This book highlights the needs and healthcare concerns of women in their midlife. Women, in their middle ages, are often overlooked by medical practitioners. From the end of childbearing to old age, approximately ages 40 to 65, their health needs are complex and changing. This is a time of challenge and opportunity when the physician and woman working collaboratively can change her health and future. Midlife healthcare is far more than hormones. Healthy behaviours such as good nutrition and exercise can be promoted that will result in lower risk and sometimes improved care of heart disease, hypertension and diabetes. Adequate screening and treatment can prevent diseases and complications. The burgeoning literature on allopathic and complementary medicine is critically evaluated and compared to established medical care. Written by 20 primary care physicians, this book will help family practitioners provide the best possible healthcare for these women.
'This book does what it says on the cover, it explores all areas of women's health not only contraception and the menopause but other health problems too.'
Source: Practice Nurse
'… an excellent source of information for those working in women' health.'
Source: Practice Nurse
'The ages from 40 to 65 are a stage in women's lives that medical literature does not often focus on. This book groups the perimenopausal years together in a way that makes clinical sense, and it covers a wide variety of the healthcare issues facing the carers these women will encounter … Keeping up to date on evidence based guidelines for cancer screening can be a daunting task. This book does a good job reviewing the current research and explaining the latest guidelines.'
Source: The British Medical Journal
'… international in its research,with studies and data from the UK and around the world … easy and enjoyable to read. It was sometimes unusual in its approach, addressing broader health issues such as exercise and nutrition in some detail.'
Source: IPM Journal
'I found this book a fascinating read; a highly evidence-based review of many issues concerning women's health, it is a resource to be values. … a superb reference book of relevance to every doctor.'
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The middle ages of women are an often forgotten time and the women are often overlooked in healthcare. Regularly, healthcare providers address only the women's hormonal needs and minimize discussion of their health and wellbeing. The opportunities for improvement for future health are immense. Women can make lifestyle changes that will profoundly affect their future health, comfort, and length of life. Treatment of hypertension and diabetes is believed to improve mortality and morbidity. Health promotion and disease prevention are possible if each woman is considered an individual and her health needs addressed personally. The medical variation in women this age is tremendous. Most women enter this age group in good health, but chronic health conditions often intrude. Changes or modifications to their healthcare, changes that are possible working collaboratively between woman and physician, will have profound effects on the way they meet their later years.
This chapter provides scientifically derived information on the proper exercise regimen for the middle-aged woman. Much research is published about the effects of exercise in older and younger women, but less information is available for middle-aged women. The chapter also addresses certain medical conditions/diseases pertaining to aging women and how exercise can function as a primary or secondary preventive tool. Available research data demonstrates that regular physical activity and exercise can improve all aspects of health, spirit, mind, and body. Exercise and physical activity can forestall the age-associated changes that can lead to dependence and disability. Regular physical activity and exercise can result in positive improvements in health and fitness. Moderate amounts of physical activity can reduce the risk of certain types of cancer, heart disease, diabetes, and obesity. The available evidence suggests strongly that physical activity and exercise can have a positive effect on morbidity and mortality.
Victoria S. Kaprielian, Department of Community and Family Medicine, Duke University Medical Center, Durham, NC, USA,
Gwendolyn Murphy, Department of Community and Family Medicine, Duke University Medical Center, Durham, NC, USA,
Cathrine Hoyo, Department of community and Family Medicine, Duke University Medical Center, Durham, NC, USA
A healthy diet is a concern of people of all ages. Two models that are useful regarding the proper balance of food types are the Food Pyramid and the New American Plate. Many patients are interested in the possibility of reducing cancer risk through diet. The relationship between diet and cancer is controversial and an area of active research. Strong evidence supports an association between obesity and increased morbidity and mortality. Recent research has linked excessive weight and body fat to a dysmetabolic syndrome, which includes diabetes, hypertension, and coronary artery disease. Eating disorders are associated most commonly with younger women-teenagers and young adults. Malnutrition is the most frequently identified determinant of severity of illness and death among cancer patients. Maintaining a balanced dietary intake helps storage of nutrients, decreases risk of infection, and accelerates healing and recovery.
The promotion of health in women during the mid-life years requires a knowledge base beyond the traditional biomedical one. This chapter focuses on the challenges and stresses confronting women in mid life in the hope of facilitating the identification of risk factors that may impair health. The interaction between self-concept and social roles (paid worker, parent, spouse or partner) is less important than might be expected but is significant for single women and women who are employed full-time. Women know which actions promote wellbeing and disease prevention. Significant changes have resulted in women arriving at mid life better educated, more assertive, and with a realistic expectation of a longer life and a greater sense of the importance of their work and personal level of achievement. Attitudes about care-giving and care-giving roles are embedded deeply in the socialized narratives of the women who provide care.
Sexuality is an important part of one's health, quality of life, and general wellbeing. Risks to sexual health can include unplanned pregnancy, the physiologic changes of transition into and through menopause and with aging, the increased probability of chronic illness and its medical and surgical treatment, abuse in any form, and sexually transmitted infections. This chapter reviews the sexual health of mid-life women, presenting results from available studies. Dihydroepiandrosterones (DHEA) was shown to be the only hormone associated positively with general well being in a study of 141 women aged 40-60. Women in this age group underestimate their risk for sexually transmitted infections, including human immunodeficiency virus (HIV), and this represents one of the more rapidly growing demographics for sexually transmitted infections and HIV. Clinicians are encouraged to raise the topic of sexual health and to assist mid-life women as they make their transitions through menopause, and with aging partners.
Mid life is a vulnerable time for women, both for the development of the problems of drinking and alcoholism, and for the manifestation of the medical consequences of long-term addiction to alcohol and tobacco. This chapter focuses mainly on alcoholism and smoking, because these are the most prevalent addictive disorders in middle-aged women and are most commonly seen and treated in family practice. Alcohol, cocaine, opiates, and nicotine dependencies co-occur. The development of addiction to alcohol and other drugs is a complex process involving many factors, including genetic, environmental, and gene-environment interactions. The principal harmful effects of heavy drinking include liver pathology, neurological complications, and cancers of the mouth, larynx, oesophagus, and breast. Alcohol dependence is treated in two stages: withdrawal and detoxification, followed by further interventions to prevent relapse. Screening for alcohol problems needs to become routine in the same way that screening for smoking is now widespread.
Gender differences in the prevalence and manifestations of depression probably result from a combination of biological, environmental, social, and other factors. Generalized anxiety disorder (GAD) is commonly comorbid with other anxiety disorders, substance abuse, and depression. Although sufferers relatively rarely seek medical advice, social anxiety is the most common anxiety disorder and the third most common psychiatric disorder in the USA. Comorbid depression, anxiety disorders, personality disorders, and substance abuse may complicate the diagnosis and management of obsessive-compulsive disorder (OCD). In addition to treating underlying medical conditions and avoiding substance abuse, the specific treatment of anxiety disorders is based on medication and psychotherapies. The principal medications used are antidepressants, benzodiazepines, and buspirone. The selective serotonin-reuptake inhibitors (SSRIs) are used widely to treat anxiety disorders, with or without comorbid depression, and have favorable side-effect profiles. Conversely, anxiety disorders often become comorbid with depression, and both conditions should be identified and managed.
Perimenopause is the time in a woman's life when she begins to experience the changes that lead to menopause. Smoking and shorter menstrual cycles can cause earlier menopause, while multigravidity and use of oral contraceptive pills are associated with later menopause. There may be additional factors, including cultural differences that influence the age of menopause. The menstrual and urogenital changes associated with perimenopause can be very distressing. Menstrual patterns are altered in many ways, including menorrhagia, menometrorrhagia, oligomenorrhea, intermenstrual bleeding, polymenorrhea, postcoital bleeding, and postmenopausal bleeding. In one small survey, 93% of women reported one of these changes in the five years prior to menopause. The challenge for the provider is to distinguish between normal and abnormal bleeding. Ultrasonography has become the standard test in the evaluation of dysfunctional uterine and postmenopausal bleeding. Hysterectomy is the only way to stop menorrhagia completely.
This chapter reviews the most common psychological features of menopause and recent research regarding anxiety, depression, and social factors. Women's religious and spiritual beliefs play an important role in their views of life and medical illness. Commonly used tools that assist in gathering spiritual and religious information from patients are the FAITH and HOPE questionnaires. The FAITH tool addresses issues of religious faith and may be more useful when the clinician is aware that the patient is religious. Spiritual counseling is full of ethical challenges, including issues of autonomy, authority, confidentiality, and coercion. Cross-cultural studies indicate that women from different cultures cope with menopause differently. Anxiety disorders should be treated with medicines indicated for that purpose, including benzodiazepines, selective serotonin-reuptake inhibitors (SSRIs), and tricyclic agents. Physicians treating patients during menopause should be alert for psychological and spiritual issues, and be familiar with treatment options, including pharmacotherapy, exercise, and counseling.
Hormone therapy (HT) is the combined use of estrogen and progestin (EPT), or estrogen alone (ET), by postmenopausal or perimenopausal women. Information and education by clinicians is beneficial to women in making their decision regarding HRT/ET. More than 30 case-control and prospective observational studies have suggested that HT provided primary prevention against coronary heart disease (CHD), secondary prevention for women with prior myocardial infarction (MI), and both primary and secondary prevention against fractures from osteoporosis. HT appears to increase the risk of stroke. Studies linking hormone replacement therapy (HRT) or ERT to ovarian cancer have been inconclusive. The US Preventive Services Task Force (USPSTF) recommends that women aged 65 years and over be screened routinely for osteoporosis. Additional health benefits from estrogen remain to be established. Effective means to minimize or eliminate risk may be instigated, including, perhaps, effectively identifying women at greater risk from HT.
The need for reliable, safe, and reversible contraception has become more evident, and the duration of their use has increased as many women opt to delay childbearing into the late third and fourth decades. Many psychosocial and economic factors will continue to affect women's contraceptive decision-making and undoubtedly will continue to influence rates of tubal sterilization. Vasectomy, like tubal sterilization, should be considered an irreversible sterilization procedure. The oral contraceptive pill is a common form of contraception in the USA. Numerous societal, biological, psychological, and legal factors must be considered when counseling women about their reproductive health. As with any physician-patient encounter, careful documentation must accompany any discussion regarding reproduction and contraceptive choices. Discussions regarding reproductive health, contraception, and sterilization must make the clear distinction between contraception and protection from sexually transmitted disease (STDs). Broad categories of assisted fertilization include hormonal assistance designed to induce ovulation and in vitro fertilization.
Cardiovascular disease (CVD) is the major cause of death in women in the USA and in the UK. The actual value of the risk factors is used to predict coronary heart disease (CHD) risk more accurately. Primary prevention should focus on the major risk factors of passive and active smoking, systolic and diastolic hypertension, elevated serum total and low-density lipoprotein (LDL) cholesterol, low high-density lipoprotein (HDL) cholesterol, diabetes, physical inactivity, and obesity. The pillars of secondary prevention are antiplatelet therapy, beta-blockers, angiotensin-converting enzyme inhibitors (ACEIs), statins, cardiac rehabilitation, a Mediterranean diet, and folic acid. Future heart attacks are prevented by the prevention of atherosclerosis or plaque formation in the coronary arteries and by the stabilization and regression of existing plaque through lifestyle modification and medication. Women must take personal preventive action to prevent CHD death and disability by working to prevent plaque formation, and promote stabilization of existing atherosclerotic disease.
There are various types of essential hypertension, as there is a variety of genetic patterns, including no patterns. The causes of hypertension include alcohol abuse, renal vascular and parenchymal disease, and certain endocrine states, including pheochromocytoma, Cushing's syndrome, and primary aldosteronism. The primary treatment of hypertension definitely starts with lifestyle changes, especially in individuals with borderline hypertension. Concomitant diseases can make high blood pressure difficult to control. Strokes are one of the most important causes of disability and the second most common cause of death worldwide. Primary prevention focuses on reducing risk factors for stroke. The six most important factors are hypertension, atrial fibrillation, history of recent myocardial infarction, diabetes, cigarette smoking, and alcohol abuse. Primary and secondary prevention of stroke by lifestyle changes, control of hypertension and diabetes, and therapeutic use of aspirin, warfarin, or angiotensin-converting enzyme inhibitors (ACEIs) will prevent further morbidity and mortality.
Osteoporosis is a major public health problem, affecting more than 40 million people, one-third of postmenopausal women, and a substantial portion of the elderly in the USA, Europe, and Japan. The risk factors for osteoporosis such as sedentary lifestyle and/or immobility, low bodyweight, cigarette smoking, and excessive alcohol consumption all influence bone mass negatively. The history and physical examination are important in screening for secondary forms of osteoporosis and directing the evaluation, although they are neither sensitive enough nor sufficient for diagnosing primary osteoporosis. The most widely used techniques of assessing bone mineral density are dual-energy X-ray absorptiometry (DEXA) and quantitative computerized tomography (CT). Treatment for osteoporosis is instituted to prevent early or continuing bone loss, with the belief that there can be an immediate impact on the patient's wellbeing and a willingness to comply with the patient's desires.
Phillippa Miranda, Department of Medicine, Division of Endocrinology and Metabolism, Duke University Medical Center, Durham, NC, USA,
Diana McNeill, Department of Medicine, Division of Endocrinology and Metabolism, Duke University Medical Center, Durham, NC, USA
The incidence and prevalence of diabetes is increasing worldwide. This chapter examines the diagnosis, prevention, and management of diabetes in mid-life women. In mid life, type 2 diabetes is the most common type of diabetes. Diagnostic criteria and classification schemes for diabetes have been proposed and published by the American Diabetes Association (ADA) and World Health Organization (WHO). Risk factors for the development of type 2 diabetes include obesity, physical inactivity, age, and family history of type 2 diabetes. Good glycemic control, through education, self-blood glucose monitoring, diet, and exercise, as well as medications, is important to minimize the increased health risks associated with diabetes. Since the complications of diabetes, including heart attack, stroke, blindness, end-stage renal disease, and lower-extremity amputation, are more prevalent with advancing age and duration of diabetes, mid-life women with diabetes must advocate for their own healthcare management.
Breast cancer has the highest incidence and the third highest death rate for cancer in women in the USA. There are several methods of screening-self-breast examination (SBE), clinical breast examination (CBE) and mammography. Multiple randomized controlled trials (RCTs) and case-control studies have shown a 20-30% reduction in mortality in women age 50-65. A meta-analysis of eight RCTs, all following women aged 40-49 years for more than 12 years, found an 18% reduction in mortality in screened women. In a meta-analysis of studies in which women older than age 65 were included, there was a non-significant reduction in mortality up to age 70. Ultrasonography, CT scanning, and magnetic resonance imaging (MRI) are being studied for their uses in delineating breast cancer and their efficacy in detecting early breast cancer. At the moment, there is no way to prevent breast cancer, although its prevention in high-risk women is under investigation.
The incidence of cervical cancer has decreased since the 1950s and stabilized in the 1980s in the USA. The rate of cervical cancer varies widely with race. The purpose of the Pap test is to detect and treat cervical intraepithelial neoplasia (CIN) and, thus, prevent invasive cancer. Case-control studies in the UK have found that cervical cancer screening by Pap test has changed the incidence of cervical cancer over the past 20 years. The frequency, initiation, and cessation of regular Pap tests are controversial. The risk factors linked with cervical cancer include infection with certain subtypes of human papilloma virus (HPV), multiple sexual partners, sexually transmitted diseases, low socioeconomic status, and smoking. Most cases of squamous cervical cancers are caused by HPV. Although the incidence decreases with age, women aged 40-65 years still need cervical cancer screening, but perhaps less often than at younger ages.
Endometrial carcinoma is one of the most common cancers in women, with an incidence of 2.6%. This chapter examines the effects of the woman's hormonal environment on the development of endometrial hyperplasia and endometrial carcinoma, additional risk factors, and preventive measures for this common malignancy. When hormonetherapy consisted of unopposed estrogen, a higher incidence of endometrial hyperplasia and carcinoma was found in women on this therapy compared with non-treated women. A systematic review of randomized controlled trials found unopposed estrogen therapy in moderate to high doses to be associated with significant increases in rates of endometrial hyperplasia. The risk of endometrial carcinoma in complex atypical hyperplasia is approximately 25%, and warrants surgical management with hysterectomy and salpingoophorectomy. The accuracy of endometrial biopsy as compared with dilation and curettage in detection of endometrial carcinoma ranges from 91 to 99.6% with sampling devices such as the Pipelle.
This chapter addresses the risk factors for ovarian cancer, known and potential prevention strategies, screening methods, early diagnosis, and specific strategies for high-risk populations. The overall lifetime risk in the general population is 1.6%. The actual risk status of women with a family history of ovarian or breast and ovarian cancer can be best determined by a complete genetic history. Genetic counseling for the patient and/or family members includes a comprehensive approach to all issues associated, including quality-of-life and ethical issues, concerns about insurance, and possible options if a diagnosis is made. Women who are known to carry BRCA1 or BRCA2 mutations should be offered a comprehensive approach, including the options of monitoring, chemoprevention, and prophylactic surgery. Preventive measures that have been offered include chemoprevention and prophylactic oophorectomy. There is good evidence that prophylactic oophorectomy reduces risk of breast cancer in women with BRCA1/2 mutations.
Colorectal cancer is the second most common cancer and the third most common cause of cancer death in women. Fecal occult blood testing (FOBT), sigmoidoscopy, colonoscopy, and a combination of these three methods are all considered valid screening methods. Screening after the age of 50 is suggested because of the prevalence of colon cancer in this age group. Between 5% and 10% of colon cancer has an inherited base, although only a few mutated genes are known. Colon cancer can be asymptomatic or may appear as iron-deficient anemia, gastrointestinal hemorrhage, change of bowel habits or constipation. The most common cause of lung cancer is smoking, which accounts for 90% of lung cancers. Surgery, radiation, and chemotherapy are the treatments, with surgery being the treatment of choice if the cancer is local. Excessive exposure to radiation, excessive tanning and burning, and fair complexion are risk factors for skin cancer.
The most common gastrointestinal (GI) complaints are constipation, diarrhea, and irritable bowel syndrome (IBS). The incidence of urinary incontinence (UI) is high. In several studies of women aged 42-50 years, more than 60% reported urine loss at some time, and more than 30% reported UI regularly. Pregnancy complications have been related positively to later UI, including loss of pelvic support, perhaps caused by multiple and large pregnancies and instrumented deliveries. Any medication with an anticholinergic effect including antispasmodics, antihistamines, antipsychotics, antidepressants, and anti-Parkinsonian drugs, can induce urinary retention and overflow incontinence. Although dysuria, polyuria, and nocturia are primarily symptoms of lower tract disease, they can also occur with upper tract infection or pyelonephritis. Indications for hospitalization and intravenous antibiotic medication include dehydration, vomiting, inability to take oral medication, and severe pain. Women with diabetes or abnormal urinary tract are more likely to need intravenous antibiotics and hospitalization.