At age 60, Kate Revington retired from her role as a university administrator so she and her partner could travel to visit their children overseas while still in good health.
A year later, in 2019, she began to notice symptoms of pelvic organ prolapse (POP), a condition in which the uterus, bowel, bladder, or a combination of the three, drop down from their normal positions and bulge into or out of the vagina. She noticed changes in her bladder and bowels, and even worse, constantly felt as if something was coming out of her vagina.
As her symptoms worsened, Revington’s family doctor diagnosed vaginal prolapse and predicted she would require surgery given her young age and the degree of prolapse. She was referred to a local gynecologist.
It would be another four years until Revington finally received the surgery required to restore her quality of life.
Like many, prolapse was not something that Revington openly discussed with family or friends.
“It’s not a sexy thing. You don’t talk about it with your friends, even women friends,” she recalls. “I felt like it made me sound like a really old lady.”
She wasn’t alone. More than 40 per cent of women will experience pelvic organ prolapse, according to studies, and almost 15 per cent of women will require surgery, which equates to more than 2.9 million Canadian women. By 2030, an aging North American population is expected to increase that demand by 35 per cent.
A 2017 study comparing wait times for prolapse surgery to hip or knee replacement at Mount Sinai Hospital in Toronto found the average wait for prolapse surgery was 210 days compared to 98 days for hip and knee replacements. The study also examined quality of life scores and found that patients awaiting surgery for prolapse showed similar emotional distress, disability and mental impact as those awaiting hip and knee replacement.
“The data is pretty clear that women who require surgery for pelvic organ prolapse and urinary incontinence are some of the longest waiters in Canada,” says Frank Potestio, an obstetrician-gynecologist in Thunder Bay and the clinical lead for gynecologic surgery at Ontario Health. He advocates for a reassessment of the priority procedures that have been untouched since 2004, when Canada’s health ministers agreed to reduce wait times in five priority areas: hip and knee replacements, cataracts, coronary artery revascularization, cancer surgery and MRI/CT scans. This narrow selection has altered provincial funding strategies and hospital allocation of resources.
“Women who require surgery for pelvic organ prolapse and urinary incontinence are some of the longest waiters in Canada.”
In Ontario, overall wait times for surgery are starting to decrease as we recover from the pandemic. But gynecologic surgery continues to have long waiters beyond set targets compared to oncology, orthopedics and ophthalmology.
Revington waited four months for an appointment with a gynecologist. The doctor confirmed her prolapse and inserted a pessary, a ring-shaped device used to hold the prolapsed tissue inside her vagina. While it improved her symptoms, she found it uncomfortable, avoided exercise and suffered from recurrent urinary tract infections.
The gynecologist discussed surgery, but this would require a referral to a urogynecologist, a surgeon specialized in complicated prolapse repairs. Revington waited another year to see a urogynecologist and then was added to one more wait list for an operation in which mesh would be placed to hold up the vagina and prevent incontinence.
The use of mesh as well as minimally invasive techniques such as laparoscopy are examples of ways in which the complexity of gynecologic surgery has increased over time. Practice guidelines have shifted and now call for specialized techniques to manage prolapse and minimize the risk of recurrence. Many gynecologists do not feel comfortable performing these more complex surgeries, explains Roxana Geoffrion, a urogynecologist in Vancouver and associate professor at the University of British Columbia.
Urogynecologists complete a two-year fellowship after their five years of obstetrics and gynecology training, but there are not enough of them to keep up with the growing demand. Part of the problem, Geoffrion says, is that urogynecology is not an accredited subspecialty in Canada, one of the few remaining countries that does not have a governing body overseeing its credentialling. Studies show that accreditation of urogynecology is crucial to increase the number of surgeons performing these high-demand procedures, as well as to improve patient outcomes and advance collaboration, research and advocacy.
May Sanaee, a urogynecologist in Alberta and president of the Canadian Society for Pelvic Medicine, says that the surgeries are funded differently in each province, contributing to a significant discrepancy in wait times across the country – women in western provinces can wait up to two years for surgery with a urogynecologist, while women in Ontario and east can wait four or five years.
“Patients should have equal access to care, regardless of which province they live in,” says Sanaee. “Historically, quality-of-life procedures for women have not been prioritized and Canadians continue to pay the price.”
Potestio notes that while patients with prolapse are waiting the longest for surgery, even more women are waiting for procedures for heavy menstrual bleeding, an issue that also requires urgent attention.
In December, Nam Kiwanuka, co-host of The Agenda, described for TVO today her year and a half year journey to get surgery for fibroids and heavy menstrual bleeding. A struggle that involved endless emergency department visits, intravenous iron transfusions and a significant amount of advocacy to receive the treatment she desperately needed.
Researchers point to gender bias as a potent factor in the devaluation of health care provided to Canadian women. A study published in July 2023 and highlighted by CBC news revealed that in eight provinces, doctors were paid on average 28 per cent less for procedures performed on females compared to similar procedures for males. Saskatchewan had the largest discrepancy at 67 per cent, followed by British Columbia at 61 per cent.
The study, which compared 22 commonly performed procedures such as vulvar versus scrotal biopsies, found that in almost 70 per cent of cases reimbursement was higher for procedures on male patients. In Saskatchewan, a procedure to untwist an ovary pays 50 per cent less than a procedure to untwist a testicle, despite being riskier and more complex. In Ontario, a specific billing code doesn’t even exist.
The authors of the study call on researchers to focus on how pay inequity affects the health outcomes of female patients and encourages advocacy efforts to correct the discrimination.
Revington was finally given a spring 2022 surgery date. She was careful to isolate for weeks ahead of time to ensure her surgery would not be cancelled. Then another twist: A call in the evening to cancel her surgery the next day. Her surgeon had COVID.
She says she hoped for a quick rebooking, but it was another 10 months before her surgery. In July 2022, her beloved partner who had patiently waited with her throughout passed away unexpectedly.
The operation went ahead last January and she was able to begin to process all that she had lost over the past four years.
“I really have worked on rebuilding,” she says. “[The surgery] made a huge difference in my life. I feel much better, have more energy and can do more things again.”