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MD Consult: Books: Goldman: Cecil Medicine: LIFESPAN GROUPS

Goldman: Cecil Medicine, 23rd ed.

Copyright © 2007 Saunders, An Imprint of Elsevier

LIFESPAN GROUPS

Many of the important health issues in women have their onset or greatest impact at certain ages and are intricately linked with women’s psychosocial and sexual development. To develop a more integrated concept of women’s health, it is instructive to look at the important health issues in women within the major lifespan groups. Several governmental and institutional sources were used to compile this information. Of these, the themes developed by the Report of the National Institutes of Health: Opportunities for Research on Women’s Health, known as the Hunt Valley Report, form the basis of this section.

Birth to Young Adulthood

As young women reach puberty, the health issues that emerge are related primarily to developmental changes involving physical and sexual growth and changing relationships within and outside the family. Central to the psychosocial development of young women is the process of gender identification and orientation and the development of self-esteem. Intentional and unintentional injuries, including an increasing frequency of acts of physical and sexual violence, are the primary cause of death and disability in young women. A small proportion of girls develop a chronic disease or disability. Most of these conditions are related to autoimmune disorders, such as lupus erythematosus, juvenile rheumatoid arthritis, and thyroid disease. Because of hormonal influences, many of these conditions first occur or are exacerbated during puberty.

Ages 15 to 44 Years

During young adulthood, mortality rates in women are relatively low and deaths due to injury predominate.

Cancer

As women progress through this age group, cancers of the breast and reproductive tract emerge as the leading causes of death, followed by unintentional injury and heart disease.

Injury

Among the unintentional and intentional injuries in this age group, motor vehicle accidents, homicide, and suicide account for three fourths of all injury deaths. The death rate from motor vehicle accidents is highest in women 15 to 24 years of age; more than half of these deaths are alcohol related. Although there is a downward trend in death rates from homicide and suicide in young women, black women are most likely to be homicide victims, and firearms are used in more than half of these deaths. Because 30% of murders in women are perpetrated by a family member or acquaintance, the contribution of ongoing family violence to these fatal events is thought to be substantial.

Human Immunodeficiency Virus Infection

The most dramatic trend in this age group, beginning in the 1980s and peaking in the mid-1990s, was the emergence and rapid rise of HIV infection as a major cause of death. Although overall AIDS incidence and mortality rates have decreased yearly since 1996, the rate of decline has been smaller in women. The biologic and social aspects of HIV infection are difficult to separate; however, current evidence suggests that gender differences in the presentation and clinical course of HIV infection are related to women’s limited access to care and lower acceptance of or adherence to treatment more than to true biologic differences. The consequences of this disease for gynecologic care and reproductive counseling in women are unique. Because of the interrelationships between the degree of immunosuppression related to HIV infection, the presence of coinfection with human papillomavirus (HPV), and an increased risk of cervical neoplasia, the Centers for Disease Control and Prevention and the Agency for Health Care Policy and Research recommend that newly diagnosed HIV-infected women have an initial pelvic examination and Papanicolaou (Pap) smear that are repeated in 6 months. If the findings of these examinations and prior Pap smears are normal and the woman has no AIDS-defining condition or evidence of HPV infection, subsequent annual screening is adequate. Women who are at higher risk because they do not meet these criteria require more frequent surveillance or additional studies, depending on the Pap smear findings.

Primary physicians play a unique role in counseling HIV-infected women of childbearing age. Because HIV can be transmitted during pregnancy and more than 40% of pregnancies are unintended, routine medical care should include discussions about effective contraceptive methods, the effects of pregnancy on HIV infection and treatment, and the potential for perinatal transmission of HIV. Treatment strategies in women who may become or are pregnant should take into consideration regimens that maximally suppress maternal viral load and reduce transmission to the fetus while minimizing toxicity. In 1994, the Pediatric AIDS Clinical Trials Group demonstrated that a three-part regimen of zidovudine reduces the risk of perinatal transmission by 70% and is effective even in women with advanced disease. Current U.S. Public Health Service recommendations for antiretroviral chemoprophylaxis to reduce perinatal transmission of HIV are evolving rapidly and take into consideration the now standard use of more aggressive combination drug therapies to treat HIV infection as well as the clinical status and antiviral drug history of the woman. Zidovudine should be part of the antepartum drug regimen in all pregnant HIV-infected women if feasible. (Treatment guidelines are updated periodically and are available at http://AIDsinfo.nih.gov.) Despite these advances, the social consequences of this disease are enormous and result in loss of productive life, disruption of family structure, and premature death. The challenge to primary physicians to help control the transmission of HIV is an essential part of national prevention efforts.

Risk-taking and Unhealthy Behaviors

An important role of physicians in the care of young women is to recognize and to reduce risk-taking and other unhealthy behaviors. Health habits become established during early adulthood. Unhealthy behaviors not only place women at risk for life-threatening events but also have important implications for the development of illness later in life. For example, early or unprotected sexual activity increases women’s risk for sexually transmitted diseases. Not only are these diseases transmitted more easily from men to women, but women are disproportionately affected because of infectious complications that can lead to disorders of reproductive function, such as pelvic inflammatory disease, ectopic pregnancy, and infertility. Unfortunately, efforts at risk reduction, particularly in the use of harmful substances, are hampered by industry and market forces and other social factors that influence women’s lives. For example, the adverse effects of cigarette smoking on lung cancer and other respiratory diseases, heart disease, osteoporosis, and reproductive function are well documented, yet 20% of women continue to smoke, and 18% of teenage mothers smoke during pregnancy.

Eating Disorders

Social and cultural factors have also contributed to the increasing prevalence of dieting and eating disorders. The American Psychiatric Association Work Group on Eating Disorders estimates that up to 4% of young women suffer from anorexia nervosa or bulimia, and an additional 5% have less specific eating disorders characterized by aberrant eating patterns and weight management habits. These disorders are often refractory to treatment and can be life-threatening. The statistics most likely underestimate the prevalence of eating disorders in young women. According to findings from the 2003 Youth Risk Behavior Surveillance System developed by the Centers for Disease Control and Prevention, 56% of adolescent women reported that they had attempted dieting in the previous month, 18% had gone more than 24 hours without eating, 11% had taken diet aids without professional advice, and 8% had induced vomiting or taken laxatives for weight control.

Reproductive Health

This lifespan group delineates women’s reproductive years. In addition to traditional childbearing and family responsibilities, women are increasingly assuming new roles. The effect of multiple and often conflicting roles on women’s mental and physical health remains to be determined but is closely linked to reproductive freedom and health. Thus, physicians need to understand the safety, effectiveness, and acceptability of current methods of contraception in culturally diverse women, including emergency contraception.[1] Because of an increased understanding of many other common disorders of reproductive function, it is also clear that general physicians can no longer view these disorders as exclusively gynecologic problems. The association of the polycystic ovary syndrome with insulin resistance and an increased risk of diabetes and cardiovascular disease and the contribution of nonreproductive causes to chronic pelvic pain highlight the general medical nature of these disorders.

Autoimmunity

One of the themes linking many of the medical disorders that have the highest prevalence in women in this age group is the role of autoimmunity. Most of the autoimmune diseases are more common in women than in men and cause greater morbidity. Many are influenced by changes in estrogen levels, particularly during pregnancy. Among the collagen vascular diseases, rheumatoid arthritis, systemic lupus erythematosus, and scleroderma have prevalence rates that are three to nine times higher in women. Many autoimmune-related endocrinopathies, such as Hashimoto’s thyroiditis and Graves’ disease, have a female-to-male ratio as high as 10:1. Less well recognized is the role of autoimmunity in recurrent pregnancy loss and infertility in women.

Mental Disorders

Among the mental disorders, depressive illnesses are twice as common in women as in men. An estimated 6.5% of women experience a major depressive episode each year, and twice that many have chronic low-grade symptoms of depression. The excess risk of depression in women begins at puberty and declines after the menopause. In addition, many women experience mood, cognitive, or behavioral changes associated with cyclic changes in hormone levels during the menstrual cycle or with marked changes in levels during the postpartum period and the menopausal transition. The genetic, biologic, and environmental contributions to women’s susceptibility to depression are not fully understood; however, hormonal factors are thought to play a major role. Women are also twice as likely as men to be diagnosed with an anxiety disorder, including panic disorder, post-traumatic stress disorder, generalized anxiety, agoraphobia, and simple phobia.

Physical and Sexual Abuse

A major cause of psychosocial morbidity in women is physical and sexual abuse. On the basis of the National Violence Against Women Survey conducted by the National Institute of Justice and the Centers for Disease Control and Prevention in 1998, 52% of women have been physically assaulted at some time during their life, and 18% have experienced a rape. Young women are at particular risk for rape; of those women who have been raped, more than half were younger than 18 years when rape first occurred. Physical and sexual assault in women is primarily a problem of partner violence. Three fourths of women who experience physical or sexual abuse after the age of 18 years are assaulted by a current or former spouse or male intimate. On the basis of this finding, states are developing legal and other preventive strategies to protect women. Unfortunately, owing to lack of knowledge and training and misconceptions about physical and sexual violence, physicians often fail to recognize or to address symptoms of abuse. Adequate screening tools are especially crucial in the emergency department, where up to one third of women who have been assaulted seek care. To ensure widespread detection of abuse, screening should become a regular part of the medical history in any setting.

Ages 45 to 64 Years

Death rates for women in this age group have declined by 30% in the past 25 years. Previously, the leading cause of death was heart disease; however, cancer is now ranked number one. This shift in mortality rates reflects primarily a decline in death rates for heart disease that has been observed in both sexes and is attributed to changes in lifestyle, such as better control of hypertension and lower blood cholesterol levels.

Many of the important chronic conditions in women first appear in this age group, and the prevalence of some increases markedly during this period. There are significant racial and ethnic differences in the prevalence of many of these conditions.

Obesity

Associated with the dramatic increase in obesity in the U.S. population during the past 20 years, 62% of women are now overweight or obese, and 34% are obese. The prevalence of obesity in particular is disproportionately high in minority women; close to 50% of black and 39% of Mexican American women are obese, compared with 31% of white women. Because obesity is a major risk factor for diabetes, heart disease, stroke, gallbladder disease, sleep apnea, and some cancers (endometrial, breast, and colon cancer) and may be a factor in osteoarthritis, weight control in women is an important public health issue.

Menopause

The emergence of many of these conditions, such as heart disease, osteoporosis, and cancer, is inextricably linked to the menopause and the marked decline in estrogen levels that occur during this age period. Hormone replacement is the most effective therapy for vasomotor and vaginal symptoms associated with the menopause and decreases bone loss and the risk of osteoporotic fractures.[2] On the basis of data from a large number of observational studies, expectations were that hormone therapy would also protect women from heart disease and stroke and may protect women from the development of colon cancer. Data from a smaller number of studies also suggested that hormone therapy may protect the brain from cognitive decline and dementia, increase quality of life, and protect the urinary tract from aging problems such as urinary incontinence.

These hopes were not borne out by findings from the National Institutes of Health–sponsored Women’s Health Initiative Trial, the first large randomized trial designed to look at the role of hormone therapy in altering the risk for development of these disorders. The combined estrogen-progesterone arm of this multicenter study was halted early in 2002 because of an increased incidence of breast cancer in women receiving active therapy, a potentially adverse outcome of hormone therapy that was confirmed in the study.[3] Rates of heart disease, stroke, dementia, and urinary problems were also increased in women receiving hormone therapy compared with women taking placebo, whereas rates of hip fracture and colon cancer were reduced. [4] [5] [6] [7] [8] Because the risks of hormone therapy outweigh its benefits, combined estrogen and progesterone should not be used as preventive therapy in postmenopausal women. The estrogen-only arm of the trial was halted 1 year later, when investigators found that even though the harmful effects of hormone therapy were less pronounced in women who used estrogen without progesterone, the risks still outweighed the benefits.[9]

Transitions in Social Roles and Life Circumstances

Whereas the menopause encompasses many of the physiologic changes that define this period, women also experience major transitions in social roles and life circumstances that profoundly affect their physical and mental health. Children leave home, many women become widowed or divorced, parenting roles change as women are called on to care for aging parents, and disabilities increase, making it difficult for some women to function within and outside the home. An understanding of these life events is essential to the comprehensive care of mature women.

Ages 65 Years and Older

Heart disease is the leading cause of death in older women, followed by cancer and stroke. Mortality rates for all three disorders rise steeply after the age of 65 years and begin to approach the rates for men. Chronic pulmonary disease and pneumonia continue to cause high death rates because of the increase and severity of infections associated with an age-related decline in immune function. Injury is the sixth leading cause of death in older women; most of these deaths are related to falls.

Illnesses of the Very Old

As women’s longevity increases, they bear the burden of illnesses that are seen primarily in the very old. Of these, the neurologic degenerative diseases, such as dementia, sleep disorders, and neurosensory and movement disorders, are particularly common in women. Unfortunately, the added years of life in women are often spent in a frail or dependent state and often result in institutionalization. Currently, women residing in nursing homes outnumber men by three to one. In particular, urinary incontinence and osteoporosis put women at high risk for institutionalization. Prevalence rates of urinary incontinence are twice as high in women as in men and affect up to half of community-dwelling women. Osteoporosis is associated with deformity and pain secondary to vertebral fractures; however, hip fracture, usually the result of a fall, is the most serious consequence of osteoporosis in older women. According to the National Osteoporosis Foundation, 85% of women older than 50 years with a hip fracture cannot walk unassisted 6 months after a fracture, and one fourth never live independently again.

Social and Psychological Changes

The social and psychological changes that women experience as they age add to the burden of illness. Social isolation increases because of death of loved ones, loss of financial stability, and increasing physical disabilities. In addition to an increasing incidence of dementia with age, mental health problems become more prevalent or serious. The role of the primary physician is to recognize and help reduce the impact of these accumulated conditions on women’s ability to function and on their quality of life.

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Copyright © 2007 Elsevier Inc. All rights reserved. –

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