Women's Health - Q1 - Mar 2019 by Mediaplanet UK&IE

Q1 / 2019 A SUPPLEMENT BY MEDIAPLANET DISTRIBUTED WITHIN THE IRISH INDEPENDENT

ORLA O’CONNOR We need to listen to what women say about their experiences of healthcare. » p2

DR CATHY ALLEN It is both heart-breaking and infuriating to witness the distress of infertility. » p4

PROFESSOR CATHERINE KELLY Unsung heroes: women living with metastatic breast cancer. » p6

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Womens Health ‘

Why are we too embarrassed to talk about periods? None of us would be here without periods - so why do we avoid talking about them like they’re something dirty, instead of embracing them as a natural part of life?

ast week, I dropped my bag on the tube. Five sanitary pads fell onto the floor, and as I rushed to pick them up, while the man sitting opposite me worked extremely hard not to look, I felt that familiar embarrassment creeping over me. Despite my feminism, my campaigning for abortion rights, my tweet storms demanding better treatment of women’s health issues, I was still deeply humiliated at the thought that this group of strangers, who I would never see again, would know I was on my period. Don’t ignore the blob It’s been this way as for long as I can Follow us

remember. Not even just around men - at my single sex school, we hid pads up our sleeves when we asked our teacher’s permission to go to the toilet, or passed tampons to friends in need as discreetly as if we were performing a drug deal in a below-average gang movie. We learn from day one to talk about periods in hushed code - “I’ve got the painters in”, “Aunt Flo is visiting”, “She’s on her TOM”. It’s drilled into us that our bodies are something to be ashamed of, rather than something to take ownership of. Not being able to take ownership of our bodies and talk about them means that, all too often, issues with our bodies are ignored. MediaplanetMarketing

After 15 years of symptoms and misdiagnoses, my mum was only conclusively diagnosed with endometriosis when a doctor spotted the damaged tissue during an operation for something else. I first went to the doctor about my similar symptoms over seven years ago, and I’m still waiting to have a laparoscopy. It all starts with blood Repealing the Eighth Amendment was, undoubtedly, a great step forward for women’s health. But we need to keep the conversation going - especially in the North where abortion is still illegal and if we are going to talk about @MediaplanetUK

women’s health, we need to start with the basics. We need to be able to utter the words, “I am on my period” in public, without us and the people around us turning a colour oddly reminiscent of the subject matter. Without that most simple starting point, how can we talk about the bigger issues? AIMEE RICHARDSON Game of Thrones Actress and Women’s Rights Activist @MediaplanetUK

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Why women’s health is still a big deal

Byline: Gina Clarke

The referendum on the Eighth Amendment represented a momentous shift in how Ireland responds to women’s healthcare needs. The National Women’s Council of Ireland believes development of a Women’s Health Action Plan in 2019 has the potential to embed real and sustained change for women’s experience of healthcare.

or Orla O’Connor, the Director of the National Women’s Council of Ireland (NWCI), this year will be one of embedding change after seeing numerous women’s health issues hit the public consciousness in recent years, from the Repeal of the Eighth Amendment to #MeToo and the Scally inquiry into cervical cancer screening. Building on this renewed drive to improve women’s experience of healthcare, the NWCI will be working with the health service this year to develop a Women’s Health Action Plan. She says, “We need to focus on women’s health because women are different from men; they experience different things while growing up and as adults. Biological factors can influence health and wellbeing outcomes and factors related to gender – such as women’s caring responsibilities – can affect treatment choices. Women’s health is about recognising these differences. Yet, there hasn’t been a strong understanding of the different health needs of women and

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men, of the need to specifically focus on women’s health needs in developing policy and in the rolling out of services. The erosion of women’s health structures, such as the Women’s Health Council and women’s health officers, was called out in Dr Scally’s report into CervicalCheck, which recommended consistent, committed attention, which is now being given to women’s health.” Scandals concerning women; trust needs to be restored Ireland has a history of scandals related to women’s health, from symphysiotomy to hepatitis-C to last year’s CervicalCheck scandal. Indeed, one of the starkest comments from women quoted in the Scally report, was ‘Why does this always happen to women?’ O’Connor says: “If we really want to improve women’s health and, crucially, if we are to restore women’s trust, we need to listen to what women say about their experiences of healthcare. This is the only way we can truly

understand how gender inequality impacts women’s health. The National Strategy for Women and Girls commits the Health Service Executive, the Department of Health and NWCI to develop a Women’s Health Action Plan. We are committed to working with our health service partners to make this plan a reality for women in 2019. “All policies are better when they are developed in collaboration with the people they are designed to support,” says Orla. “We need to speak to women about their experiences of healthcare. That’s the first conversation that has to be had.” Tackling health inequalities for women in Ireland “Developing the Women’s Health Action Plan will enable us to address the range of health issues women experience. The plan will also need to be mindful of the needs of particular groups of women who have poor health outcomes. These women must be a priority. For example, traveller women have a life expectancy ten years lower than the

ORLA O’CONNOR Director, National Women’s Council of Ireland (NWCI)

population and incidences of lung cancer among women are higher in deprived areas, with poorer survival rates.” Looking after women’s reproductive health “There is a real sense of achievement in progressing women’s reproductive rights in Ireland. For the first time abortion is being provided by the public health service. The service still needs improvement to ensure that all women who need abortion can access it here at home. But we are also at the beginning of significant change in wider reproductive healthcare with attention turning to the need for comprehensive sexual health education and universal access to contraception. Women’s reproductive healthcare services should be designed around the lifelong needs of women and girls. That’s why NWCI’s Every Woman Model for Reproductive Healthcare is based on six components: sexual health education; contraception; sexual and reproductive health services; pregnancy care;

reproductive cancer care; and menopause services. We have a way to go to achieve such comprehensive services and we will continue to campaign until each element is in place.” Women are central to achieving change O’Connor concludes, “After the Repeal referendum, young women are energised in articulating their own health needs. They recognise the possibilities for change and their own power to achieve it. We need to build on this momentum to secure a health service that is women-centred and that can meet the health needs women themselves have identified.” NWCI will now focus on achieving clear commitments and investment from government for women’s health and on developing a women’s health action plan that is stretching and ambitious for women across the country.” Read more at healthnews.ie MEDIAPLANET

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Diagnostics’ key role in ovarian cancer fight

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DR SHARON O’TOOLE Senior Research Fellow, Departments of Obstetrics and Gynaecology and Histopathology

More accurate diagnostics coupled with increased symptom awareness are the key weapons Irish women have in the battle against ovarian cancer.

ednesday 8 May is World Ovarian Cancer Day, a day when women will be asked to ‘BEAT’ ovarian cancer. The acronym ‘BEAT’ reminds women to seek medical help at an early stage if they have any of the following symptoms for three weeks or more:

B E A T

loating that is persistent and doesn’t come and go

ating less and feeling full more quickly bdominal and pelvic pain you feel most days

oilet changes in urination or bowel habits

‘The silent killer’ Ovarian cancer is known as the silent killer because early symptoms are vague and often confused with bowel problems such as Irritable Bowel Syndrome (IBS). It’s currently the sixth most common female cancer in Ireland affecting over 400 women each year and killing two in three. The problem is that almost seven in every 10 cases are diagnosed at an advanced stage. As the population ages, agerelated cancers are increasing in frequency but for ovarian cancer which is most common in women aged over 50 – science is yet to come up with an effective screening programme. If doctors could catch ovarian cancer at an earlier stage, survival rates could triple.

Research successes Sharon O’Toole is the Senior Research Fellow (histopathology) at Trinity College, Dublin, which takes a lead in gynaecological cancer research. Among her successes, she has helped identify diagnostic and prognostic biomarkers for ovarian cancer, which give pharma and diagnostics companies better understanding of the risk factors and the development stages of the disease. This allows them to develop more accurate tests and better treatments. O’Toole says: “Classifying the various subtypes of ovarian cancer has changed our thinking. Understanding what we are dealing with is an important first step in improving diagnostics and treatments.” Today, patients have a say in the development of diagnostics and

treatments, via research forums run by institutes such as Trinity, the Irish Society of Gynaecological Oncology Public and Patient Involvement Group as well as the cancer charities. O’Toole believes additional biomarkers would improve on current diagnostics. “This allows us to offer a more accurate diagnosis and the most appropriate course of treatment. This would enable doctors to take a less aggressive surgical approach in some women.” While use of the new technology becomes more mainstream, the job of beating ovarian cancer has to start with women and their GPs. O’Toole says: “It’s important that women talk to their GPs about their symptoms and any family cancer history. IBS rarely starts in women aged over 50. If you have symptoms, always get them checked out.”

Key Advances: Key advances into ovarian cancer research include the study of a novel protein in the body. A test for this protein, the Roche Elecsys® human epididymis secretory protein 4 (HE4), with the current test (often combined with ultrasound) for a tumour protein known as Roche Elecsys® CA 125.

Sponsored by

Follow Roche Diagnostics at @Roche_Dia_Irl Read more at ovacare.ie CREDIT: WAVEBREAKMEDIA

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Lifestyle changes have affected our reproduction in the last 50 years

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DR CATHY ALLEN Consultant Obstetrician and Gynaecologist and Specialist in Reproductive Medicine, National Maternity Hospital and Merrion Fertility Clinic, Dublin and Member of the Institute, Obstetricians and Gynaecologists

Changes in health, lifestyle and society have impacted greatly on human reproduction, particularly in females, over the past 50 years. But there is more we can do to help infertility.

018 maternities, compared with with previous decades, show higher average age of first time mothers, smaller family sizes, increased case-complexity, more C-section deliveries, and better neonatal outcomes. Fertility problems are more common than people realise Despite developments in health and technology, the fundamental biology of reproduction remains unchanged. Patients are often surprised to learn how common fertility problems are (one in six couples), and how success rates of fertility treatments are more limited than realised. Female age is still the biggest single determinant of ability to conceive, miscarriage and livebirth rates. The optimal biological time for fertility and maternity is in the 20s, with a clinically apparent ‘threshold’ for fertility problems seen in women over 35 years. Older mothers are less likely to have straightforward pregnancies Female fertility requires the availability of eggs from a finite store, which diminishes in quantity and quality over time. The health of the reproductive tract can be affected by progressive conditions such as endometriosis and uterine fibroids. From a social perspective, better education and career opportunities can mean more financial security and personal readiness to raise a family. But delay incurs the possibility of negative age-related fecundity risks. Infertility rarely makes headlines because we’re focusing on teens not getting pregnant Infertility has a low profile in the wider picture of Irish healthcare and its resourcing. This may be because infertility has not traditionally received recognition for the morbidity it entails. Fertility is also a deeply private matter, so patient representation is not as forthcoming as for other disorders. It is possible that the traditional focus on avoiding pregnancy in young adult years impedes public awareness of the potential for infertility in later adulthood. In any case, public awareness of fertility issues – although less than ideal – seems to be improving. An old perception of stigma with infertility is being gradually dispelled by brave individuals sharing their personal stories. IVF should be made more financially accessible It is both heart-breaking and infuriating to witness the distress of infertility, which could be treated successfully, but this treatment is denied to those who cannot afford it. For example, for a woman who has lost both fallopian tubes to ectopic pregnancies, IVF offers a realistic chance of pregnancy. Or for an azoospermic man (no sperm in the ejaculate), a surgical sperm retrieval is an option. But unless these individuals have considerable disposable income, there is little hope. Such patients are not uncommon, but because of chronic inequity they remain the voiceless and the choice-less in modern Irish healthcare. Read more at healthnews.ie

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Women shouldn’t struggle on with menopause DR CLIONA MURPHY FRCPI FRCSI MRCOG BSCCP Chair of the Institute of Obstetricians and Gynaecologists Consultant Obstetrician & Gynaecologist, Coombe Women’s and Infants University Hospital

As women become older, changes in their body can impact their lives, whether that’s difficulty sleeping, becoming more emotional or just having a touch of mind fog. A recent bout of media attention on the changes women go through while ageing has been helpful in raising awareness. But more can still be done.

or Dr Cliona Murphy, as Consultant Obstetrician and Gynaecologist in the Coombe Women and Infants University Hospital and Tallaght University Hospital, it is her role to support women as they go through changes in life, such as menopause, and she says 'awareness' is key. “When women get to their 40s, they’re often not expecting their periods to change. While that can be the first sign of the menopause, there are many more side effects that can come with it. Symptoms can include hot flushes, night sweats, an uncontrollable rush of blood to the face; all of which can all be distressing. “Many might have disturbed sleep and feel exhausted in the morning, which can play havoc with work situations and can be distressing. There are also more physical causes such as palpitations, feeling that their bones are aching, lacking energy, experiencing joint pains, or experiencing vaginal dryness, making sex painful. What women need to realise is that these symptoms are absolutely normal and that they don’t need to struggle on.” Menopause isn’t a disease Dr Murphy is spreading the message that menopause isn’t a disease, it is just a way of life. She says, “For many

years, focus has been on maternity and gynaecological problems that need surgery. But, while these are important, we still need recognition about the second phase of our life. “In England and Ireland, women are living to 78-80, so our quality of life has to be prioritised. To do this, I’d like to make links with midwifery colleagues when it comes to planning for the future. I would also like to see links with other colleagues for the ‘whole life’ concept of women’s health and see how we can integrate things more.” Preparing women for menopause This approach would become heavily focused on preventative medicine, giving advice and actively preparing women for the peri-menopause and menopause. From addressing fears and concerns such as prolapse, to information on physiotherapy and strengthening the pelvic floor as well as offering support with diet and exercise. Dr Murphy adds, “These are all non-surgical interventions that can optimise people’s wellbeing before they even need surgery.” With our lifestyles constantly changing, cases of osteoporosis are on the rise and some factors – such as taking certain contraception or HRT – can inflate these risks. The benefits of the modern age, however, mean that

GPs can now prescribe much more tailored options to suit our personal circumstances and family history. Protect against brittle bones “We can protect against osteoporosis with a diet rich in calcium and vitamin D, combined with exercise – particularly weight-bearing – to help protect our bones. If the diet is low in those vitamins, supplements can help.” When women reach middle age, they should attend their screening checks, such as mammograms and smear tests, and if possible, have an overall health check. Dr Murphy adds, “I use my time with patients to go through family history, check they’ve attended their screenings and ask them about diet. These touch points can add value to any visit. But the most important thing is to make women see that if there are any changes along their journey into the second phase, whether that’s menopause or other symptoms, they should be able to go and ask their GP for help.” For further advice about menopause, the British Menopause Society has a range of helpful information online. Read more at healthnews.ie

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Forget about your contraception - and stay protected If taking a pill every day isn’t ideal, a “fit and forget” method of contraception could be right for you. They’re highly effective - and last for up to ten years.

social media storm broke out recently after confirmation that women who take the contraceptive pill can continue the active pills without a break - and skip their period. It was clear from the online reaction that, for thousands of women, avoiding periods would be a welcome relief. But there are already contraceptive methods that can do this without a daily pill.

periods lighter or less frequent, or stop them altogether.

The most effective contraception available They’re known as long-acting reversible contraceptives or LARCs – what we call “fit and forget” methods. They last for up to ten years and, because there’s no chance of user error, they’re the most effective forms of contraception available – more than 99% effective. Three types – the hormonal coil, the injection and the implant – work by slowly releasing hormones into the body. They can make your

It’s a myth that you can’t get the coil unless you’ve had a baby Some myths around LARCs persist like you can’t get a coil if you haven’t had a baby (not true); or that they’re not suitable for teenagers (also not true).

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Non-hormonal contraception There’s also a LARC that may be suitable for women who are looking for alternatives to hormonal contraception. The copper coil is just as effective as the other LARCs and can also be used as emergency contraception up to five days after unprotected sex.

DR CAITRIONA HENCHION Medical Director, Irish Family Planning Association

over time, women who don’t have medical cards may find the upfront cost beyond their means - it can amount to a few hundred euro. But we hope that barrier will fall; the Department of Health is working on plans for the provision of free contraception for anyone who needs it.

Costs may be high now, but in future, contraception may be free One disadvantage is cost. Though LARCs are highly cost-effective

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What you need to know about breast “This is me” cancer LIZ YEATES CEO, Marie Keating Foundation Byline: Gina Clarke

Breast cancer awareness might be more common in the 21st century, but that doesn’t mean we should be complacent.

or Liz Yeates, CEO of the Marie Keating Foundation, it was her own journey through breast cancer that incentivised her to reach others and raise awareness. She knew that the earlier her disease was caught, the better the outcomes might be. Indeed, Marie Keating, after whom the foundation is named, might have still been with us at the age of 71, if only she had seen a doctor sooner. All women should get to know their breasts Yeates says, “I knew I had had cysts before, so I wasn’t too alarmed to find a lump – I just assumed it was another cyst. But during a mammogram, the scan picked up something more sinister, which there was no way I would have caught. So screenings really do help.” Right now, in Ireland, survivorship rates for breast cancer are around 83%, which is almost double the 43% Marie Keating faced 20 years ago. The charity continues to act in her name, and their nursing teams reach around 22,000 women every year, teaching them the important early signs and symptoms. From breast changes, such as puckering, dimpling or lumps, to other lifestyle-led risk factors, such as smoking or weight gain. You may be at greater risk if breast/ovarian cancer runs in your family But when it comes to hereditary conditions, there is certainly an increase of awareness, mainly through celebrities – such as Angelina Jolie, who has talked about her battle with the BRACA 1 gene. Yeates adds, “We would ask anyone with a family history of breast or ovarian cancer to look a little closer into the condition. Perhaps a lot of the ladies in your family just died young without any diagnosis? We can certainly help with the warning signs.” The foundation also helps women who have been through breast cancer or are currently being treated, from survivors learning to live again without the upheaval of hospital, to supporting friends and family who are helping their loved ones get through it. They also provide workshops for those undergoing palliative care, which can offer practical support as well as emotional. Cancer can be preventable Most of all, Yeates wants the foundation to get the message across that a lot of cancer is preventable. She says, “We know that a healthy lifestyle can reduce anyone’s chances of developing cancer.. From stopping smoking to getting your heart rate up five times a week and staying safe in the sun. There are lots of resources out there and I would encourage anyone to go and check them out.” Read more at healthnews.ie

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My journey with metastatic breast Unsung heroes: cancer women living with metastatic breast cancer BERNIE WALSH Metastatic Breast Cancer Patient

Cancer. Yes, I knew the word, but I didn’t fear it until it knocked on my door in October 2012.

inding a lump after getting out of the shower was the start of my cancer journey. Surgeries, followed by chemotherapy, hormone treatment and radiotherapy took eight months of my year, but 2013 was not going to get away from me, so I took part in the 5k Pink Run in aid of cancer research and then, a month later, the annual 5k in aid of the Marie Keating Foundation. I felt so good about myself as I had never taken part in anything like this before.

“It took cancer to give me the kick up the backside to start living my life.” I honestly believe that taking part in the Marie Keating Foundation run that day was meant to happen. They have been a great support to me since we hooked up over the past number of years and even more so when, what I thought was a muscle spasm in my back in July 2017, turned out to be cancer revisiting me… I thought I had given it enough of my time, but sure, it must like me! “Cancer does not define me” I believe that if you let cancer take over your life it will. I’m living with cancer but it’s not my life. Thankfully, my great medical team were able to sort out a partial removal of the tumour in my spine and I’m now on daily medication and monthly treatment in hospital as well as check-ups every three months with my oncologist. I recently joined a group - Positive Living with Metastatic Breast Cancer, which is organised by the Marie Keating Foundation. We all take encouragement from each other; none of us know what tomorrow will bring, so we are just enjoying today. “Don’t sweat the small things; life is too good to miss” I have been given another chance at life. I love every day because I’m here and can experience the little things – like the sun on my face or the rain on my hair. I feel I have a purpose in life, I work part-time with lovely people and I look forward to going in every day. Coming home and sharing the day with my young adult kids… What could be better than that? I’m still dancing with cancer but I have better moves than it does! Read more at healthnews.ie

PROFESSOR CATHERINE KELLY Consultant Medical Oncologist

For most women who are diagnosed with breast cancer that involves their breast and lymph nodes, once they are treated, their cancer never returns. Women with metastatic breast cancer are those whose breast cancer has spread to other organs such as bone, liver or lung. Metastatic breast cancer is very treatable but in most cases it is not cured.

he goal of treatment is to maintain quality and length of life. Life expectancies of between two to four years are often quoted, however some women only live for a number of months while others live for many years. Many women with metastatic breast cancer continue to work. Often, the people around them have little if any knowledge of their disease. Many women can be treated with hormone blocking tablets. Oestrogen-driven cancer can be treated with hormone therapies – often for several years before patients may need chemotherapy. Women with metastatic HER2-positive breast cancer can be treated with anti-HER2 antibody drugs for many years too. Some of these patients have no evidence of metastatic disease after a few months of treatment. About 15% of women have triple negative breast cancer and these women need chemotherapy. But, recent clinical trial results have shown that, in the future, these women may benefit from immunotherapy, which is very exciting. Shock, anger, sadness and fear are common responses to diagnosis Coping with a diagnosis of metastatic breast cancer is hard. A person can feel shock, anger, sadness and fear, and the uncertainty of not knowing what the future holds. Some women continue to work for the sake of normality, or because financially they must. Women with children fear the impact their diagnosis will have on them and how they will cope in the future. Without question, all women need support from a multidisciplinary team of specialists and from their family and friends. As a society, we need to shine a spotlight on metastatic breast cancer. We need to listen to these women, understand and address their unique needs and allow them to express their fears. We need to fight for the best clinical trials with the most promising drugs for them. Read more at healthnews.ie MEDIAPLANET

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Supporting health choices of female students THERESA LOWRY-LEHNEN ISHA Assistant PRO and Student Health Nurse, IT Carlow

he Irish student population continues to grow year-onyear, and with it, the demand for student health services in thirdlevel education. CSO statistics show 52.2% of the 225,628 third-level students in 2016/17 were women. 68.5% of all 20-year-old women were students, highlighting the need for more awareness and promotion of women’s health issues, as well as better resourcing of services to meet the specific health requirements of female students.1,2 Help with health during college Student health services are not gender-specific, but women’s health needs often are – menstrual issues, contraception, pregnancy, breast care, cervical screening – but other health issues such as UTIs, STIs, and some mental health problems, especially depression and anxiety, are also prevalent in female students. Contraception is one of the main health concerns among female students, with a clear demand for convenient, reliable, affordable contraception, especially longacting reversible formulations (LARC), which should be the method

of choice for this population group. This is because of their vastly superior efficacy in relation to failure rates, and as they are the only form of contraception linked with a reduction in abortion rates.3,4,5 Abortion is free; contraception should be free too! Emergency contraception is now accessible over-the-counter, but the cost for all methods of contraception, particularly LARC, is still an issue for many students. With termination of pregnancy now available – free – in Ireland, the provision of free contraception, especially LARC/ emergency contraception, needs to be addressed to ensure provision of evidence-based best practice and care to young Irish women. Other important health issues include education about cervical screening and encouraging regular self-breast examination from a young age. Increase in STIs among 15-24-year-old women Recent national figures published in November 2018 show a 5% increase in STIs, up to 13,629. Among 15-24

DR AOIFE O’SULLIVAN ISHA President and GP Student Health Department, University College Cork

year-olds, 59% of recorded STIs were in women. 62% of all chlamydia and 81% of genital herpes cases in this age group are also in females.6 The provision of free, accessible STI screening nationwide is vital for third-level students, as is sexual health education regarding risks and prevention. Many UCC students surveyed only reported condom use ‘some of the time’ – the need for female students to have to insist on condoms is a very concerning trend; male students must also be encouraged to insist on using protection. Chlamydia is the most common STI, with diagnoses increased up to 7,408.6 Up to 80% of females with chlamydia have no symptoms. Likewise, most recent figures show gonorrhoea diagnoses in Ireland have risen to 2,249 cases.6 Undiagnosed chlamydia/gonorrhoea can affect future fertility – an added concern for young women and men. Female students’ mental wellbeing is lower than their male peers College students represent a vulnerable population regarding mental health issues. The years

during which young adults enter into and attend third-level education, represent a high-risk period for mental health disorders. In a 2012 national survey regarding the mental health profile of over 8,000 young Irish adults (17-25-years, females presented with lower levels of wellbeing than males. Overall, 48% of female students reported a score indicative of poor mental wellbeing. Body image issues and eating disorders are also more prevalent among female students.7,8 Sexual harassment/violence is another serious issue. In a 2018 survey of 632 students, by the NUI Galway SMART Consent research, 54% of first-year women students reported experiencing sexual hostility or crude gender harassment at some point since starting college. This rose to 64% among second-year and 70% among third-year female students.9 Increased alcohol consumption among female students A notable recent health-related behaviour change is an increase in alcohol consumption among female students. They are now drinking

as much as - and more - than male students. In a 2015 UCC study, 67.3% of women reported hazardous alcohol consumption, versus 65.2% of men.10 More women are being diagnosed with smoking-related cancers, with lung cancer now the main cause of cancer death among women. Low self-esteem, worries about weight gain, or wanting to fit in, contribute to young women starting/continuing to smoke.11 Education and healthy lifestyle advice for women regarding consent, vaccination, contraception, screening, nutrition, exercise, dangers of drugs, alcohol and smoking is ongoing in student health centres. It is important we support, promote and improve the health choices of our female student population.