Women's Health in Mid-Life: A Primary Care Guide

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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.

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Editorial Reviews

Doody's Review Service
Reviewer: Hemant Kumar Satpathy, MD (Saint Joseph Hospital)
Description: This excellent, concise book covers the unique health issues that women face in midlife.
Purpose: The purpose is to discuss midlife health issues of women. The objective is appropriate and the book meets the author's goal.
Audience: Although the book is meant for family practitioners, it would be useful for students and residents. The author has a good grasp of these issues.
Features: This book nicely covers women's health including the physiological changes of midlife, health problems, and cancer prevention. I am impressed with the breadth of topics covered. Looking at the table of contents, I do not think the author missed any health issue of midlife. The best part of the book is the simple language. Each chapter has abundant current references and most of the tables are appropriate and can be quickly accessed. The only constructive comment I have is that the discussions could have been little more in-depth.
Assessment: The author has addressed the health problems in an important stage of female life. There are not many books selectively addressing the women's health in midlife. This book will interest primary care doctors treating women.
From the Publisher
"The author has addressed the health problems in an important stage of female life. There are not many books selectively addressing the women's health in midlife. This book will interest primary care doctors treating women." Doody's Review ServiceG

"Keeping up to date on evidence based guidelines for cancer screening can be a daunting task. This book does a good job of reviewing the current research and explaining the latest guidelines." Linda Rogers, Johns Hopkins University, British Medical Journal

"This book was easy and enjoyable to read." Institute of Psychosexual Medicine Journal, Rachel Whitby, and Steve Adams

3 Stars from Doody
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Product Details

  • ISBN-13: 9780521823401
  • Publisher: Cambridge University Press
  • Publication date: 3/28/2004
  • Edition description: New Edition
  • Pages: 374
  • Product dimensions: 5.98 (w) x 8.98 (h) x 0.83 (d)

Read an Excerpt

Cambridge University Press
0521823404 - Women's Health in Mid-Life - A Primary Care Guide - Edited by Jo Ann Rosenfeld



Jo Ann Rosenfeld

The middle ages of women are an often forgotten time and the women are often overlooked in healthcare. No longer in their childbearing and birth control years, and not yet geriatric, the women are frequently ignored or their needs and wishes combined into one homogeneous group. Regularly, healthcare providers address onlythe women's hormonal needs and minimize discussion of their health and wellbeing. These women, who are from the ages of 40 to 65, are in a variety of situations and circumstances, both medical and social. These ages are a time of change, stress, and opportunity.

Despite the fact that there are more women than men at every age, this time of change is poorly studied and understood for women (Figure 1.1). Many large population studies have not included women, have included only a few women, or have not reported data by gender. Few studies have examined this age group. The change to adolescence, adulthood, and elder has been well examined and researched. Each of these ages has their own specialists (obstetrician/gynecologist or geriatrician). However, the middle ages are often neglected. Menopause is not a disease, a definite time, or a curse. Its needs, challenges, and effects on women's health are not understood well. Familial and social stresses may be challenging or overpowering, as the woman has to redefine herself within society, employment, and her family.

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. Quitting smoking, improving exercise regimens, and achieving ideal body weight can improve the rest of a woman's life. Treatment of hypertension and diabetes is believed to improve mortality and morbidity. Screening for cancer may improve mortality. Health promotion and disease prevention are possible if each woman is considered an individual and her health needs addressed personally.

The social variations and changes in this age group are immense. The woman can be a new mother, a mother of small children or adolescents, childless, a grandmother living with her husband or family, a widow alone, or a

Figure 1.1 Population by age and gender, from US Census 2000.

Figure 1.2 Percentage increase in families headed by grandmothers/grandparents 1990-1997. (From Casper, L. M. and Bryson, K. R. Co-resident grandparents and their grandchildren: grandparent maintained families. Population Division, US Bureau of the Census, Washington, DC, March 1998. Accessed April 13, 2003.)

grandmother raising small grandchildren. Twenty five million women aged 15-44 in the USA are childless.1 Approximately 19% of women age 40-44 were childless in 1994 in the USA, almost double the number in 1970.2

They can be single, married, divorced, or widowed. The traditional depiction of the aging mother or grandmother with "empty nest" concerns may not be valid. The number of never-married women aged 39 almost tripled from 1970 to 1994, from 5 to 13%.1 The woman may have husband, mother, grown children, or their children living with her. Women are more likely to be living alone than men. Approximately 14% of women live alone, and this number has doubled from 1970 to 1994.1 In the past decade, the number of grandmother-headed families has increased tremendously, and those grandparent- or grandmother-headed families are more likely to be in poverty or receiving public assistance (Figures 1.2 and 1.3).3

Figure 1.3 Percentage of households with children headed by different groups. (From Casper, L. M. and Bryson, K. R. Co-resident grandparents and their grandchildren: grandparent maintained families. Population Division, US Bureau of the Census, Washington, DC, March 1998. Accessed April 13, 2003.)

Figure 1.4 Percentage of women, by age, who are uninsured.

Approximately 25% of women of this age are carers of their parents or their spouses' parents. Most of these women are in the workforce as well, at the midpoint or highpoint of their careers. Approximately 57% of all women are in the workforce.1 They may be secure financially, or recently downsized, fired, widowed, or divorced, or without work or insurance. Approximately 12-15% of US women of this age are medically uninsured (Figure 1.4). They may be comfortable at work or fighting a new boss.

The medical variation in women this age is tremendous. Most women enter this age group in good health, but chronic health conditions often intrude. These women are more likely to be disabled and have disabling arthritis and diabetes.4 Women are more likely than men to die of heart disease and stroke, but are less likely to die from cancer and lung disease (the latter is due to the greater history of smoking in men and may change over the coming years).2 The reaction and changes women make to these diseases, illnesses, and disabilities will profoundly affect how their lives progress over the last third of their years.

These women must not be viewed either as "finished" or unimportant simply because they are finished with childbearing and/or approaching menopause, nor must they be considered pre-elderly. They have their own needs and challenges. 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.


  1. Women in the United States: a profile. US Department of Commerce, Economics and Statistics Administration. Bureau of the Census. Washington, DC. 1995. Accessed April 21, 2003.

  2. Record share of new mothers in labor force. Department of Commerce, Economics and Statistics Administration. Bureau of the Census. Washington, DC. October 24, 2000. Accessed March 1, 2003.

  3. Casper, L. M. and Bryson, K. R. Co-resident grandparents and their grandchildren: grandparent maintained families. Population Division. US Bureau of the Census. Washington, DC. March 1998. Accessed April 13, 2003.

  4. Highlights of Women's Earnings in 2000 (report 952). US Department of Labor, Bureau of Labor Statistics. August 2001. Accessed April 10, 2003.

Part I

Health Promotion


Physical activity and exercise

Tanya A. Miszko, Ed. D., C. S. C. S


For our ancestors, physical activity was ingrained in daily life. In the early 1900s, before automobiles were invented and mass-produced, walking was a common mode of transportation. Today, automobiles are used for leisurely one-mile drives to the local video store or half-mile treks to the grocery store. Improved technology has reduced our physical activity level by making life "easier."

This "easier" way of life has added to increases in cardiovascular disease, hypertension, high cholesterol, osteoporosis, obesity, and diabetes mellitus. In 1999, cardiovascular disease was the leading cause of death for women in the USA. The American Heart Association states that one in five women has some form of blood vessel or heart disease, 5.7 million women have physician-diagnosed diabetes mellitus, and almost half (46.8%) of non-Hispanic white women are overweight; 23.2% are obese. Genetics cannot be ruled out as a contributing factor to these chronic conditions, but it must also not be an excuse.

In addition to increased morbidity, physical inactivity also has an effect on the economy, amounting to $24 billion of US healthcare expenditures.1 The yearly cost of medical care for a physically active individual is approximately $330 less than that for an inactive person. Furthermore, if inactive people became active, $76.6 billion in year-2000 dollars would have been saved in direct medical costs.1 Intuitively, these data would be an alarming incentive for health insurance companies to embrace interventions that focus on the prevention of disease; however, that medical paradigm is not yet emphasized. Because medical costs increase around age 45-54 for inactive women, this is a perfect time for women to take charge of their physical, as well as financial, health.1

During a woman's middle-aged years, many physiological changes occur, some of which are modifiable. The risk of cardiovascular disease increases. Regular physical activity can reduce the risk of premature death from coronary artery disease, colon cancer, hypertension, and diabetes mellitus.2 However, more than 60% of adult Americans are not regularly physically active, 25% of adult Americans are not active at all, and women continue to be less active than men.2 The World Health Organization states that "age 50 marks a point in middle age at which the benefits of regular physical activity can be most relevant in avoiding, minimizing, and/or reversing many of the physical, psychological, and social hazards which often accompany advancing age."3 Middle age is an opportune time for the middle-aged woman to make lifestyle changes and take charge of her life.

This chapter will provide scientifically derived information on the proper exercise regimen for the middle-aged woman. Much research is published about the effects of exercise in older (>60 years) and younger (18-25 years) women, but less information is available for middle-aged women (45-60 years). This may be due partially to the plethora of physiological changes that are occurring during those years, especially the changes in the hormonal milieu. This chapter will also briefly address certain medical conditions/diseases pertaining to aging women and how exercise can function as a primary or secondary preventive tool. Available research data will demonstrate that regular physical activity and exercise can improve all aspects of health, spirit, mind, and body.

Benefits of exercise

Case: Hattie is a 55-year-old first-grade teacher. She has had diet-controlled type Ⅱ diabetes for two years, although her last hemoglobin A1C was 7.8% and her morning fasting blood sugars are running 150-180 mg/dl. She weighs 83 kg. At her regular follow-up, you discuss the effects of exercise and the possibility that it might reduce her sugars and her weight. She shrugs, saying that she is on her feet all day and that should be enough exercise.

A distinction must be made between physical activity and exercise. Physical activity refers to any bodily movement produced by skeletal muscles and that results in energy expenditure, such as mowing the lawn, grocery shopping, and doing household chores.4 Exercise, on the other hand, is physical activity with the purpose of improving some component(s) of fitness (muscle strength and endurance, cardiorespiratory endurance, body composition, flexibility), such as regular participation in an endurance-training or strength-training program at an intensity that will confer physiological and performance benefits.2

Exercise and physical activity can improve most aspects of mental and physical health.3,5-7 The benefits derived, however, are specific to the type of exercise performed (Table 2.1).

Table 2.1 Benefits of exercise

Resistance training Endurance training Yoga T'ai chi

Increases muscle strength Increases aerobic capacity Increases muscular strength and endurance Reduces fall rate
Increases type Ⅱ fiber area Reduces blood pressure Increases flexibility Decreases depression
Increases muscle cross- sectional area Increases bone mineral density Increases aerobic capacity Increased positive affect
Increases or preserves bone mineral density Reduces anxiety (state and trait) Reduces fatigue in cancer patients

Regular physical activity

Moderate levels of physical activity have significant effects on a woman's health. Burning approximately 150 kilocalories per day or 1000 kilocalories per week leads to a reduction in the risk of coronary heart disease by 50% and of hypertension, diabetes, and colon cancer by 30%.2 After adjusting for covariates such as age, smoking, alcohol use, history of hypertension, and history of high cholesterol, women who are regularly physically active are 50% less likely to develop type Ⅱ diabetes (relative risk = 0.54) than women who are not regularly active.8 Vasomotor and psychosomatic symptoms associated with menopause are also reduced with moderate amounts of activity.6,9 Examples of moderate levels of physical activity are depicted in Table 2.2.

Regular physical activity can also reduce the risk of colon cancer, the third leading cause of cancer incidence and mortality in the USA. The risk of colon cancer is reduced by 40-50% in highly active people compared with low active individuals.10 The mechanisms responsible for a reduction in the risk of colon cancer are:

  • reduced transit time in the bowel, which decreases exposure to carcinogens;

  • reduction in insulin action, which decreases colon mucosal cells;

  • increase in prostaglandin F2α, which increases intestinal motility;

  • reduction in prostaglandin E2, which increases colon cell proliferation.

The evidence for exercise providing a reduction in the risk of breast cancer, however, is equivocal. In a cohort of 37 105 women who exercised regularly, there was a lower risk of breast cancer compared with those who did not exercise.11 The Nurses' Health Study suggests that the risk of breast cancer is reduced modestly in physically active women (relative risk = 0.82).12 Decreased body fat and estrogen levels may be responsible for the reduction in

Table 2.2 Examples of moderate levels of physical activity

Washing a car for 45-60 minutes Less vigorous, more time
Playing volleyball for 45 minutes
Gardening for 30-45 minutes
Wheeling oneself in wheelchair for 30-40 minutes
Walking 1.75 miles in 35 minutes (20-min mile pace)
Basketball (shooting baskets) for 30 minutes
Bicycling five miles in 30 minutes
Pushing a stroller 1.5 miles in 30 minutes
Raking leaves for 30 minutes
Walking two miles in 30 minutes (15-min mile pace)
Dancing fast (social) for 30 minutes
Water aerobics for 30 minutes
Bicycling four miles in 15 minutes
Jumping rope for 15 minutes
Shoveling snow for 15 minutes
Walking stairs for 15 minutes More vigorous, less time

Sources: US Department of Health and Human Services. Physical activity and health: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention; 1996.

breast cancer risk associated with exercise.13 More research is needed in this area to substantiate exercise's protective effect against breast cancer.

Small increases in physical activity level and subsequently energy expenditure have a positive effect on psychological outcomes and physiological parameters in middle-aged women. Women who increase their level of physical activity by at least 300 kilocalories per week have a smaller reduction in high-density lipoprotein (HDL) cholesterol with advancing age and are less depressed and stressed than those women who remain at their current activity level.14 Women who are physically active have higher resting metabolic rates and lower body fat, but similar fat-free mass, body mass index, and body weight compared with their sedentary counterparts.15 These results suggest that physical activity is a component of a healthy lifestyle.

Resistance training

Although resistance training has been proven to alter positively some of the modifiable risk factors for disease (obesity, hypertension, low bone mass, etc.), fewer than 16% of the US population between the ages of 18 and 64 years participate regularly in a resistance-training program.16 Women who participate in a resistance-training program increase muscle strength and power, alter muscle ultrastructure (type Ⅱ fiber area), increase or preserve bone mineral density, and improve cardiovascular risk factors for disease.17,18

© Cambridge University Press
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Table of Contents

List of contributors; 1. Introduction Jo Ann Rosenfeld; Part I. Health Promotion: 2. Physical activity and exercise Tanya A. Miszko; 3. Nutrition Victoria S. Kaprielian, Gwendolyn Murphy and Cathrine Hoyo; 4. Psychosocial health promotion of mid-life women Cathy Morrow; 5. Sexual health Margaret R. H. Nusbaum; 6. Alcoholism, nicotine dependence and drug abuse Mary-Anne Enoch; 7. Depression and anxiety Anne Walling; Part II. Hormonal Changes: 8. Physical changes in menopause and perimenopause Margaret Gradison; 9. Spiritual and psychological aspects of menopause. Melissa H. Hunter and Dana E. King; 10. Hormone therapy Kathy Andolsek; 11. Contraception and fertility Tracey D. Conti; Part III. Disease Prevention: 12. Prevention of coronary heart disease in women Valerie K. Ulstad; 13. Hypertension and stroke Jo Ann Rosenfeld; 14. Diagnosis and treatment of osteoporosis Jeannette E. South-Paul; 15. Diabetes in mid-life women Phillippa Miranda and Diana McNeill; Part IV. Cancer Prevention: 16. Breast cancer: screening and prevention Jo Ann Rosenfeld; 17. Cervical cancer: prevention, screening, and early detection Jo Ann Rosenfeld; 18. Endometrial cancer: prevention, screening, and early detection Ellen Sakornbut; 19. Ovarian cancer: prevention, screening, and early detection Jo Ann Rosenfeld; 20. Colon, lung, and skin cancer: screening and prevention Jo Ann Rosenfeld; 21. Common gastrointestinal and urinary problems Jo Ann Rosenfeld; Index.

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