Women's Health

Women outnumber men in the U.S. geriatric population. Currently, approximately 40 million Americans are postmenopausal women, with a projected increase to 60 million by 2030, when one in four women will be over 65 years of age. Fully 66% of all 85-year-olds are women, and women make up 85% of all nursing home residents. Of the approximately 32 million elderly Medicare beneficiaries, 19 million are women. Therefore, by default, geriatric medicine is a specialty concerned predominantly with the health of older women. A thorough understanding of this topic is important for all who care for older adults.

Appreciating principal causes of mortality is the first step to better understanding. Coronary heart disease is the leading cause of death for American women; one in five women is affected by some form of the disease. In 2001, 498,900 women died from heart attacks and other coronary events, comprising 53.6% of all coronary deaths that year. Unfortunately, many women remain unaware of their heart disease risk, considering it a primarily “male” disease. Public awareness campaigns are under way to help change this misconception. Cancer is the second leading cause of death, and stroke is the third, in women over 65 years of age.

Screening and preventive medicine remain important components of comprehensive health care as a woman ages. The U.S. Preventive Services Task Force (USPSTF) recommends annual mammography and clinical breast exams to at least 70 years of age and potentially thereafter if a woman has a reasonable life expectancy at that point in her life. Pap smear testing can be stopped in most women by 65 years of age if they have a single established sexual partner (or are abstinent), have had regular screening throughout their lifetime, and have no history of an abnormal Pap smear. Pelvic exams, however, should be continued annually as a screening measure for intrapelvic or vaginal abnormalities. Finally, the USPSTF recommends bone densitometry at least once for all women age 65 years and older.

Women undergo predictable physiological changes as they age. On average, menopause begins at 51 years, after which estrogen levels drop precipitously. Estrogen target organs, such as the vagina, uterus, cervix, and oviducts, undergo atrophy in the low-estrogen environment. Vaginal atrophy results in decreased vaginal secretions, wall thinning, and greater susceptibility to infection. Resultant vaginal dryness can lead to painful sexual intercourse and [Page 580]decreased libido. Menopause-related skin changes in collagen synthesis and hair distribution cause decreased skin elasticity and increased prominence of coarse facial hair. Loss of estrogen receptor stimulation in the bladder wall leads to decreased bladder muscle tone, which can exacerbate urinary frequency and incontinence. Following menopause, levels of total and low-density lipoprotein cholesterol and triglycerides increase, whereas levels of high-density lipoprotein decrease. This results in a lipid profile of increased risk, and rates of myocardial infarction and stroke amplify. The relationship between the loss of estrogen and cognitive dysfunction remains unclear.

Hormone replacement therapy has been used to help mitigate some of these physiological changes, but its role in menopause has changed dramatically over the past 10 years. In 2002, the Women's Health Initiative (WHI), a large nationwide randomized controlled trial of conjugated estrogen and medroxyprogesterone versus placebo therapy, stopped prematurely after an average of 5.2 years of follow-up due to increased risks of coronary heart disease, stroke, venous thromboembolism, and breast cancer in the population receiving hormonal therapy. However, the absolute risk of an adverse event in a woman on hormonal therapy remained very low (19 additional events per year per 10,000 women). Fracture and colon cancer rates were reduced in the treated group, but those who did develop colon cancer had more aggressive tumors. As a result of the WHI findings, hormone replacement therapy's primary indication is now one of perimenopausal symptom control, with therapy used for the shortest duration possible. Because systemic absorption is negligible at appropriate doses, local vaginal estrogen therapy remains an acceptable long-term therapeutic option for many women with atrophic vaginitis or other postmenopausal genitourinary conditions.

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