A Mid-life Checkup

A comprehensive mid-life checkup is essential to preventing long-term problems and enhancing the body’s functions. A mid-life checkup provides you and your healthcare practitioner with an opportunity to discuss your family medical history, evaluate your current health condition, and screen for potential future problems. It also establishes a baseline for monitoring the many “normal” physical and hormonal changes you go through with age—which is especially important for women approaching menopause, but also useful for detecting conditions that are not related to menopause as well.

Many conditions are more likely to develop—or begin developing—during mid-life, such as:

• Obesity
• Diabetes
• Thyroid disorders
• Hypertension

For these rea­sons, both the North American Menopause Society (NAMS) and the American College of Obstet­rics and Gynecology (ACOG) have published guidelines re­garding comprehensive health evaluations for women at mid-life. Such a checkup should include:

• A detailed medical history, including psychological and social concerns
• A complete physical exam, including height, weight, and blood pressure, as well as breast, pelvic, and thyroid exams
• Laboratory tests, including blood tests to check hor­mones and other biomarkers for thyroid, ovarian, cardiovascular, and metabolic functions

Providing a Medical History 

A thorough medical history is essential to accurately evaluate an individual’s risk for potential health problems. Many conditions, such as thyroid dys­function, tend to run in families. Include any psychological concerns in addition to physical health concerns.

Habits that commonly affect your quality of health include:

• Diet
• Exer­cise
• Stress management
• Tobacco use
• Alcohol consumption

An honest discussion about your lifestyle will help assess their impact on your long-term health and allow your healthcare practitioner to recommend changes to promote well-being.

Tell your healthcare prac­titioner about all surgeries or procedures, including a complete list of past and current medications. Include all prescription and non-pre­scription treatments, as well as alternative or natural remedies and supplements. Mixing treat­ments may cause one or more of them to be less effective or may prove harmful.

The Physical Exam 

An annual physical exam typi­cally includes breast and pelvic exams to screen for cancer, as well as a thyroid exam. A physical exam also measures height, weight, and blood pres­sure that will help provide a con­text for changes with age. With these three simple measures, your healthcare practitioner can begin to assess your risk for osteoporosis, cardiovascular disease, and obesity-related con­cerns such as diabetes and gall bladder disease.

Height 

Measuring your healthy, adult height is useful for catching signs of osteoporo­sis. Height should be measured at approximately the same time of day each visit, if possible, as it varies slightly throughout the day. An over­all height loss of more than 1.5 inches from your maximum adult height may indicate osteoporosis. If you experi­ence height loss or are at risk for osteoporosis, your healthcare practitioner may suggest a bone density test for a more accurate assessment. (For more information on bone health, see our related Connections articles No Bones About It! and Osteoporosis.)

Weight 

Weight is an important indicator of potential health problems, es­pecially if you are overweight. Obesity is strongly associated with many conditions, including:

• Diabetes
• Gall stones
• Osteoarthritis
• Certain types of cancers

Your healthcare practitio­ner is not only interested in your current weight, but any trends over time. Unexplained weight gain or loss, in combination with oth­er symptoms, may contribute to a diagnosis of other health problems. Other weight-related indica­tors your healthcare practitioner might discuss are body mass in­dex (BMI) and body shape.

BMI is a measure of body fat based on height and weight. While it is not a perfect indica­tor, a woman with a BMI rating of 30 or greater is considered obese. This means that, if she does not lose the extra weight, she is more likely to face additional health problems than a woman who is at a normal weight.

Because using BMI may be an imprecise measure of weight health, body shape, or waist circumfer­ence may be a better indicator of health risks. Waist-to-hip ratio provides an estimate of intra-abdominal fat, often described in terms of “apple” or “pear” shaped body types. Excess fat in the waist or stomach area (the apple shape) is more closely associated with conditions such as dia­betes, hypertension, and heart disease than excess in the hip area (the pear shape).

A wom­an with a waist circumference greater than 35 inches (40 inches for men) is considered to be at greater risk for heart disease and Type 2 diabetes. If you are overweight at mid-life, attaining and maintaining a normal weight for your height and body type is one of the most important measures you can take to improve your long-term health. (For more information, see our Connections article “Weighing In” on Hormone Balance.)

Blood Pressure 

High blood pressure (hypertension) is a fairly reliable indicator of cardiovascular disease, espe­cially in women. Women who have used oral contraceptives are more likely to have high blood pressure, and women who are post-menopausal and/or of African descent are at the greatest risk for cardiovascu­lar disease. Hypertension does not exhibit symptoms, so it is important to check your blood pressure regularly—especially at mid-life, as its occurrence in­creases with age.

For a more accurate reading, blood pressure should be checked two ways:

1. While you are seated, after sitting quietly for approxi­mately 5 minutes
2. Using a method called the Ragland postural test, in which you lie quietly on your back for 5 minutes, take a blood pressure reading, stand up, and immediately take another reading.

Sustained elevated readings may indicate the need for life­style changes, such as changing your diet and getting more exer­cise; your healthcare practitioner may also suggest medi­cal treatment.

Low blood pressure (hypotension) may also occur in mid-life. Symptoms include cold hands or feet, weakness or light-headedness, and heart palpitations. Mention these symptoms to your healthcare practitioner, as they are also associated with low adrenal function. (For more information, see our Connections article on High Blood Pressure.)

Breast Exam

As of 2020, a woman’s lifetime risk of developing breast can­cer is considered to be approximately 1 in 8. As a result, most women have al­ready had a clinical breast exam by the time they reach mid-life. While the risk of breast cancer declines with age, the risk never totally disappears, so continue annual breast exams with your healthcare practitio­ner. (For more information, see our Connections article on Breast Health Awareness.)

Pelvic Exam 

An annual pelvic exam, in­cluding a Pap test and a rectal exam, is just as important dur­ing mid-life as it is during the childbearing years. At mid-life, a pelvic exam provides an op­portunity to screen for uterine, ovarian, and endometrial can­cer. The rectal exam screens for colorectal cancer, the third most common cancer among both men and women in the United States.

Most healthcare practitioners recommend annual pelvic exams, even if the uterus and both ovaries have been re­moved. The primary purpose of a Pap test is to screen for cancer­ous or pre-cancerous conditions in the cervix and vagina. It may also be used to evaluate hormon­al changes or their effects.

Thyroid Exam 

Thyroid dysfunction is particu­larly prevalent among women and the elderly. During a mid-life checkup, your healthcare practitioner will probably examine the area near your thy­roid (on your neck) to see if it is enlarged. If you exhibit any symptoms that could be thy­roid related, he or she may also request lab tests to assess thyroid function. (For more information, see our Connections article on Hypothyroidism.)

Laboratory Tests 

A comprehensive mid-life checkup will most likely include laboratory tests to assess your thyroid, ovarian and cardiac functions, especially if you have known risk factors. Depending on your family history and other risk factors or symptoms, your healthcare practitioner may also want to evaluate your glucose tolerance to screen for diabetes and related conditions.

Thyroid Function 

Laboratory tests that measure hormone levels can provide detailed information about thyroid function. The thy­roid-related hormones most often measured include triiodothyronine (T3), thyroxine (T4), and thyroid-stimulating hormone (TSH). These hormones primarily regulate metabo­lism, but also affect protein synthesis, carbohydrate and lipid metabolism, and vitamin absorption.

The thy­roid hormones most often measured include triiodothyronine (T3), thyroxine (T4), and thyroid-stimulating hormone (TSH) to get the full picture of a patient’s thyroid function. These hormones primarily regulate metabo­lism, but also affect protein synthesis, carbohydrate and lipid metabolism, and vitamin absorption. TSH is a pituitary secretion that triggers the thyroid gland to release T3 and T4 into the bloodstream.

Another indicator of thyroid imbalance is measuring reverse T3, which blocks normal T3 activity at the receptor sites and T4 transport into the cell. Testing for thyroid antibodies will alert you to the possibility of autoimmune thyroiditis. However, some practitioners believe that the typ­ical thyroid test results may not be an accurate indicator of thy­roid function because they do not account for the intracellu­lar effects of the hormone.

The Barnes basal temperature test is another way to check thyroid function:

1. Before go­ing to sleep, put an ordinary thermometer next to your bed
2. In the morning, upon awakening and with as little movement as possible, place the thermometer under your armpit and lie quietly for ten minutes

If your tempera­ture is between 97.8º and 98.2º, your thyroid is prob­ably functioning normally; if not, talk to your healthcare practitioner about request­ing more detailed thyroid testing.

Ovarian Function 

Most women associate menopause with a decline in ovarian function, primar­ily resulting from decreasing estrogen levels. But the shift from pre- to post-menopause is complex and may be a lengthy transition. Many healthcare practitioners agree that reproductive ag­ing precedes menopause by at least 10 years.

Despite the decline in fertil­ity that accompanies aging, women can still become pregnant until menopause is confirmed (usually 12 con­secutive months without menses). Knowing if or when you are menopausal is not as important as accurately assessing your ovarian func­tion, because that will play a far greater role in your overall health and well-being.

A mid-life checkup can help you evaluate your reproduc­tive and hormonal health. It also helps prepare you for the changes ahead. Many of these changes disrupt ovarian function, such as:

• Estrogen levels fluctuate and decline with age while other hormones fluctuate and rise
• The number of follicles rap­idly declines
• The ovaries begin to decrease in size
• Menstrual cycles become more erratic

Healthcare practi­tioners sometimes measure follicle-stimulating hormone (FSH) to gauge if you are near menopause. However, oral contraceptives and oth­er medications may interfere with FSH and other hormone levels. Confer with your healthcare practi­tioner about stopping them for several weeks before the lab tests to achieve a good reading.

Once you are past meno­pause, the levels of estradiol (the primary estrogen pro­duced) and estrone (the second most abundant estro­gen) are significantly reduced, and the ratio of the two is reversed, with estrone be­coming more abundant than estradiol. During the years preceding menopause, how­ever, these measures are of little value because hormone levels can fluctuate widely. Hormone testing, in conjunc­tion with keeping track of symptoms such as irregular bleeding and hot flashes, will help you and your healthcare practitioner monitor your ovarian and hormonal health at mid-life.

 Cardiac Function 

Because cardiovascular dis­ease is the leading cause of death among both men and women, a mid-life checkup should include a thorough as­sessment of cardiac function. Blood pressure is one component of that assessment, while cholesterol levels and other biomark­ers are used to complete the picture.

Cholesterol tests typically measure the total cholesterol, low-density lipoprotein (LDL), and high-density lipopro­tein (HDL). Cholesterol levels may fluctuate with stress and the time of year. Therefore, calculating an average from multiple screenings may yield a more accurate assessment.

In the past, it was thought that reducing overall cholesterol should be the goal to prevent cardiovascular disease. However, additional evidence then in­dicated that the ratio of total cholesterol to HDL was a bet­ter indicator of heart disease than the levels of LDL or total cholesterol. Now, taking into account data from nearly 20 years of long-term studies, high cholesterol is not regarded as predictive of heart disease as originally thought for people under 60 years of age, and smoking and high blood pressure are considered more reliable predictors of heart attack or stroke for peo­ple at mid-life.

Oxidized LDL is emerging as a more important cardiovas­cular marker than the usual cholesterol measurements. Oxidation in the body is anal­ogous to rusting. This test can help measure the level of oxidative stress in the body, which some practitioners be­lieve is more predictive of heart disease, heart attacks, and other health problems.

Other biomarkers considered to be indicators of cardiac risk include:

• High-sensitive C reactive protein (hsCRP), which measures inflammation, is considered to be an in­dicator of the risk of heart attack or stroke.
• Homocysteine, which is associated with stress, is an extremely irritat­ing molecule and results in cardiovascular tissue damage and clogged ar­teries. Deficiencies of folic acid and vitamins B6 and B12 can increase homo­cysteine levels.
• Elevated levels of fibrino­gen, a blood coagulant, may also indicate a higher risk for cardiovascular disease.

Each of these biomarkers may be improved with lifestyle changes, including in­creased exercise. (For more information, see our Connections article Matters of the Heart.)

Glucose and Insulin Tolerance 

Impaired glucose function (diabetes mellitus) is as­sociated with or a known contributor to many other health problems, including:

• Excess weight
• Hypertension
• Hormone imbalances
• Ac­celerated aging

Prediabetes and Type 2 diabetes (formerly called adult-onset diabetes, but now found in younger age groups as well) have be­come so common that they are considered to be nearly epidemic, with potentially deadly consequences.

The onset of diabetes may pre­cede its diagnosis by a decade or more, and many people develop the disease without realizing it. For anyone who is obese or has a family history of diabetes, a mid-life checkup should include glu­cose/insulin testing. People in ethnic groups that have a higher incidence of diabetes (such as patients of African, Hispanic, or Native Ameri­can descent) should also have their glucose/insulin function test­ed regularly.

Predicting the risk of diabetes as early as possible allows for more time to make the necessary lifestyle changes to possibly prevent its occurrence. Routine preventive measures include fasting glucose tests to predict metabolic syndrome and dia­betes. However, testing for fasting insulin also provides an earlier warning sign because abnormalities in insulin func­tion tend to show up sooner than in glucose.

A biomarker commonly measured for evaluating long-term blood glucose con­trol is glycated hemoglobin (A1C). The blood test for A1C measures the level of glu­cose attached to hemoglobin, the oxygen-carrying protein in red blood cells. Glycation, the process by which glucose attaches to a cell, is associated with cell aging. High hemoglobin A1C is not only as­sociated with diabetes but also metabolic syndrome, heart disease, dementia, and some cancers. (For more information, see our Connections articles on Insulin Resistance and Diabetes.)

Vitamin D

Another important biomarker to keep tabs on at mid-life and beyond is vitamin D, a hormone, which plays a crucial role in maintaining the health of bones, brain, and blood vessels. Vitamin D has also emerged as having a strong anti-cancer effect. Because our primary source of vitamin D is sunshine, it is nearly impossible for people in the northern climes, and those who consistently use sunscreen, to maintain adequate levels of vitamin D without supple­mentation. (For more information, see our Connections article Vitamin D: The Sunshine Hormone.)

Conclusion 

For some people, a comprehensive mid-life checkup may be a lifesaver. Advancements in our understanding of the various biomark­ers mentioned can alert you to potential underlying health issues. Perhaps more importantly, a mid-life checkup may steer you toward lifestyle changes that might prevent future health prob­lems and improve your long-term well-being.