For nearly all women, the 40s will be the last decade of their menstruating lives, a fact that can have far-reaching implications for health risks they will face in the coming decades.
The 40s are also when cardiovascular and cancer risks begin to rise, so it’s a crucial year to take stock of your current health and make the changes to improve your health where possible, says Stacey Rosen, a cardiologist at Northwell Health in New York.
“It’s an important time for optimizing blood pressure, cholesterol, weight, physical activity—all of that—because frankly, much of this gets harder and more is at stake once you get through menopause,” Rosen says. “The 40s is the decade to really firm up your preventive opportunities.”
Coronary heart disease is the leading cause of death in women, and eight out of 10 women between the ages of 40 and 60 have at least one risk factor for heart disease. The old standbys for reducing risk remain a healthy diet and regular physical activity, ideally at least 150 minutes a week of moderate to intense aerobic activity and two days of strengthening exercises.
Exercise and healthy diet are also ways to reduce risk of cancer just as that risk begins rising in women’s 40s. Be ready to add two new cancer screenings to your routine health maintenance this decade.
Breast and colon cancer screenings begin
Cancer risk begins gradually increasing in the 40s, so women should continue their cervical cancer screenings every three to five years, but they will begin other cancer screenings as well. The U.S. Preventive Task Force (USPSTF), an independent and impartial panel that reviews all the evidence on health screenings, recommends women start getting screened for two of the biggest cancer killers of women: colorectal cancer and breast cancer.
The task force started recommending in 2021 that women of average risk get their first colorectal cancer screening at age 45. Ideally, that should be a colonoscopy—the gold standard for colon cancer prevention, which only needs to be repeated every 10 years.
Fourth in our six-part series
Most people know the basics of living healthy: eat and sleep well, exercise, schedule an annual check up, and get the recommended vaccinations. But keeping up with self-care plus getting screenings for cancer and other diseases can be daunting. “Health” also varies for women at different stages of their lives. So, we’re bringing you a women’s health series that covers the most important health issues for women in each decade. Here is the fourth of those, reviewing where women in their 40s should be putting their focus to live their best, healthiest life.
“Probably 90 percent of colorectal cancer deaths are preventable if we could have scoped them in a timely fashion and undergone a high-quality colonoscopy,” Rajeev Jain, a gastroenterologist at Texas Digestive Consultants in Dallas, says. That’s because colonoscopies don’t simply look for cancer; they also detect and remove polyps that can grow into cancer.
There are other options for colorectal cancer screening, including a stool test every year, a DNA stool test (Cologuard) every one to three years (though these have a higher false positive rate), and other types of imaging tests every five years.
These may seem preferable since they’re non-invasive and a colonoscopy is invasive and requires a prep leading up to the procedure. But Jain tells his patients to compare the bowel prep to the alternative of getting chemo and surgery if you develop colorectal cancer. The noninvasive tests can only diagnose existing cancer whereas a colonoscopy can both diagnose and prevent it. “If you want to prevent cancer, it’s a high-quality colonoscopy with removal of polyps,” Jain says.
The recommendations for when women should get their first mammogram, and then how frequently, has changed many times over the years. The biggest reason for that is that the recommendations change as more evidence accumulates to provide a clearer picture of the balance of benefits and harms of screening.
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The USPSTF has just updated their advice again to recommend women get their first mammogram at age 40 and then get screened every two years thereafter.
Joann Elmore, an internal medicine physician at the University of California Los Angeles who specializes in studying cancer screenings, says it’s important to understand that cancer screenings have harms in addition to benefits. Aside from the discomfort of the procedure itself, those harms include the risk of false positives, “where the test may say you have cancer, and you end up not having it, but it leads to a cascade of many additional tests,” Elmore says.
That’s not to dissuade women from getting screened, but it does suggest it’s important for women of average risk to not seek more screening than they need and to be aware that false positives are common.
“With breast cancer, one in 10 mammograms will have an abnormality and the woman will be called back for additional testing,” Elmore says. “This is part of the screening process, and don’t be too shocked when you get that.”
One way to decrease the likelihood of false positives is to get a 3D tomosynthesis mammogram if you can because they provide much more information, Elmore says.
Sexual and reproductive health
Though many women continue to have pregnancy and childbirth into their 40s, most will have left behind childbearing in their 30s. If you’ve managed to keep the same OBGYN all this time, you hopefully have built a solid patient-provider relationship with them. That means you can ask them to help you optimize your health in general and prepare for what’s coming with perimenopause, the period of time leading up to menopause, during which their body gradually produces less estrogen and they start having fewer periods.
Hopefully they’re also screening you regularly for depression, anxiety, excessive stress, and intimate partner violence as well.
Metabolic and vascular health
The 40s are also a time to assess whether you had any adverse pregnancy outcomes, such as gestational diabetes, preeclampsia or hypertensive disorders of pregnancy, preterm birth, pregnancy-related mood disorders (such as postpartum depression) or repeated fetal losses. All of those can increase your cardiovascular risk, so you’ll want to be more vigilant about your blood pressure, blood sugar, and cholesterol.
Your blood pressure should be tested at least every two years if it remains below 120/80, but that increases to annual screenings if you develop high blood pressure. Similarly, cholesterol checks only need to be every five years unless the numbers inch above normal, in which case you’ll need more frequent screening. You should have begun diabetes screening in your 30s, and that should continue.
Some women in their 40s may develop thyroid issues, sometimes unmasked by pregnancy, says Jill Rabin, an OBGYN at Northwell Health in New York. Though it’s not officially recommended by any agencies, Rabin says it’s wise to consider getting baseline labs to find out their TSH and free T4 levels. These hormones help regulate metabolism and other bodily functions, and their levels can be an indicator of how well the thyroid is functioning.
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If you develop symptoms of an overactive or underactive thyroid, talk to your doctor about whether it’s appropriate to get thyroid labs or a referral to an endocrinologist. Symptoms of an overactive thyroid, or hyperthyroidism, include unexplained weight loss, a rapid heartbeat, excessive sweating or heat intolerance, swelling in the neck, shaky hands, muscle weakness, sleeping difficulty, and nervousness or irritability. Hypothyroidism, an underactive thyroid, includes symptoms such as fatigue, weight gain, cold intolerance, joint or muscle pain, dry skin, thinning hair, depression symptoms, and a slowed heart rate.
Above the neck
Everyone should get a baseline eye exam at age 40 and then repeat it based on what it reveals, your family history, and your symptoms.
Continue dental cleanings twice a year, or possibly more often if you’re lax on your oral health (such as not regularly flossing).
Many women will start to notice changes in their skin in their 40s, including starting to develop fine wrinkles and dynamic wrinkles, the ones that result from repeated facial expressions, says April Armstrong, a dermatologist at the University of California Los Angeles.
“The 40s is when you start to notice a visible decline in your skin elasticity and moisture, so you’ll notice the skin is dryer and starts to get a little bit thinner,” Armstrong says.
“There’s no universal recommendation for everyone to get a skin cancer screening in their 40s,” Armstrong says, but she advises vigilance for those who have skin cancer risk factors, such as a history of extensive sun exposure or tanning bed use or those who have a family history of melanoma or non-melanoma skin cancers. She encourages women to do self-monitoring, following the ABCDE rule to look for any suspicious moles or discolorations.
Armstrong also recommends women incorporate a retinol or, ideally, a retinoid into their skincare routine in their 40s to blunt the effects of sun damage to the skin. But as always, the most important part of skincare is sun protection, including regular use of sunscreen. Even if your foundation makeup contains sunscreen, these often contain filters that allow rays through, so Armstrong recommends putting a regular sunscreen on underneath and then applying makeup on top of it.
Vaccines
Finally, it’s important not to neglect your opportunity to avoid infectious diseases that can be prevented by timely immunization. Continue to get the annual flu and COVID-19 vaccines to reduce your risk of complications and hospitalization from these illnesses. These vaccines are especially important for those with certain risk factors, such as obesity or high blood pressure, but even middle-aged individuals with no existing health conditions can end up hospitalized from flu or Covid infections.
The 40s are also women’s last opportunity to get the human papillomavirus (HPV) vaccine to reduce risk of infections from the nine HPV strains that cause nearly all cervical cancer and many vulvar, vaginal, anal and oral cancers. Cervical cancer rates have been rising in women aged 30-44, and women can get the HPV vaccine through age 45.
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