A Mid-Life Checkup
To keep your car running smoothly, you probably take it in for regular oil changes and other routine maintenance. As the car ages, you might also take it in for a 50,000-mile checkup to make sure it is still performing properly.
While most people realize the importance of preventive maintenance for their vehicles, many do not realize that a comprehensive mid-life checkup is equally important to preventing long-term problems and enhancing their performance “down the road.”
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 provides a valuable baseline for monitoring the many “normal” physical and hormonal changes you go through as you age.
This is especially important if you are a woman approaching menopause. In addition, conditions that are not related to menopause—such as obesity,
diabetes, thyroid disorders or hypertension—often develop during mid-life. 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.
A thorough medical history is essential for accurately evaluating your risk for potential health problems because many conditions, such as thyroid dysfunction, tend to run in families. Including any psychological issues, as well as physical health concerns, is crucial because the mind-body relationship is fundamental to your well-being.
An honest discussion about your lifestyle habits such as diet, exercise, stress management, tobacco use and alcohol consumption will help your healthcare practitioner assess their impact on your long-term health. This honest assessment may provide a “wake up call” that may encourage
you to make changes in your lifestyle choices.
Telling your healthcare practitioner about all surgeries or procedures, and current and previous medications is also essential. Make sure to 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 actually prove to be harmful.
Finally, discussing your own perception of your health is also important. People usually have a pretty good sense when there is something wrong with their body, so trust your instinct if you think you may have a health problem.
The Physical Exam
An annual physical exam typically includes breast and pelvic exams to screen for cancer, as well as a thyroid exam. In addition, a physical exam also
includes measures to track your height, weight and blood pressure. Establishing a baseline for these aspects of your health at mid-life will help provide a context for changes as you 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.
A baseline measurement of 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 your height varies slightly throughout the day. An overall height loss of more than 1.5 inches from your maximum adult height may be an indicator of 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.
Weight is a very sensitive matter for many women, but it is also a very important indicator of potential health problems, especially if you are overweight. Obesity is strongly associated with a wide range of conditions, including diabetes, gall stones, osteoarthritis and certain types of cancers.
Your healthcare practitioner is not only interested in your current weight, but any trends—up or down—over time. Unexplained weight gain or loss, in combination with other symptoms, can 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 (you can go to nhlbisupport.com/bmi to calculate your BMI). While it is an imperfect indicator, a woman with a BMI rating of 30 or greater is considered obese, which means she is more likely to face additional health problems than a woman who is at a normal weight, if she does not lose that extra weight.
Body shape or waist circumference may be a better indicator of health risks. Your waist-to-hip ratio provides an estimate of intra-abdominal fat (see figure). An excess of fat in the waist or stomach area (the apple shape) is more closely associated with diabetes, hypertension and heart disease than an 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.
NOTE: If you are overweight at mid-life, the single-most important thing you can do to improve your long-term health outlook is to attain and maintain a normal weight for your height.
Hypertension (high blood pressure) 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 post-menopausal women and black women 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:
- While you are seated, after sitting quietly for approximately 5 minutes
- 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. In addition, your healthcare practitioner may suggest medical treatment.
Low blood pressure (hypotension) can also occur in mid-life. Symptoms may include cold hands or feet, weakness or light-headedness and heart palpitations. Because these symptoms are also associated with low adrenal function, it is important to mention them to your healthcare practitioner during your mid-life checkup.
As of 2012, a woman’s lifetime risk of developing breast cancer is considered to be about 1 in 8 (or a little over 12%). As a result, most women have already had a clinical breast exam by the time they reach mid-life. The good news is that the risk of breast cancer actually declines as we age. However, the risk never totally disappears, so continue both your annual breast exam with your healthcare practitioner, as well as your monthly self-exams.
An annual pelvic exam, including a Pap test and a rectal exam, is just as important during mid-life as it is during the child-rearing 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 US. For these reasons, 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 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 your thyroid function.
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.
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). TSH is actually a pituitary secretion that triggers the thyroid gland to release T3 and T4 into the bloodstream. These hormones primarily regulate metabolism; they also affect protein synthesis, carbohydrate and lipid metabolism, and vitamin absorption.
Typically, a thyroid test measures your TSH level. If it is out of range (either low or high), further evaluation of your T3 and T4 hormone levels may be necessary. In addition, measuring reverse T3, which blocks normal T3 activity at the receptor sites and T4 transport into the cell, will indicate if it is out of balance. Testing for thyroid antibodies will alert you to the possibility of autoimmune thyroiditis. However, some practitioners feel that the typical thyroid test results may not be a true indicator of thyroid function because they do not account for the intracellular effects of the hormone.
Another easy, simple way to check your thyroid function is to perform the Barnes basal temperature test. Before going to sleep, put an ordinary thermometer next to your bed. 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.
Most women associate menopause with a decline in ovarian function, primarily resulting from decreasing estrogen levels. But the transition from pre- to post-menopause can be lengthy and is far more complex than that. In addition, most healthcare practitioners agree that reproductive aging precedes menopause by at least 10 years.
A mid-life checkup can help you evaluate your reproductive and hormonal health, as well as establish a baseline to prepare you for the changes ahead.
As you age, estrogen levels fluctuate and decline, other hormones fluctuate and rise, the number of follicles rapidly declines, the ovaries begin to decrease in size, and cycles become more erratic—with each of these conditions wreaking havoc with ovarian function. So when, exactly, is menopause?
Many healthcare practitioners use a measure of follicle-stimulating hormone (FSH) to gauge if you are near menopause. However, oral contraceptives and other medications can interfere with FSH and other hormone levels, so you should 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 wildly.
Despite the decline in fertility that accompanies aging, women can still become pregnant until menopause is confirmed (usually 12 consecutive months without menses). Therefore, women who stop taking oral contraceptives to achieve more reliable hormone test results should employ another birth control method in the meantime.
In essence, 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.
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.
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, mentioned earlier, is one component of that assessment. 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 can fluctuate with stress and the time of year. Therefore, calculating an average from multiple screenings may yield a more accurate assessment.
Originally, reducing overall cholesterol was the desired goal. Then, new evidence 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, with data from nearly 20 years of long-term studies, high cholesterol is not nearly as predictive of heart disease as originally thought for people under 60 years of age. Smoking and high blood pressure are much 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 an increase in exercise. A mid-life checkup can sound the warning bell for you to make the changes necessary to reduce your cardiac risk.
Impaired glucose function (diabetes mellitus) is associated with or a known contributor to many other health problems, including excess weight, hypertension, hormone imbalances and 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 can precede its diagnosis by a decade or more, and many people develop the disease without even 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 African Americans, Hispanics and Native Americans) should also have their glucose/insulin function tested regularly. The sooner the better when it comes to predicting diabetes, because it provides more time to make the necessary lifestyle changes to possibly prevent it from occurring.
Routine measures include fasting glucose tests to predict metabolic syndrome and diabetes. However, testing also for fasting insulin 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 (blood sugar) attached to hemoglobin, the oxygen-carrying protein in red blood cells. The process by which glucose attaches to a cell is called glycation, and it is associated with cell aging. High hemoglobin A1C is not only associated with diabetes, but also metabolic syndrome, heart disease, dementia and some cancers.
Another important biomarker to keep tabs on at mid-life and beyond is vitamin D, which is actually a hormone. 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. Adequate levels of vitamin D are a critical factor in maintaining the health of our bones, brain and blood vessels. Vitamin D has also emerged as having a strong anti-cancer effect.
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 possible trouble “down the road.” Perhaps more importantly, a mid-life checkup may steer you toward lifestyle changes that could prevent future health problems and improve your long-term well-being.