Disease of the arteries is the Number One cause of death in women over 50. Whether the cause is heart attack or stroke, arterial disease kills one woman in every four.

The arteries carry blood from the heart all round the body, and so it is important for our health that they remain in good condition. If they become narrowed, or clogged up, then the blood can’t flow so freely, and there is a much increased chance that the flow will suddenly become completely restricted, causing a heart attack or a stroke.

Some of the factors that contribute to heart disease are outside our control, such as the natural ageing process, and the hereditary aspect of heart disease; other risk factors we can do something about, by giving up smoking, not drinking too much alcohol, taking enough exercise, eating the right diet and learning how to handle stress.

One of the factors that increases the risk of developing diseases of the arteries is being male; until the age of 40-50, far more men than women die of heart disease. In fact, it is unusual for otherwise healthy pre-menopausal women to have heart attacks, whereas, sadly, it is not unusual for men in this age group to do so. The reason is thought to be the protective effect of a woman’s oestrogen. Once a woman is past the menopause (whether natural or surgical) her risk of having a heart attack increases, until by the age of 75-80 she has the same risk as men.

The reason for this is possibly to do with cholesterol. There are two forms of cholesterol flowing through the blood vessels: low density lipoproteins (LDLs) which build up on the walls of the blood vessels and are ‘bad for you’, and high density lipoproteins (HDLs) which are ‘good for you’ because they latch on to the LDLs and absorb them through the artery walls to be disposed of by other organs in the body. Many years of research have shown that oestrogen lowers the level of LDLs and raises the level of HDLs. As high levels of LDLs increase the risk of arterial disease (by blocking the arteries), and high levels of HDLs are good for you (because they remove the LDLs), oestrogen has a very positive protective effect.

Also, at times of increasing age, when the major arteries of the body are narrowing, HRT is thought to widen them and so allow blood to flow more freely. In fact, women on HRT tend to have healthier arteries than those not on it; even women of 70 or more can benefit from this protective effect of HRT.

As you will read in Chapter 8, there is a small but increased risk of developing breast cancer after several years on HRT, a fact that has received a lot of publicity. However, heart disease and stroke are the largest single cause of death among women in this country, completely dwarfing the number of deaths from breast cancer. The average reader of this book over the age of 50 is many times more likely to die from heart disease or stroke than from breast cancer (although under the age of 50 the risk of breast cancer is greater). A great deal of research has been carried out in recent years into HRT’s effect on menopausal symptoms and osteoporosis, but much less into its effect on arterial disease. This balance is beginning to change, and over the next few years more will become known about the effect different hormones have on heart disease and stroke. Although HRT was originally prescribed primarily to treat hot flushes, etc, and more recently also to prevent osteoporosis, it is likely that in future years it will be prescribed mainly for its role in reducing the risk of heart disease and stroke. Even now, it is thought that women who take oestrogen have one-third to one-half the risk of developing these two conditions than women who don’t.

(It is worth noting here that almost all the studies that show the beneficial effect of oestrogen on arterial disease have been carried out on women taking oestrogen alone, and not oestrogen with progestogen, although recent work suggests that progestogen may not detract from oestrogen’s cardiovascular protection; there have not yet, however, been any results based on long-term data.

To gain significant protective effect against arterial disease, you may need to stay on HRT for two years or so, preferably longer, and the effect will diminish once you stop. Even then, the oestrogen only reduces your risk of developing these diseases, it cannot guarantee that you won’t get them. We are not immortal!

*18\42\4*

Attitudes to physical beauty still seem harsher for women in their middle years than for men of the same age. We are so geared to youth, and youth is so tied up with femininity and sexuality, that once you reach menopause you may be viewed as ‘past it’.

The environmentalist and anti-nuclear campaigner Dr Helen Caldicott, whose marriage of twenty-six years broke up on the eve of her fiftieth birthday, says blinkered attitudes do not help. ‘In the eyes of some men, older women . . . have lost almost all value when they reach menopause because their hormones are no longer at the level they were before.’ Dr Caldicott has achieved a new beginning and a sense of liberation and independence since moving out of the family home, to settle first on the north-east coast of New South Wales and then in Gippsland, Victoria. ‘Doing it released me and made me understand the strength I had.’

Women actors complain that few challenging roles are available once they reach about forty-five. While men such as Sean Connery, Sam Neill and Robert Redford still play romantic leads into and beyond their fifties, women are rarely seen in such parts. Genevieve Picot, who played the role of the obsessive Celia in Proof and is deputy federal president of the Actors Equity section of the Media, Entertainment & Arts Alliance, says she is frustrated about being considered ‘old’ in the industry. ‘The irony and the disappointment for me is that as a performer I’m feeling much more confident and my skills are so much better than they were ten or fifteen years ago, yet I just don’t have the opportunity to use them very much.’

There are signs of change, however, the most obvious place being on television, where presenters and commentators are increasingly likely to include women over forty who do not necessarily look like stunners.

The highly regarded SBS newsreader Mary Kostakidis believes women themselves must make the first move. She refuses to dye her greying hair because she sees no point in camouflaging the maturity and complexity that come with midlife and beyond. ‘As a younger woman I was often attracted to older men because of these sorts of qualities. And now that I’ve arrived there myself, I’m not about to cover up the fact.’

She says that women presenters on Australian television are still largely ornamental. ‘It’s boring. We are an ageing population, and decision-makers who cannot accept this and act accordingly are behind the times. In many cultures older women assume positions of great status and respect. Australian women also have pride in their years. The time must come when they are no longer discarded for no other reason than their age. If not — if our institutions don’t reflect our values — our democracy is a farce.’

Women throughout Australia are, like Mary, Helen and Genevieve, asking questions, getting information, and deciding what is important for them at midlife and beyond.

*133\38\8*

Who would have believed, a generation ago, the current popularity of ‘alternative’ therapies and the challenge they have thrown down to orthodox medicine? There was little to indicate in the 1970s that the so-called fringe therapies like naturopathy, homeopathy, traditional Chinese medicine and herbal medicine would attract a vast pool of clients who alternated between orthodox and less conventional practitioners with breezy savoir-faire.

Equally unexpected were the greening of the Western diet and the enthusiastic adoption of power walking, jogging, aerobics and weight training by women of all ages. Many older women took to the challenge with gusto, viewing their increased involvement in physical activity as an antidote to the lack of strenuous exercise in their lives. When the 1991 Bulletin/Qantas Businesswoman of the Year, Sara Henderson, was writing her bestselling autobiography From Strength to

Strength and its sequel (still to be published at the time of writing), she felt the need to restructure her writing days to include short time-outs for exercise.

‘I’d played sport till I was forty-five, mainly tennis and squash. And there was a lot of physical activity at Bullo, down in the yards, working gates, building fences, lifting cases of beer in and out of the store. [Sara and her daughters own and run Bullo River, a remote Northern Territory cattle station.] To keep in nick when I’m writing twelve hours a day, I take a few minutes off every hour or so and do a couple of hundred skips. In the evenings I walk some kilometres along the airstrip with the dogs and, before going to bed, I do weights for my upper body for twenty minutes or so.’

Sara went through a fairly straightforward menopause when she was fifty. There were several months of irregular and heavy bleeding, followed by a return to normal periods, then irregularity again and so on, the whole process taking about three years and coinciding with the deaths of her husband, mother and son-in-law. Sara has not had HRT, says that people comment on how well she looks, and remarks on how well she feels. She enjoys a balanced diet mainly of fresh meat, vegetables and fish, does not smoke, and since the age of forty-five has drunk alcohol on special occasions only.

Whether women choose HRT or not, they should be aware of the range of lifestyle changes and alternative or complementary therapies capable of lessening menopausal symptoms and enhancing long-term health.

A common criticism of alternative therapies is the lack of solid scientific evidence about their effectiveness and safety, a problem compounded by the lack of quality control in the manufacture of some substances. As with HRT, uncertainties about effects should be considered carefully in assessing the benefits and risks.

*96\38\8*

‘The fact is that women are relatively protected, in terms of their cardiovascular status, by having oestrogens. It’s relative because it’s true as long as they have oestrogens. After the menopause, however, the incidence of heart disease rises rapidly, parallel to that in men; and as everybody knows, women live on average seven years longer. While men may have a head start, women have a higher chance of living widowed and with serious cardiovascular disease.’

Another unpalatable reality is that the causes and the most effective prevention *and treatment strategies for heart disease in women are still being learned, whereas they are well established for men with heart disease. This discrepancy relates to the male focus of much heart disease research, a fact that concerns health authorities in many countries. ‘Women die of heart disease almost as often as men do, but later in their lives,’ says Judith Dwyer, who chairs the Women’s Health Committee of Australia’s major health watchdog, the National Health and Medical Research Council. ‘It is surely inexcusable to base clinical advice on data that is good for the gander but may be worse than useless for the goose, even if that data is easier to gather.’

Judith Dwyer says the exclusion of women as participants in heart research is longstanding and ingrained in the system that governs trials of new pharmaceuticals. ‘Drug companies in Australia are almost required to use only healthy, young male volunteers when testing new formulations,’ she says. ‘It seems to me to be perfectly possible to develop methods of avoiding many of the perceived problems, such as the danger of liability in the case of pregnancy in women.’ In a bid to overcome the problem, a new approach has been devised to redress this kind of imbalance in Australian heart research.

*61\38\8*

It is a hormone that contributes to feelings of wellbeing and to the maintenance of a woman’s so-called ’secondary sexual characteristics’ such as distribution of hair, type of voice, and libido. Although testosterone is usually thought of solely as a male sex hormone (also known as an androgen), this is incorrect. It is more accurately described as ‘the third female sex hormone’. Women are already producing testosterone during childhood and continue to do so for the rest of their lives.

TESTOSTERONE AS PART OF HRT If you have had your ovaries removed surgically, you may become aware of lethargy and loss of libido. The addition of testosterone to HRT, or perhaps testosterone on its own, may prove helpful in your case.

*27\38\8*