Clinical Review

Your age-based guide to comprehensive well-woman care

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The mature woman: 40–64 years

Transition to postmenopause. The menstrual changes through perimenopause to postmenopause are often accompanied by changes in sleep patterns, vasomotor symptoms, and increasing vaginal dryness.

Open your eyes to a patient's insomnia

Perimenopausal and postmenopausal women report a much higher rate of insomnia than age-matched men.10 Women with moderate to severe vasomotor symptoms are more likely to report greater nighttime wakefulness and a greater number of nighttime long-awake episodes than women with mild vasomotor symptoms.11 Insomnia can be associated with poor work performance and mood changes.

Hormone therapy: Be conservative

In the past, hormone therapy, with various estrogen and progestin combinations, was recommended to help prevent a number of diseases, including cardiovascular disease (CD) and osteoporosis. Based on clinical trial results, the current recommendation is to limit the use of hormone therapy in postmenopausal women to the treatment of vasomotor symptoms and vaginal symptoms caused by hypoestrogenism. To treat these problems, the lowest doses of hormones that are effective should be used for the shortest periods of time that achieve symptom resolution.

The older woman: 65+ years

Successful aging. Based on observational studies, behavioral and health factors associated with successful aging include more than 12 years of education; high socioeconomic status; absence of diabetes, asthma, stroke, and lower respiratory tract disease; absence of depression; presence of at least five close personal contacts; frequent walking; moderate use of alcohol; and nonsmoking status.12

Know her risks, and watch for them

Cardiovascular disease. Among women, CDs cause more deaths than malignant neoplasms, chronic lower respiratory disease, Alzheimer's disease, and accidents combined. Black women have rates of CD approximately 40% greater than white women. Hypertension, hypertriglyceridemia, obesity, and sedentary lifestyle among black women account for a part of this increased risk.

Effective lifestyle interventions for primary CD prevention in women include smoking cessation, a diet such as DASH (Dietary Approaches to Stop Hypertension) rich in fruits and vegetables, regular physical activity, and weight management.13

There are important gender differences in aspirin efficacy for primary prevention of stroke and myocardial infarction (MI) in men and women. Among women, aspirin used for primary prevention appears to reduce the risk of stroke but not MI.14 Among men, aspirin used for primary prevention appears to reduce the risk of MI but not stroke.15,16 Based on these and other data, the USPSTF has recommended that aspirin not be used to prevent stroke in men but recommends aspirin to prevent stroke among women 55 to 79 years of age when benefits outweigh risks of gastrointestinal bleeding.17

Atrial fibrillation (AF), a risk factor for stroke, is more common in women than in men. In addition, women with AF who are not anticoagulated are at greater risk for stroke than men with AF who are not anticoagulated.18 The mechanisms that influence these gender differences are not well characterized.

Respiratory illness. Among women, the prevalence of chronic bronchitis and emphysema increased more than 2.8-fold from 1980 to 2000.19 These diseases are major contributors to physician office visits, hospitalizations, disability, and death. Tobacco use is the major risk factor that accounts for the marked increase in COPD among women during recent decades, although ambient pollutants in the environment, home, and workplace are also important contributors to COPD development.

Cognitive decline. Alzheimer's disease afflicts approximately twice as many women as men. Part of this difference is due to the greater longevity of women, but additional variables, such as gender differences in neurobiology, are also contributory. The role of estradiol in the development of Alzheimer's disease remains controversial.

Osteoporosis. This disease occurs about five times more frequently in women than in men. Among Medicare patients, the cost of caring for a hip fracture is more than $40,000 in the first year postfracture. Hip fracture is associated with a high risk of rapid health decline. Interventions that successfully prevent hip fracture are associated with a reduced mortality rate.20,21

What may lead to your patient's death, according to her age?

Keep in mind the top causes of death for her age when you examine and counsel your patient. For a young teenager, for instance, accidents are the most common cause of death. Therefore, emphasize to her the importance of risk-reducing interventions, such as wearing helmets while biking and seatbelts while driving and practicing water sports safely.

Age 13–18 yearsAge 19–39 years
  1. Accidents (unintentional injuries)
  2. Malignant neoplasms
  3. Intentional self-harm (suicide)
  4. Assault (homicide)
  5. Diseases of the heart
  6. Congenital malformations, deformations, and chromosomal abnormalities
  7. Chronic lower respiratory diseases
  8. Cerebrovascular diseases
  9. Influenza and pneumonia
  10. In situ neoplasms, benign neoplasms, and neoplasms of uncertain or unknown behavior
  1. Malignant neoplasms
  2. Accidents (unintentional injuries)
  3. Diseases of the heart
  4. Intentional self-harm (suicide)
  5. Human immunodeficiency virus disease
  6. Assault (homicide)
  7. Cerebrovascular diseases
  8. Diabetes mellitus
  9. Chronic liver diseases and cirrhosis
  10. Chronic lower respiratory diseases
Age 40–64 yearsAge 65 years and older
  1. Malignant neoplasms
  2. Diseases of the heart
  3. Accidents (unintentional injuries)
  4. Chronic lower respiratory diseases
  5. Cerebrovascular diseases
  6. Diabetes mellitus
  7. Chronic liver disease and cirrhosis
  8. Septicemia
  9. Intentional self-harm (suicide)
  10. Human immunodeficiency virus disease
  1. Diseases of the heart
  2. Malignant neoplasms
  3. Cerebrovascular diseases
  4. Chronic lower respiratory diseases
  5. Alzheimer's disease
  6. Influenza and pneumonia
  7. Diabetes mellitus
  8. Nephritis, nephritic syndrome, and nephrosis
  9. Accidents (unintentional injuries)
  10. Septicemia
Source: Mortality Statistics Branch, National Center for Health Statistics; 2004.

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