Download PDF Engineering for Women's Health April 25, 2022 Volume 52 Issue 1 The articles in this issue describe the latest technologies for detection of breast and other cancers, approaches to reduce the incidence of premature births, and remote monitoring for pregnancy, a development of particular interest as the pandemic discouraged many people from going to a doctor’s office or hospital. The Role of Engineers in Women's Health Thursday, March 24, 2022 Author: Nicole Danos Improved health outcomes for women are associated with improved life outcomes for all. It may seem puzzling that engineers have a social and ethical responsibility to improve women’s health. But although there is talk about Industry 4.0, efforts to address women’s health are not even at 1.0 yet. There is an urgent need for engineering approaches to improve women’s well-being and health. The fact that this issue of The Bridge is dedicated to this topic suggests that engineers are ready to work in this area. Why Is Engineering for Women’s Health Important? Women are half of the global population, and often the primary caregivers of the young and the elderly. Improved health outcomes for women are associated with improved life outcomes for all. I offer my perspective on obstacles, what needs to be done to promote a focus on women’s health, and examples of pioneering engineers and innovators in this area. Many of the points I raise are not unique to engineering. But as a discipline devoted to using science and technology to improve lives, engineering has a unique potential to increase its impact by expanding both its knowledge of women’s health and the angles from which solutions can be pursued and developed. Obstacles to Engineering Contributions to Women’s Health Questions Not Being Asked I am a biomechanics researcher by training. For my research as a muscle physiologist interested in female athletes who become mothers, it was impossible to convince agencies to fund my work. This is because, although there is a huge gap in knowledge of muscle physiology (summarized in Bø et al. 2017), there isn’t a recognized problem to which I can point as needing solving. This lack is not because data were sought and not found but because nobody asked. There are myriad aspects of women’s health for which there are no published studies or data. This is true of myriad aspects of women’s health, as illustrated by the following questions—for which there are no published studies or data. For example, in the medical establishment it is common knowledge that ligaments and tendons become softer with pregnancy, but how many women experience musculoskeletal problems or injuries during pregnancy and lactation? How long does it take for these tissues to return to prepregnancy material properties? Is there a cost to the mother when performing normal activities with connective tissues that have different material properties than before? Do the changes in tissue property result in more injuries for pregnant and postpartum women? The answers to these questions are not known because they haven’t been asked in a systematic way. Not Listening to Women Prominent figures such as tennis player Serena Williams and five-time Olympic track and field athlete Allyson Felix have said publicly that their pregnancy and birthing experiences nearly cost them their lives because medical professionals ignored their reports of feeling unwell. If women’s reports of their health experiences are not heeded at such critical times, when their lives and those of their babies are at risk, what else is ignored and unrecorded? Felix’s experience is particularly telling. Her sponsor (Nike) wanted to cut her pay by 70 percent when she became pregnant and included provisions for reduced compensation if her athletic performance suffered as a result of her pregnancy. Beyond the social justice aspect of this move, it was not based on any scientific data that pregnancy impairs athletic performance. Inadequate Research and Data A few recent studies have considered how the menstrual cycle affects athletic performance. They show that effects vary considerably among individuals such that it is not possible to establish a single rule that would apply to the majority of women (Barba-Moreno et al. 2022; Bø et al. 2017; Sims et al. 2021; Taipale-Mikkonen et al. 2021). Personalized medicine will be key in promoting women’s health. Therefore, the commitment by engineers to engineer better medicines and advance health informatics—two of the NAE’s 14 Grand Challenges for Engineering—will be a critical contributor to this effort. In addition, much more research is needed, taking into account a variety of demographic and other factors. Culturally Biased Research The Centers for Disease Control and Prevention reports that in 2019 non-Hispanic Black women died at rates 250 percent higher than White women from pregnancy-related causes (Hoyert 2021), and that the life expectancy for Black females born in 2008–18 is less than that of birth year–matched White females. Interestingly, Hispanic women survive motherhood at better rates and live longer than both Black and White women. What can be learned from these differences? What questions are not asked because of the absence of Black, Brown, Indigenous, and Hispanic women in studies and in decision-making positions (Gupta 2021)? What Can Engineers Do? Lack of attention to women’s health is a global concern. In 2020, 324,000 women died of cervical cancer, 90 percent of them in low- and middle-income countries (Sung et al. 2021). And all over the world, women aged 24–35 are 25 percent more likely to live in poverty than men of the same age (Azcona et al. 2021). What low-cost, accessible healthcare options can be engineered for these women? The following measures can help improve women’s health through engineering. A transdisciplinary approach will be key to the effectiveness of these efforts. Collect Data on Women’s Health Organizations that seek to fund the improvement of women’s health should also support the collection and dissemination of such data. They can extend their reach and effectiveness by partnering with social scientists, epidemiologists, and international organizations to apply engineering methods to track, analyze, and identify the health challenges faced by women around the world. Academic engineering research has a particularly catalytic role to play. It can generate the background data needed for industrial innovation, identify social constraints on current engineered solutions, and train the next generation of transdisciplinary engineers. A collaborative effort between academic and clinical research will be essential in assessing the efficacy of advanced health informatics tools. Believe the Data and Believe Women The data on female biology and health show that the state of knowledge about women’s health is inadequate, underinformed, and biased. A conscious effort is needed to expand data collection, study it with an open mind, and allow the data to change perceptions of longstanding “knowledge”—including the idea that there is a single, homogeneous female experience. Encourage Transdisciplinary Collaboration and Training Transdisciplinary collaborations can blend training in engineering with training in nursing, public health, and public policy (among others). Such programs can both train the next generation of broadly aware engineers and, more importantly, help identify and describe the multiple facets of unresolved health and wellness issues faced by women. Actively Include More Women at All Levels Simply the presence of women is not enough. Women on engineering teams need to feel safe and supported in their experience—during pregnancy, postpartum, menstruation, menopause, or any other health condition specific to women, whether they are cisgender or transgender. One way to achieve this is to support women’s access to and success in positions of authority, to introduce new perspectives and ask questions that have been too long neglected. Lobby for a National Institute of Women’s Health Collection of the data required for a complete picture of the state of women’s health, ways to improve it, and differences in female and male biology needs to be a national priority and approached with the same scientific rigor as other national priorities. Data and information about women’s health are lacking because questions haven’t been asked in a systematic way. The National Institutes of Health is already making advances by requiring that gender be included as a biological variable in studies it funds to address the gap in understanding of female biology (since historically only male subjects have been used). A National Institute of Women’s Health would take this a step further, include trans women in its scope, and create a concerted effort to fill the historical gap with a clear goal of improving women’s health—which extends well beyond menstruation and motherhood. Women differ from men in their immunological response to infections, including covid-19 (Takahashi et al. 2020; Wehbe et al. 2021); pharmacological responses (Farkouh et al. 2020); brain neuroanatomy, function, and susceptibility to neurodegenerative diseases (Liu et al. 2020); and more (e.g., van Kessel et al. 2021). Engineering Pioneers in Women’s Health and Wellness In my search for studies of maternal biomechanics I have come across researchers and innovators in many areas of academia and industry who are working to reimagine a more equitable and healthier world for women. Following are selected examples (in addition to those described in this issue’s articles). Some are clearly dedicated to women’s health; others illustrate entrepreneurial innovations dedicated to women’s well-being and quality of life. Ananya Health (https://www.ananya.health/) is building a portable medical device to treat cervical precancer in remote regions of the developing world, where over 90 percent of the women who die annually from this preventable cancer occur (Sung et al. 2021). The laboratory of Dr. Mariana Alperin (https://alperinmlab.org/) is developing evidence-based bioengineering approaches for pelvic floor reconstruction. She is asking questions and collecting data on the biology of pelvic floor muscles throughout a woman’s life, then designing bioengineered solutions based on these data, which are currently completely lacking. Researchers and innovators in many areas of academia and industry are working to reimagine a more equitable and healthier world for women. Women of Wearables is a UK-based organization that supports women in wearable technology, health technology, and femtech, a term applied to technology products for women’s health (e.g., fertility solutions, period tracking apps, and sexual wellness). The involvement of more women in wearable technology is leading to the collection of data and identification of women’s health challenges that need attention. Big data approaches may lead to more solutions. A collective of innovators, Make the Breast Pump Not Suck, applies sociological insights to the design of breastfeeding and other postpartum solutions for parents. They are especially attentive to those who traditionally face extra barriers such as women of color, women of lower socioeconomic backgrounds, and queer and trans parents. Elevating the visibility of the struggles these women face in maternity has led to crowdsourcing design solutions as well as the involvement of well-established and well-funded academic research labs. Hologic has designed a technology to treat abnormally heavy menstrual bleeding in women who are not looking to get pregnant, and several companies offer period swimwear. Both of these technologies allow women to realistically imagine not having to sit out one quarter of their life because of menstruation. Saysh (https://saysh.com/) is a shoe and lifestyle company founded by Allyson Felix. It designs athletic shoes for women while also empowering a collective of women “to undermine inequality with female creativity and athleticism.” Sheertex, founded by Katherine Homuth, is a company that invented indestructible tights. Its website puts the company motivation plainly: “Humans have walked on the moon—so why did tights still break at the first sign of bad luck?” Conclusion Multiple factors contribute to the disparities in health care for women. But at a time when engineering has enabled self-driving cars, image recognition software, and space travel to the sun, I have faith that it can also play a role in reducing these disparities. Resources are available for information and inspiration. These include, for example, interdisciplinary engineering programs such as the master of science in engineering for sustainability and health at my home institution; it brings together natural scientists with social scientists, clinicians, and engineers to educate the next generation of engineers. Other resources are available at Femtech Focus, Femtech Insider, and the Femtech Collective. We all can work to improve women’s health outcomes, even those of us who already make this our life’s work. References Azcona G, Beegle K, Bhatt A, Muñoz Boudet AM, Newhouse D. 2021. Four facts you need to know about gender and poverty today. UN Women Research Highlight, Mar 5. Barba-Moreno L, Cupeiro R, Romero-Parra N, Janse de Jonge XA, Peinado AB. 2022. Cardiorespiratory responses to endurance exercise over the menstrual cycle and with oral contraceptive use. Journal of Strength and Conditioning Research 36(2):392–99. Bø K, Artal R, Barakat R, Brown WJ, Davies GAL, Dooley M, Evenson KR, Haakstad LAH, Kayser B, Kinnunen TI, and 6 others. 2017. Exercise and pregnancy in recreational and elite athletes: 2016/17 evidence summary from the IOC expert group meeting, Lausanne. Part 4 – Recommendations for future research. British Journal of Sports Medicine 51(21):1516–25. Farkouh A, Riedl T, Gottardi R, Czejka M, Kautzky-Willer A. 2020. Sex-related differences in pharmacokinetics and pharmacodynamics of frequently prescribed drugs: A review of the literature. Advances in Therapy 37(2):644–55. Gupta AH. 2021. Surprise: Women and minorities are still underrepresented in corporate boardrooms. New York Times, Jun 7. Hoyert DL. 2021. Maternal Mortality Rates in the United States, 2019. Hyattsville MD: CDC National Center for Health Statistics. Liu S, Seidlitz J, Blumenthal JD, Clasen LS, Raznahan A. 2020. Integrative structural, functional, and transcriptomic analyses of sex-biased brain organization in humans. Proceedings of the National Academy of Sciences 117(31):18788–98. Sims ST, Ware L, Capodilupo ER. 2021. Patterns of endogenous and exogenous ovarian hormone modulation on recovery metrics across the menstrual cycle. BMJ Open Sport & Exercise Medicine 7. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, Bray F. 2021. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: Cancer Journal for Clinicians 71(3):209–49. Taipale-Mikkonen RS, Raitanen A, Hackney AC, Solli GS, Valtonen M, Peltonen H, McGawley K, Kyröläinen H, Ihalainen JK. 2021. Hormonal contraceptive phase on physiological variables monitored during treadmill testing. Frontiers in Physiology 12. Takahashi T, Ellingson MK, Wong P, Israelow B, Lucas C, Klein J, Silva J, Mao T, Oh JE, Tokuyama M, and 26 others. 2020. Sex differences in immune responses that underlie COVID-19 disease outcomes. Nature 588:315–20. van Kessel L, Teunissen D, Lagro-Janssen T. 2021. Sex-gender differences in the effectiveness of treatment of irritable bowel syndrome: A systematic review. International Journal of General Medicine 14:867–84. Wehbe Z, Hammoud SH, Yassine HM, Fardoun M, El-Yazbi AF, Eid AH. 2021. Molecular and biological mechanisms underlying gender differences in COVID-19 severity and mortality. Frontiers in Immunology 12:1603.  UN Women, Facts and Figures: Economic Empowerment (https://www.unwomen.org/en/what-we-do/economic-empowerment/ facts-and-figures), Jul 2018.  www.engineeringchallenges.org/challenges.aspx  Figure 1: Life expectancy at birth, by sex and race and Hispanic origin: United States, 2008–2018 (https://www.cdc.gov/nchs/data/hus/2019/fig01-508.pdf) , National Center for Health Statistics, Centers for Disease Control and Prevention  World Health Organization fact sheet: Cervical cancer (Jan 20, 2022), https://www.who.int/news-room/fact-sheets/detail/ cervical-cancer  https://linktr.ee/women_of_wearables  https://makethebreastpumpnotsuck.com/  https://www.hologic.com/hologic-products/gyn-surgical- solutions/novasure-endometrial-ablation  https://www.goodhousekeeping.com/clothing/g36801184/ period-swimwear-bathing-suits/  https://femtechfocus.org/; https://femtechinsider.com/; https://femtechcollective.com/home About the Author:Nicole Danos is an assistant professor of biology at the University of San Diego.