In 1979, emergency medicine was officially established as a specialty in the United States, making it one of the youngest primary medical specialties.^1-3 Not only is emergency medicine a newcomer, but it also has one of the lowest research outputs of any medical specialty. ^4-6 Emergency medicine focuses on immediate impact and is frequently pressured for time, favoring efficiency and practicality.^7,8 The novelty of this specialty, paired with the high demand on emergency physicians, leaves large evidence gaps across many conditions.^9–11

At the same time that emergency medicine was emerging, the U.S. Food and Drug Administration (FDA) issued guidelines discouraging the inclusion of women in medical research.¹² This attitude persisted until 1985, when the U.S. Public Health Service concluded that excluding women from research was causing harm. It was not until 1993 that the National Institutes of Health (NIH) Revitalization Act mandated the inclusion of women in federally funded research.¹² As a result, for much of emergency medicine’s early development, both the specialty itself and the evidence base guiding care were built without adequate representation of women.

Emergency medicine has only been operational for roughly 50 years, during which clinical research output has not always been the top priority. Pair this with the historical exclusion of women from research, and it is not surprising that there remains a paucity of data investigating women’s health in emergency medicine. A review of the literature found that only two percent of emergency medicine studies reported gender-specific outcomes, and only 10 percent included gender as a variable in analysis.¹³

Despite these gaps, women’s health conditions commonly present to the emergency department (ED). A woman presenting to the ED is more likely to experience longer wait times, more likely to be misdiagnosed, more likely to report undertreated pain and receive fewer pain medications, and more likely to report worse patient experiences and outcomes than a man.¹⁴ A shortage of evidence-based practices guiding the management of women’s health conditions may contribute to these disparities.¹⁵

I came to understand this gap not through a textbook, but through my own experience. In my second year of medical school, I awoke in the middle of the night with severe, unprovoked unilateral pelvic pain. The pain was significant enough to make me nauseous and ultimately brought me to the ED. I was found to have a malpositioned IUD, but it was thought to be non-contributory to my pain. The following day, I asked my primary care physician to remove it. Shortly thereafter, my pain resolved.

This experience raised a series of questions for me. Were other women experiencing this? How many women had mispositioned IUDs and pelvic pain? Could IUDs be the cause of acute pelvic pain? Are mispositioned IUDs on the differential diagnosis for women presenting with atraumatic pelvic pain? Is this something that even matters for emergency medicine practice?

At the time, there was an incredible paucity of data regarding the role of malpositioned IUDs in acute pelvic pain in the emergency setting. The pathophysiology felt straightforward—a foreign body can cause pain—yet there was no meaningful body of literature addressing it. Since that time, a case report and case series have been published suggesting a link between malpositioned IUDs and acute pelvic pain, and the role of emergency medicine in their treatment.^16,17 A preliminary single site retrospective study has found that nearly one in four women who previously had IUDs and presented to the ED were found to have a malpositioned IUD. The majority of these patients presented with pelvic symptoms as their chief complaint, yet a malpositioned IUD is not routinely considered on the differential.

This raises the question: What else might we be missing in the realm of women’s health? Much of the data guiding women’s health in emergency medicine comes from obstetrics and gynecology or family medicine settings —environments with longitudinal follow-up, controlled appointments, and subspecialty expertise.^15,18 The emergency department is different.

The ED is episodic, time-pressured, and focused on ruling out life-threatening pathology.^7–9 When evidence is extrapolated from other specialties without validation in the acute care setting, important nuances may be missed.^9,10

The issue extends beyond pelvic-related complaints. Cardiovascular disease, including acute coronary syndromes, frequently presents differently in women, contributing to delays in diagnosis and worse outcomes.^19,20 Autoimmune diseases disproportionately affect women and often have variable or nonspecific presentations.²¹ Women’s pain is more likely to be undertreated in emergency settings.^14,22 Yet women remain underrepresented in clinical trials, and sex-specific analyses remain inconsistent despite NIH mandates.^12,23 When research fails to account for biological and sociocultural differences, disparities in care become structurally embedded.^15,24

Emergency medicine prides itself on rapid decision-making under uncertainty. However, uncertainty driven by evidence gaps is not benign.^9,10 Research demonstrates persistent information gaps in EDs that affect patient care and outcomes.⁹ When those gaps intersect with historically underrepresented populations, inequities may widen.^12,13,24

My experience as both patient and trainee revealed how easily women’s symptoms can be minimized when data are sparse. It also revealed an opportunity. Emergency medicine is still evolving as a specialty.^1-3 Its evidence base continues to develop, and with that development comes responsibility.

Closing gaps in emergency medicine research is not simply about representation. It is about diagnostic accuracy, equitable pain management, and patient safety.^14,15,19 If emergency medicine is defined by its commitment to treating anyone, anytime, for anything, then its research must reflect the full spectrum of the patients it serves.

Ms. Petelinsek is a medical student at the Spencer Fox Eccles School of Medicine with a focused interest in emergency medicine and women’s health, particularly acute pelvic pain and gaps in evidence-based care. She is an active researcher and advocate dedicated to advancing equitable, patient-centered care through clinical research, education, and health systems innovation.

References

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