Our expert OB-GYN Dr. Katherine Macaulay talks menopause, mammograms, the latest thinking on self-breast exams, osteoporosis, and contraception.
What concerns do women aged 45-55 most often come to you with?
Mostly changes in their menstrual periods due to the onset of perimenopause. The average age of starting perimenopause is around 47, and the average age of menopause is around age 52. The average duration of perimenopause is 3-4 years, and the first sign is a change in your menstrual cycle length, or that’s the most common reason.
Other symptoms are hot flashes and night sweats, although typically these start when women are having longer days in between their periods, and when they start skipping months and starting to enter into the menopause transition. That’s what we call perimenopause.
Sometimes bleeding can get heavier and more frequent before it gets lighter and less often and then stops completely. Often in this age group, women can be more likely to be diagnosed with uterine fibroids or polyps in the uterine lining, which can lead to bleeding issues as well.
Do you find most women do their own regular breast exams?
No, they don’t. And they express feeling very guilty about that, they tell me, ‘I feel so bad!’ But we don’t even recommend them anymore.
Really?! I didn’t know that. Why?
It really hasn’t been shown to be effective to do a systematic monthly regular breast exam. Even the American Cancer Society really just recommend women to be ‘breast aware’. Be aware of any changes in your breasts, if you have any pain, or if you look in the mirror and notice anything different about your breasts or see redness on the skin. Women do find their own breast cancers but we used to have women hang these little cards in the shower, which caused a lot of anxiety. There were a lot of false positives because women didn’t always know what they were feeling so it’s not been proven that that approach really is what finds breast cancers earlier. But women do need to be aware of any changes and bring them up with your physician. You can still lather up and check yourself periodically. If you feel a mass or anything abnormal, or feel and see redness, definitely call your doctor.
When should women start having annual mammograms?
The American College of Obstetricians and Gynecologists recommends starting them at age 40. Personally, I begin the discussion when a patient turns 40. There’s some controversy when an ‘average risk’ (no family breast cancer history) woman should start having them, as in whether they should start at age 40, 45, or 50.
All medical bodies agree though it should be no later than 50 years old. Between 40-49 is where they disagree. Some women are concerned about the risk and they feel reassured to have an exam annually, which may weigh into it. Another patient may read that mammograms aren’t really as accurate or useful until a woman turns 50.
The US Preventative Services Taskforce is the one committee that recommends starting annual mammograms at age 50. So, if a woman wants to start at 50, she can. It’s not a hard and fast rule but I tend to recommend starting the conversation at age 40 and working with the woman with what she wants to do. The American Cancer Society recommends women get annual mammograms by age 45.
In a nutshell, start a conversation about breast cancer screening with mammography at age 40 and make a decision with your provider whether you prefer to start at 40 or 45, but certainly no later than 50 years old.
How long should you keep on having mammograms?
The American Cancer Society says to start at 45 years old and have them annually until age 54, and then you can choose to start having them every other year. Personally I think it’s easier to start at 40 and go every year. But the worry about that is there are more false positives for women in their 40s, and that can cause anxiety. It really needs to be discussed between the doctor and the patient because the woman’s feeling, fears and concerns about risks is going to weigh in on how much screening she wants to do. These guidelines are for an average risk for a woman who is asymptotic and doesn’t have a family history or concern on a breast biopsy before.
Do screening recommendations change to every two years because the risk of breast cancer goes down after 55?
No. I think part of it is because if you’ve had annual screening during that window and you’ve had no problems then you could go for longer intervals, because you’ve had a decade of knowing nothing has been missed. But most of my patients in that age group still go annually.
When should women have their first osteoporosis screening? And are there any warning signs? For example, I was told I had significant tooth bone loss by my dentist and I was advised to take a test, which turned out fine.
The US Preventative Task Force and the National Osteoporosis Foundation (now known as the Bone Health & Osteoporosis Foundation) both recommend the bone density test for osteoporosis at age 65 for women.
Generally, it would only be done younger than age 65 if there were some risk factors identified, like your dentist’s comments. The test isn’t usually recommended before your periods have stopped though unless you have a long history of amenorrhea or your estrogen levels were low.
Other red flags are if a woman’s parent had a hip fracture from osteoporosis, if the patient has a history of steroid use for other medical conditions, if they have a thyroid disorder, or if they have a very low body weight from an eating disorder. Even if they’ve recovered and still have just a thin frame, I would watch more closely and screen earlier.
The medications for osteoporosis are pretty potent so as to prevent fracture and you can’t really take them long term, so you really don’t want to initiate them too early. Your doctor may consider what the value of doing a screening is if the patient isn’t extra high risk. Some people might have a degree of low bone mass but we don’t always act on that, so I don’t know how helpful screening exams are if you do them too soon. Certainly by the age of 60 I’m looking more closely, but by 65 I would definitely recommend the test for women.
Do you give family planning and contraceptive advice to women aged 45-55?
I do. It’s a general approach to all women in that age group. You’re still at risk of pregnancy until you reach menopause. And menopause is not based on a blood test, it’s a natural process and a clinical diagnosis. If you’ve gone 12 consecutive months without your period in the right age range (45-55), then we say you’ve reached menopause. Then we say you no longer need to use contraception. But until that point there is still a risk of pregnancy.
I was counselling a 47-year-old about birth control recently as she was having irregular periods and I told her there was still risk. And then she had an unplanned pregnancy! I counsel women about the need for contraception until they reach menopause and then what type they want to use is very much an individual preference. There are different risks and benefits for all approaches and options.
Dr. Katherine Macaulay is a Professor of Obstetrics, Gynecology, and Reproductive Sciences at UC San Diego School of Medicine, where she also heads up the Menopause Health Program.
