Women in minimally invasive gynecological surgery and endometriosis challenges and overcoming

The gender gap in surgery is narrowing compared to the past, with more women pursuing surgical careers (Bruce et al. 2015; Hu et al. 2019). However, female representation in surgical specialties does not reflect their increased numbers in medical school classes (AoAM 2018; Epstein and Epstein 2017; Jonasson 2002; Phillips, Tannan, and Kalliainen 2016; Weiss et al. 2014). In 2020, women accounted for 13.2 percent and 7 percent of England’s and Ireland’s surgical consultants, respectively (AoAM 2018; Phillips, Tannan, and Kalliainen 2016). According to 2017 data from the Association of American Medical Colleges, women consisted of less than 25 percent of doctors in ten surgical specialties in the US (Jonasson 2002). Another report from the Royal Australasian College of Surgeons stated that approximately one-third of the 2018’s applicants to surgical training and education programs of Australia and New Zealand were actually women (Weiss et al. 2014). Finally, women were a minority among Japanese surgeons in 2012, with a proportion of 6.9 percent of the whole Japanese surgical society (Epstein and Epstein 2017). Due to an increasing spotlight, gender discrimination and bias (GD/bias) are identified and reported in many aspects of surgical training and practice in the developed world (Bruce et al. 2015; Hu et al. 2019). While subjective gender discrimination remains hard to quantify, objective evidence of disparity is seen in the dearth of females in leadership positions, pay inequities, and underrepresentation in academics. Recent attention to GD in medicine and other walks of life has largely made overt bias widely unacceptable. However, women continue to face and deal with “unconscious” or implicit bias that results from an interplay of complex factors such as societal norms, stereotypical gender roles and learned behaviors (Phillips, Tannan, and Kalliainen 2016). A 2017 study looking at women as department chairs and full professors showed dismal results, with few women making it beyond the rank of instructor and assistant professor, and even fewer making it to full professor and department chair (Epstein and Epstein 2017). Similar statistics are seen in other developed nations such as Great Britain and Japan, where Kyoto University noted no female associate or full professors in Surgery from 2009 to 2013 (Okoshi et al. 2014). Moreover, the Society of British Neurological Surgeons noted that out of 315 neurological surgeons, all 16 full professors were men (Wilkes et al. 2015).

Women face many obstacles when it comes to advancing in their professional careers and may be much worse should they choose to pursue a surgical career. In addition to all the prejudice, there are also the barriers related to the equipment and devices themselves, which are manufactured for the male universe. A study tried to assess whether females compared with males face greater ergonomic strain with the use of four advanced energy laparoscopic devices (LigaSure, HALO PKS, ENSEAL, and Harmonic scalpel) (Wong, Moore, and Carey 2022). Women significantly reported physical complaints and inappropriate fit of the LigaSure, HALO PKS, ENSEAL, and Harmonic scalpel. Female sex was associated with fivefold greater odds of physical complaints with laparoscopic device use. Further investigation of the surgeon factors underlying device-related strain is a critical next step to understanding and reducing surgeon ergonomic injury (Wong, Moore, and Carey 2022). The path for female surgeons is bumpier and filled with traps. According to Doris Henne-Bruns, MD, emeritus director of the Clinic for General and Visceral Surgery of Ulm University Hospital, Germany: The biggest obstacles are still the difficult working conditions per se and the compatibility between family and career (Maugg 2022).” Never in her 40-year career has she countenanced the idea that women are not finding their way into surgery purely because of the ergonomics, not even when mentoring female students. “Other reasons have a much bigger impact,” said Henne-Bruns (Wong, Moore, and Carey 2022). These reasons include operations that last for many hours, shift work, and the difficult working hours (Maugg 2022). The problem of ergonomics still outranks the very well-known problem of work-life imbalance in surgery, wrote Bellini and her colleagues in their article. All these factors directly affect women’s options, how they work, operate, or garner practical experience, and eventually lead women to decide against a surgical career (Maugg 2022). Female surgeons in Germany are faced with other challenges, Blank continued. “Young female surgeons must first prove themselves in the men’s club of surgery and are put under a lot of pressure. They must work harder to be accepted by their colleagues. They also encounter patriarchal and outdated thought processes all too often, even among younger colleagues. But surgery is an incredibly beautiful and satisfying profession. After an operation, you can see the result, what has been achieved, just like an artisan (Maugg 2022).”

Gynecologists who perform minimally invasive surgery often treat endometriosis, which is a disease that distorts the pelvic anatomy and requires surgical skill, dexterity, and a lot of training to perform. Endometriosis, defined as “endometrium-like glands and stroma outside the uterine cavity,” is associated with pelvic pain and infertility. Deep and cystic ovarian endometriosis are associated with severe pain and sexual dysfunction. Surgical excision of deep endometriosis improves pain and quality of life, bowel function, and sexual function (Cervantes et al. 2023). The prevalence of endometriosis affects approximately 10 percent of the women in reproductive age from all ethnic and social groups and impairs women’s quality of life. Chronic pelvic pain and infertility are the most common symptoms, primarily affecting women in their early 30s. However, some women are asymptomatic the mean time for diagnosing endometriosis is 7 years from the onset of symptoms (Cervantes et al. 2023). Among all clinical presentations of endometriosis, deep infiltrating endometriosis (DIE) is the growth beneath the peritoneum and can involve the uterosacral ligaments, vagina, bowel, bladder, or ureters. Multifocal disease is observed in most women with DIE, with a mean of four lesions and mainly affecting the left side of the pelvis general, the depth of infiltration of the nodule in the DIE is correlated to the type and severity of symptoms. Surgery is the mainstay of treatment for DIE (Quintairos et al. 2022). Studies reveal it improves quality of life when comparing the period before surgery with 12- and 48-month follow-up. There was a significant increase (p, .001) in the scores in all the SF-36 domains when comparing T0 vs T12 and T0 vs T48, with higher average scores at T48 corresponding to the domains of physical functioning, role physical, and social functioning (scores of 85.56, 75.69, and 73.61, respectively). In conclusion, laparoscopic treatment of bowel endometriosis improved the long-term quality of life of patients (Araujo et al. 2014).

Last but not least in March we celebrate both endometriosis awareness and celebrate Women’s International Day, which is a perfect opportunity to recognize and honor the integral role that women play in the field of surgery treating other women and improving their overall quality of life. Throughout history, women have pushed boundaries challenged societal norms and broken barriers to provide the best possible care to their patients. However, it is essential to acknowledge the significant obstacles that women in surgery face daily. They have not only to navigate the technical intricacies of their profession but also to confront biases and stereotypes that can limit their advancement and recognition.

The path to becoming a successful surgeon is often filled with challenges and sacrifices. Balancing personal and professional responsibilities can be particularly demanding for women. Society’s expectations and gender biases often add an additional layer of burden to their already heavy workload. Despite these hurdles, women in surgery have demonstrated unwavering determination and resilience. Their commitment to providing the highest level of care to patients with endometriosis should serve as an inspiration to all aspiring surgeons. One of our society’s main goals is to empower and inspire young women in the field of surgery. By highlighting the achievements of women surgeons and raising awareness about the unique challenges they face, we hope to encourage more women to pursue surgical careers and contribute to the advancement of medical care for endometriosis and other gynecological conditions. In conclusion, let us remember that Endometriosis Awareness Month not only sheds light on the condition itself but also emphasizes the exceptional strength and dedication of the women who choose to specialize in this field. Their contributions are invaluable, and it is our duty to support and encourage them in their endeavors.