Health screening in midlife

Screening means testing for a problem before it causes symptoms, so it can be caught early. In midlife the list is mostly about the heart and blood vessels, blood sugar, bones, and breast and cervical cancer.

The Pakistan Menopause Society's recommendations note that women may come to a doctor at menopause with period problems, symptoms or for a general check-up, and call that visit a chance for opportunistic screening. Table 1 of the recommendations spells it out: use the menopause visit for prevention, and check blood pressure, body weight, fracture risk, blood sugar, cholesterol and tobacco use.

Midlife is when several risks start to climb at once, and the guidelines are careful not to blame it all on hormones. The PMS recommendations ask doctors to avoid implying that all midlife disease comes from falling estrogen: age, lifestyle and other conditions play their part.

For South Asian women this matters more. NICE says people of a South Asian background are prone to carrying fat around the middle, and that their risk of heart disease and diabetes rises at a lower BMI (NG246 1.9.11). The Pakistan Menopause Society also lists endemic vitamin D deficiency and a high burden of osteoporosis among the challenges in Pakistan (section 4.1).

In the Pakistan Menopause Society's recommendations

Table 4 of the recommendations sets out investigations and screening by area. In our own words:

• For the heart and metabolism, a fasting blood sugar or HbA1c test and a cholesterol profile may be considered according to age, risk and affordability. High blood pressure, diabetes, raised cholesterol or chest pain should be investigated and referred.
• For bones, doctors are asked about falls, fractures and height loss, and to consider a DXA bone density scan where available for women at higher risk, such as those with a previous fragility fracture, early menopause, long-term steroid use or repeated falls.
• For breasts and the cervix, screening suited to age and risk, and a mammogram every three years after the age of 50. A breast lump, nipple discharge or skin change needs prompt assessment, not a wait for the next screen.
• For mood, validated questionnaires to screen for depression and anxiety at menopause consultations (section 4.2.4.6).

At a baseline visit, they ask for blood pressure, BMI and, if possible, waist measurement. Breast and pelvic examinations are done when symptoms, risk or screening call for them, not routinely for every woman.

In the UK

NICE NG23 asks doctors to talk about keeping up to date with national screening (1.9.1). In England, the NHS website describes the NHS Health Check for adults aged 40 to 74 who do not already have heart disease, diabetes, stroke or certain other conditions. It covers height, weight and waist, blood pressure and cholesterol, sometimes blood sugar, and questions about family history and lifestyle. The NHS says your GP or local council should invite you every five years, and if you have not been invited and think you are eligible, you can contact your GP practice. For cervical screening, the NHS invites women aged 25 to 64 in England every five years, and its test checks first for HPV, a virus that can change the cells of the cervix. Tests differ, so ask your doctor which one you are offered and how often it should be repeated.

The Gulf states run their own screening programmes, with their own ages and costs. Your doctor will know which apply where you live.

If you cannot remember your last blood pressure reading, cervical screen or mammogram, that is reason enough to ask at your next appointment. Bring what you know about your family: heart attacks and strokes, blood clots, broken hips or osteoporosis, and cancers such as breast or ovarian cancer, with the age each one happened. The PMS recommendations list family history of heart disease, blood clots, osteoporosis and cancer among the history a doctor should take (Table 2).

On HRT? The Menopause Society says some types of HRT may make breasts look denser on a mammogram, which can make the image harder to read and lead to extra mammograms or biopsies.

Some findings should never wait for screening. A breast lump, bleeding after menopause, chest pain or sudden breathlessness needs a doctor promptly, whatever your screening dates say.

In many families, a woman's health check is the one that gets postponed: the children's appointments come first, then her husband's, then her parents'. A screening test is quick, and it is easier to keep looking after everyone if someone has looked at you too.