CENTERS FOR DISEASE CONTROL AND PREVENTION
Volume 16 • Number 1 • Winter 2003

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Health-Related Quality of Life Among Women

Health-related quality of life is a particularly important issue among women. Women consistently report worse health than men on the Healthy Days measures in the Behavioral Risk Factor Surveillance System (BRFSS). For example, in response to the question “For how many days during the past 30 days was your mental health not good,” in 2001 more men (71%) than women (61%) answered none, and more women (14.7%) than men (10.3%) reported 8 or more days a month of poor mental health. According to Wanda Jones, DrPH, Deputy Assistant Secretary for Health (Women’s Health) and Director of the Office on Women’s Health in the Department of Health and Human Services (HHS), several factors contribute to women’s diminished quality of life (QOL), including a longer life span, major physiologic changes unique to women, and an increased risk of being the victim of interpersonal violence. 

Women, on average, can expect to live almost 6 years longer than men. Among children born in 2000, life expectancy is 79.5 years for girls and 74.1 years for boys. At least partially because of this longer life span, women’s quality of life is more likely to be compromised by diseases that are more prevalent among older people, such as diabetes, osteoporosis, Alzheimer’s disease, and osteoarthritis. These conditions not only limit function, but over time they may be life-threatening. Each of these disorders leads to increasing impairment and diminished quality of life. For example, 

• Of the 10.3 million Americans with diagnosed diabetes, 8.1 million are women. The prevalence of diabetes is 2 to 4 times higher among black, Hispanic, American Indian, Asian, and Pacific Islander women than among white women. 
• Osteoporosis, characterized by the thinning and increasing brittleness of bones, affects more than 25 million Americans, 80% of whom are women. More than half of all women over age 65 suffer from this condition. 
• An estimated 4 million people in the United States are victims of Alzheimer’s disease, the most common cause of dementia for people older than 65. In 1995, more than 13,600 women died of the disease. It also takes a heavy toll on the quality of life of the caregivers (primarily women) of people with Alzheimer’s. 
• Nearly 26.4 million of the 42.7 million Americans with arthritis are women. It is the most common and disabling chronic condition reported by women. 

Physiologic Changes Affect Women’s QOL 
The three physiologic changes unique to women that affect women’s quality of life are menstruation, childbirth, and menopause. These changes can affect women’s health both physically and mentally. 

Gynecological problems are common among women of reproductive age. More than 4.5 million women aged 18 to 50 report at least one chronic gynecological condition each year. Half of all women who menstruate experience some pain during menstruation, and 10% of them suffer from pain so severe (dysmenorrhea) that it interferes with their daily routine. A large proportion of these women have uterine fibroids, endometriosis, or both, said Dr. Jones. Nearly two of every five women between the ages of 14 and 50 experience some symptoms of premenstrual syndrome (PMS)— 10% with symptoms severe enough to disrupt their usual activities. 

Menorrhagia, or very heavy menstrual bleeding, is a common cause of impaired QOL among women. According to Anne Dilley, MPH, PhD, of the CDC Hematologic Diseases Branch, heavy menstrual bleeding is the reason for approximately 10% of all visits to gynecologists. Many women with menorrhagia are reluctant to leave the house for a day or two each month because of selfconsciousness, the potential for embarrassment, discomfort, and exhaustion related to anemia. “For women with menorrhagia, periods are a negative monthly event,” she said. In addition, menorrhagia is the primary indicator for approximately 28,000 hysterectomies performed each year, as well as for numerous other procedures. 

According to Dr. Dilley, the need for many of these surgical procedures could be eliminated, and women’s quality of life improved, if the underlying cause of the heavy bleeding were accurately diagnosed. In roughly 50% of all cases of menorrhagia, the cause is unknown. However, recent research by CDC and others has indicated that at least 20% of these cases of unknown origin are due to a bleeding disorder, most often von Willebrand’s disease (VWD). People with VWD have a reduced amount of von Willebrand’s factor in their blood. Because this factor is essential to clotting, a lack of it can result in prolonged mucosal bleeding. The disease is not unique to women, but their monthly periods cause them to be more regularly affected by VWD than men. 

Diagnosis of bleeding disorders in women is complicated by the fact that hemophilia, the best known and most severe form of bleeding disorder, occurs mainly in men. For this reason, most women don’t suspect that a bleeding disorder may be the cause of their menorrhagia, and even physicians tend to drastically underestimate its frequency. A recent CDC survey asked gynecologists what percentage of cases of menorrhagia, in their opinion, are due to an inherited bleeding disorder. The average answer—less than 1%—was far from the 20% found in recent research. According to Dr. Dilley, this lack of familiarity with bleeding disorders among both women and their health care providers is largely responsible for the average 16-year interval between the onset of VWD and its diagnosis. Because VWD and other mild bleeding disorders are very responsive to treatment, diagnosis is a critical step in alleviating the effects of menorrhagia. 

As part of a congressionally mandated program, CDC recently embarked on a study to reduce complications among people with bleeding disorders. The study aims to better quantify the effects of bleeding disorders on women’s quality of life and the extent to which diagnosis and treatment improves quality of life. The Healthy Days measures are among those being used in this study to detect possible improvements. 

Another condition related to physiologic changes among women is urinary incontinence, which affects 13 million Americans—11 million of them women. Although half of all older adults experience episodes of incontinence, this condition is not limited to seniors. In fact, one of every four women aged 30–59 experiences urinary incontinence. Women are most likely to develop this problem during pregnancy, childbirth, and physical activity or after menopause due to weakened pelvic muscles or pelvic trauma. Urinary incontinence can result in embarrassment; loss of self-esteem; restriction of physical, social, and sexual activities; and depression. 

Depression Takes a Major Toll on Women 
Women may be twice as likely as men to report experiences of anxiety and depression, according to Indu Ahluwalia, MPH, PhD, a CDC epidemiologist. An estimated 12% of American women experience a major depression during their lifetimes, compared with 7% of men. This greater prevalence may be due to physiological differences, life circumstances, coping abilities, and resources, and to women being more likely to report depressive symptoms, according to Dr. Ahluwalia. 

Dr. Jones offers another reason that women are more prone to depression and mental stress: Women with caregiving responsibilities are more affected by what’s going on around them. As a result, concern for the well-being of their family directly affects their quality of life. “Despite the greater participation of women outside the home, women still tend to define themselves in terms of their family,” said Dr. Jones. “Multiple responsibilities, particularly when coupled with care of children or elders in the household, can be a source of increased stress and reduced quality of life.” 

A recent CDC study of health-related quality of life indicators among women of reproductive age (18–44 years) found that women in this age group experience a substantial amount of physical and mental distress, depression, and stress and anxiety, and a high proportion of these women do not get enough rest or sleep. 

Women Are Often Victims of Violence 
In addition to age-related and physiologic causes, women’s quality of life can also be disrupted by violence, a major public health problem for American women. More than 4.5 million women are victims of violence each year. Of these women, nearly two of every three are attacked by a relative or someone they know. Women are 6 times more likely to be abused by someone they know than are men and 10 times more likely to be victims of sexual assault. 

Women are also much more likely than men to be victims of interpersonal violence (IPV), defined as physical or sexual abuse by an intimate partner. An estimated 26%–40% of women experience IPV during their lifetime, and this estimate rises to 54% when psychological and emotional abuse is included in the definition. IPV, which has been reported to be the most common cause of nonfatal injury to U.S. women, is a major source of chronic physical and psychological problems. As Dr. Jones points out, IPV isolates women. “As a result of the physical and mental effects of IPV, women may be unwilling or unable to leave the house or to keep medical appointments,” she said. 

Are Some Women More Prone to Reduced QOL Than Others? 
Socioeconomic status (SES) is an important factor in determining a woman’s quality of life, according to Dr. Ahluwalia. “Women with lower incomes and lower levels of education are much more likely to report mental distress and physical health impairment,” she said. For example, of women with less than a high school education, 18% reported frequent mental distress, and 15% reported frequent physical health impairment. In contrast, only 8% of women with a college education reported frequent mental distress, and only 4% reported frequent physical health problems. Similarly, women with incomes less than $15,000 a year were much more likely than women with annual incomes greater than $75,000 to report mental distress (20% compared with 8%) and physical problems (15% compared with 4%). Dr. Ahluwalia stated that these differences may relate both to differences in access to care and in resources for coping with mental and physical distress. 

Dr. Jones pointed out that, because women of minority racial and ethnic groups are more likely than white women to live below the poverty level and to have less than a high school education, SES and race/ethnicity are closely intertwined. As a result, women of minority racial/ethnic groups are at increased risk for many of the chronic diseases that affect quality of life. 

Efforts Are Under Way to Improve QOL Among Women 
Before effective interventions can be developed to help women improve their quality of life, data must be collected on the specific factors that affect women’s QOL. Much of what we know at this point is anecdotal rather than quantifiable, according to Dr. Jones. CDC and other agencies and offices within HHS have studies under way, and future efforts are being planned to collect these data. 

Because all available data point to SES as a critical factor in determining QOL among women, HHS and its agencies are already examining new approaches for improving access to high-quality health care for lowincome women. For example, HHS’s Community Centers of Excellence in Women’s Health has adopted an integrated approach, offering coordinated “one-stop shopping” that covers all aspects of a woman’s health throughout her life span, including active management of the socioeconomic and cultural influences that often stand in the way of quality health care for underserved women. In addition, HHS and its agencies are supporting culturally sensitive educational programs that encourage women to take personal responsibility for their own health and wellness. “Such programs can help us to meet the special needs of women and to improve quality of life for all women,” said Dr. Jones. 

For more information, contact the HHS Office on Women’s Health, Department of Health and Human Services, 200 Independence Avenue, SW Room 730B, Washington, DC 20201 (telephone: 202/690-7650; fax: 202/205-2631) or visit their Web site at www.4woman.gov/owh.

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This page last reviewed August 17, 2004

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