services in different contexts, and the impacts and management of symptoms at work are required when developing policies and sex-appropriate support services. A lifespan approach is needed, recognizing changing PH care support needs of servicewomen throughout their lives and careers (ACOG 2024 ), as well as in response to their occupational roles and responsibilities. ADF servicewomen have suggested that there is a need for greater preventative education for all military personnel (i.e. PH norms, toileting habits, and preparing for and overcoming challenges in austere settings), promotion of simple and effective strategies to support PH (i.e. pelvic floor muscle training, regular toilet breaks), greater training in PH support for Physical Training Instructors, military and veteran health practitioners, routine screening of PH in health monitoring questionnaires, and greater encouragement and support to access specialist PH services (Freire et al. 2023 ). Knowledge translation tools to support implemen - tation of evidence-based healthcare guidelines (Janvrin, Korona-Bailey, and Koehlmoos 2023 ) and training in sex-responsive care (Godier ‐ McBard, Gillin, and Fossey 2022 ) have also been suggested for improving quality of military healthcare available. Utilizing a holistic framework, such as the social ecological model, has been proposed to ensure that individual, community, and organizational factors, as well as the overarching cultural values and policies are considered and addressed when developing sex-sensitive military health services (Trego and Wilson 2021 ). The findings of this study are influenced by the limited number of respondents and large number of incomplete surveys, potentially limiting external validity, and constraining the ability to explore risk factors for PH issues within sub-groups of ADF women. The large number of incomplete surveys are likely attributable to its length and breadth (30–60 min completion time), the effectiveness of the recruitment strategy, and external factors influencing military personnel during survey administration (i.e. ADF personnel provided extensive community support during 2019–2020 Australian bushfire and COVID-19 response). Recall bias, particularly for veterans whose last period of active-duty service may have been years previous, and the focus on PH may have attracted more respondents with concerns, inflating the prevalence statistics. These risks were countered by reporting prevalence statistics for symptoms that occurred frequently (at least once per week), assuming non-responses meant the respective issue had not been experienced and comparing responses between currently serving and veteran respondents. Some of the reported prevalence data may also be influenced by symptom overlap that can occur between conditions (e.g. pelvic pain, endometriosis, sexual dysfunc - tion). Finally, the non-probability sampling method employed potentially limits generalizability of the findings to other ADSW, though the sample had a similar demographic profile to that of ADF women (Department of Defence 2019 ; O’Shea, Pope, Freire, and Orr 2023 ).

This survey of female ADF personnel and veterans found PH concerns are common and include a multitude of symptoms and factors that may impact on their urinary, bowel, musculoskeletal, sexual, and/or reproductive health. The prevalence of investigated conditions ranged from 2% to 41%, which was similar to other reported data in female military personnel and general population samples. One- quarter of servicewomen also reported two or more frequently occurring co-existing PH issues. Whilst the study does not provide insight into the impacts of PH symptoms on work, optimizing specific support may reduce stress common biological sex-specific challenges may pose. This study adds to 322 S. O’SHEA ET AL. a growing body of literature establishing sex-specific needs in female military personnel. Therefore, it is incumbent upon military organizations to determine how their services can better meet the requirements of all personnel across occupational contexts. Acknowledgments The research team would like to acknowledge Gail Fuller (Spatial Data Analysis Network, Charles Sturt University), and Dr John Salmon, Specialist Obstetrician & Gynaecologist (MBBS, FRANZCOG, FRCOG, DDU) for their support and advice in survey development, as well as the Women Veterans Network Australia as survey sponsors, and the Defence Health Foundation for funding the research project. In addition, we would like to thank all the servicewomen and veterans who generously shared their time and experiences for the study. Dr Simone O’Shea had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Disclosure statement No potential conflict of interest was reported by the author(s). Funding The work was supported by the Defence Health Foundation, Australia, Medical Research Grant 2018. Author contributions Simone O’Shea: responsible for research concept and design, survey development, data collection and analysis, drafting and revising the manuscript. Rod Pope: contributed to research design, data interpretation and editing the manuscript. Katharine Freire: contributed to data analysis and editing the manuscript. Robin Orr: contributed to editing the manuscript and providing military context. Disclaimer The opinions expressed within this manuscript are those of the authors and do not necessarily reflect those of the Australian Department of Defence or the Department of Veterans’ Affairs. Data availability statement The dataset generated and analyzed during the current study is not publicly available without permission from the ADF due to privacy and ethical restrictions. Please contact the corresponding author.

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Appendix 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Mood Physi cal Activity Personal life Energy levels Sleep Sit >20mins GIT ADF work Clothing P r o p o r t i o n o f r e s p o n d e n t s w i t h p e l v i c p a i n Quite a bit+ Somewhat Little to none Figure A1. Impacts of pain on servicewomen reporting frequent episodes of pelvic pain ( n = 98). Abbreviations: Sit >20 mins, sitting for periods longer than 20 min; GIT, gastrointestinal tract function; ADF work, occupational duties within Australian Defence Force WOMEN & HEALTH 325 0 10 20 30 40 50 60 70 80 90 Endometrial Uterine Reproductive Bladder Prolapse Cancer Other No. of servicewomen Pre ADF During ADF Post ADF Figure A2. Categories of urogynecology surgery experienced by servicewomen and timing in relation to service within the ADF. Note: Endometrial includes ablation, laparoscopy and laparotomy for endometriosis and myomectomy. Uterine includes hyster - ectomy, hysteroscopy, uterine repairs, ovarian cyst removal, oophorectomy, salpingectomy and salpingolysis. Reproductive includes in-vitro fertilization (IVF) procedures, tubal ligation, other contraceptive procedures, abortion, and ectopic pregnancy. Bladder includes procedures for UI, fistula repairs and cystoscopy. Prolapse includes anterior and posterior vaginal repairs. Cancer includes procedures large loop excision of transformation zone (LLETZ), biopsy and laser for abnormal cell growth. Other includes procedures for hernia repair, hemorrhoids, and vaginismus. 0% 10% 20% 3 0% 40% 50% 6 0% 70% 80% 9 0% Nil Other Painful u rination Painful d efaecatio n Altered b owel move ments Sexual pa in/dysfun ction Fatigue Abdominal pain/blo ating Menorrhagia Back/Pelvic pain Dysmenorrhoea Proportio n of resp ondents Figure A3. Symptoms experienced by servicewomen with a diagnosis of Endometriosis ( n = 87). 326 S. O’SHEA ET AL. 0% 5% 10% 15 % 20% 25% 30 % 35% 40% 45 % Seen as sig n of weak ness Told to/g iven by D r Reduce le akage wor ry Hygiene Control Birth con trol Ease/Conv enience Manage sy mptoms/is sues Work envi ronment/t empo Proportio n of resp ondents Figure A4. Reasons servicewomen manipulated menstrual cycle ( n = 159). Abbreviation: Dr, doctor 0% 10% 20% 30% 40% 50% 60% P r o p o r t i o n o f r e s p o n d e n t s Figure A5. Proportion of servicewomen with a diagnosis of POP utilizing each management strategy ( n = 61). Abbreviation: PFM ex, pelvic floor muscle exercises; PF physio, pelvic floor physiotherapy; mod, modification; Mx, management; Nil, no management strategies identified; avoid, avoidance of specific tasks; E-stims, pelvic floor muscle training using electrical stimulation; estrogen, estrogen replacement therapy; Sx, surgery. WOMEN & HEALTH 327