Table Of ContentA HARVARD MEDICAL SCHOOL
SPECIAL HEALTH REPORT
A guide to
Women’s Health
:
Fifty and Forward
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WOMEN’S HEALTH: FIFTY AND FORWARD Contents
SPECIAL HEALTH REPORT
Medical Editor Taking stock of your health at midlife . . . . . . . . . . . . . . . . . . 2
Hope Ricciotti, MD
What you can’t control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Associate Professor of Obstetrics,
Gynecology, and Reproductive Biology, What you can control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Harvard Medical School,
Beth Israel Deaconess Medical Center
Understanding your health risks . . . . . . . . . . . . . . . . . . . . . . 3
Executive Editor
Cardiovascular disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Anne Underwood
Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Writer
Beverly Merz Lung cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Copy Editor Chronic obstructive pulmonary disease . . . . . . . . . . . . . . . . . . . 11
Robin Netherton
Alzheimer’s disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Creative Director
Accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Judi Crouse
Breast cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Production/Design Manager
Lori Wendin Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Illustrators Influenza and pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Scott Leighton, George Middleton
Colorectal cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Published by Harvard Medical School
Ovarian cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Gregory D. Curfman, MD, Editor in Chief
Urmila R. Parlikar, Senior Content Editor
SPECIAL SECTION
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Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
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The goal of materials provided by Harvard Health Publications
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This report is not intended as a substitute for personal medical
advice, which should be obtained directly from a physician. Cover Image: © Mike Watson Images | Thinkstock
Dear Reader,
You’ve been making health decisions all your life. You probably make the everyday choices—
what to eat, when to exercise, and how long to sleep—almost instinctively. You’ve also en-
countered occasional medical decisions, like which screening tests to have, which pills to take
to prevent illness, or which procedures to undergo to feel better.
At midlife, however, medical decisions are changing and coming more frequently—when to
have mammograms, colonoscopies, or bone density tests, for example. You may be trying to
decide whether to have bunion surgery or a knee replacement. Or you may be puzzling over
the best way to manage your arthritis or irritable bowel syndrome. You know these decisions
are important. They can mean identifying and treating a disease while a cure is still possible,
or minimizing troublesome symptoms, reducing pain, and preserving mobility.
Yet the lifestyle choices you make can also have an enormous impact on your overall health.
Women’s health studies have shown that it’s never too late to feel better by living better. For
example, following a plant-based eating plan may reduce your risks for a number of problems,
including heart attack, stroke, diabetes, and Alzheimer’s disease. Women who exercise regu-
larly are less likely to feel depressed and anxious and less likely to develop a host of chronic
debilitating conditions. And did you know that getting sufficient sleep—from seven to nine
hours a night—will not only boost your energy, but also help you lose weight and keep it off?
One thing that always strikes me in dealing with my patients is that women are not just dif-
ferent from men physiologically and emotionally, but different from one another as well—in
their genetic endowment as much as their life experiences. And each woman ages differently,
too. As a result, your individual health concerns aren’t likely to be the same as they were 30
years ago, nor are they likely to be identical to those of your friends.
This report is about health, not disease. Its goal is not to serve as an exhaustive compendium
of treatments, but rather to help you determine the conditions for which you are at greatest
risk and do your best to avoid them. It will also help you better manage chronic conditions
that may erode your quality of life and develop strategies for maintaining an active, produc-
tive life going forward. It is designed to give you the information to make choices today that
will ensure you the best health possible tomorrow.
Sincerely
Hope Ricciotti, M.D.
Medical Editor
Harvard Health Publications | Harvard Medical School | 10 Shattuck Street, Second Floor | Boston, MA 02115
Taking stock of your health at midlife
M
idlife can be a woman’s halftime celebration. changes occur at different rates throughout the body
Not only is it an opportunity to reflect on and and from person to person.
rejoice in the life you’ve lived, but it is also a good Family medical history. If an immediate family
time to plan your strategy for the future. member—a parent or sibling—developed a prob-
If you’re like most women, menopause is likely lem such as heart disease or cancer, especially if it
to give you a new perspective on life and health. Pre- occurred early in life, it could mean that you are at
menstrual syndrome, menstrual discomforts, and risk as well. Shared genes explain some of this risk,
reproductive issues are no longer a concern. Hot but so do shared lifestyles, such as the food you eat
flashes and other perimenopausal symptoms are and how active you are.
gradually disappearing. As you move into the sixth
decade of life, you may be feeling the burst of energy
What you can control
and optimism that anthropologist Margaret Mead
famously termed “postmenopausal zest.” It may surprise you to know that what you can control
In the following decades, your health focus will often affects your health much more than the factors
continue to shift. Initially, you are likely to be most you can’t change. For all the media coverage of genetic
concerned with preventing or managing the con- discoveries, for example, it turns out that many genes
ditions that become more prevalent as estrogen are responsive to lifestyle changes such as improve-
declines—for example, osteoporosis, heart disease, ments in diet and exercise. With healthful lifestyle
sexual dysfunction, skin changes, and bladder control. changes, disease-promoting genes become less active,
Once you have reached your eighth or ninth decade, while those that protect you become more active. Here
you may be more focused on staying strong enough to are just a few such factors to consider.
live independently, pursue the hobbies that give you Whether you smoke. Roughly one in five Ameri-
pleasure, and enjoy your family and friends. can women smokes. If you are one of them, kicking
Every step of the way, the choices you make can the habit may be the single most important thing you
have a real impact on your health. So how do you start can do to improve your health, simultaneously reduc-
planning for a healthy future? First, acknowledge what ing your risks of heart disease, stroke, and various
you can’t control. Then put your energies into chang- cancers.
ing what you can change—for the better. What you eat. Consuming a healthy diet on a
regular basis is one of the best ways to help prevent—
and manage—heart disease, high blood pressure, and
What you can’t control
type 2 diabetes. Doing so can even reduce your risk of
Even though you can’t change the following factors, dementia.
knowing your risks can help you plan for the future. How much you move. Get active, live longer. Not
Age. As people grow older, their bodies undergo only that, but live better. Study after study has linked
gradual physical changes that are normal and inevi- greater amounts of physical activity to improved
table. Such changes begin with random genetic mis- health.
takes that occur as cells divide and DNA is improperly Intrigued? Turn to the next chapter and start eval-
copied. Over time the cellular damage accumulates, uating your own health portfolio, so that you can start
affecting every tissue and organ of the body. These making wise investments in your health.
2 Women’s Health: Fifty and Forward www.health.harvard.edu
Understanding your health risks
I
f you are in midlife or later, you may have already tal forces, and lifestyle choices. Death statistics from
experienced some signs of aging: your joints may the CDC illustrate how the leading killers of women
ache occasionally, you may not recall names as eas- change with age (see Table 1, below).
ily as you once did, and you may not sleep as well This chapter will give you an idea of the factors
as you used to. Many of the chronic conditions that likely to put you at greatest risk for a variety of condi-
begin to plague women in midlife are due, in part, to tions in the years to come. Any measures you can take
declining levels of estrogen, which helps to maintain to protect yourself specifically against a given disease
tissues in the body’s reproductive organs as well as in are discussed in each section. Fortunately, many mea-
the breasts, brain, bones, bladder, and cardiovascu- sures reduce risks across the board; the Special Sec-
lar system. Genetic makeup is also complicit, as are tion of this report—“10 steps to a longer and healthier
the cumulative effects of normal aging, environmen- life,” beginning on page 20—is devoted to them.
Table 1: Leading causes of death in women by age, 2013
This chart shows the top 10 causes of death (expressed as a percentage of total deaths) in women at different ages. You can see how the
risk of the three leading killers for all ages combined—heart disease, cancer, and chronic lung diseases—changes with age by following
the red, yellow, and pink boxes. Chronic lung diseases include asthma and chronic obstructive pulmonary disease (COPD), which itself
encompasses two diseases—chronic bronchitis and emphysema. Septicemia refers to blood infections.
AGE 45–54 55–64 65–74 75–84 85+
Cancer Cancer Cancer Cancer Heart disease
1
33% 38% 36% 23% 29%
Heart disease Heart disease Heart disease Heart disease Cancer
2
15% 17% 18% 22% 10%
Accidents Chronic lung diseases Chronic lung diseases Chronic lung diseases Alzheimer’s disease
3
10% 6% 9% 8% 8%
Chronic liver disease Accidents Stroke Stroke Stroke
4
4% 4% 4% 7% 7%
Chronic lung diseases Diabetes Diabetes Alzheimer’s disease Chronic lung diseases
5
K 4% 4% 4% 5% 5%
N
A
R Stroke Stroke Kidney disease Diabetes Influenza and
6
3% 4% 2% 3% pneumonia 3%
Diabetes Chronic liver disease Accidents Influenza and Accidents
7
3% 3% 2% pneumonia 2% 2%
Suicide Septicemia Septicemia Accidents Diabetes
8
3% 2% 2% 2% 2%
Septicemia Kidney disease Influenza and Kidney disease Hypertension
9
2% 2% pneumonia 2% 2% 2%
Influenza and Influenza and Alzheimer’s disease Septicemia Kidney disease
10
pneumonia 1% pneumonia 2% 1.3% 2% 2%
Source: CDC.
www.health.harvard.edu Women’s Health: Fifty and Forward 3
Cardiovascular disease
more common in women, especially younger women
Cardiovascular disease is the leading cause of death in (average age 49).
women, killing more women in the United States than In microvascular disease, the problem begins
all types of cancer combined— 290,000 a year for heart not in the major coronary arteries, but in the smaller
disease versus 277,000 for cancer. But heart disease arteries that branch off those larger vessels. Instead of
encroaches more stealthily in women than it does in developing plaques that burrow into the vessel wall or
men, with symptoms beginning about a decade later. jut into the open passage through which blood flows,
And it doesn’t always manifest itself the same way as the smaller vessels suffer from inflammation that nar-
it does in men. rows and stiffens them (see Figure 1, below). They
As the name implies, cardiovascular disease can’t dilate to increase blood flow in response to the
affects the vessels that wrap around the heart, bring- body’s demands, so the heart doesn’t get all the blood
ing oxygenated blood to the heart muscle itself. This it needs. Moreover, damage to the inner walls of these
includes the major coronary arteries, which lie on the small vessels can lead to spasms that further reduce
surface of the heart, and a web of ever-smaller vessels blood flow to the heart, causing symptoms such as
that branch from the coronary arteries to saturate the fatigue, diffuse chest discomfort, shortness of breath,
heart tissue with blood. and sometimes heart attacks.
Trouble begins when excess cholesterol—carried Unfortunately, there are no good tests for detect-
through the bloodstream in protein-coated particles ing microvascular disease, since the standard tests
known as LDL, or “bad” cholesterol—builds up in were designed for detecting problems in large vessels.
artery walls. In a perfect world, you would have suf- People with symptoms such as chest pain first undergo
ficient HDL, or “good” cholesterol particles, to sop noninvasive stress tests to determine whether the heart
up the excess and carry it to the liver for disposal. But is getting enough blood as oxygen demands increase.
many women do not have enough HDL. The immune
system sees the cholesterol that remains in vessel walls
Figure 1: Causes of ischemic heart disease
as an invader and launches an inflammatory attack.
White blood cells gobble up the cholesterol, becom-
Coronary artery disease
ing engorged with fat and mired in the vessel walls,
where many of them die, spilling their contents. In Open artery
an attempt to isolate the damage, the immune system
then encases the area in a fibrous coat, forming ath-
Plaque buildup
erosclerotic plaque. But because the cholesterol hasn’t
been eliminated, the inflammatory process persists.
According to the classic model of cardiovascular Hardened artery
disease, this plaque can reduce blood flow to the heart,
causing chest pain (angina). It can also lead to heart Microvascular disease
attacks in one of two ways. Plaque can build up inside Open microvessel
a coronary artery until it blocks blood flow completely,
Constricted
starving the heart muscle of oxygen and nutrients. Or,
microvessel
more frequently, unstable plaque can rupture under
pressure. A blood clot then forms over the ruptured
Ischemic heart disease is reduced blood flow to the heart.
plaque, and it’s the clot that blocks the artery.
According to the classic model of the disease, trouble begins
However, it turns out that there is a third way to
when plaque builds up inside a coronary artery, which eventually
develop cardiovascular disease and heart attacks. It thickens and hardens, obstructing blood flow. The newer view of
involves a condition known as coronary microvas- ischemic heart disease suggests that the tiny vessels feeding the
cular disease—and while this can affect men, it is heart can also become stiff and narrow, reducing blood flow.
4 Women’s Health: Fifty and Forward www.health.harvard.edu
If these tests indicate reduced blood flow to the heart,
Heart hint
the next step is coronary angiography—an x-ray that
shows where the vessel is blocked and the size of the Statins are drugs that work by altering the metabolism
obstruction. Once pinpointed, the blockage may be of cholesterol. They lower “bad” LDL and triglycerides
and nudge up “good” HDL. The benefits of statins seem
flattened during coronary angioplasty or bypassed
to outweigh the risks (primarily of muscle pain and liver
with a vessel graft. However, as many as 30% of women
damage) for women with heart disease, but haven’t
with angina have “clear” angiograms. In addition to been shown to decrease the risk of a fatal heart attack in
performing these tests, then, your doctor will place a healthy women.
lot of weight on your family history of heart disease, However, 2013 guidelines issued by the American Col-
other medical problems you may have (such as over- lege of Cardiology (ACC) and American Heart Association
(AHA) recommend considering a statin if your risk of a
weight or diabetes) that can contribute to heart disease,
heart attack or stroke is at least 7.5% in the next decade.
and a detailed analysis of your symptoms.
If you’re at increased risk for heart disease and can’t get
Prevention of microvascular disease involves the your LDL cholesterol down to acceptable levels, discuss
same basic measures that you would take to prevent the matter with your doctor. If you’re on the fence, a
classic heart disease. high-sensitivity test for CRP—an indicator of inflamma-
tion—may help you decide.
Risk factors
Many factors interact to increase your risk of develop-
ing heart disease (see “Calculating your risk,” below, to coronary artery disease before age 65 or a father or
estimate your own risk). brother who developed it before age 55. While your
Age. After 55, a woman’s chance of having a heart heritage doesn’t necessarily consign you to heart dis-
attack begins to rise steadily. Not coincidentally, by ease, it should serve as a signal to be alert for symp-
that time, most women have gone through meno- toms and to keep other risk factors under control.
pause, and the protective effects of estrogen—raising Ethnicity. African Americans, Mexican Ameri-
HDL and lowering LDL cholesterol levels—are dis- cans, Native Americans, and native Hawaiians are
appearing. Postmenopausal women are two to three all more likely than people of European descent to
times as likely to develop heart disease as women the develop heart disease. Researchers are still trying to
same age who are still menstruating. determine how much of the risk stems from genetics
Family history. You have a strong genetic risk if and how much from cultural practices.
you have a mother or sister who was diagnosed with Smoking. Smoking is the leading preventable
Calculating your risk
Three different calculators are available online to help you estimate your risk of a heart attack in the next 10 years.
The Framingham The Reynolds Risk Score, based The ACC/AHA Heart Risk Calcula-
Risk Calculator has been on data from the Women’s Health tor is based on the 2013 guidelines
developed and modified over the Study, was created to better predict developed by the American College
years based on data from partici- risk in women. It requires the results of Cardiology and the American
pants in the Framingham Heart of a high-sensitivity blood test for Heart Association for assessing heart
Study. You can find it online at C-reactive protein (hsCRP test; see disease risk. Its principal purpose is to
http://cvdrisk.nhlbi.nih.gov. “Inflammation,” page 7). The help determine whether an individual
Reynolds calculator is available at might benefit from taking a statin.
www.reynoldsriskscore.org. It is at www.cvriskcalculator.com.
The three ask for slightly different information and may yield different results. However, they can give you a general idea of
whether you should review your risk factors with your doctor.
www.health.harvard.edu Women’s Health: Fifty and Forward 5
mal, those 100 to 129 as near to above optimal, 130 to
159 as borderline high, 160 to 189 as high, and greater
than 190 as very high.
By contrast, the more HDL in your bloodstream,
the lower your chances of having a heart attack. Find-
ings from the Framingham Heart Study (a long-run-
ning landmark study of factors contributing to heart
disease) and elsewhere suggest that every one-point
rise in HDL lowers the risk for heart attack 2% to 3%.
The NCEP guidelines consider levels of 60 mg/dL or
above as protective against heart disease, while levels
below 40 mg/dL increase your risk. nkstock
hi
presHsuigreh bdlaomodag perse tshseu rcee l(lhsy lpinerintegn asriotenr)i.e Hs,i gphr obmlopotd- Stockbyte | T
ing the immune system to mount an inflammatory ©
The higher your HDL, or “good” cholesterol, the lower your response that contributes to the development of ath-
chances of having a heart attack. Research suggests that
erosclerotic plaques. These plaques cause the arteries
every one-point rise in HDL lowers the risk by 2% to 3%.
to stiffen, which drives up blood pressure even more,
setting up a vicious circle. If these plaques enlarge,
cause of death in the United States, and one in three rupture, or break off, they can also lead directly to
smoking-related deaths is from cardiovascular dis- heart attacks and strokes. The chance of developing
ease. Even nonsmokers increase their heart disease complications increases with higher levels of blood
risk by 25% to 30% when they live with smokers. That pressure.
said, the damage is reversible. Within a year of quit- Your blood pressure reading has two parts. The
ting, former smokers have slashed their risk in half. first and higher number (systolic blood pressure)
Fifteen years out, they have erased almost all of it. represents the pressure while the heart is beating
Diabetes. An adult diagnosed with diabetes and shows how hard the heart works to push blood
has the same high cardiac risk as someone who has through the arteries. The second and lower number
already had a heart attack. At least 65% of people with (diastolic blood pressure), which represents the pres-
diabetes will die from some type of cardiovascular dis- sure when the heart is relaxing and refilling with blood
ease—a death rate that is two to four times that of the between beats, shows how forcefully arteries are being
general population. Diabetes can also cause chronic stretched most of the time.
kidney disease, which in turn can increase the risk of The Joint National Committee on Prevention,
cardiovascular disease even more. That’s because dam- Detection, Evaluation, and Treatment of High Blood
age to the kidneys’ filtering capacity allows substances Pressure defines normal blood pressure as below
like renin (which increases blood pressure) to build up 120/80 millimeters of mercury (mm Hg), prehyper-
in the bloodstream, harming blood vessels. tension as 120–139/80–89, hypertension stage 1 as
Unfavorable cholesterol profile. The more LDL 140–159/90–99, and hypertension stage 2 as 160/100
in your bloodstream, the greater your heart risk. The or greater. If your systolic and diastolic pressures fall
National Cholesterol Education Program (NCEP), a into two different categories—if, for example, your
division of the National Heart, Lung, and Blood Insti- pressure is 130/75—your degree of hypertension will
tute of the National Institutes of Health (NIH), has be based on the higher category.
been evaluating the evolving medical evidence on The results of the Systolic Blood Pressure Inter-
cholesterol for several decades. It categorizes LDL lev- vention Trial (SPRINT), reported in November 2015,
els below 100 milligrams per deciliter (mg/dL) as opti- may change recommendations for treating high blood
6 Women’s Health: Fifty and Forward www.health.harvard.edu
The reduction in cardiovascular events was only 16%
Where’s the salt?
for women of all ages, compared with 28% for all men.
To keep your blood pressure in check, it may help to cut Before the SPRINT results came out, doctors had
back on your salt intake. The 2015–2020 Dietary Guide-
begun to question the wisdom of strict blood pressure
lines for Americans recommend limiting sodium to 2,300
goals in older adults. As blood vessels stiffen with age,
milligrams (mg) per day for the general population, and
suggest that people 51 and older should consume even slightly higher blood pressure values might be needed
less—1,500 mg. That’s less than half the amount the aver- to keep plenty of blood flowing to the brain and heart,
age American consumes. If you’re looking to scale back on they thought. However, the study results indicate
salt, you may want to begin with processed foods, which,
that many older adults may benefit from more inten-
together with restaurant food, provide most of the sodium
sive therapy. So if you’re past age 75 and your systolic
in the average person’s diet. Following are the top 10
sources of salt, according to the CDC. The ranking is based blood pressure is over 140 mm Hg, you may want to
on both the total sodium content of foods and how often weigh the potential risks and benefits of lowering it
people eat these foods.
further with your doctor.
1. b reads and rolls In the SPRINT trial, lowering blood pressure to
2. c old cuts and cured meats 140 mm Hg or less required an average of two blood
3. p izza pressure medications, and achieving a pressure of
4. p oultry (such as breaded chicken strips or nuggets) 120 mm Hg or less took an average of three drugs.
5. s oups Moreover, the rate of serious adverse effects from
6. s andwiches therapy, including kidney damage, fainting, and bouts
7. c heese of abnormally low blood pressure, was significantly
8. p asta dishes (such as spaghetti with meat sauce) higher among participants who were more intensively
9. m eat dishes (such as beef stew or meatloaf with treated.
tomato sauce) Metabolic syndrome. About 23% of American
10. savory snacks (such as chips and pretzels). women have metabolic syndrome, a constellation of
attributes that increases the risk of developing dia-
Check the sodium content on the Nutrition Facts panel
of every packaged food you buy. It will be listed both in betes and coronary artery disease. Any woman with
milligrams and as a percentage of the recommended daily three or more of the following meets the diagnostic
sodium allowance per serving.
criteria for metabolic syndrome:
• waist size greater than 35 inches
• blood pressure that is 130/85 mm Hg or higher
pressure. That study involved 9,361 people with high • HDL cholesterol that is less than 50 mg/dL
blood pressure but not diabetes, 38% of whom were • triglyceride level that is 150 mg/dL or higher
women. Participants were randomly assigned to one • fasting blood glucose level of 110 mg/dL or higher.
of two groups. The first group received conventional If you meet the criteria for metabolic syndrome,
blood pressure treatment designed to lower systolic consider it a wake-up call to change your habits. (See
blood pressure to a target of less than 140 mm Hg. “10 steps to a longer and healthier life,” page 20.)
The other received more intensive treatment aimed at Inflammation. Mounting evidence that inflam-
achieving a lower target—less than 120 mm Hg. The mation is a major player in atherosclerosis has led
results determined that, over all, participants who researchers to develop a test for a marker of blood
were treated intensively had a 25% reduction in risk vessel inflammation. For years, doctors have mea-
for heart attacks, strokes, and death from cardiovas- sured blood levels of C-reactive protein (CRP), an
cular causes, compared with those on conventional indicator of inflammation, to monitor diseases such
therapy. Among participants ages 75 and over, the as pneumonia, rheumatoid arthritis, and lupus. How-
reduction was 33%. However, women received less ever, a high-sensitivity test, called hsCRP, is more
benefit than men from the more intensive treatment. specific to blood vessels.
www.health.harvard.edu Women’s Health: Fifty and Forward 7
