Research for a New Age

Recent findings about women's health have startled gerontologists. For example: A high percentage of older women experience urinary incontinence. About 37 percent of women age 60 and over living in the community - not in nursing homes - have urinary incontinence. In the Baltimore Longitudinal Study of Aging, more than 50 percent of women have reported at least one episode of urinary incontinence. The popular idea that menopause brings depression appears to be a myth. In reality, only 10 percent of women going through menopause are depressed at any one time, and the depression is related primarily to factors other than menopause, according to the Massachusetts Women's Health Study, sponsored by NIA.

Research on women's health is expanding rapidly, but the unexpectedness of findings like these stands as a warning that huge gaps exist in our knowledge of how women age.

The importance of filling these gaps cannot be overstated. Women make up a large proportion of the population age 65 and over, and they are at high risk for heart disease and stroke, various forms of cancer, and the other major killers. An estimated 80 percent of all people with osteoporosis are women. Frailty, hip fractures, and disability in the later years are all more common among women than among men. The majority of nursing home residents are women.

Women's health issues cover a wide gamut, from the strictly medical, such as osteoporosis, to the sociocultural, such as caregiving. This section covers two of the most pressing medical issues, osteoporosis and urinary incontinence. It also discusses menopause, a transition in women's lives with medical, social, cultural, and behavioral dimensions. Other sections in this book discuss frailty and disability (page 35) and caregiving (pages 20, 42).

How Can Osteoporosis Be Prevented ?
Osteoporosis may affect one in four women over age 60 and nearly half of all people over 75. This condition, in which bones gradually lose mass, become thin, and break easily, contributes to 1.3 million bone fractures a year in older people. About 250,000 of these are hip fractures, leading frequently to disability, dependency, and institutionalization. From 12 to 20 percent of those who suffer a hip fracture do not survive the following 6 months.

Studies, most relatively small, have shown that osteoporosis can be prevented. Hormone replacement therapy, which is appropriate for some women, stops or slows bone loss. Calcium supplements and vigorous exercise that puts weight on bones have also prevented bone loss in some studies. But which of these methods is most effective? Which is safest? Do they work better, alone or in combination?

Answers to these questions are on the way. Encouraged by earlier studies, researchers at six university medical centers are now testing exercise, nutritional supplements, and hormone replacement on a larger scale in clinical trials known as STOP/IT (Sites Testing Osteoporosis Prevention/Intervention Treatments). STOP/IT is comparing the three strategies in more than 1,300 women and men age 65 and over. With results expected in 1996, these are the first trials large enough to determine which of the three interventions, alone or in combination, is most likely to work in this age group.

Studies are beginning to collect precise data on the natural history of the menopause, including changes in and interactions between bone density, being measured here, hormonal fluctuations, and body composition.

How Does Menopause Affect Women?
A woman's higher risk of osteoporosis is linked to menopause, a time when estrogen levels fall sharply and bone loss accelerates. The risk of heart disease and stroke also is higher for women after menopause. This is a field, however, where little else is certain.

To the question most women ask at this time - "should I have hormone therapy?"- there is still no unequivocal answer. On the one hand, studies have shown that estrogen reduces bone loss and may reduce the risk of heart disease. On the other hand, questions about estrogen and breast cancer risk remain and are hotly debated. Even questions about the short-term effects of estrogen (to reduce the discomforts of menopause and delay bone loss) and the best way to take estrogen cannot be answered with certainty.

In the search for answers, NIA researchers at the Institute and around the country are looking at menopause from several angles. What actually happens physiologically in the years around menopause (the "natural history" of the menopause) is one focus. Another line of research is comparing the pros and cons of various kinds of hormone replacement - estrogen alone, estrogen with a progestin, progestin taken continuously, progestin taken cyclically.

NIA researchers are looking not only at what happens during menopause, but also at how it happens. The loss of ovarian follicles, the dramatic decrease in estrogens, and the rising levels of follicle stimulating hormone are all well documented. But their mechanisms and fundamental causes remain unknown. A host of factors - in the immune system, the brain, the hormonal system - may be involved and need to be explored.

Menopause is a transition in women's lives with personal and social dimensions, and these too may influence health. Culture and lifestyle, for example, could affect the experience and effects of menopause. In Japan, women report hot flashes and other signs differently and less frequently than in western countries. How much of this difference is due to culture or lifestyle and how much to genetics is unknown.

Attitudes and beliefs about menopause need study. The Institute's Massachusetts Women's Health Study found that many women expect the "change of life" to bring depression and irritability. The evidence, however, suggests that this is not so or at least much less common than believed. Whether or not a woman's - or society's - expectations about menopause influence the way it is experienced is one of many unanswered questions.

From Research to Practice: A Case Study

  The results of NIA research reach far beyond the laboratory. Here is an example of how research findings on urinary incontinence reach people and their physicians.

1982-present: Studies show that about 37 percent of women age 60 and over living in the community - outside institutions - are afflicted with urinary incontinence.¹ About 4 percent of these women (or over 800,000 women) are troubled with severe incontinence (sudden loss of urine associated with exertion, such as coughing or lifting)².

1984-1989: Studies show that women can reduce incontinent episodes.

• Behavioral training - regular, scheduled voiding, such as once an hour and exercising the muscles that control urination - results in approximately an 82-to 94-percent improvement in bladder function in a study at the NIA's Gerontology Research Center³.
  
• A clinical trial at Virginia Commonwealth University, supported by NIA and the National Center for Nursing Research, finds that a program of bladder training reduced incontinent episodes by 57 percent⁴.

1988: The NIH consensus conference on Urinary Incontinence concludes that "contrary to public opinion, most cases of urinary incontinence can be cured or improved⁵."

March 1992: The Agency for Health Care Policy and Research, working with NIA, issues a guideline for treating incontinence that recommends bladder training as an initial therapy, provided a comprehensive clinical evaluation has been done.

July 1992: An estimated 90,000 physicians and nurse practitioners receive a Clinical Bulletin about urinary incontinence, a joint initiative of the National Institute on Aging and the Alliance for Aging Research (copies available from the NIA Information Center at 1-800-222-2225).

1993: Ongoing studies continue to explore ways that older people can prevent or control incontinence both inside and outside nursing homes⁶. Recently it has been shown that approaches successful outsides nursing homes are equally successful with the people in long-term care settings, especially when nurses are enlisted to introduce certain changes in care which foster continence.