Pharmacists play a vital role in assisting women with their healthcare needs throughout all stages of life. In this installment of our women’s health series we look at factors more common in mature females
- Several digestive disorders tend to be more common in older adults—including reflux or heartburn
- The ability of our digestive system to absorb nutrients from food is reduced as we age, making it more difficult to break down and absorb vitamin B6, B12, iron and calcium
- It’s not uncommon for post-menopausal women to experience vaginal atrophy and dryness as a result of the drop in oestrogen levels
As healthcare professionals who are frequently in contact with women, community pharmacists can assist older women to embrace a positive mindset about ageing, as well as address any health concerns they might have.
Not only is it important to encourage regular health checks and screenings, but pharmacists can also help mature female customers to better understand the ageing process and the physiological changes that can sometimes affect their health.
A helping hand with heartburn
While ageing has less effect on the digestive system than it does on other organs, several digestive disorders tend to be more common in older adults—one of which is reflux or heartburn.
Heartburn may not be a direct result of ageing but factors such as the natural weakening of the lower esophageal sphincter, menopause, weight gain, and even medication use (in particular antidepressants, calcium channel blockers and beta blockers) can contribute to the increased prevalence of heartburn in older women.
General practitioner Dr Jill Thistlethwaite explains that acid reflux occurs when the oesophageal sphincter does not close properly. “This allows gastric acid produced in the stomach to enter the oesophagus, causing symptoms such as heartburn and regurgitation. Symptoms of acid reflux are common and can vary in severity.
“A number of other factors can trigger acid reflux in patients and can also be responsible for making symptoms worse. Being overweight can cause acid reflux by increasing the amount of pressure on the abdomen, which in turn can cause the oesophageal sphincter to weaken, allowing the oesophagus to be exposed to higher amounts of gastric acid. Weight loss has been shown to improve symptoms of acid reflux in patients who are overweight and even modest weight loss has been shown to be beneficial.
“Acid reflux is not usually a serious condition and symptoms can be managed with over-the-counter or prescription medicines. Antacids can help relieve symptoms by neutralising the stomach acid. H2-receptor-antagonists on the other hand work by reducing the amount of acid produced by the stomach. Although both H2-receptor-antagonists and antacids provide rapid relief of symptoms in patients with acid reflux, antacids are ineffective in managing symptoms in the long term and should be reserved for the relief of mild or occasional symptoms only.
“Patients who experience frequent symptoms of heartburn (two or more episodes per week) or symptoms severe enough to impair quality of life are considered to have gastro-oesophageal reflux disease (GORD).
“People with GORD are usually prescribed a 4-8 week trial of proton pump inhibitors (PPIs). Although PPIs are generally considered a safe and effective treatment for GORD, some side effects have been associated with their use. Long-term use of PPIs has been associated with an increased risk of gastrointestinal infections, Clostridium difficile, pneumonia, osteoporosis and hip fracture and kidney disease, however, the risk of developing these complications is relatively low.”
Alongside medicines, there are a number of lifestyle measures that can be discussed and may help alleviate the symptoms of heartburn. Recommendations include:
- Eating smaller meals
- Avoiding lying down after eating
- Avoiding eating or drinking for two to three hours before bedtime or vigorous exercise
- Drinking most fluids between meals rather than with meals
- Elevating the bedhead (if symptoms are troublesome at night)
- Decreasing alcohol consumption
- Stopping smoking
- Losing weight
It’s important to reassure women that almost everyone experiences heartburn at one time or another. However, if the symptoms become severe or occur more frequently referral may be warranted.
Dr Thistlethwaite says, “ In some patients, acid reflux can lead to complications or may have more serious causes that require further investigation. Referral may also be needed in patients who do not respond well to treatment, or in those who present with red flags.
“Red flags include recurrent vomiting, difficulty swallowing (dysphagia), unexplained weight loss, vomiting of blood and the presence of an abdominal mass. Patients presenting with these signs and symptoms should be advised to speak to their GP. Patients aged 60 or over with new onset of reflux symptoms and those with a history of gastrointestinal cancer in a first degree relative should also be referred.”
Discussing nutrient needs
As we age our nutritional needs can vary. For example, sufficient calcium intake and vitamin D is essential for bone health. Meanwhile, iron is important for storing and transporting oxygen around the body and supporting immune function.
Danielle Steedman, Blackmores advisory naturopath says, “The old adage ‘you are what you eat’ should actually be ‘you are what you can absorb’. Unfortunately the ability of our digestive system to absorb nutrients from food is reduced as we age. There are numerous changes that occur in the gastrointestinal system that are responsible for this. One such change is the reduced production of acid in the stomach making it more difficult to break down and absorb vitamin B6, B12, iron and calcium.”
Charlene Grosse, advanced accredited practising dietitian at Specialised Nutrition Care, Perth, advises, “73% of adult women in Australia are not meeting the recommended daily calcium intake and nearly a quarter of women fall short on their dietary intake for iron compared to only one in 30 men.”
Nicole Dynan, accredited practicing dietician and owner of The Good Nutrition Co in Sydney, explains, “Adequate intake of calcium is particularly important for women around the time of menopause to help reduce the risk of developing osteoporosis.
“Other people at risk include those who consume large amounts of caffeine, alcohol, carbonated drinks and those taking steroid medications. In addition, calcium deficiency can be found in people with malabsorption problems, such as Crohn’s disease and coeliac disease.
“For most people, however, eating a balanced diet with the recommended intakes from each of the five food groups will provide them with enough calcium to meet their needs. The recommended dietary intake (RDI) of calcium for women over 50 is 1300 mg per day.
“For an extra boost, dairy foods are an excellent source of calcium. If dairy isn’t tolerated, choosing alternative milks with ‘added calcium’ is recommended.”
With regards to iron, Ms Grosse explains, “There are two types of iron obtained from food. Haem iron comes from animal sources and is absorbed more efficiently and in a different way to non-haem iron, which comes from plant-based sources (legumes, tofu, cashew nuts, raw spinach, for example).
“While some foods can help our bodies absorb iron, others inhibit absorption. To help improve iron intake, people should avoid tea, coffee or calcium during or directly after having an iron rich food or fluid.
“Plant foods should be cooked to increase the amount of iron that can be absorbed by the body and eating foods rich in vitamin C with iron-based plant foods can assist absorption.
“Pharmacists can also advise on medications that can interact and interfere with iron absorption. Antacids, proton pump inhibitors and calcium supplements are amongst the medicines known to inhibit iron absorption.”
Signs of iron deficiency can include:
- Tiredness/fatigue (reduced physical work capacity)
- Reduced concentration
- Pale skin
- Increased infections (reduced immunity)
While mature women need less iron than their younger counterparts, it’s still important they are getting an adequate supply to reduce the risk of anaemia. The RDI for females aged 51 years and above is 8mg per day.
In the same way that our skin changes as we age, a woman’s vagina alters throughout the different life stages. For example, it’s not uncommon for post-menopausal women to experience vaginal atrophy and dryness as a result of the drop in oestrogen levels.
Dr Michele Kwik, gynaecologist and member of the Australasian Menopause Society, explains, “When eggs are being produced and the ovaries are working, they’re making oestrogen, which protects our heart, bones and keeps the vagina healthy.
“When we reach the age of menopause we run out of oestrogen and that’s when all the changes start to happen; it’s a reflection of low oestrogen levels. So when women go through menopause they start to catch up to men in terms of the risks of heart attack and stroke, the bones get brittle and they might get these urinary and vaginal symptoms.
“When you lose oestrogen the vaginal skin gets very thin and easily irritated. Lots of women will start to complain about vaginal dryness and irritation and they might start to get more urinary infections.”
“Pharmacists can talk to women about optimal vaginal care. Suggest steering clear of soaps and taking a shower rather than a bath, as sitting around in soapy water can lead to irritation.
“Recommend the use of non-fragranced body care products, cotton underwear and suggest they refrain from using panty liners or pads, as these do not allow the skin or vagina to breath.
“You can also recommend using a topical oestrogen cream. This is applied to the outside of the vagina and a little bit inside; the nerve endings of the vagina are on the lower third which indicates how high the cream needs to go. It can be applied nightly for a couple of weeks before dropping back to using it twice a week.
“Urinary tract infections can also be more common post menopause due to the low oestrogen levels. This causes the vaginal and urethral walls to become dry, fragile and more easily irritated. The use of vaginal oestrogen cream can be helpful in reducing the risk of recurrent urinary tract infections.”
While vaginal health might not be the easiest conversation to have, it’s important for pharmacists to normalise the discussion and advise women of the treatments available.
Indeed, if left untreated vaginal dryness can lead to painful intercourse (dyspareunia). “It’s important to recognise that dyspareunia can have many causes, can be superficial or deep, acute or longstanding, due to many things including atrophy, infection, lack of arousal or surgical, psychological or dermatological causes. It can have a big impact on quality of life and should be approached in a sensitive and constructive way,” says Mary Stewart, senior medical officer—research and education at Family Planning NSW.
“If the dyspareunia is caused by vaginal dryness, then there are different ways to manage it. Sometimes a water-based lubricant is all that is needed but there are also vaginal moisturisers that are used regularly, rather than at the time of sex. If the dryness is due to atrophy related to low oestrogen associated with menopause then local oestrogen treatment might be the best option.”
Ms Stewart adds, “It’s important for the woman to be examined to ensure the correct diagnosis. There are other dermatological causes of dyspareunia that need to be excluded or managed appropriately, such as lichen sclerosis.”
Through positive communication pharmacists can help women to recognise that not all the physical changes associated with menopause and growing older are negative.
Mature women can be encouraged to take stock of their current health status and make positive changes to maintain or improve their general wellness to help ensure a healthy future.