Women’s Health by the Decades

By Megan Willome

Part III: The 40s — Fast and furious

Pictured: Photo by Cecy Ayala

This month the Wacoan continues a series on women’s health, one decade at a time. We consider the 40s, a midpoint when most women are still relatively healthy while experiencing the changes that come as the childbearing years draw to a close.

Patricia Horner Wilcox, M.D., calls the 40s “your fast and furious 40s.” It’s a decade in which a woman may go from having a child straight into menopause. It’s a time when life is busy with career and family. And it’s a season when many a woman begins to take stock of her life: Is she happy? What might she need to change to become happier?

“This can be a great reflective time, an introspective time, a good pit stop in our lives if we have some unfinished business,” Wilcox said. “The 40s can be a very exciting time for the better.”

One reason Dr. Wilcox is so interested in questions like these is because she’s always been interested in people. She majored in psychology at Baylor University before going to McGovern Medical School at University of Texas Health Science Center. She did her residency in family practice in Waco at the Family Health Center. Now she works both at Ascension Medical Group Providence at Sanger Avenue and at Sanger Avenue Aesthetics, which she started in 2005.

Wacoan writer Megan Willome spoke with Dr. Wilcox by phone to learn how midlife resembles adolescence, what women should know about hormonal changes and why women are so darn great.

WACOAN: What are some of the concerns you hear from women in their 40s?

Wilcox: I like to think of the 40s as your fast and furious 40s. It’s an interesting time zone because in the early 40s, and even to late, it’s still a childbearing time. It’s definitely on the later end, but I can think of three patients recently who have had babies in their 40s, whether from fertility issues or they wanted a large family or they’ve gotten together with a spouse at a later age or had career or schooling that made it to where they postponed childbearing, and now is the time for them.

It’s usually not a time people purpose for [childbearing], in their 40s, but you never know when you’re going to go through perimenopause or menopause, and then you may need artificial means [to become pregnant]. It’s an interesting decade because of that.

I had a patient who had a baby, several years ago, then was immediately in menopause at 42. That’s why I think it’s a fast and furious time.

WACOAN: What else makes the 40s unique?

Wilcox: A lot of times people do have children or are at the height of their careers and are involved heavily with activities, so it’s also a time where we see medically that they maybe don’t have time to exercise or watch their diets. Patients talk about grabbing fast food on the way to the ballpark to watch a kid’s practice. We see a lot of concerning things that can start coming up [in the 40s]. Good genetics maybe can’t help ward off everything anymore. People who have never had trouble with weight because they’re so active in sports and athletics, now are having more difficulty. It’s a good time to come in for a tune-up.

WACOAN: What screenings do you recommend?

Wilcox: In this early midlife area, we recommend mammograms at age 40, doctor’s breast exams, Pap smears. The Pap smear guidelines have changed through the years. We used to recommend them every year, but now, depending on some of the outcomes of your results, now it’s every three years and every five years for HPV testing (if they still have their cervix, if they haven’t had a hysterectomy).

It’s a good time to come in and see your doctor about weight, cholesterol, check blood sugar, check blood pressure. For females in their 50s and 60s, we start seeing events — like cardiac events. If we get people in to the doctor in their 40s, we can start strategizing things that might cause them problems later on.

There may be more things that would be checked, like vitamin D, thyroid. Family history may dictate other screenings. If there’s a strong family history of colon cancer, we don’t typically recommend a colonoscopy in the 40s, but we may recommend it if a family member was young when they had colon cancer. We’d want to do it 10 years before that [family member’s] diagnosis. We might do Cologuard testing [an at-home kit for colon issues]. It’s very important that they come in and talk with the doctor to individualize things with their family history and their past history that we need to be looking at.

WACOAN: What menstrual changes should a woman bring up with her doctor?

Wilcox: In pertaining to bleeding and irregularities, the question any woman in her 40s should bring up is any question you have. I have patients say, ‘I bet you don’t like a list,’ but I love a list. It helps the patient gather the thoughts of what’s bothering them.

Like most physicians, I can scan someone’s list pretty fast. Often it includes questions about whether there’s too much bleeding, too little, change in intercourse, dryness, leakage. Then in keeping with that I’m able to decide whether they would benefit from hormones. Sometimes hormones can be placed, things like IUDs, [intrauterine devices]. We look at risks with [hormones]: Do they have a family history of breast cancer? Have they had blood clots in the past? We’re presenting all the different options for them.

We do get a lot of questions about it. Some people become overachievers, two periods a month. Some have their last period and then never have another. Many in between have irregularity.

WACOAN: A lot of concerns women have in this age range stem from decreased estrogen, which is to be expected, correct? Regardless of what stage of perimenopause or menopause you’re in?

Wilcox: Yes, but not everyone’s path is the same, physically, on how they feel. I had a patient in her 90s who said she’d always had hot flashes all her life. Some people waltz through without any hot flashes and feel great, but other people have hot flashes, flushing. They notice their skin is dryer, notice decreased energy.

Depending on the severity, decreased estrogen can cause more dryness vaginally, can cause different types of infections and create more pain. Sometimes a woman has a general feeling of depression and anxiety about how everything else is going with her. But it’s not every person, just like not every person after they deliver a baby will have a huge mood swing — some people do though.

There’s been a lot of use of alternative hormones that I think, depending on who’s providing them, alternative things can cut both ways. Just like weight loss products: There can be some snake oil salesmen. You have to be sure that what you’re getting makes medical sense and you know what the side effects are. If someone is doing certain kinds of hormones, [the doctor] needs to make sure they’re rechecking the levels.

WACOAN: What can you tell me about hysterectomies — when they are recommended, when they’re not, and what women should expect in terms of recovery?

Wilcox: I don’t do them. I defer to the OB-GYN.

One of the big ones that’s life-threatening is endometrial cancer. You’d see a gynecological oncologist. If someone thinks they’ve gone through menopause and then has any kind of bleeding, notify your doctor immediately. Post-menopausal bleeding is assumed to be endometrial cancer unless proved otherwise.

Sometimes a hysterectomy will be done if there’s a lot of fibroids, if there are reasons a patient can’t be on hormones. Sometimes also if someone’s had breast cancer and is still at the point where they’re not in menopause, the oncologist may be recommending hysterectomy and removal of ovaries.

Sometimes it can be done for spotty bleeding, but now OB-GYNs have such advanced techniques. [Ascension Medical Group Providence Women’s Health] is always coming up with new procedures. They’re trying to do less and less major surgery; they may do ablations, [removing layers of tissue], instead. If you’re a menstruating female and you’re anemic, we try to get that under control.

The crazy thing with it is over the years I’ve been practicing, with the hysterectomy, people are back to work so fast. It’s not as big of a procedure as it used to be. Because they can do some of these less-invasive procedures, they try to do those before [a hysterectomy] or use medicines that can help. They’ll do it in rare times for pain, but that’s more of a rarity.

WACOAN: Let’s talk about menopause, even though not every woman will enter it in her 40s.

Wilcox: Some of our traditional medicine, in menopausal time, isn’t great. Some of the hormone creams, even vaginal creams, are so expensive. We’re in a time where we have to look at each individual person and determine what’s best for her. Your family doctor or OB-GYN can be helpful with that.

I used to say that when someone was going into menopause they should be on Premarin [estrogen] and Prozac [antidepressant]. A lot of women near the end of their 40s may be approaching menopause or perimenopause, and there can be a lot of depression and anxiety, sometimes from psychological things going on with the patient or from physical things.

Also during this time there’s a lot of stress. People say, ‘Why am I doing this? Why didn’t I do that? What’s my purpose in life?’ Stress within marriages. Even stress with what I might call ‘buyer’s remorse’ in relationships they’re in. In the 40s is a good time to take a deep breath: ‘Am I happy with what I’m doing? Am I helping others? Is my priority in life power, money, prestige?’ In light of Lent and Easter, ‘Are my priorities in line with my faith? Do I have a faith?’

WACOAN: So it’s a time for re-evaluation.

Wilcox: I see a lot of people, adolescents in their early 20s and someone in their early 40s, who they both start asking, ‘Is this everything I thought it would be?’ It’s a powerful time to talk with a physician. If depression is hormonal, if it’s clinical, there are medications. Sometimes they need a counselor to talk to. Sometimes it’s referring them to different support groups — we’re so fortunate in Waco. I’m a Christian, and there are so, so many good strong Christian groups.

The 40s is a big time when people see another fork in the road. We always want people to stay in good relationships, but sometimes if it’s an abusive relationship, we’re trying to help someone figure out the next steps in their life, and sometimes that helps them physically.

WACOAN: Do some patients have difficulty talking about these concerns?

Wilcox: Women a lot of times will say they have decreased libido and [ask] what’s wrong with them. That’s more of a norm. If intercourse is painful, you may learn that’s not something you want to do.

A good family doctor, when you go in [to talk about these things], is not going to be surprised. People have a rash on their buttocks, and they apologize because they think that’s going to shock me, but it doesn’t shock me. They apologize when they’re going through depression or anxiety because they feel ashamed, and we don’t feel differently about them. Those are just as important of issues for us to hear and help heal. You can bring all that up. A good physical exam in your 40s is an important point to do that.

WACOAN: I’m glad you’re bringing up mental health issues because I think it’s not talked about enough for women in this stage of life.

Wilcox: When people are in adolescence or in their 20s and have been through abusive things, they, as a coping mechanism, sometimes can’t talk about it. Unfortunately they may make decisions to use alcohol and drugs, have multiple sexual partners. A lot of times in their 40s I see people that start realizing they’ve been upset, and it hearkens back to former abuses that now psychologically they’re able to deal with. They’ve got that maturity that they’re ready to not blame themselves and are ready to deal with some of the pain they went through. They feel like they’re in a safer environment, feel more in control. Things people have been holding onto — bitterness, pain from childhood — that can be dealt with.

And while they’re dealing with that pain, if they’re getting wrinkles, we can do Botox on them.

WACOAN: I know that’s something you offer at Sanger Avenue Aesthetics. How do you divide your practice between there and Ascension Providence?

Wilcox: It’s not an even division. I’m full time with Ascension Medical Group Providence at Sanger. On the off hours I’ll do Sanger Avenue Aesthetics. We’re more like a boutique for aesthetics. I want to make sure we pay specific attention to people and are not worried about large quantities of patients — we want to do good work on people individually.

I’m also board-certified in obesity medicine. We’ll be expanding some things with that [at Sanger Avenue].

WACOAN: I didn’t know obesity medicine was something a physician could be board-certified in.

Wilcox: Yes. We use a sculpture machine [WarmSculpting with SculpSure] that is a fat laser that goes to fat sources, a warm sculpting machine.

Also something exciting in aesthetics is the MonaLisa Touch, [a laser machine for in-office gynecologic procedures]. It helps with vaginal dryness, vaginal laxity, urinary leakage, painful intercourse.

WACOAN: I’ve never heard of it. What is it, this machine?

Wilcox: It’s a CO2 fractional laser. It has a vaginal probe and an exterior probe. We’re having a lot of great success for people who can’t take hormones. The FDA is always funny about wording, but it helps increase collagen in the perineum and vaginal area. It’s a series of procedures. There are other machines that do it, but it’s made purposefully for that.

WACOAN: I want to talk about some other changes women see in their 40s, including skin, hair and eyes.

Wilcox: What we see in the 40s, in regard to skin changes, you do tend to see more laxity in skin, more wrinkles, more sun-damaged areas, so be applying good sunscreens and good makeups with sunblock in them. If in our adolescent and teen years we were doing baby oil and iodine, then we’re looking for melanomas. Even if there aren’t cancers, you can tell people who have been out in the sun — of course, walking out to your car in summer in Texas you get sun. We encourage floppy hats.

For hair, it’s around in your 40s that women worry about hair loss. My hairstylist won’t want me talking about this, but thinning can come from hair that’s been stripped too much or from intricate braids that tear hair. It’s important to use good products. Thinning — stress can do that, thyroid can do that. It’s also sometimes where you can look at pictures of your mother and her mother and see balding in the family, genetically. There’s not an easy solution. There are some biotin-type things, but those can affect the liver if done in too high dosages. Even dermatologists don’t like to do a ton with hair. If you’re not childbearing, you can use over-the-counter Rogaine products, but there’s some risk, and when you stop them, the hair will come out.

Eyes — it’s tied a lot to your health. Typically the ophthalmologist will say in their 40s that people will need readers [reading glasses]. But if they have high blood pressure or diabetes, they need their eyes checked. If your vision goes out for a moment, you need to be checked out. There can be retinal detachment or something else — those aren’t as common in the 40s, but the eyes can be a barometer of your health. It’s good for an ophthalmologist to have a look, have your eyes dilated. Ophthalmologists and optometrists will get a better look at the eyes with their machines.

WACOAN: What has surprised you about the 40s?

Wilcox: It’s a foreshadowing for people [when they] go through retirement. In the 40s that’s a road sign for us who are married and in relationships. I do see down that road, which I didn’t know about 15 years ago.

When people start retiring and husbands are coming home, there are a lot of problems. They don’t know how to relate to each other. Men come home from high-powered jobs and are suddenly going to tell the wife what she should be doing in the kitchen that she’s been doing all those years they’ve been together. Husbands are not as good at having friends, so the husband may be trailing [the wife] like a puppy.

Because we’re so busy, it’s easy to not take time out with your spouse or good friends. If in our 40s we still have good relationships, we need to work through them and problem-solve and find close friends and something you can do as a couple so you’re not meeting a stranger when you retire.

WACOAN: What would you like to tell women in their 40s?

Wilcox: I remember when I turned 40 and felt down for a couple hours, then I realized, who cares? I’m thankful God let me live till I’m 40. There are so many strong women doing great things who look fantastic and feel fantastic.

The 40s are an exciting decade, so they just need to be embraced. You’re old enough to have experienced a lot of things and matured from a lot of things, and you’re not as fearful of as many things in life. You’re thankful for a lot of the decisions you’ve made, and if you’re not, you still have time in your life to change them.

The key thing is to embrace where you are in life. The Bible talks about when you put your hand to the plow, don’t turn back — meaning enjoy where you are. Be thankful. Some women say, ‘I wish I was in my 20s,’ and I say, ‘Do you really?’ Each decade has trials of its own. I think the strength in your 40s is that you have maturity and most people are able-bodied and able to enjoy life and relationships and typically have a lot of time that you can change things if you don’t like them.

We as women are more complicated than men, but that also makes us so fun and so great.