the food and drug administration (fda) of the united states established their office of women's health around this time, in 1991, concentrating on the underrepresentation of women in research, especially with cvd. in 1993, the fda created a guide for researchers to follow when including women in their studies, with an updated action plan for this published in 2014. it is important to note that the 1993 policy effectively reversed one established in 1977 that called on fertile women to be excluded from clinical trials, which had furthered the lack of women present in research at the time. this was done to address concerns of birth defects among infants and changes in estrogen and progesterone in postmenopausal women. between 1988 and 1991, only 50% of the data analysis from trials that were not designed for women, accounted for the difference in gender. it was assumed that the drugs given to men would work if prescribed to women. the institute of medicine, also from the united states, moved forward with other milestones by publishing papers in 2001 and 2010 that recognized sex and gender for the first time as variables crucial in women's health. also in 2010, the canadian institutes of health research and the canadian institute of gender and health produced a tool to make incorporating sex and gender as variables easier in research. this was followed shortly by the world health organization, which in 2014, promoted more gender-specific approaches to data analysis and health-inequality monitoring to ensure that a more sustainable approach was taken to this research. in 2015, the national institutes of health and the united nations both endorsed the necessity for gender-specific reporting or providing a reason for why it was not included in studies to ensure that researchers are held accountable. the united nations specifically advocated for gender-sensitive strategies to be established by 2030. following in north america's footsteps, the league of european research universities proposed a list of suggestions for how to undertake gender-specific research for universities, governments, and more. in 2016, two vital reports from oxford and the united nations, "women's health: a new global agenda" and "global strategy for women's, children's, and adolescents' health (2016–2030)", were published, bringing much-needed attention to this issue. the european commission in 2016 provided a published guide for horizon 2020 to address participation gaps for women in research and strategies to approach this. these are not the only steps that have been taken to include women in the scientific community. there have been numerous policies and practices already established and continuing to be added to address the growing concern of cvd. the centers for disease control and prevention division of heart disease and stroke prevention initiated the well-integrated screening and evaluation for women across the nation (wisewoman) awareness campaign in 1993. it was created to educate women on the risk factors associated with cvd and encourage healthier lifestyles to limit that risk. in 1999, the aha created the guide to preventive cardiology for women guideline to be used by the scientific community. this was the first of its kind in advising cvd management in women. in 2004, the 1999 guideline was replaced by the evidence-based guidelines for cardiovascular disease prevention in women by the american heart association. these guidelines underlined the importance of including women in research and challenged the notion that men and women are the same for cvd pathogenesis and these differences should encourage research and treatment to be approached accordingly. there were additional updates to this in 2007 and 2011. the european society of cardiology and european health network in 2006 started the transnational project for the prevention and management of cvd, where its objective was to "address the significant burden of cvd in europe and to determine specific areas of intervention to contribute to preventing avoidable deaths and disability". the hellenic cardiac society, a european organization, followed this up with a national action plan for cvd projected for 2008 to 2012. its aim, through the american heart association and many other guidelines, was to prevent cvd, primarily heart disease and stroke. in 2011, the american house of representatives put forward huge legislation called the "heart disease, education, analysis, research, treatment for women act or heart for women act". this is intended to provide healthcare professionals and others with gender-specific information for appropriate medical treatments. also in 2011, the european society of cardiology released guidelines for the management of cardiovascular diseases during pregnancy: the task force on the management of cardiovascular diseases during pregnancy of the european society of cardiology. as pregnancy is a crucial unique factor to consider in women, these guidelines encouraged the scientific community to be able to tailor treatment plans accordingly. there was one update to this made in 2018. the journal of american college of cardiology released a state-of-the-art review in 2017 called "quality and equitable health care gaps for women: attributions to sex differences in cardiovascular medicine". this discussed the quality and equity of health care received by women. in that same year, the released survey results that provided insight into the awareness within healthcare providers, and the gaps present in the research and clinical applications thus far.