Please note: This archive was last updated in 2005.

RHO archives : Topics : Older Women

Key Issues

This section provides summaries of issues related to the health and health needs of older women. Click article references to read article abstracts from the Annotated Bibliography. Also see the Program Examples for more information.


Population aging and health

Because the number of women over age 50 will grow rapidly in developing countries over the next three decades (Hill 1996; Bonita et al. 1996), health issues related to aging are receiving increased attention (Delmas and Fraser 1999). Women already outnumber men in the over-60 age group in developing countries, and they will increasingly dominate in years to come (Bonita et al. 1996). Women enter old age carrying the burden of gender disparities, including chronic health problems associated with childbearing, poverty, widowhood, vulnerability to violence, and the burden of caregiving (Kane 2001; Pratt 1997; Senanayake 2000). Added to this is discrimination against older people by every element of society, including health care personnel (HelpAge 2002), and chronic health problems that develop with hormonal changes at menopause (Bonita 1998; Senanayake 2000).

More attention must be paid to the health problems of older women in developing countries so that they can remain healthy and active even as they grow older (WHO 2002). Key health issues for older women include life-threatening cardiovascular conditions and cancer, disabling conditions such as osteoporosis and incontinence, and mental health disorders such as dementia and depression (PATH 1997; Hill 1996). Addressing the health needs of older women requires a multidisciplinary approach that addresses government policies, public awareness and attitudes, and social services, in addition to the health care delivery system (Simon and Dong 2003). Programs should recognize that men also face challenges as they age; indeed, an over-emphasis on gender may undermine efforts to help the elderly (Knodel and Ofstedal 2003).

Top of page

Chronic gynecological and urinary problems

Studies in developing countries have found that women carry a heavy burden of gynecological and urinary problems throughout their reproductive years and into later life, in part due to the limited medical care they receive during labor and delivery (Kane 2001; Ashford 2002). Common problems include menstrual disorders, urinary and reproductive tract infections, stress urinary incontinence, cervicitis, and uterine prolapse (Al-Qutob 2001; Bang et al. 1989; Bhatia et al. 1997; Deeb et al. 2003; Walraven et al. 2002; Younis et al. 1993). Obstructed labor, which may last for several days where women lack access to modern health care facilities, leads to the most serious complex of problems (Cron, 2003). These include fistulas, bladder problems, PID, amenorrhea, infertility, and nerve damage. The loss of fecal and urinary control associated with fistulas can transform women into social outcasts; childlessness also contributes to high rates of divorce among these women (Arrowsmith et al. 1996; Wall 1999; Wall 2002).

Improving access to and the quality of obstetric care may prevent many chronic gynecological problems. For example, prompt access to emergency obstetric services can prevent fistulas, and pelvic floor muscle training during pregnancy may prevent subsequent problems with urinary incontinence (Morkved et al. 2003). Also important, however, is combating the gender inequities and social problems that contribute to these conditions, including early age at marriage, poverty, and malnutrition (Hilton, 2003; UNFPA 2002; UNFPA and EngenderHealth, 2003).

Many women in developing countries do not seek help for their gynecological problems. Some consider their symptoms to be normal, while others do not realize treatment is available, are embarrassed to discuss their symptoms with a provider, or cannot afford treatment (Kumari et al. 2000; Parikh et al.). Thus it is essential to educate and empower women so they seek appropriate care (Walraven et al. 2001). At the same time, health care providers may need training to identify and appropriately treat these problems (Bonetti et al. 2004). Genital prolapse, for example, can be treated with Kegel exercises, pessaries, or surgery (Poma 2000; Thakar and Stanton 2002), and there is an even wider array of options to treat urinary incontinence, including inexpensive physical and behavioral therapies such as bladder training, pelvic floor muscle exercises, and biofeedback (Berghmans 2000; Cammu et al. 2000; Piya-Anant et al., 2003; Siu et al., 2003; Subak et al. 2002; Weatherall 1999; Weiss and Newman 2002). Fistula repair has proven more successful when conducted in centers specializing in appropriate surgical techniques, psychological counseling, and social rehabilitation (UNFPA 2002) (see program example from Ethiopia).

Top of page

Breast cancer

While the incidence of breast cancer is generally lower in developing than developed countries, rates are rising because of reproductive, lifestyle, and socioeconomic changes as well as the aging of the population (Collaborative Group 2002; Forbes 1997; Gao et al. 2000). Age is the single most important risk factor for breast cancer, but other risk factors include early age at menarche, late age at menopause, older age at first childbirth, short duration of breastfeeding, family history of breast disease, use of oral contraception or hormone replacement therapy, exposure to radiation, alcohol consumption, and possibly diet and exercise (Collaborative Group 2002; Hirose et al., 2003; Lee et al. 2003; Lipworth et al. 2000; Matthews et al. 2001; McPherson et al. 2000; McTiernan et al., 2003; Pathak and Whittemore 1992). Concerns that induced abortions increase breast cancer risks have proven unfounded (Bartholomew and Grimes 1998; Collaborative Group 2004; Davidson 2001; Paoletti et al., 2003; Ye et al. 2002).

Since little can be done to prevent breast cancer (Vogel 2000), interventions have focused on detecting tumors in their early stages, when they can be more easily and effectively treated (Miller 1996; Schwartsmann 2001; Vorobiof et al. 2001). This strategy, which is known as downstaging, can be especially valuable in developing countries where women generally present with later stages of breast cancer (Hoffman et al. 2000; Sankaranarayanan et al. 1999). Raising public awareness of breast cancer can help overcome many of the barriers to early detection, including lack of knowledge and social stigma (Braun and Itano 2001; Nzarubara 1999), although access to health care also plays a role (Modeste et al. 1999). The 2002 Global Summit Consensus Conference on International Breast Health Care has recommended that early detection efforts in low-resource settings begin with public education and awareness activities (Anderson et al. 2003). These can contribute to downstaging by teaching women to visit providers when they first note signs or symptoms of breast cancer and by teaching providers to respond promptly to such symptoms. Mass screening programs, however, are the most effective way to detect tumors early, and the Global Summit recommends adding mammographic screening as soon as resources permit.

Mammography, which uses x-rays to detect tumors and anomalies in breast, is the only screening method so far proven to reduce mortality (Bjurstam et al. 2003; Duffy et al. 2002; Humphrey et al. 2002; Klemi et al., 2003; Nystrom et al., 2002; Otto et al. 2003; Tabar et al. 2003), although there is considerable debate about its benefits (de Koning, 2003; Olsen and Gotzsche 2001; Miller et al. 2002). Because it requires sophisticated machinery, continuing supplies of films and chemicals, skilled technicians, and experienced radiologists to achieve reasonable levels of accuracy, mammography may not be feasible in limited-resource settings. A more suitable alternative may be clinical breast examinations—that is, manual palpation of the breast by specially trained health workers (Barton et al. 1999; Mittra et al. 2000). Clinical breast examination is less sensitive than mammography and may contribute little to early detection when added to a mammography screening program (Bancej et al. 2003), but studies suggest that it may offer substantial benefits where resources are limited and regular mammography screening is not feasible (Albert and Schulz 2003; Miller et al. 2000; Zotov and Shyyan 2003). As yet, no randomized trials of clinical breast examination alone have been conducted to test its impact on mortality. The Global Summit recommends that clinical breast examinations should be part of routine health examinations but should not form the basis for a screening program (Anderson et al. 2003). Studies suggest that this approach offers benefits, but no trials have been conducted to test its impact on mortality (Miller et al. 2000). Breast self-examination (monthly palpation of the breasts by women themselves) has not been shown to reduce breast cancer mortality rates (Baxter 2001; Hackshaw and Paul 2003; Thomas et al. 2002), although research continues.

Where the incidence of breast cancer is low, the costs of mass screening outweigh its benefits, and other more pressing health problems should take priority (Leung et al. 2002; PATH 2002; Reichenbach 2002). Any activities directed to breast cancer should focus on palliative care for women diagnosed with breast cancer, including psychological support, information needed to make informed decisions, and relief from symptoms such as pain (Bishop et al. 2001; Shapiro et al. 2001). Where the incidence of breast cancer is higher, the top priority is to ensure that diagnostic tests and effective treatments are accessible and affordable for women with symptoms—which is a major challenge for many low-resource countries (Holcombe et al. 1999). Only after diagnostic and treatment services are in place should a program consider instituting mass screening.

Top of page


Osteoporosis and its major complications, hip and spine fractures, affect one in three postmenopausal women and will become an increasingly important problem in developing countries as the proportion of the population over age 65 increases (Delmas and Fraser 1999) and as changes in diet and exercise associated with socioeconomic development lead to higher incidence rates (Lau 2002; Koh, 2002).The incidence of osteoporosis and associated fractures varies widely between and even within countries. While risks are at least twice as great for women as men in the United States and Europe, elsewhere the gender gap may be smaller (Cumming and Melton 2002). Risk factors for osteoporosis include low body-mass index, low calcium intake, little physical exercise, and smoking, whereas childbearing and breastfeeding may be protective (Cure-cure et al. 2002; Huo et al., 2003).

The key to prevention is diet and exercise: adequate calcium and vitamin D consumption and exercise early in life help build optimum peak bone mass, while later in life they reduce the rate of bone loss after menopause (Atkinson and Ward 2001; Chien et al. 2000; Iqbal 2000; NAMS 2001; Picard 2000). For example, one large-scale prospective study has found that walking four hours a week reduces the risk of hip fracture by 41 percent (Feskanich et al. 2002). In postmenopausal women at low risk of fractures, lifestyle changes may be all that is needed to manage osteoporosis (NAMS 2002). In women at high risk, who have a history of fractures and/or low bone-mineral density, drug therapies may also be needed. Selective estrogen receptor modulators (SERMS), bisophonates, and calcitonin offer alternatives to hormone replacement therapy that may be safer for women (Altkorn and Vokes 2001; Delmas 2002; Sherman 2001). Screening women for bone mineral density is expensive, however, as is treatment. Simple self-assessment tools, based on age and weight, may reduce the number of women who need bone mineral density tests (Geusens et al. 2002; Kung et al., 2003), but screening programs of any kind may not be feasible or appropriate for developing countries where resources are limited and incidence rates are low (Hui 2002).

Top of page

Contraceptive choices for older women

Women remain fertile until and even beyond menopause, but physical and lifestyle changes dictate different contraceptive choices for older women (Best 2002; Shabaan 1996). Low-dose oral contraceptives (OCs) may be a good choice for healthy, nonsmoking, menopausal women without risk factors for cardiovascular disease, because OCs may reduce bothersome symptoms associated with the menopausal transition (such as irregular menstruation and hot flashes), increase bone density, and reduce women's long-term risk for osteoporosis (Burkman et al. 2001; Kaunitz 2001; Michaelsson et al. 1999; Seibert 2002). They do, however, have the disadvantage of masking the onset of menopause. Researchers in Thailand are testing the use of OCs as an inexpensive and effective alternative to hormone replacement therapy (HRT) (Taechakraichana et al. 2000) and vaginal estrogen creams (Chompootaweep et al. 1998) for postmenopausal women.

There have been concerns that DMPA injectables reduce bone density and thus may not be a good choice for older women (Berenson et al. 2004; Cromer 1999; Scholes et al. 2002). These losses are reversed after discontinuing the method (Scholes et al. 2002), however, and after menopause long-term DMPA users experience less bone loss than other women (Cundy et al. 2002). DMPA also protects against uterine fibroids, but it may exacerbate the unpredictable bleeding patterns that older women frequently experience (Best 2002).

Although the IUD offers the long-term protection many older women want, it may increase their already heightened risk of uterine bleeding. Also, fibroids may prevent proper placement of the device (IMAP 1997; Shabaan,1996). Irregular menstruation and ovulation make natural methods more problematic as women age. An alternative is the levonorgestrel intrauterine system (LNG-IUS), which continuously releases progestin into the uterus. This reduces excessive menstrual bleeding and can protect the endometrium of older women on estrogen replacement therapy for menopausal symptoms (Best 2002; Wildemeersch et al. 2002).

Barrier methods may be a reasonable choice for older women since they offer lubrication when vaginal dryness is a problem and their lower levels of effectiveness are not as important for older, less fertile women. Irregular menstruation and ovulation make natural methods more problematic as women age, although older couples may be more likely to follow instructions carefully and abstain from intercourse when called for (IMAP 1997).

For a chart summarizing the advantages and disadvantages of various contraceptive methods for older women, see FHI's "Contraceptive Considerations for Older Women" ( For a more detailed discussion of each method, see RHO's Contraceptive Methods section.

Top of page


Because of social, cultural, and physical differences, women do not necessarily experience the same menopausal symptoms and health risks in different areas of the world (Lock and Kaufert 2001). During the transition to menopause, known as perimenopause, women may experience vasomotor, urogenital, and psychological symptoms as well as sexual dysfunction. However, the prevalence of each symptom varies widely between countries (Damodaran et al. 2000; Dennerstein 1996; Frackiewicz and Culter 2000; Gelfand 2000; Soares and Cohen 2001).

Generally, women in developing countries tend to view menopause and its symptoms as a natural process that does not require medical care, and they know little about health issues related to menopause (Defey et al. 1996; Mashiloane 2001; Wasti et al. 1993). Their reluctance to seek treatment has been reinforced by health care systems that focus on fertility issues and marginalize older women (Bavadam 1999). This situation is beginning to change, however, as doctors share a more negative view of menopause with their patients and encourage older women to consider medical interventions (Chirawatkul et al. 1994; Haines et al. 1995). As a result, educated women from higher social classes in developing countries are beginning to consider menopause a health problem and seek treatment for it, although they may not fully understand it (Obermeyer et al. 2001; Taechakraichana et al., 2003).

There are many possible therapies for menopausal symptoms, including oral contraceptives, various hormone preparations, and herbal remedies (Lobo 1999). Some medical experts, however, have concluded that most women do not require treatment for menopausal symptoms. Rather they see perimenopause as an opportunity for counseling on exercise, diet, nutrition, stress-reduction, and other lifestyle changes that can minimize future health problems (Frackiewicz and Culter 2000; Clinical challenges 2000). Questions also have been raised about the importance of hormonal factors for womens long-term health, based on worldwide epidemiological data on cardiovascular disease, osteoporosis, and dementia (Meyer 2001).

Top of page

Hormone replacement therapy

Recent studies, most notably the Womens Health Initiative (WHI,, have overturned a long-established consensus about the benefits of hormone replacement therapy (HRT) (NHLBI 2002). While observational studies suggested that HRT protected women against cardiovascular disease and other serious health problems, these results were due to systematic selection biases: women who chose to use HRT were healthier, more affluent, and better educated than other women (Grimes and Lobo 2002). In contrast, unbiased randomized clinical trials have found that HRT actually increases womens risk of cardiovascular disease and stroke (Grady et al. 2002; Grodstein et al. 2001; Heckbert et al. 2001; Herrington et al. 2000; Hulley et al. 2002; Holbraaten et al. 2000; Manson et al., 2003; Wassertheil-Smoller et al. 2003; Writing Group 2002). Most recently, the Women’s Health Initiative confirmed an increased risk of stroke for women on estrogen-only as well as combined hormone therapy (Anderson et al. 2004).

Results from the Women’s Health Initiative (Chlebowski et al. 2003) and Britain's Million Women Study (Million Women Study, 2003) confirm earlier studies showing an increase in risk of breast cancer among HRT users (Chen et al. 2002; Colditz and Rosner 2000; Li et al. 2000; Ross et al. 2000; Schairer et al. 2000), although the increased risk of breast cancer seems to be confined to combined estrogen-progestin therapies (Li et al. 2000; Li et al. 2003). The WHI also found that the tumors in HRT users were similar in type but detected at a more advanced stage than those in the placebo group, suggesting that combined HRT both stimulates the growth of tumors and makes them harder to detect (Chlebowski et al., 2003). This contradicts previous studies suggesting that breast cancers in HRT users are detected earlier and have a better prognosis, but these observational studies suffer from methodological weaknesses (Antoine et al. 2004). In contrast, previous studies had suggested that breast cancers tumors were detected earlier (Gajdos et al. 2000) and of a more favorable type (Manjer et al. 2001), leading to a better prognosis. The WHI found no significant impact of HRT on endometrial and ovarian cancers (Anderson et al., 2003), in contrast to smaller studies which have found HRT increases the risk of both (Fernandez et al., 2003; Jain et al. 2000; Lacey et al. 2002; Rodriguez et al. 2001).

A smaller arm of the WHI has found that that both estrogen-only and combined hormone therapy increase the risk for cognitive decline and dementia among women over age 65 (Espeland et al. 2004; Rapp et al. 2003; Shumaker et al. 2004; Shumaker et al. 2003). Case-control, observational, and prospective studies, while suffering from methodological limitations, leave open the possibility that estrogen-only therapy or hormone therapy at an earlier age might have positive effects on cognition and prevent dementia (Fillit 2002; Hogervorst et al. 2000; LeBlanc et al. 2001).

HRT does hold some benefits. It remains the most effective way to treat vasomotor symptoms associated with menopause (NHLBI 2002), although the WHI found that combined hormone therapy did not have a clinically meaningful effect on health-related quality of life (Hays et al. 2003). Continuing use of HRT also prevents bone loss and osteoporosis, which is associated with fractures (Bunyavejchevin and Limpaphayom 2001; Cauley et al., 2003; Ettinger et al. 1996; Schneider et al. 1997; Torgerson and Bell-Syer 2001), reduces the risk of colon cancer (Chlebowski et al. 2004), and may help women maintain their sexuality (Sarrel 2000). Lower dosages, different estrogen and/or progestin formulations, and alternate modes of application may improve the safety of hormone therapy.

It is important that women reaching menopause are fully counseled about the short- and long-term risks and benefits of HRT and alternative therapies (Hammond 1999; NPWH 2002). Treatment decisions should consider the symptoms, concerns, and risk factors of the individual patient, as well as the likely duration of therapy (Rymer et al. 2003). Given that the overall risks of long-term hormone therapy seem to outweigh its benefits (Writing Group 2002), physicians should consider alternatives such as dietary and lifestyle changes and other classes of drugs to prevent cardiovascular disease, osteoporosis, and cancers (NHLBI 2002). These include selective estrogen receptor modulators (SERMs), such as tamoxifen and raloxifene, bisophonates, and statins (Altkorn and Vokes 2001; Lobo 2001; NHLBI 2002).

Top of page

Complementary and alternative medicine

Growing concern about potentially harmful effects of hormone replacement therapy has prompted women to try a wide variety of complementary and alternative medicine (CAM) therapies for relief from menopausal symptoms such as hot flashes (Kang et al., 2002). Researchers also have begun investigating the ability of CAM therapies to prevent chronic diseases associated with aging. Phytoestrogens, such as soy and red clover, have attracted special attention because they may act as weak estrogens and offset falling hormone levels at menopause. Both the quantity and quality of evidence on the efficacy and safety of botanicals is limited: few randomized, controlled trials have been conducted; most studies have been small and short-term; and the types and doses of foods and formulations tested have varied widely, as have outcome measures (Kronenberg and Fugh-Berman, 2002).

Soy isoflavones have attracted a great deal of interest because women in Japan, China, and Korea, who eat diets rich in soy, experience relatively few menopausal symptoms (Vincent and Fitzpatrick, 2000). While study results conflict and the size of any effects appears modest, soy consumption may reduce hot flashes (Huntley and Ernst, 2004), increase bone mineral density (Ho et al., 2003), protect against breast and endometrial cancer (Peeters et al., 2003; Xu et al. 2004; Yamamoto et al., 2003), and decrease cholesterol and lipid levels that contribute to cardiovascular disease (Kang et al., 2002; Vincent and Ftizpatrick, 2000). The effects of soy isoflavones—and therefore the results of the studies—may depend on the amount consumed (which is many hundreds of times higher in Japan than North America), whether they are consumed as foodstuffs or as pills, and age at consumption. The only safety concern is the possibility that soy might stimulate growth of estrogen-dependent breast tumors.

There have been many clinical trials but only four randomized controlled trials of black cohosh, a native American plant widely sold as a standardized, commercially prepared extract. While black cohosh has proven safe (Dog et al., 2003), its efficacy in reducing hot flashes remains controversial, as does its mechanism of action (Borrelli and Ernst, 2002; Kronenberg and Fugh-Berman, 2002). The few studies conducted of other dietary supplements, including red clover, dong quai, evening primrose, and ginseng, have not found them effective in treating menopausal symptoms (Kang et al., 2002; Kronenberg and Fugh-Berman, 2002; Tice et al., 2003), although one study suggests that red clover can protect against bone loss in postmenopausal women (Atkinson et al. 2004).

Top of page

Impact of HIV/AIDS on older women

Many older people are sexually active and thus at risk of HIV/AIDS. The risk may be even greater for women, since physical changes at menopause heighten their vulnerability to infection. Sexual abuse, work as traditional midwives, and caring for HIV-infected family members create additional opportunities for infection (Wilson and Adamchak 2001). Overall, people over age 49 account for 5 to 7 percent of all AIDS cases in developing countries and 10 to 14 percent in developed countries (Knodel et al. 2002). HIV/AIDS progresses more rapidly in older people, and its diagnosis may be delayed as health providers often assume that symptoms are signs of age-related illnesses. Older people also may be less knowledgeable about AIDS because prevention programs target younger people. It is important for family planning and reproductive health providers to discuss sexual behavior with older women, teach them about HIV/AIDS and safe sex practices, encourage them to use condoms, and recommend HIV tests when symptoms arise (Best 2002).

Older women also suffer indirectly from the AIDS epidemic as adult children frequently return home when they become sick with HIV/AIDS. In a role reversal, older women, who would normally expect their adult children to help support them, instead carry the emotional, physical, and financial burden of caring first for their dying children and then their orphaned grandchildren—at the same time that they are trying to cope with their own medical problems, such as arthritis, hypertension, and diabetes. Because caregiving is traditionally a female role, growing reliance on home-based care is entrenching gender inequalities (Health & Development Networks 2004). Studies in Africa and Asia also have cataloged many negative effects on individual elderly caregivers, who are overwhelmingly female. These include:

  • Physical exhaustion from around-the-clock nursing in addition to household chores and child care.
  • Loneliness and social isolation, either because they cannot leave the sickbed or because they are shunned by friends and neighbors.
  • Poverty and financial hardships due to lack of time to tend fields or do paid work, the loss of their childrens income, and the need to pay for treatment as well as food and clothing for their children and grandchildren.
  • Emotional distress, grief, and depression (Lindsey et al. 2003; Saengtienchai and Knodel 2001; Williams and Tumwekwase 2001; WHO 2002).

These elderly caregivers currently receive little support from the health care system, but international organizations are beginning to focus attention on their needs. These include supplies and training so that older women can do a better job of nursing sick family members and so that they can protect themselves from infection by using universal precautions. They also need counseling to cope with the emotional stress and stigma of their situation, some kind of income support to keep them out of poverty, and affordable health care for their own medical problems (HelpAge 2003; International HIV/AIDS Alliance 2004; UNAIDS 2002; WHO 2002). Home- and community-based care programs, such as the "Grandma Cares" project in Thailand, may be an effective and affordable way to meet their needs (HelpAge 2002). Swaziland has proposed another approach: paying women US$30 per month to look after orphans, in an effort to both recognize the value of women’s work and also provide essential economic support ( For more information about the HIV/AIDS epidemic and alternative care models, see RHO's HIV/AIDS section.

Top of page

Healthy aging

The World Health Organization (WHO) is promoting a broad approach to aging that goes beyond the prevention and treatment of disease. WHO's "active aging" policies seek to extend healthy life expectancy, increase productivity, and improve the quality of life among older people (WHO 2002). Diet and exercise are important considerations for healthy aging: proper nutrition, aerobic exercise, and strength training can help prevent a wide variety of chronic diseases, maintain immune response, and preserve cognitive function (WHO and Tufts 2002). Of special importance for women is the relationship between exercise, calcium, vitamin D, and osteoporosis. Adequate exercise and nutrition early in life ensures that women build bone mass and later in life maintains bone density and prevents fractures (Burghardt 1999; Chien et al. 2000; Iqbal 2000; Picard et al. 2000). However, there has been little research on the nutritional issues facing the elderly in developing countries, who may reach old age after a lifetime of poor nutrition (Dangour and Ismail 2003).

Health education can encourage older women to make healthy lifestyle choices and to seek regular screening for breast and cervical cancer (McVeigh 1995; Sulak 1996). WHO guidelines can help develop culturally sensitive dietary and exercise recommendations appropriate for specific countries (WHO and Tufts 2002).

Top of page

Designing health services for older women

Menopause offers an excellent opportunity to teach women the importance of maintaining a healthy lifestyle, including regular exercise, good dietary habits, stress management, and screening for reproductive cancers and osteoporosis, all which helps prevent disease and maintain quality of life (Burghardt 1999; Ohki et al. 2001; Sulak 1996). However, reproductive health services in developing countries largely focus on women of childbearing age and marginalize older women (Bavadam 1999). Lack of services is compounded by womens ignorance of the health issues facing them as they grow older and by acceptance of health problems as part of the normal aging process (Modeste et al. 1999; Imogie 2000; Ramoso-jalbuena 1998). As a result, older women may not take action to reduce their health risks or even seek treatment until they have serious symptoms.

Thus health promotion and education programs are as important as health care services for older women. While some health education programs are directed to women who have already entered perimenopause (McVeigh 1995), others try to raise awareness of issues like breast cancer earlier in life, among maternal and child health care clients (Nzarubara 1999). By counseling younger women on nutrition, exercise, and smoking, family planning and reproductive health programs can help them enter menopause with lower risks for chronic disease (IMAP 1997). Older women also can benefit from expanded services at family planning and reproductive health facilities, including counseling and treatment for menopausal symptoms, screening for reproductive cancers and osteoporosis, and advice on nutrition and exercise (Elias and Sherris, 2003; Pinotti et al. 2001). A project in Ukraine to introduce breast cancer screening combined a substantial public education campaign with training and other technical assistance directed to health care providers (Zotov and Shyyan 2003). Programs must be careful, however, not to focus on women’s physical health to the exclusion of psychological issues (Tannenbaum et al. 2003).

When older women and men become seriously ill, disabled, or unable to care for themselves fully, they need comprehensive care, including emotional support and help with household chores as well as health services. Community- and home-based care systems, which rely on family and volunteer caregivers, are the most cost-effective way to supply such care where resources are limited (HelpAge 2001; Sieu 2000). It is essential, however, that formal health care systems provide training and support for the family and community members who act as primary caregivers (Ohaeri et al. 1999).

Top of page