Postreproductive disability-free life expectancy – An increasing gender gap

The demise of the Duke of Edinburgh, whilst a sad event, is an example of a healthy and productive lifespan, which most would like to emulate.

Most women now have a one in six chance of achieving his age.

In 2016–2018, an English female could expect to live 83.2 years, of which 19.3 years (23%) would have been spent in ‘not good’ health. That is with disability, and although females live an average of 3.6 years longer than males, much of that time is in fact, spent in poor health with disability – they experience only 0.5 more years of good health than men.

Rates of disability-free life expectancy are similar to those for healthy life expectancy. ¹

When broken down for individual illness and social groups these sex discrepancies become even larger.

Male Female

Osteoporosis 849 6732

(UK Biobank) ²

Healthy life expectancy is an estimate of the number of years lived in ‘very good’ or ‘good’ general health, based on how individuals perceive their general health. Disability-free life expectancy is an estimate of the number of years lived without a long-lasting physical or mental health condition that limits daily activities. ³

The recent UK census gives a chance to define the needs of the population in terms of need and future disability. There is increasing evidence that disability-free life expectancy is compromised in women after the menopause, compared with similar aged men. This disparity increases with age and has major economic, health and happiness implications for both groups.

Looking at the health of the population of England and Wales in respect to activity-limiting health problems or disabilities, we find that more than 10 million people were reported to have activity-limiting health problems in 2011; however, results show that this has fallen slightly since 2001.

The forthcoming UK government Women’s Health Strategy, which closes in May 2021, provides another a venue and potential insight to this hidden problem. ¹

Long-term data from the USA exists. ⁴ As to whether women’s disadvantage has grown with respect to late-life disability, despite well-established evidence that women are more likely than men to have activity restrictions in later life, little attention has focused on gender differences in long-term trends.

Women make up a substantial share in the USA; 57% of the population aged 65 years or older and an even larger share, 68% in the USA of those receiving assistance with daily tasks.

Regarding the percentage of years expected to be lived without disability, for a 65-year-old man, this figure increased – from 78% in 1982 to 81% in 2011 – but it remained stable for women at 70%.

At older ages, the improvement for men is even more marked: 43% of remaining years at age 85 years were expected to be active in 1982 compared with 60% in 2011. For women comparing 1981 and 2011, the proportion of remaining years at age 85 years, expected to be active, did not improve and was indeed was static at 35%. ⁴

For public health officials interested in improving functioning of the older population, ⁴ this analysis suggests that greater focus on quality rather than quantity of life, emphasizing risk factors more commonly found among women, may be an effective strategy for extending active life.

Findings from the USA ⁴ showed that women are more likely than men to develop a number of debilitating conditions including osteoarthritis, depressive symptoms, fall-related fractures, osteopaenia, osteoporosis and Alzheimer’s disease (AD) and related dementias.

Clearly from this US data, ⁴ the risk of disability is much greater in postreproductive females than males. We need to identify the exact proportions of this largely unrecognized problem. Why this gender split, is the important question? And why does it increase even more, with very old age?

Further census data will help, the detailed analysis of the current census will be of great benefit, if the right questions and analysis is performed. These are: sex, age, parity, social class and geographical area. Relevant economic analysis is also needed. ⁵

Hormonal risk factors, in particular menopause, predict AD endophenotype in middle-aged women. ⁶ These findings suggest that the window of opportunity for AD preventive interventions in women is early in the endocrine aging process.

The use of the UK Biobank may be helpful in such a dissection of the facts with the recognition that the Biobank population has inherent bias ⁷ and is not directly comparable with census data.

Can better menopause education and management, in time, lead to reduced disability?

The data suggests that menopause and the related hormone deficiencies, is one of the contributing factors, but how do we improve the health of the postreproductive female population? Ensuring women are empowered and educated appropriately about consequences of menopause, including later health effects, and the role of HRT would be a good start, but from the recent BMA article, ⁸ it is clear that medical professionals fail to recognize, understand and seek help for their own menopause symptoms, how then can we expect the general public to? It is hoped that better education about menopause will lead to improved quality as well as quantity of life.

Of course, education about menopause needs to improve in medical schools and throughout all speciality training. But perhaps the key would be in ensuring general practice is appropriately funded, educated and supported in delivering better menopause care. General practice already has well-established preventive programmes in, for example, cardiovascular health and diabetes care, and if the same principles could be applied to appropriate HRT prescribing and lifestyle education around perimenopause, then this has the potential to improve women’s health longer term. Perhaps the simple addition of routinely providing information to women about menopause and treatment options at their over 50s health check, or earlier, could be transformational.

The forthcoming UK government women’s health strategy offers hope and could result in National Guidelines and reduction of the high incidence of avoidable disability in the female population. It is hoped that such data analysis will point the way to potential preventive therapeutic and lifestyle interventions, using up to date, current knowledge relating to menopause management, with its potential to prevent chronic disability.