Gynecologists treat “genitourinary syndrome of menopause” with many modalities, but a common treatment is vaginal estrogen. Many women are concerned about the risks of estrogen, and there are very significant differences in the absorption of topical vaginal estrogen and systemic hormones, taken orally or topically as a patch or gel.
First, let’s define genitourinary syndrome of menopause. The lack of estrogen in the vaginal wall and vulvar tissues causes thinning of the tissue and decreased blood supply. The symptoms include vaginal dryness, burning, irritation, decreased lubrication, painful intercourse, and urinary symptoms of urgency, frequency, painful urination, incontinence and increased urinary tract infections. Quality of life can be adversely affected. The frequency of these symptoms is reported in 20-45% of postmenopausal women, but actually most women experience at least one of these symptoms.
Vaginal estrogen products are provided in creams, vaginal pills, and and a silicone ring that is left in place for three months. Although the serum level of estrogen rises when these products are first administered, the maintenance dose results in a serum estrogen level that remains in the postmenopausal range. The question is whether these products are related to in increase in blood clots, heart attacks, strokes, and breast cancer.
The significant symptoms of genitourinary syndrome and the need for long-term use of vaginal estrogen makes it critical that studies be done to demonstrate safety. A study in Menopause: The Journal of the American Menopause Society, published in January, 2018, analyzed data from the Women’s Health Initiative. The use of vaginal estrogen was evaluated through self-assessment questionnaires, but type of vaginal estrogen was not stratified. The average age of patients in the study was 65 years, and mean follow-up was 6-7 years, with an average time using the products was about 40%.
The study results demonstrated that postmenopausal women who took vaginal estrogen had similar risks of breast cancer, stroke, colon cancer, endometrial cancer, blood clots and pulmonary emboli as those who had not used vaginal estrogen. The study actually demonstrated decreased risks of hip fracture and coronary artery disease.
Breast cancer patients on aromatase inhibitors will exhibit an increased serum estrogen level than the reduced level of estrogen derived from use of these medications, and probably should not use vaginal estrogen products. Women who have or have had breast cancer may be able to use vaginal estrogen if approved by their oncologist on a case by case basis.
If you read the package insert of vaginal estrogen products, the labeling is the same as higher dose systemic products. The American Menopause Society is advocating for a change in the labeling because this study and almost every other observational study done thus far do not demonstrate an increased risk for vaginal estrogen users. Currently the FDA is considering a proposal to change the warning label. Stay tuned!
Marilyn C. Jerome, MD
Foxhall OB-Gyn Associates
Menopause: The Journal of the American Menopause Society, Volume 25, Number 1, January 2018. Breast cancer, endometrial cancer, and cardiovascular events in participants who used vaginal estrogen in the Women’s Health Initiative Observational Study. Carolyn Crandall, MD, et al.
New guidelines were recently issued by the American College of Cardiology and the American Heart Association regarding ideal blood pressure values in adults. The guidelines were revised from the previous ones after a panel of 21 experts reviewed more than 900 studies.
The new guidelines are as follows:
BP < 120/80 is normal
BP 120-129/<80 is considered elevated
BP 130-139 systolic or 80-89 diastolic is Stage 1 hypertension
BP 140-159 systolic or 90-99 diastolic is Stage 2 hypertension
BP >160 systolic and >100 diastolic is Stage 2 hypertension
BP >180 systolic and >120 diastolic is considered a hypertensive crisis and demands immediate treatment.
The scientists emphasized the accuracy of BP measurements, and the importance of considering an average of several BP’s taken at several visits. They also emphasized at-home blood pressure monitoring.
These new definitions will categorize almost half of the US adult population as having hypertension, and more than 80% of those over the age of 80 will fall into the hypertensive range.
Not all of those with the new diagnosis of hypertension will need medication as treatment.
The physician takes into account a person’s cardiovascular risk factors as can be determined by several algorithms. A person already diagnosed with heart disease should always be treated, as well as anyone over the age of 65.
The primary treatment for hypertension for those with a lower risk is considered lifestyle modifications. These modifications include losing weight, following the DASH diet (Dietary Approaches to Stop Hypertension), reducing salt intake to less that 1500 mg per day, while increasing potassium intake to 3500 mg per day in the diet. It is also recommended that physical exercise should be at least 30 minutes three times per week, and alcohol limited to two drinks per day or less for men and one drink per day or less for women.
Older adults who aggressively treat hypertension have demonstrated lower cardiovascular mortality and morbidity without being subjected to increased risks of hypotension and falls.
Around the age of menopause, women are less likely to be hypertensive than men, but as women age, their prevalence of hypertension is greater than men of the same age.
It used to be that medication was considered if the BP was greater than 140/90, but now the
threshold is 130/80 unless lifestyle modifications are successful. It seems that ideal BP is 115/75 or less. The reason for this change is that individuals with blood pressures above this range do show increases in cardiovascular risk, and earlier intervention can lower these risks.
An app called the ASCVD Risk Estimator (http://tools.acc.org/ASCVD-Risk-Estimator) can determine if a person’s 10 year risk of developing heart disease is greater than 10%, and therefore should be treated with medication.
More aggressive treatment of hypertension is expected to save lives by preventing coronary artery disease, strokes, and kidney failure. Reducing systolic blood pressure by just 10mm Hg will result in a 20% reduction in major cardiovascular events, with a 17% reduction in coronary artery disease, a 27% reduction in strokes, and a 28% reduction in heart failure. Mortality for all causes decreases 13%. Larger decreases in blood pressure result in even greater reductions of morbidity and mortality.
The purpose of the new guidelines should raise awareness of the importance of BP on heart disease risks, promote lifestyle modifications, and support the use of antihypertensive medication in those with higher blood pressures, or increased risk of cardiovascular disease.
P.S. In my medical practice, I encourage patients to purchase a BP monitoring device. They are inexpensive and easy to use. I ask patients to monitor their blood pressures over several weeks, taking measurements at different times of the day, and providing their primary care practitioners with a log of BP measurements. This attempt at more accurate data will hopefully help practitioners determine who will benefit from medication intervention.
Stay tuned for a future blog which will explain the DASH diet.
Marilyn C. Jerome, MD
Foxhall OB-Gyn Associates
The North American Menopause Society: First to Know, November 17, 2017.
Revised ACC/AHA guidelines categorize many more midlife women with high blood pressure.
By Howard Hodis, MD
When the Women’s Health Initiative was proposed more than 20 years ago, there were studies that demonstrated that hormone replacement decreased the risk of heart disease. The purpose of the WHI was to determine if giving women hormone replacement after menopause would decrease their future risk of heart disease. It was shocking to us as physicians when the initial data demonstrated an increase in stokes, heart attacks, and cancer in women who took hormones vs. placebo. But, the fifteen year follow-up data demonstrated no increase in mortality for any cause in women who took hormones vs. those who took placebo.
How could these two data points be consistent? The answer is not totally clear, but now we think that timing might be a contributing factor. It is now believed that the effect of hormone therapy (HT) on heart disease depends on when a woman initiates therapy.
Starting HT younger than age 60, or within the first ten years of menopause, decreased coronary heart disease by 32-48%, and decreased all-cause mortality by 30-39%.
The reduction is mortality was due to decreased cancers and heart disease, which are the two leading causes of death in women. Younger postmenopausal women, those ages less than 60, had a greater reduction in cardiac mortality, 54-61% reduction, vs. those women over 60, whose reduction was less but still quite good, 26-43%. This benefit was independent of the type of progesterone that was prescribed.
Mortality related to cancers was decreased 23-43% will all hormonal regimes, and this was not dependent on whether hormones were started before or after age 60.
There was no increased risk of strokes if hormones were started HT in the first 10 years after the onset of menopause, although the risk of blood clots did increase with HT.
So, how does one decide what to do? Your risk factors have to be evaluated, but if you are generally healthy, the studies support the safety and benefit of HT.
Marilyn Jerome, MD
Foxhall OB-Gyn Associates
Menopause: The Journal of The North American Menopause Society. Volume 24, November 2017
Dr. Victor Henderson, MD, MS, NCMP. Early and late intervention on vascular disease ad related outcomes: further evidence from the Early Versus Late Intervention Trial With Estradiol
The North American Menopause Society has coined the term “Genitourinary Syndrome of Menopause.” This recognizes that many women after menopause experience bothersome symptoms that affect the vagina, vulva, bladder, and the pelvic musculature. This syndrome refers to changes in the tissues of the vagina and vulva that become thin and dry with loss of estrogen after menopause. Another contributor related to aging is muscle weakness which occurs in all parts of our body, and the pelvic muscles are no exception. The pelvic floor is the group of muscles that are attached to the pelvic bones, and form a sling that supports our internal organs (uterus, badder and bowel) , as well as allow passage of the urethra, vagina, and rectum from internal to external. This complex system facilitates and accommodates childbirth, as well as control of urination and defecation. As muscles weaken with age and childbirth, and as the vaginal tissue thins with lack of estrogen, function can change.
Some women experience urinary problems that include frequency, urgency, incontinence, and increased urinary tract infections. Fecal incontinence and uncontrolled passage of gas are embarrassing and limiting. The use of pads and diapers is extremely common among the elderly. Vaginal atrophy and thinning of the vaginal wall can make intercourse painful, and even impossible. Gynecologists often prescribe vaginal estrogen to improve the vaginal mucosa and decrease burning with intercourse. Although there can be some improvement with urinary symptoms, many patients may face surgical procedures for prolapse and stress incontinence.
Gynecologists are now paying more attention to the pelvic floor muscles. Pelvic floor physical therapy and pelvic floor muscle training can teach the optimal function of the pelvic muscles and improve pain and dysfunction including incontinence, frequency, painful intercourse, and fecal incontinence of stool and gas. Other symptoms of pelvic floor dysfunction may include the feeling of incomplete defecation, painful urination, and pain in the pelvis, genitals or rectum.
In order to determine if you have pelvic floor dysfunction, a history and pelvic exam are performed. An exam can determine if there is atrophy of the tissues of the vagina and vulva, and prolapse of the organs. Muscle activity can be tested by using probes that measure the degree of muscle contraction of the vagina and the rectum. More sophisticated testing includes cystometrics which studies bladder function, and x-rays which can be used to evaluate the process of defecation.
Pelvic floor muscle training and physical therapy should always be considered as a first-line therapy when pelvic floor dysfunction is suspected. Pelvic floor muscle training uses probes or sensors to measure and teach the correct use of pelvic muscle contraction and relaxation. It is not painful at all. Improvement can be expected in about 75% of patients. Vaginal estrogen products can be used to improve vaginal tissue thickness and blood flow. Muscle relaxers can be used to relax the pelvic muscles if increased contractions are noted. There are also many medications available for overactive bladder. Surgery is an option for patients with prolapse of the bladder, rectum or uterus, or for patients with severe stress incontinence that is not corrected by non-surgical approaches.
Marilyn Jerome, MD
Foxhall OB-Gyn Associates
Cleveland Clinic, June 2, 2017
Pelvic Floor Dysfunction
Mammograms have been the mainstay of breast cancer screening for many years. The standard mammogram consists of four views which are taken as each breast is compressed from top to bottom and laterally. A radiologist interprets the mammogram by looking for a mass in the breast tissue. Breasts are composed of fat and glands.
Fat in a breast is very dark black and contrasts glandular tissue which is white. Dense breasts are composed of glandular tissue that can appear very white on a mammogram and can hide masses. Some breast masses are quite dense and contain calcium deposits that are more easily visible. Some types of cancer, often the lobular type, is often not as dense and can not always be seen within normal breast tissue. Therefore, mammograms are not without false negatives. We also know there are false positives, areas that look suspicious and need to be biopsied and cause much anxiety, but turn out to be benign.
Researchers and radiologists are looking for better tests: less false negatives and false positives, less discomfort for women, less risks, and less cost. The latest improvement in mammography is the 3D mammogram. With this technique, the breast tissue is visualized in "slices" that reduces overlapping tissue that can appear as a tumor because of superimposed images, and can demonstrate small tumors that were obscured by surrounding tissue. The result in studies that have been done demonstrate 17-34% less "call backs" for additional testing, and an increased breast cancer detection rate of as much as 50%. There was not found to be an increased in detection of DCIS with the 3D mammogram.
Although this new mammogram has improved detection rates, often finding cancers that are less than 10 mm, some cancers can be still be missed. At the recent North American Menopause Society meeting last week, attention was give to research being done on tests that target metabolically active tissue: the sestambi scan and MRI's. Molecular breast imaging has the potential of finding many more cancers than mammograms. An abbreviated MRI is being developed that will be much less expensive and more widely available. Stay tuned for further developments!
Plenary Symposium B: Advances in Breast Imaging, Dr. Emily F. Conant, M.D.
Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
North American Menopause Society Annual Meeting, 2017
Think about these numbers.
Approximately 30% of people over the age of 65 fall every year. That number approaches 40% by age 70. 10-15% of all falls result in a serious injury or fracture. 94% of hip fractures are caused by falling. In an 8 year period from 2001-2008, 4 million adults over the age of 65 had an emergency room visit for a fracture. The risk certainly increases with age, and women fracture twice as often as men. Half of these fractures require hospitalization, which can lead to rehab, loss of mobility, and loss of INDEPENDENCE. We fear losing our independence more than anything as we age!
So, what are the risk factors for falling? The number one risk factor is lack of muscle strength. This muscle weakness increases the risk of falling 4-5 times. A history of falling increases the risk 3 times. Other factors that increase the risk include balance issues, visual impairment (bifocals distort vision), arthritis, depression, cognitive impairment, age, and medications.
Other risk factors include Parkinson’s disease, fear of falling, heart disease, orthostatic hypotension, urinary incontinence, depression, stroke, chronic pain, and a sedentary lifestyle.
Some of these factors are modifiable.
A particularly vulnerable time for older adults is post-hospitalization. When adults come home from the hospital, often in pain, maybe undernourished, and on multiple medications, the risk of falling is much increased. Over 40% fall within 6 months of discharge, with half causing severe injury. There are twice as many hip fractures in the month after a hospitalization.
Drugs that increase the risk of falling are benzodiazepines (Valium), antidepressants including SSRI’s, sleeping pills, antihypertensives, and psychotropic drugs. Often when medication doses are changed, or other drugs are added, interactions can cause side effects such as dizziness.
Decreased mobility caused by muscle weakness, osteoporosis, and medical problems such as obesity and diabetes can all lead to falls and fractures. Fractures must be taken seriously and some can be prevented. Fractures lead to loss of quality and length of life. Pain, immobility, and disability lead to decreased quality of life. 20-24% of those who sustain a hip fracture die within one year of the fracture! 40% of those who sustain a hip fracture are unable to walk independently, and 60% will still need assistance one year later. 33% of those who fracture will end up in a nursing home or be unable to ever live independently again.
90% of older adults rank staying in their homes and living independently as their number one concern. Preventing fractures is a significant intervention that can help to achieve this goal.
Physicians should be asking their patients about falling: the frequency, circumstances, loss of consciousness, and factors which led up to the fall. Appropriate studies should be done and interventions can be made to decrease risk.
So what can we do as patients to prevent falls and fractures? Modify your home environment by eliminating throw rugs, wires, and objects that clutter. Use more lighting, especially night lights to show the path to the bathroom. Install rails and bars to help stability with movement. Avoid ladders and put items at arm’s length. Minimize or taper medications that have effects on balance and cognition. Exercise, participate in balance, strength and gait training. Tai Chi is very effective. Treat visual impairment. Treat cardiac arrhythmias or other conditions that can cause fainting, including installing a pacemaker if needed. Take Vitamin D, to reach a serum level of 40 ng/ml. This may take 2,000-4,000 IU per day to achieve this goal Wear reasonable shoes, don’t walk on ice, and be careful about curbs and uneven pavement. Schedule physical therapy for musculoskeletal problems that can lead to imbalance or difficulty walking. Decrease or avoid medications such as sedatives, sleeping pills, psychotropic drugs, antihistamines, drugs for overactive bladder, and decrease alcohol! Alcohol on top of multiple medications can cause serious interactions, dizziness, and loss of consciousness. The elderly should practice getting up off of the floor, so that if they fall, they can get up again.
It is so important that we do not look at fractures and falling as just part of getting older. There is much that we can do, and starting sooner that later can make a huge difference in how long we can live happily independent!!
Marilyn C. Jerome, M.D.
Crash, Snap: Falls Cause ‘Osteoporosis-Related” Fractures. What Can a Clinician Do?
NAMS Pre-meeting, October 11, 2017
Dr. Neil Brinkley, M.D.
University of Wisconsin School of Medicine and Public Health
Why am I shrinking?
Not a day goes by that a patient voices a concern about her loss of height. It is not unusual to lose up to two inches after menopause.
We know that loss of vertebral height from osteoporosis fractures is one cause, but many patients who do not have osteoporosis of the spine also experience loss of height. As one of my colleagues put it, “your discs go from marshmallows to pancakes.” Simplistic yes, but it gets the point across. In the October, 2017, issue of Menopause,a study was reported that looked at intervertebral discs in men and women by MRI. The data seems to suggest that there is an increase in deterioration in the discs of the lumbar spine in women in the first 15 years after menopause which is independent of the aging process. This deterioration may contribute to increased vertebral fractures as the “cushion” between vertebrae is degraded.
What causes this deterioration? We know that there is deceased connective tissue such as collagen, as well as loss of water in the discs. Estrogen can preserve some of the collagen and molecules that hold water.
The impact of vertebral fractures is tremendous. It is thought that 15-20% of women in their 60’s will sustain a vertebral fracture, and 50% of women aged 80-84 have sustained a fracture.
Only about one third of fractures are diagnosed. Vertebral fractures, as hip fractures, are associated with increased mortality which extends up to 20 years.
The morbidity of vertebral fractures includes severe pain, decreased mobility, and an increased fall risk due to a change in a person’s center of gravity. Kyphosis (which is the curve of the spine forward) can cause problems with breathing and eating, and can lead to increased bouts of pneumonia .
Vertebrae are most susceptible in the anterior portion of the bone. A movement as simple as bending over can compress a vertebrae, and once one is fractured, it puts more force on adjacent vertebra, causing a domino effect. The decreased cushioning of the shrunken discs adds to the increased risk of fractures.
The chemical composition of the intervertebral disc is complex, as it contains various types of connective tissue and molecules that hold on to water. The vertebral column is a fascinating structure that must adapt to changes in muscle activity and heavy loads that must distribute the pressure evenly along the spine. When the chemical structure of the disc changes with age and menopause, tears and clefts in the discs weaken them which increases the degradation. There is some evidence that a reversal of some of these changes may occur with estrogen. Studies have shows that intervertebral discs have estrogen receptors, and that fibrous cells of the discs proliferate in the presence of estrogen. Estrogen also increases the collagen in bone which is an important factor in the prevention of osteoporosis.
Women who remain on estrogen after menopause have higher disc heights than women not on estrogen. We also know that estrogen prevents osteoporosis. It is becoming more clear that the genesis of vertebral fractures depends on not just the vertebral bone, but the cushions supporting them. Although more studies need to be done, this is fascinating science that explains why we seem to be shrinking!
Menopause: The Journal of the North American Menopause Society, October, 2017,
Editorial: Menopause and the Intervertebral Disc, Yves Muscat Baron, M.D.
Breast cancer is the most common cancer diagnosed in women, and second only to lung cancer in deaths per year in the US. About 250,000 new cases are diagnosed per year, with approximately 40,000 deaths. We know that 12% of women will be diagnosed with breast cancer in their lifetimes. No doubt, this is a disease that has touched us all one way or another.
Now there is some good news about breast cancer mortality.
In the recent publication CA: A Cancer Journal for Clinicians and its companion Breast Cancer Facts and Figures, it was noted that breast cancer mortality has decreased 40% from 1989 to 2015. This decrease translates into 322,000 lives saved over that period of time. This contrasts with an increase in breast cancer mortality from 1975 to 1989, where mortality increased about 0.4% per year.
So, what has changed during that period of time?
There have been many improvements in breast imaging in the last 20 years. Mammography has improved, with digital mammography and now tomosynthesis (3D imaging) adding to technical advances. Ten years ago it seems that most breast cancers were diagnosed that were larger than 1 cm in size. Now with tomosynthesis, many breast cancers are found that are less than 1 cm. When you think about the fact that a breast cancer is three dimensional, the difference between a 5 and 10 mm tumor is not half, it is much less. Less tumor volume translates into less invasion into nearby lymph and blood vessels. I believe we will continue to see decreases in mortality due to this recent technology.
Other advances are in treatment options. New forms of chemotherapy developed since the 1980's prevent metastases and recurrences. Tamoxifen, an anti-estrogen, was developed in the late 70's and is used to treat hormone sensitive breast cancer, and also for prevention in high-risk women. Aromatase inhibitors which prevents estrogen production in postmenopausal women also reduces recurrences. Herceptin treats breast cancers which contain a high level of HER2, a protein on breast cancer cells that is a growth factor which makes these tumors more aggressive.
More targeted therapies are currently being developed.
We have come a long way, but there is still a long way to go. Today's news, reported in the Washington Post, is very encouraging!!!
Marilyn C. Jerome, MD
Foxhall Ob-Gyn Associates
Washington Post, October 4, 2017. Study shows long-term drop in deaths from breast cancer
“No link between hormone therapy and all-cause or cause-specific death rates in the
Women’s Health Initiative
Those of us who have practiced gynecology as long as I remember very well the day that the Women’s Health Initiative (WHI) results were made public. It was July, 2002, and the news was unexpected. The Women’s Health Initiative was a study started in 1994 to determine if hormone therapy (given as conjugated equine estrogen and medroxyprogesterone acetate) would prevent cardiovascular disease in women between the ages of 50-80. Previous data were consistent with cardiovascular benefits for women who took hormones, so this study was initially hopeful. Instead, the initial data demonstrated that there were more heart attacks, strokes, blood clots, and breast cancer in women on the therapy. There were less osteoporotic fractures and colon cancer, but the risks outweighed the benefits. That day, many women stopped hormones and chose to tolerate their menopausal symptoms, rather than accept these additional risks.
In the last 15 years, the researchers have continued to collect data, and stratified the results related to age. Women in their 50’s had fewer risks than women in their 70’s. In the last 15 years, there has been broader use of transdermal estrogen and bioidentical progesterone, which may have a different safety profile. Many years later, researchers compared mortality statistics for women who took hormones in the WHI, vs. women who were taking placebo.
The study reported today in the Journal of the American Medical Association, looked at mortality rates for women who participated in the WHI.
Among 27,000 women who were randomized to hormones or placebo who on average took hormones for 5-7 years, and were followed up for 18 more years, the mortality rates were statistically equivalent. This included mortality for all causes, including heart disease and cancer.
Although it is not recommended that women take hormones to prevent chronic diseases, this data suggests that if women choose to take hormones to help them through the menopausal transition, long-term mortality rate is not affected. This is good news!
A decision to take hormone therapy is an individual decision made by a women and her physician, taking into account her medical history, physical findings, and family history.
Marilyn Jerome, MD
Foxhall OB-Gyn Associates
JAMA, 2017: 318 (10), 927-938
Menopausal Hormone Therapy and Long-Term All-Cause and Cause-Specific Mortality,
The Women’s Health Initiative Randomized Trials, JoAnn Manson, MD, DrPH, Aaron K. Aragaki,MS, Jacques E. Rossouw, MD, et al
Did you ever consider that working may be beneficial to your health? There is now data that demonstrates that working longer may increase your longevity.
In 2016, a study was published in the Journal of Epidemiology and Community Health which demonstrated that healthy people who retired one year later than those in the control group, decreased their risk of dying during the study period, which lasted 18 years, by 11%. Retirees who had health problems also lived longer if they postponed their retirement. A French study linked later retirement with a decreased risk of dementia and Alzheimer’s disease.
It could be that a job that you enjoy may be associated with more social connections, increased physical activity, and provide a purpose, creative outlet or a challenge. All of these factors have been associated with improved health.
Not all studies agree. In an Australian study published in the Journal of Economics, researchers
linked overall health to longevity, with no benefit of a later retirement. Of course, health problems my be a reason that people retire, a factor that may affect some of the study models. Your work environment may make the difference. A person who works in a positive work environment that is challenging and fulfilling may have very different health effects than a person who works in an environment that is stressful or hostile, causing physical or psychological stress.
Many women in their later working years need a change. They may choose to take advantage of more flexible work schedules such as working part-time or working from home when possible. Finding a position that is less demanding, with less management responsibility can often decrease stress. Some women may look at their careers, having achieved their goals, and switch careers entirely, doing something different that arose from an interest, hobby, or previous work experience. Becoming a consultant in your field offers an opportunity to use your skills and contacts, and manage your work schedule as you wish.
Dr. Nicole Maestas, who is an associate professor of health care policy at Harvard Medical School, feels that working longer can increase financial security and in some cases, improve health. She believes that women should try to remain engaged in the workforce as long as possible.
When to retire is a complex decision which depends on many factors including finances, health, and a person’s individual work situation. Now it appears that there is at least some data that working longer may be good for your health!
Harvard Women’s Health Watch, Volume 25, Number 1, September 2017