Reproductive Health: Women in their middle years and beyond
The health of women during their middle and older years is beginning to be recognized as important in many countries. Women age 35 years and older are an important force in the social, cultural, and economic spheres in their community, yet their health needs often are overlooked. Furthermore, the population of older women (age 50 and beyond) is increasing everywhere, particularly in developing regions (see Table 1). As women age, their health is influenced by many factors: their living conditions, reproductive history, work and home life demands, diet, exposure to infectious and chemical agents, and availability of health care. Certain conditions—some influenced by menopause and others by aging—also affect older women's health and well-being. In many developing countries older women have limited access to health care services, which tend to focus on younger women and their children.
Although definitions vary regarding what constitutes "the middle years," this article looks at reproductive health issues affecting women between the ages of 35-55-before, during, and after menopause. Menopause is defined as the permanent cessation of menstruation, which generally occurs between the ages of 45-55 (in some women menstruation stops abruptly, in most many months of irregular bleeding precede the final menstrual period). The median age of menopause is 50-52 in industrialized countries and about one to two years younger in developing countries. Cigarette smoking is associated with earlier age at menopause. The menopausal transition—the period before menopause when hormonal and clinical changes occur—lasts about four years. Reported physical symptoms associated with the menopausal transition vary among different cultures. Specific diseases associated with the hormonal changes accompanying menopause-circulatory diseases and osteoporosis—also vary in incidence somewhat among different regions.
Much of the information presented here is summarized in a report of a World Health Organization 1994 Scientific Group meeting that updated a 1980 report, reviewed menopause research, and made recommendations for research and clinical practice. Most of the research on menopause comes from developed countries; it is important to generate more data on menopause-related health problems and intentions from developing countries.
Table 1Women Aged 50 and Older(as a percent of total population ) by Region |
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1990 |
2020 |
Total Increase1990-2020 |
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| Asia | 15% | 24% | 316 million |
| Latin America and Caribbean | 14% | 24% | 53 million |
| Africa | 10% | 12% | 49 million |
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Source : Yung, 1994 |
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THE PHYSIOLOGY OF MENOPAUSE AND RELATED SYMPTOMS
As a woman approaches menopause, the hormone levels in her body start to shift. Estrogen and progesterone levels decline sharply, stabilizing a few years after the final menstrual period. Levels of the two pituitary hormones, follicle stimulating hormone (FSH) and luteinizing hormone (LH), become variable during the menopausal transition, but increase over time.
In addition to irregular bleeding patterns and declining fertility, menopausal women may experience vasomotor symptoms (hot flushes, night sweats), urogenital problems, and psychological symptoms (see Table 2). Not all women experience or report all these symptoms. Also, some symptoms are experienced more commonly before and during menopause and others after. In a study of almost 3,000 women (aged 40-60) in seven Southeast Asian countries, complaints of vasomotor symptoms and urinary incontinence were largely associated with the menopausal transition through to the first year after menopause, while psychological symptoms largely occurred after menopause. Menopausal symptoms are usually less severe in women who experience natural menopause compared to those in whom menopause is induced by removal of their ovaries or cessation of ovarian function due to chemotherapy or radiation.
Declining estrogen levels lead to urogenital atrophy (decreased vaginal and bladder muscle tone), a thinner vaginal epithelium, and vaginal dryness, which can make intercourse painful. Urinary problems—urgency of urination, pain on urinating, and incontinence (leaking urine)—are reported to affect 25-50 percent of postmenopausal women. Pelvic floor muscles that have been damaged from repeated pregnancies further compound the problem of urinary incontinence.
HEALTH CONSEQUENCES OF MENOPAUSE
Certain health risks, including cardiovascular diseases and osteoporosis, increase after menopause.
Cardiovascular diseases. In almost all parts of the world, cardiovascular disease (CVD) is one of the most common causes of death in older women. While various environmental and genetic factors contribute to CVD (diabetes, cigarette smoking, family history of heart disease, and hypertension), data from developed countries indicate that postmenopausal women have a twofold to threefold increase in CVD compared to premenopausal women of the same age.
The risk of CVD increases after menopause due to hormonally influenced changes in blood lipid profiles. Postmenopausal women have higher cholesterol levels (including total cholesterol, very-low-density lipoprotein cholesterol, and low-density lipoprotein cholesterol) than premenopausal women. Other conditions linked to CVD also may be associated with menopause. A recent study in Argentina that assessed risk factors for CVD found that menopause was associated with psychosocial risk factors for CVD (insomnia, depression, irritability}, as well as hormonally influenced blood lipid changes.
Osteoporosis. Menopause also triggers a process of reduction in bone mass that can result in pain, disability, and increased risk of fractures (particularly hip and spine fractures in women aged 60-80). The link between osteoporosis and menopause is related to decreasing ovarian hormone levels, particularly estrogen. Lack of calcium in the diet, inadequate exposure to sunlight, and inactivity also affect bone density. Other risk factors include short stature, being underweight, alcoholism, and cigarette smoking.
Globally, osteoporosis is estimated to occur in about 10 percent of women over the age of 60. Prevalence varies by region and population. It is rare in African countries, frequent in India, and becoming more prevalent in Asian countries. Its incidence is not well documented in Latin America. Earlier age at menopause may be linked to younger age at hip fracture. Data from Pakistan (where the mean age of menopause was 47 years) found that the mean age of hip fracture in women was considerably lower than reported from other parts of the world.
OTHER COMMON REPRODUCTIVE HEALTH DISORDERS ASSOCIATED WITH AGING
Cancers. Reproductive tissue cancers (breast, ovary, endometrium, vulva, cervix ) all can be influenced over time by exposure to estrogens and progestins, whether produced by a woman's body or taken therapeutically. The two most frequent cancers among postmenopausal women are breast cancer and cervical cancer.
Breast cancer is the most common cancer among women in all developed countries (excluding Japan) and in Northern Africa, South America, and Western Asia. Since breast cancer is influenced by exposure to estrogen, risks increase with later age at first pregnancy, earlier age at menarche, and later age at menopause. Obesity in postmenopausal women also increases risk of breast cancer.
Cervical cancer is the most frequent cancer among developing country women and the second most frequent cancer in women worldwide. About 500,000 new cases of cervical cancer occur annually worldwide—80 percent
Table 2Symptoms and Consequences of Menopause |
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Vasomotor |
Urogenital |
Psychological |
Other |
Long-term Health Consequences |
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| Hot flushes | Irregular bleeding | Anxiety | Insomnia | Increased risk of heart disease | ||
| Sweating | Incontinence | Irritability | Backache | Declining bone mass | ||
|
Palpitation |
Bladder infections | Headache |
increased bone fragility |
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| Dizziness | Vaginal infections | Fluid retention | ||||
| Pain during intercourse | ||||||
of these are in developing countries. Poorer countries and poorer groups of women within countries—are at higher risk. Southern Africa and parts of Latin America have a particularly high incidence. Cervical cancer can be controlled through screening at-risk women and treating women with precancerous and cancerous lesions: cervical dysplasia precancer can be successfully treated on an outpatient basis.
Genital prolapse. Repeated pregnancies and obstetric trauma can lead to genital prolapse, a painful, debilitating condition. Genital prolapse can involve the vaginal wall or uterus descending below their normal positions. It also can involve protrusion of part of the bladder or rectum from the vagina. A study of gynecological morbidity in rural Egypt found that more than half of women surveyed were suffering from different types of genital prolapse.
Urinary and reproductive tract infections (RTIs). As women age, various factors make them more susceptible to urinary tract infections, including decreased bladder tone, incomplete voiding, gentile prolapse, and, in some cases, reduced immune function. Prolapse also can compound reproductive tract infections (vaginitis, cervicitis, PID). In the study of morbidity among women in rural Egypt, women with vaginal prolapse had three times greater risk of reproductive tract infection compared with women not suffering from prolapse. Little is known about women's relative risk of sexually transmitted disease (STD) as they age, but the vaginal changes (thin, dry, epithelium and altered pH) likely make women more susceptible to STD infection.
HEALTH INTERVENTIONS
Educational and emotional support during menopause also is important in helping women deal with symptoms and share concerns. Good health at menopause and beyond is most influenced by a woman's overall health. For example, the best way to prevent CVD is to eat an appropriate diet, get regular exercise, and abstain from smoking. To prevent osteoporosis, it is important to have an adequate diet (including sufficient calcium) throughout life, regular exercise, and to abstain from cigarette smoking and excessive alcohol use.
Health education. Health education about the importance of a proper diet and the risks of smoking is particularly important for menopausal women since they often are not aware of the possible long-term effects of menopause. Among 200 perimenopausal women in Hong Kong and Southern China, none was aware of the problem of osteoporosis or cardiovascular disease in postmenopausal women.
Techniques to reduce urogenital discomfort. Some effects of menopause and aging can be alleviated by specific strategies. For example, continuing to participate in sexual activity may protect women against vaginal atrophy; use of a vaginal lubricant can alleviate discomfort due to vaginal dryness. Regular Kegel exercises (voluntary contraction of the pelvic and uro-vaginal muscles) can help strengthen the pelvic floor and relieve some forms of incontinence and pelvic discomfort. Pessaries are an option for treating prolapse in some women. A pessary is a simple device inserted in the vagina that helps support the pelvic and vaginal muscles. Pessaries come in a variety of shapes and sizes and must be fitted by a clinician.
Appropriate screening. For some health problems associated with aging, regular health screening and appropriate interventions can help reduce morbidity and mortality. For example, routine blood pressure screening can help identify and monitor women at risk for hypertension and related CVD, so that changes in diet and exercise patterns or medication can be recommended if necessary.
CONTRACEPTION FOR WOMEN IN THE MIDDLE YEARS
Although many women have achieved their desired family size by the time they reach 30, women remain fertile until menopause. Contraception is recommended until one year after menses cease. Access to appropriate and acceptable contraception for women in their later reproductive years is important because pregnancy after age 35 carries increased health risks for both a woman and her child. A woman's choice and use of contraceptives during this period is influenced by whether she may want more children, as well as factors such as existing disease conditions (diabetes, hypertension, obesity, anemia, genital tract disorders), previous experience with contraceptives, and smoking status. For women who are experiencing menopausal symptoms, estrogen-containing hormonal methods may be good choices as they can alleviate some symptoms.
Because older women are more likely to have pre-existing, conditions, family planning programs should provide careful screening and counseling for these women when providing contraception. Table 3 provides a summary of methods and issues for women aged 35 and older. For detailed information on eligibility criteria for using contraceptives see Outlook, Volume 13, Number 4 and Volume 1, Number 1)
PROGRAM IMPLICATIONS
The population of women in their middle years and beyond is growing, especially in many developing regions. Programs that address the health needs of these women need to be strengthened. An initial step is to provide training to health care personnel on the reproductive health problems associated with menopause and aging. Strategies also should be developed to promote good health behavior in older women. Appropriate educational messages about the long-range value of proper diet and exercise, and the need to seek medical help if specific health problems or concerns arise need to be developed and disseminated. Carefully targeted programs for hypertension and cervical cancer screening also should be considered.
A key challenge will be reaching women who no longer interact with the health care system. In many settings, it may be feasible to use primary health care networks to provide basic services. Community women's organizations may be a particularly appropriate means to communicate with women about the need for and availability of services. To support all of these efforts, community health messages that present the health of middle-aged and older women as important to the whole community are critical.
Source: Outlook, Volume 14, Number 4, March 199
Table 3Contraception for women age 35 and older |
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Method |
Advantage |
Restriction on Use |
Counseling Issues |
| Sterilization |
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|
|
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Hormonal Contraception Combined OC or Injectable
Progestin-only contraception (mini-pill, injectable, NORPLANT®) |
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|
|
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lUDs Copper-releasing lUD
Hormone-releasing lUD" |
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|
|
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Barrier Methods Male or female condom
Diaphragm, spermicide |
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| Periodic abstinence |
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•For a full description of eligibility criteria for contraceptive use, see Outlook, Volume 13, Number 4 and Volume 14, Number 1. "Hormone-releasing IUDs are more expensive and less available than copper-releasing lUDs. |
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Having our Soy
by Adriane Fugh-Berman, M.D
AIthough tofu, miso, and green soybeans have been an integral part of the traditional diet in many Asian countries, soy products have been slower to catch on in the U.S.
But a flurry of scientific interest in the health benefits of soy has been generated by recent research suggesting that a high-soy diet may account for lower rates of cancer and heart disease in Asian women. (Benefits are seen in those who consume an average of 20 to 40 grams of soy protein per day.) In addition to being high in protein, calcium, and fiber, soybeans and the products derived from them contain plant estrogens, also called phytoestrogens, which may lower the risk of developing breast cancer and reduce menopausal symptoms such as hot flashes. Soy may also help lower cholesterol levels and protect against cardiovascular disease.
Chinese and Japanese women have a significantly lower incidence of, and mortality from, breast cancer than Western women, and several studies show that Asian women who eat a traditional diet have lower breast cancer rates than those who have converted to a Western diet. While there are several crucial differences in the diets—Asians eat less fat and protein and more carbohydrates than Westerners—any researchers feel that the high consumption of phytoestrogens by Asian women is the key to their lower breast cancer rates.
The health potential of soy rests on the premise that even though plant estrogens are very weak estrogens (the strongest among them is only 1/200th as strong as human estrogens), they may perform functions similar to some of our own, stronger estrogens. And they are quite versatile—much of the potential of phytoestrogens (as well as some of the confusion about them) stems from the fact that they appear to have different effects in pre- and postmenopausal women.
For premenopausal women, whose bodies generate a significant amount of estrogen, researchers think phytoestrogens have what is known as an antiestrogenic effect: they bind to the estrogen receptors in our bodies, competing for space with our own estrogens. This surplus of estrogen then seems to send a chemical message to our hormone factories to take a break. One theory is that women who eat plant estrogens every day have a constantly lower rate of production of homegrown estrogen and thus a lower risk for hormone-related cancers (higher levels of bodily estrogen have been linked to increased risk for breast cancer).
In addition, a number of animal studies suggest that phytoestrogens may attach to estrogen receptors of tumors, and actually inhibit the growth of cancer cells. Researchers at the University of Alabama at Birmingham's Department of Pharmacology and Toxicology found that baby rats exposed to a substance known to cause breast cancer had a cancer rate 40 percent lower when they also received genistein, a phytoestrogen found in soybeans.
There is yet no conclusive evidence that phytoestrogens help prevent breast cancer in postmenopausal women. Breast cancer rates rise with age, and Asian women have lower breast cancer rates at all ages than Westerners. However, one study of Chinese women in Singapore found that soy intake seemed to have a preventative effect only for premenopausal women.
In fact, in postmenopausal women, phytoestrogens are thought to have an estrogenic effect: because there is less estrogen produced during and after menopause, phytoestrogens supplement women's natural estrogen, giving our bodies a mild boost. One study showed that the vaginal cells of postmenopausal women who ate a soy-supplemented diet looked more like those of premenopausal women.
And soy may account for the fact that Asian women rarely complain of hot flashes. Researchers hypothesize that phytoestrogen intake may make the menopausal drop in estrogen an easier descent for Asian women— lowering estrogen levels enough before menopause and buoying their bodies after menopause. Westerners, on the other hand, start at a higher level and fall to a lower level. Of course, societal factors may also come into play: it's difficult to determine the importance of the fact that Asians respect age while Westerners worship youth.
Perhaps one of the most exciting breakthroughs with soy is its potential as an alternative to hormone replacement therapy (HRT). Researchers at Wake Forest University are now comparing the effects of soy versus conventional forms of HRT, in the hope that soybeans will offer the same benefits without the same risks. Soybeans appear to lower cholesterol levels and the risk for cardiovascular disease. While soybeans are proportionally high in fat, they are low in calories and do not add many fat grams to the diet, particularly if soybeans replace high-fat meats. A metaanalysis of 38 controlled trials found that heavy consumption of soy protein reduced total cholesterol by an average of 9.3 percent, lowdensity lipoprotein cholesterol by 12.9 percent, and triglycerides by 10.5 percent.
Of course, soy products are not all created equal: a recent study compared tofu, a commercial soy drink, and soy-based nutritional formulas. Tofu had 10 times the amount of phytoestrogens as the soy drink, and formula had only trace amounts of phytoestrogens (though other studies have found phytoestrogens in soy-based formulas). The way that soybeans are processed affects nutrients; for example, calcium is added to bean curd in the process of making tofu (see box).
There is now a range of soy products being produced and they are becoming increasingly available—in supermarkets instead of just in health food stores. And while the idea of eating eight ounces a day of tofu may still be a hard sell in some quarters, the health benefits may make it well worth the try.
Adriane Fugh-Berman is a scientist and board member of the National Women's Health Network.
Source: Ms., January-February 1996
Dressed to kill the link between Cancer and Bras
Imagine shopping for a bra, and finding that the small label on the back contained the words, "Warning: Wearing Bras May Cause Breast Cancer." It's ridiculous, you say. How can an article of clothing as seemingly innocuous as a bra have any relationship to disease?
Having reached cultural-icon status, bras are rarely viewed as anything less than a feminine necessity, an object of womanhood, and an anchor for fashion. They make you think about Madonna, not about mastectomy. They create cleavage, not cancer.
But as you shall learn, bras are more than objects of fashion. They transform more than appearance. For women, breasts rate as one of the most important features of their bodies. This bias is no doubt emphasized by our society's preoccupation with breasts. Styles of women's clothing, from underwear to nightgowns to bathing suits to business suits, focus on breasts and the bustline. Breasts are truly an obsession. Ironically, this obsession with breasts may be a root cause of cancer.
THE LYMPHATIC SYSTEM
The cancer connection is that bras may have an effect on the lymphatic system. The lymphatic system is part of the immune system which cleanses the body of toxins. The general course of events in the body is that the bloodstream shuttles blood to the lungs, liver, and kidneys for cleansing and rejuvenation. This cleansing of the tissues occurs constantly and is essential to maintaining the health and integrity of the body's tissues.
THE CANCER CONNECTION
If a woman wears a close-fitting garment, such as a bra, it may cause moderate but not severe constriction of the breast tissue. Signs of this could be indentations or red marks on the skin beneath the breasts, or other indications of irritation. There may not be much pain, since the tissue is getting blood and fresh oxygen. However, there would be some swelling of the tissue, although this may not be apparent in soft, fatty tissue such as that of the breast.
When you consider the lymphatic drainage of the breasts, it seems plausible that the armpit lymph nodes and the lymphatics leading to them are constricted by a bra. The drainage to the breastbone lymph nodes may also be hampered, particularly by bras that have underwires. In short, the immune system of the breast is being hampered in its job by the bra.
DRESS FOR HEALTH
Are we saying that all cancers could be caused by clothing? Of course not! Tight clothing may simply serve as a handicap to our immune system because of its effect on the lymphatic system. In combination with other noxious stimuli and events, such as toxins, stress, poor diet, and so forth, the construction of our bodies by clothing can set up a protracted process of degeneration, possibly leading to cancer.
THE CONFORMING BREAST
One excellent course of action for most women is to reduce the time the bra is worn each day. Wearing a bra for less than 12 hours daily seems to be extremely protective against breast cancer. Put on your bra as late as possible before going out, and remove it as soon as you return home.
Do not wear a bra to sleep! As suggested by the Bra and Breast Cancer Study, wearing a bra to sleep is the riskiest lifestyle behavior of all. For most women, at night is the only time that breast tissues get a much-needed rest from constriction. So take off your bra before going to sleep and, if you do wear clothes in bed, select only loose-fitting garments.
Perhaps just as important as the amount of time the bra is worn is the construction and fit of the bra. When shopping for one, keep in mind that the more a bra tries to shape your breasts, the more pressure it will apply to the breast tissue. Therefore, try to avoid bras with underwires or other stiff breastshaping components.
[Excerpts from Dressed to Kill by Sydney Ross Singer and Soma Grismaijer@ 1995 Avery Publishing]
Source: The Healthy Options News Digest, March/April 1997