Sexuality - Interest

1. Most studies of middle-aged and older women
demonstrate that interest in sexual intimacy
continues into advanced old age. Prevalence varies
by area, country and population surveyed. From
30% of community dwelling US women older
than age 65 to 95% of community dwelling Danish
women the same age have stated that they have
regular intercourse. According to a length study
conducted by the Consumers’ Union, most
women over age 65 engaged in sexual activity at
least once a week.15 Older women report less
sexual activity than men the same age, correlating
with the availability of a socially sanctioned
partner.16
2. The most important correlation between
continued sexual activity in older women is
availability of a healthy partner. Women often
marry older men, who may develop chronic
illnesses, disability, or die before women. Women
who are widowed, divorced or single are less likely
to continue their sexual activity. Various studies have noted a sharp decrease in sexual interest and
activity among women in their late 60s. For many
women, this may be a source of considerable
frustration. Societal expectations and
misconceptions about the physiological effects of
aging on sexuality contribute to this distress.
Aging signs may result in feelings of decreased
sexual attractiveness.
3. For women without a partner, masturbation may
be an option.
4. However, sensitive inquiry about sexual beliefs,
practices, and concerns will be needed before any
recommendations can be made. Providing
education will enable the woman to make
informed decisions.
5. Many social issues may contribute to a lack of
sexual interest or responsiveness, such as
monotony, preoccupation with career and
finances, physical and mental fatigue,
overindulgence in food and drink, and fear of
failure in sexual performances. Excessive life
stressors, socioeconomic issues, patterns of
disinterest in sexual activity as a young adult also
may decrease middle age sexual intimacy.
6. Arthritis and stiffness can make sex difficult.
Asking the partners to come into the office in
comfortable clothes or sweatsuits is a method of
helping them to try different and more
comfortable positions. Taking an acetaminophen
or NSAID before sex may help stiffness.
7. Refraining from alcohol and heavy meals before
sex is helpful.
8. Reviewing drugs used by either partner may allow
the substitution of one that affects sexual
functioning.
9. Lubrication with exogenous creams may help.

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Aging Midlife

1. Women in midlife, age 40 to 65, can use guidance
regarding the impact of chronic illness, hormonal
changes, and medications on sexual functioning.
Women at this age may be experiencing changes
in family structure and the psychosocial
adjustments these demand. The variety of needs is
amazing. Midlife women may be trying to become
pregnant, be menopausal, be widowed, or caring
for young children or grandchildren.
2. Women may express fears about the effect of time
and hormones on their self-image and desirability.
Information about physiological changes that do
occur and exploration of the woman’s beliefs
about sexuality at this age are essential.
3. Most physiological changes associated with aging
affect the sexual response cycle of the older woman.
Estrogen-deficient vaginitis, insertional dyspareunia,
and reduced lubrication are common complaints
associated with menopause. The use of artificial
lubricants can reduce the symptoms and pain.
4. As women age, the excitement phase of the sexual
cycle can occur more slowly. For many
menopausal women, it may take 5 minutes rather
than 10 to 15 seconds in the excitement phase to
achieve lubrication. More and more direct genital
stimulation may be needed during the arousal
or excitement phase.
5. The plateau phase may also become longer. The
orgasmic phase may become shorter and orgasms
may be painful. Contraction may be spasmodic
rather than rhythmic. Nonetheless, women retain
the potential to return to the excitement phase and
to experience multiple orgasms.

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Facilitation

Facilitation
1. Physicians can best assist their patient to maintain
healthy sexual functioning by taking a sexual
history and exploring a patient’s sexual concerns,
fears, and expectations.
2. Physicians may suggest positional changes,
environmental changes (placement of pillows, use
of hot tubs or waterbeds) and alternative activities
to penetrational intercourse such as hugging,
caressing, cuddling, and mutual masturbation.
3. Both the patient and her partner must be willing
to consider suggestions regarding alternative
positions and practices.
4. Good communication between the partners is
essential. The partners should be encouraged to
discuss their concerns and reservations.
5. Referrals to certified sex therapists and to chronic
disease support groups or on-line support groups
or chat rooms may be helpful.

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Chronic illness

Many individuals begin to experience the onset of
chronic illnesses during the fifth and sixth decades of
life. Diseases such as cardiac and circulatory problems,
diabetes, arthritis, osteoporosis, chronic obstructive
pulmonary disease, hypertension, neurological disorders,
and depression, among others, have a profound
impact on sexual functioning (Table 6.1).
1. Heart disease
The effects of cardiac illness on men have been
well researched. Few studies have addressed the
specific issues of women following a cardiac event
and their unique counseling needs. Women may
receive less counseling, including referral to
cardiac rehabilitation, than men do. Resumption
of sexual activity following a cardiac event may
elicit fear and anxiety. Women may choose to
avoid returning to their previous level of sexual
activity fearing a reinfarct or death. Symptoms
such as chest discomfort, shortness of breath, and
excessive sweating are deterrents to the
resumption of sexual activity in women.
a. Women can resume sex when climbing two
flights of stairs no longer causes anxiety or
chest pain. Education regarding the impact of
the sexual response cycle on cardiac function
is essential.
b. Explaining the number of metabolic equivalents
(METs) used during sex as compared with
common daily activities can help to reduce
anxiety. Patients must understand the need to
avoid heavy eating and drinking prior to sex to
reduce the potential stress on the heart. Patients
should be advised to discontinue sexual activity
if they become short of breath, experience chest
pain, or become too anxious, and to notify their
physician of their symptoms as soon as possible.
Reassurance and education can help to reduce
anxiety among women with cardiac disease.
2. Hypertension
Hypertension medications may affect the sexual
response cycle negatively (Table 6.2).
3. Diabetes
a. While impaired or decreased sexual functioning
is a complication of diabetes in men, the sexual
impact of diabetes on women is not well defined.
Early studies found that women with diabetes
often suffer significant orgasmic difficulty.10
Few more recent studies have investigated this
information. Results of subsequent research
have been inconclusive or contradictory.
b. Sexual dysfunction has been reported in 42%
of women with type 2 diabetes and in 18–27%
of women with type 1 diabetes.11 Women with more diabetic complications are more likely to
have sexual dysfunction.
c. Neuropathies alone have not been found to
contribute to sexual dysfunction in women
diabetics.
d. Many psychosocial problems that are
associated with diabetes can impact sexual
functioning.
e. Renal failure has been linked to several types
of sexual dysfunction in women. Anhedonia,
decreased vaginal lubrication, and anorgasmia
have been associated with women on
dialysis.12 Women with chronic renal failure
often have a hypoactive sexual desire disorder.
The source of this dysfunction may be
multifactorial, including chronic disease,
medications, and psychosocial issues.
4. Spinal-cord injuries
a. Spinal-cord injuries result in multiple types
of losses for the patient and her partner.
Self-esteem, perceptions of body image, social
roles, and feelings of dependence are all
affected. The degree of impairment dictates
the effect on sexual function. For example,
muscle spasticity may make penetration
difficult.
b. Therefore, an assessment of the patient’s
sensory capacity and mobility are important
in offering anticipatory guidance.
Recommendations may include encouraging
the patient to improve self-esteem and
self-image and to make advanced preparations
for sexual intimacy. The woman should tend
to bowel and bladder care before initiating sex
to avoid any accidents that would have
psychological consequences.
c. The timing of the sexual activity may be
important to avoid fatigue or spastic
responses.13 Sensate focus exercises may be
helpful to the patient and her partner.
Experimenting with different positions may
also be helpful.
5. Decreased mobility problems
a. Diseases that result in decreased mobility or
flexibility, such as multiple sclerosis, arthritis,
or connective tissue disorders, often lead to
sexual inactivity. Joint stiffness, decreased
flexibility, muscle spasms and increased tone,
pain and other symptoms affect a woman’s
ability to engage in sexual intimacy.
b. Multiple sclerosis has been associated with
decreased libido, delayed and decreased
lubrication, decreased orgasmic capacity, and
anorgasmia in many women. Fatigue,
spasticity, contractures, loss of manual
dexterity and incontinence may contribute to
sexual problems.14
c. The use of assistive devices, muscle relaxants,
and vibrators may help to alleviate the distress
and disability caused by contractures, muscle
weakness, and spasms.
d. Bowel and bladder training programs may be
recommended when incontinence is a problem.
e. For some patients, the use of corticosteroids
has produced improvement in sexual
functioning.
f. For women with arthritis, timing of sexual
activity to coincide with optimal physical mobility and pain relief may help. Specific
suggestions, such as positional changes
(side-by-side, woman on top, use of chairs, or
use of hot tubs) can aid the arthritic woman
maintain her sexual activity.
6. Scleroderma
a. Scleroderma can have negative effects on
sexual functioning. Women with scleroderma
and Sjogren’s syndrome have high rates of
sexual dysfunction.
b. Common problems include vaginal dryness,
dyspareunia, and decreased orgasmia. Other
changes such as joint pain, contractures,
and muscle weakness may interfere with a
woman’s sexuality.

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Disability

1. Studies have addressed the sexual needs of
spinal-cord injuries, little research has assessed
the sexual health needs of persons born with
physical and intellectual disabilities. Societal
attitudes toward sexual expression among people
with intellectual disabilities have not been
favorable. Families, fearing exploitation and
abuse, may shield their impaired children from
obtaining any sexual knowledge or keep them
from participating in appropriate sex education
programs.
2. Clearly, an assessment of the intellectual
capabilities of the individual is needed to
determine the person’s ability to consent to sexual
overtures. Similar problems may arise among
individuals with congenital physical disabilities.
In both cases, the physician must address the
concerns of the parents, provide education,
anticipatory guidance to the child or young adult,
and encourage responsible sexual behavior.
3. Appropriate confidentiality is important also.
Treading the difficult line between giving the
non-independent woman appropriate confidential
information and consultation and helping her
work within her family system may be
challenging. Understanding guardianship and
family relations will help.

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Breast cancer

1. A diagnosis of breast cancer brings numerous
psychological, emotional, relational, and sexual
ramifications for the woman, her partner and her
family. Cultural and personal views of the breast
as a symbol of femininity and attractiveness and
conversely as a source of life and nutrition,
play a role in how the woman and her partner
respond to the diagnosis.
2. Assessing the woman’s self concept, her body
image, expectations of fertility, and her sense of
femininity when discussing treatment options are
important. Women also fear the response of their
partners to potentially disfiguring surgeries.
Involving the partner in the treatment is
important. The adjustment process can be
improved by encouraging the partner to view
the surgical site early, discussing issues of
revulsion or avoidance (of the breast and the
partner) and addressing concerns about sexual
activity causing pain.
3. Sexual dysfunction occurs frequently among
breast cancer patients. However, the source of the
dysfunction has not been linked solely to the
diagnosis and treatment of breast cancer. The
sequelae of treatments, premature menopause,
depression, the impact of medication and
chemotherapy and preexisting sexual problems
may all contribute to dysfunction in breast
cancer patients.
4. A relationship exists between menstrual status and
sexual functioning in the woman who has breast
cancer. Chemotherapy induced menopause causes
vaginal dryness, and other hormonal changes
exacerbate sexual problems.8 Women who have
had chemotherapy and younger women who have
had premature menopause are more likely to
have problems with sexual function.
5. Women who have undergone reconstructive
surgery following mastectomy often complain of
loss of sensation and pain in the breast.9 Direct
stimulation of the breast is no longer as
pleasurable and may affect the quality of the
sexual interactions between the woman and her
partner. Women who have had total mastectomies
and reconstructive surgery are more likely to
experience significant sexual problems than those
who have undergone lumpectomies.

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Gynecological cancers

1. While the sexual consequences of gynecological
cancers vary according to the treatment needed,
dyspareunia is more common among women who
have radiation than surgical interventions.6
2. Vaginal dilators may be used for women
experiencing dyspareunia following radiation
treatment or surgical interventions. Use of the
dilator two or three times a week may reduce
anxiety about pain and enable the woman to
resume sexual activity more comfortably and
experience penetration without pain.7
3. Different positions may be used so that the couple
can find the better ones for themselves.

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Medical problems and sexuality Cancer

1. The diagnosis of cancer has a profound effect
upon the woman, her partner and her family.
Loss, fear, anxiety, anger, and depression are
common responses to the diagnosis. Loss may be
related to expectations of fertility, of experiences
as becoming less whole, less feminine, and more
vulnerable to the exigencies of life. Fears
associated with the treatment, pain, loss of
control, change in perceived desirability, and
death are frequent responses. Those cancers that
affect sexual organs are traumatic for the patient
and her partner. Since cancer provokes crises in a
woman’s life, exploring the nature and quality of
significant relationships is essential.
2. Partners of cancer patients also experience
reactions to the illness that may include fear
of loss and hurting the patient, irrational fears of
contamination or contracting the disease, or a
decreased sense of her desirability.
Communication between partners is crucial.The physician can facilitate communication,
provide information about the treatment and
outcomes, and explore the patient’s understanding
of what cancer means to them.
3. Pain, or the anticipation of experiencing pain,
may have a negative effect on the woman’s interest
in sexual intimacy. Premature resumption of
sexual activity before the woman is ready
physically, psychologically, and emotionally may
occur in order to relieve anxiety about her
partner’s perceived sexual needs and a need to
affirm her desirability as a woman.

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Postpartum

1. Following delivery, women gradually return to
former levels of sexual desire and interest,
although physiological factors such as vaginal
bleeding or dyspareunia may contribute to
decreased sexual interest during the postpartum
period.
2. Fatigue, lack of sleep, psychological concerns, role
overloads, and stress may also have a negative
impact upon the resumption of sexual activity in
the new mother.
3. The husband’s fear of injuring his partner may
impact the couple’s resumption of sexual activity.
The family physician can offer guidance as to ways
to cope with the numerous adjustments a couple
experience when they become parents.

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Pregnancy

1. Pregnancy creates many physical and
psychological changes in the woman’s and
couple’s relationship. The woman may have body
image changes, physical discomfort, and fears for
the safety of the pregnancy.
2. Sexual desire decreases during the first trimester,
increases during the second trimester, and
decreases again in the final trimester. Some studies
have linked advanced pregnancy to decreased
sexual desire and satisfaction.
3. For couples who want to continue sexual intimacy
throughout pregnancy, the physician may
recommend positional changes that are more
comfortable for the woman and can accommodate
the enlarging fetus. Use of pillows under the
woman’s head and back or reclining to decrease
the shortness of breath that comes with lying flat
will help the sexual relationship. Alternative
positions, such as side to side or the woman on
top, may be preferable. Sex without penetration
may be more comfortable.
4. Unless the woman is at high risk for or develops
premature labor, there is no medical reason,
except discomfort, to stop having sexual relations
during pregnancy.

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Sexuality and adolescence Initiation of sexual intimacy

1. Adolescence is a time of great physiological,
emotional and psychological change. It is a time of
exploration, emancipation, and a search for
self-identity. Sexual intimacy is one aspect of
accomplishing this transition.
2. Many women, especially teenagers, define
themselves by their relationships to others. Having
sexual relations may cement these relationships.
3. In the USA, more than three-quarters of boys
and two-thirds of girls have had sexual intercourse
by their senior year of high school. Nearly half
of all 15–19 year olds have had sex at least once.1
By age 19, 70% of teenagers have had sex.
4. US teenagers are waiting longer on average to
have sex than they did previously. Three-quarters
of girls state that they started sex in the context of
a relationship with a “steady” boyfriend.1
5. The onset of sexual intimacy varies among
adolescents. Peer pressure, feelings of love and
attraction, curiosity, and wanting to be “grown
up,” are all among the reasons cited by teenagers
for initiating sexual experimentation.2 Family
factors such as divorce or single-parent homes and
abuse also influence the initiation of sexual
activity.3 Environmental and behavioral factors
such as drug and alcohol use, delinquency, poor
self-esteem, and decline in school grades have also
been linked to premature sexual experimentation
among adolescents.4
6. Physicians should be sensitive to the issue of
emerging and possible confusing sexuality in gay
and lesbian adolescents. As many as 10% of all
adolescents have concerns about sexual identity
issues.5
7. In some teenage girls, sexuality is related to poor
self-esteem. Reminding them that they have a
right to refuse, to enjoy, and to request is
important.
STDs and pregnancy
1. Relatively few adolescents admit to planning
sexual encounters. However, more sexually
experienced teenagers are using contraceptives
and most of these are using condoms, especially at
first intercourse.
2. Lack of comfort with their bodies, poor
self-image, and embarrassment may interfere with
a teen’s willingness to consider contraception.
3. Teens may be reluctant to discuss these issues with
their physicians. Establishment and assurances of
confidentiality and its limits will help create an
atmosphere of trust.
4. Adolescents, especially those who begin their
sexual activity at a younger age, are more likely to
have multiple sexual partners over time,
exhibiting a type of serial monogamy, which also
places them at a higher risk for STDs or
pregnancy.
5. Adolescents need reassurance of their normality
and the normality of their concerns, reaffirmation
of the need for contraception and prevention of
STDs, and confirmation for their right to
enjoyment and lack of pain and ability to refuse.
6. Exploring the teen’s understanding of sexuality,
including dreams, fantasies, homosexual thought,
masturbation, hormonal and body changes,
reproduction, contraception and prevention of
STDs is important.

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Sexuality through the life-cycle

Introduction
1. Sexuality is a significant aspect of all individuals’
lives. Physicians and health care professionals who
provide continuing care to individuals and
families have an opportunity and responsibility to
provide appropriate counseling, anticipatory
guidance and education. Many women consider
their physicians as experts in the area of human
sexuality.
2. Sexual issues are frequently ignored in practice.
Sexuality provides individuals a way to express
their feelings, demonstrate caring and
communicate and develop intimacy with another
person. Sexual expression becomes a source of
pleasure and fulfillment. For couples, it is a
powerful form of conversation.
3. Many medical, psychological, and developmental
concerns impact sexual behavior. These include
psychosocial development, contraception, STDs,
and the impact of various illnesses such as
depression, substance abuse, physical disability,
heart disease and diabetes on sexuality. If not
discussed, this may be ignored.
4. When talking with the woman about sexual
histories and concerns, consider the age, culture
and religious background of the individual. For
some this may be embarrassing or inappropriate,
whereas many women will seize the opportunity
with welcome relief.

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Conclusions

Providing excellent psychosocial care to women
throughout the life-cycle is one of the most complex
and rewarding tasks a primary provider will undertake.
The attention, time, and focus by the provider to
the broad spectrum of emotional, developmental, economic,
cultural, and social issues that will impact one’s
health will be time well spent. Women, by virtue of
their unique caretaking, childrearing, and employment
responsibilities, have special concerns that require care
and attention. Respect and appreciation for the value of
psychosocial care will not only lead to better care of
patients, but better satisfaction by providers.
This chapter has focused on the psychosocial
health care of women and suggested shifts in the
paradigm of the approach in order to meet the needs
of women that may be unique to them. However,
many feel that the precepts and principles of relational
thinking are relevant to both genders and support
an overall approach that is more sensitive to the
needs and realities of all. Viewing one’s patients,
regardless of gender, through a relational lens offers
the possibility of humanism as a guiding ideal for
medicine. Perhaps, as practitioners care for the caretakers
in our culture, this ideal might be better realized
throughout medicine.

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Older women

Although poverty is an enormous issue in the psychosocial
life of any woman, this issue becomes more
important in elderly women. Women older than the
age 65 constitute the fastest growing segment of the
population and comprise the significant majority of
that total population.
By the year 2012, people age 65 and older will
comprise 14% of the total population, twice the
number in 1956.20 Moreover, women comprise an
even higher percentage of the elderly poor (72%),
and twice as many African-American women live in
poverty as Caucasian. Elderly women are half as likely
as men to have pensions and four times more likely to
become indigent and require Medicaid for nursing
home or other care.21
As women age, life-cycle tasks evolve significantly.
There is enormous diversity of life experience, health
status, economic conditions and overall social supports
each individual woman experiences. Many providers
will first come to know women during this
time as the frequency of visits tends to increase with
the development of health problems. Eighty percent
of elderly women older than age 65 have at least one
chronic health condition. Concerns about health may
well dominate over psychosocial concerns as well as
substantially impact quality of life.
Eighty per cent of elderly women older than age 65
have at least one chronic health condition.
Attention to psychosocial health may reap significant
benefits. The aging woman may have more time
for reflection, more knowledge about herself and life,
and be less driven by sociocultural norms of success
and achievement. This age has the potential to be a
time of enormous satisfaction. A lifetime of caretaking
for others may be turned, finally, toward the self.
Women may need permission to do so, and may
benefit from support and encouragement to see the
value in evolving roles.
It can also be deeply unsettling to no longer be
needed in familiar roles. What is perceived as a time
of freedom and independence to some can be a source
of depression and loss for others.
Major financial changes, whether caused by retirement,
death of a supporting partner, or divorce can
dramatically alter the course of an older woman’s life.
Statistically, a woman in America who reaches age 65
can expect to live another 19 years, a lengthy period of
time to finance and survive.
Several psychosocial challenges are likely to present
themselves as women age. Loss of partners, loved
ones, spouses, and siblings may place a woman at risk
of isolation, living alone, and marked diminution of
social supports.
Women who have enjoyed lifelong independence
may find themselves facing gradual dependence secondary
to physical decline. Our profoundly mobile
society may mean that children, grandchildren, and
other potential sources of support may be substantial
distances from each other. Retirement from work
may be associated with pleasure and joy in newfound
freedom or may result in a loss of sense of identity,
value and importance.
In this culture, aging women are not usually
revered and beloved for their wisdom and past work,
though surely, such family systems exist as places of
support for some. An individual’s ethnicity will influence,
to some extent, how older women are valued
within a family and community. Western culture, and
thus providers, tend to focus on loss in the elderly
rather than gain.
As chronic medical conditions mount, numbers of
prescriptions increase, and visits to the office become
regular, the provider and the individual can both lose
sight of the health that does remain. Gains of this
time in a woman’s life should be celebrated. A new
grandchild, volunteer work that is meaningful, travel,
pleasure in time spent with loved ones all contribute
to the health of an aging individual. These should be acknowledged and celebrated in the course of the
care as surely as the blood pressure should be
monitored.
Isolation is one of the greatest psychosocial risk
factors, and can lead to, or be a symptom of, depression.
Recognition by the provider that an aging individual
is becoming isolated can be an important step
in preventive care.
Isolation is one of the greatest psychosocial risk factors,
and can lead to, or be a symptom of, depression.
End of life issues are challenging for all providers,
and perhaps even more so for patients with whom
practitioners have developed strong relationships. Yet
the fruits of long relationship can be realized powerfully
in such times. All wish for a peaceful death. If the
provider genuinely knows the patient, then s/he genuinely
knows their wishes.
Inevitably, except for sudden unexpected deaths,
the process of physical decline, diagnosis, work up,
and treatment often moves women away from the
primary care arena into specialty and intensive care
settings. Primary providers can lose touch with their
patients, yet this is a time when their continued presence
can be quite valuable. Occasionally, the provider
will be the only individual who has had direct and
clear conversation about a woman’s wishes toward the
end of life. A provider’s responsibility clearly extends
through the end of life in such cases.
Confusion and conflict within families, particularly
gatherings of those from distances, may demand
the distinct voice of the provider who has had these
important conversations. It is a component of good
psychosocial care to assist the extended family in such
times, and honors a provider’s relationship with the
individual. Countless patients have experienced a
sense of abandonment by providers as the time for
medical intervention passes and the time arrives for
allowing the inevitable to occur. “A peaceful death can
only be possible if it is understood that the power of
death in the end triumphs over human science and
artifice, and that only a stepping aside to allow it to
happen can be faithful to the force of nature and
the respect owed to patients.”22 Practitioners must
remain present in order to see these relationships
through, to facilitate that stepping aside if need be,
and to continue the process of providing good psychosocial
care to those left behind.

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Adult women

As women emerge from adolescence into adulthood,
issues of relationship persist, but the complexities of
attaining a livelihood, sustaining oneself, and possible
partnering come more directly to the fore.
Many young adult women will be continuing to
traverse tasks of adolescence, while many others will
have long since been pushed prematurely into assuming
sets of responsibilities normally thought of as
adult. The developmental tasks faced in adulthood
are numerous (Table 5.4). These broadly apply to
most women in a western culture but will be affected
powerfully by ethnicity, culture and circumstance.
Few women, if any, follow a smooth developmental
trajectory. Economic forces will shape this
trajectory tremendously and poverty is consistently
identified as a major source of psychosocial stress.
Sexual orientation may have significant influence
on the accessibility of social supports upon which one
might depend. Changing social mores may affect how
openly a woman remains single, is lesbian, adopts children of color, and lives her life. Job and legal
changes may allow closeted women to live more
openly than previously, or the reverse may occur.
Threats of violence, harassment, and intimidation
are daily facts of life for millions of women. Constructing
a model for “normalcy” in women’s lives is
not reasonable. There are simply as many variations
as there are women. Table 5.5 presents some suggestions
for psychosocial screening questions that may
facilitate a deeper discussion of these issues.
Constructing a model for “normalcy” in women’s lives
is not reasonable.
Research that explores psychosocial correlates of
health has highlighted attributes that may be relevant
for the provider. One large study examined psychosocial
factors and their relationship to coronary heart
disease in 750 women between the age 45 and 64.
Women who developed angina and coronary heart
disease were 2–3 times more likely to score higher on
scales measuring type A behavior (emotional lability,
ambitiousness, and “non-easygoing”), suppressed
hostility and anger, tension and anxiety.10 A followup
study examining this same group 20 years later
revealed similar findings but added low educational
level, lack of vacations, and perceived financial status
among employed women as risk factors.11 Measurable
associations exist between divorce, lower socioeconomic
class, lower educational attainment, and
limited social supports, on the one hand, and cardiovascular
disease, cardiac arrhythmias, sleep disturbance,
depression, and anxiety, on the other.12,13
Conversely, overall health has been shown to have
strong correlations with role satisfaction (particularly
work related),14 higher socioeconomic class, caring
for a family, strong social supports, high self esteem,
and larger social netw orks. 15,16,17
Clear differences exist in mortality between lowest
and highest income women and educational attainment
level. Many argue that the higher rates of morbidity
and mortality found in low income groups are
solely explained by differences in health related
behaviors such as alcohol and tobacco consumption.
While no doubt a factor, other studies refute these as
the major etiology and find that education level, social
stresses, and social roles at work and home are independent
risk factors.18,19
Women are the caretakers in the culture; this role
can be a source of great satisfaction, identity and
fulfillment, but can also be the source of enormous
stress and frustration.
How caretaking affects women will be highly
dependent on a host of associated factors: support
systems, relief from the role, degree of caretaking, presence of more than one generation requiring
caretaking, and the nature of the caretaking relationships,
among many others.
The full time working woman (some 65% of
women) who is responsible not only for young children
but also aging parents or relatives is at high risk
of being overwhelmed by these responsibilities.
Relationships with those being cared for may be
warm and loving or may be fraught with anger, unresolved
issues, and confusion.
The provider should be aware of the caretaking
responsibilities of their patients and how these will
affect psychosocial and overall health. Providers can
serve not only as a source of this needed caretaking
but also assist women in realistic assessment of the
demands upon them, and assist with finding alternatives
where needed.

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Psychosocial health through the life-cycle – adolescents

Providing humane, thoughtful psychosocial care to
young women during the period of enormous transition
and growth that marks adolescence is exciting
and often very challenging for the provider. The
stakes may be high and there is significant content
in screening, assessment, and risk factor identification
that need to be covered. Often adolescents do not
really want to talk, and there are medical aspects of
a visit with which to contend.
The 1990s brought an explosion of work, both
scholarly and popular, about the risks and transitions
for adolescent girls in western culture. Galvanizing
public attention to the issue, the American Association
of University Women Study of 1990 looked at
3,000 young girls and boys age 9 to 15. The results
clearly identified the costs and risks of coming of age
in America within a patriarchal cultural and educational
system. The study found that the passage to
adolescence was particularly treacherous for girls,
marked by decreased confidence, decreasing abilities
in math and science, and an increasingly critical attitude
toward their own body.5
Passage to adolescence was particularly treacherous
for girls, marked by decreased confidence, decreasing
abilities in math and science, and an increasingly
critical attitude toward their own body.
More recent studies of academic success show that
girls achieve substantially higher than boys in reading
literacy (in the developed world) while continuing to
lag in mathematics and science achievement. However,
those differences are narrower than in past
decades.7
Relationally speaking, girls begin to lose their
voice. The pressures and messages about being female
in a western culture sufficiently quieted the strong
and confident younger girls as they learned to be nice,
get along, and accommodate others. “At the crossroads
of adolescence, the girls in the study describe a
relational impasse that is familiar to many women:
a paradoxical or dizzying sense of having to give up
relationship for the sake of ‘relationships’ ” (page 216).5
Thoughtful psychosocial care can be provided by
attending to this fact. By caring about and creating
relationship with adolescent girls, providers come to
know them and identify those risks that arise from
this dissociation from self. The clinician can seek to
identify relationships that may be sources either of
strength and support, or discord and vulnerability.
Table 5.3 presents one series of inquiries that may
be used as screening questions regarding relationship.
A question might lead to a series of others that illuminate
a conflict or highlight a strength. Keeping an ear attuned to a sense of disconnection, whether from
parents, friends, school, or others can provide the tip-off
to other questions to pursue in more depth. Listening
carefully to an adolescent’s version of their relationship
to others helps to avoid the land mines of assumptions,
whether about sexuality, values, or “normalcy.”
Adolescent girls value relationship. They describe
most anxiety about abandonment and they may be
most at risk when they abandon themselves,1 by dissociating
from their own confident younger girl
voices in order to accommodate to the pressures and
expectations of the culture around them.
Studies that have attempted to isolate correlates of
psychosocial health through these turbulent years
have identified active participation in all girl sports
teams as a positive factor.8 Sports involvement helps
not only with body image issues as girls come to view
their bodies as competent and strong, but ongoing
support of other girls in relationship to themselves
can help in weathering the doubt and self-negation so
ubiquitous during this time.
Sports involvement helps with body image issues as
girls come to view their bodies as competent and
strong, and by providing the ongoing support of
other girls.
A study of resilient adolescent teens who became
mothers identified relationships, insight, and initiative
as the positive correlates of coping well with this
major transition.
An additional strategy might be called responsibility/
rebellion. This may be a quality particularly
valuable for adolescents. Some young women who
were determined to prove that they would not fail or
do poorly as all the surrounding systems predicted,
thrived.9
Given the value placed on relationship, the primary
care provider should appreciate the relationship
with an adolescent over time and not despair of the
limited “progress” that seems to be made in any given
individual visit. Many a provider has been suprised
and pleased to learn how strongly the young girl
identifies them as “my doctor.”
Creating the environment of trust necessary for a
productive care relationship with an adolescent if the
provider also cares for the extended family, is challenging.
Issues of confidentiality need to be addressed
directly and adhered to faithfully for the provider to
sustain credibility with the adolescent. Identification
as “my doctor” will be facilitated by seeing the adolescent
alone.
The primary care provider should appreciate the relationship
with an adolescent over time and not despair
of the limited “progress” that seems to be made
in any given individual visit.

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Principles of psychosocial care for women

The busy provider, hustling through a day packed
with sick patients and interspersed with physicals on
well children and adults, has her doubts about all this.
For many, taking care of ill people and performing
well care with the requisite attention to preventive
counseling and screening, and doing this well, is
more than a day’s work. Nonetheless, it is also true
that when practitioners enter the exam room and ask
“how are you?” they begin the process of providing
good psychosocial care.
The principles of good psychosocial care are both
simple and complex. A caring, attentive ear that
remains alert to the woman’s own understanding of
her life in relation to self, to others, and to the systems
and institutions that comprise her life is a beginning.
Fueled by genuine interest and curiosity, good psychosocial
care has, at its heart, a deep and abiding respect
for women and their enormous strengths and vulnerabilities.
It is dependent upon relationship; that exists
and is developing each moment of an encounter. For
most providers, this is knowledge acquired over time,
both in the general sense and in the specific.
The broader culture has not inculcated providers with
a sense of deep respect for women.
The broader culture has not inculcated providers
with a sense of deep respect for women. Many come
to the practice of medicine with biases and stereotypes
about the roles and capabilities of women. Even if providers are raised in families with positive messages
about women, popular culture has muddled that
message to some extent.
Good psychosocial care of women respects relationships
as fundamental and is capable of viewing
the world through relational lenses. It avoids judgment
and labeling and is willing to accept a world
view different from one’s own. It demands some
fearlessness about feeling and asks for, at times,
reconsideration of the more traditional medical rules
about boundaries. It may, at times, call for emotional
investment on a provider’s part and remains open to
that possibility. Nonetheless, thoughtful psychosocial
care fully respects appropriate boundaries.
Good psychosocial care is sensitive to the
dilemmas faced by women in the culture and does
not trivialize them. Respect for the burdens placed by
assumptions and prescribed roles that have oppressed
women is critical.
Good psychosocial care does not fail to acknowledge
these hard realities and appreciate the power
of them, and it does not shirk from addressing
them. It respects the enormous diversity of women’s
lives and does not make assumptions of normalcy.
It remains sensitive to the dilemmas faced by
women within the medical culture and seeks to
improve upon them.
If the relational model is used to consider health
care, the major risk factors threatening psychosocial
health become more apparent. Those events and
influences that lead to major disconnection will be
the most likely to disturb the well-being of an individual
woman. The potential dislocations that occur
as a result of social change, coupled with the significant
mobility of the culture provide enormous opportunity
and potential for major disconnection.
Disconnections such as death (particularly of a
child), job loss, divorce, partnership dissolutions,
domestic violence, trauma, or illness may seriously
threaten a woman’s sense of her self and her world.
Women remain particularly at risk for economic
dislocation, whether by earning less then men for
equivalent work, or through divorce, partnership dissolution,
or spousal death. Psychological and biological
health are all at substantial risk during such times when
a woman’s sense of control over her environment and
life is seriously threatened. Her ability to process, grieve,
and ultimately grow through such events is predicated
upon her own internal and external support systems
that may facilitate, or may threaten, her survival.
The potential dislocations that occur as a result of
social change, coupled with the significant mobility
of the culture provide enormous opportunity and
potential for major disconnection. Women remain
particularly at risk for economic dislocation, whether
by earning less then men for equivalent work, or
through divorce, partnership dissolution, or spousal
death.
A helpful model for considering the coping styles
of women facing major disconnections is that of
resiliency, the ability to rebound from adversity.
Wolin and Wolin have described seven features of
the resilient individual from their work with survivors
of troubled families (Table 5.2).6 These features will
cluster in varied fashion depending on the personality
and circumstances of the loss or disconnection faced,
and a given woman may utilize one or several of these
qualities in coping. For the provider, assessment of
the ability and diversity of such strategies may highlight
risks and illuminate strengths, while suggesting
other potential strategies for improved coping.
Knowledge of the individual, her experience with
previous coping strategies that were successful or not,
and awareness of the presence or absence of support
may all serve to help the provider care for and work
with an ill woman. A past experience of acceptance by
a provider is very powerful. Knowledge that she will
be accepted for her coping strategy and heard
empathically rather than lectured to about what she
“should” do is powerful.
Well-meaning friends and cultural mores often
dictate to women how they should cope or grieve.
Mores about acceptable grief, whether temporal
or topical, often tyrannize women. A climate of acceptance, a sense that she is right to do it her way, in
her own time is very powerful. Avoiding a tendency
to immediately medicate signs and symptoms of psychological
distress may also be valuable and appropriate.
Many women will benefit from a steadying hand
from their provider rather than a prescription.
Avoiding a tendency to immediately medicate signs
and symptoms of psychological distress may also be
valuable and appropriate. Yet, the provider need also
exercise caution about minimizing and downplaying
distress.
Yet, the provider should exercise caution about
minimizing and downplaying distress. Supporting
women through periods of reactive depression, overwhelming
grief, and intense feeling without judging
or pathologizing can be among the most important
and powerful clinical interventions practitioners will
ever perform.
Nonetheless, there are circumstances when prescriptions,
active interventions, and referrals are absolutely
necessary. The clinical judgment of the provider
must always be alert for the signs and symptoms of
major depression, suicidality, and life threatening
behaviors. In fact, an environment of trust and relationship
improves the likelihood that dangerous disconnections
will be more readily identified by the
provider and interventions more readily accepted.
Many women have had their feelings and concerns
minimized in the medical setting. Some arrive
to these environments primed to be ignored or to
have their feelings discounted. Lesbian women and
women of color have often been the victims of
insensitive and irrelevant care. Women are much
more likely than men to have had their behavior
and symptoms labeled. Providers who are inclined
toward curiosity rather than judgment, understanding
instead of diagnosis, and mutuality rather than
strict doctor–patient roles may find they are more
successful at providing good psychosocial care.

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Women’s psychological development

Relational theory sees women in a context broader
than that assigned by their reproductive abilities or
gender driven caretaking roles. If development is
understood as unfolding from infancy onward via
one’s affiliations, there will be a much broader context
from within which to understand women as they are
self defined rather than as role or gender defined.
Being “self defined” means recognizing that women
are both self defined and in relationship to others,
whatever the context of that “other” might be.
Relational theory, therefore, would suggest that
autonomy means being in relation and caring, but
not to caring which is dependent or oppressive.2
Candib asks us to consider what is requisite to create
a working model of adult development for clinical
practice (Table 5.1).2
Relational theory suggests that autonomy means
being in relation and caring, but not to caring which
is dependent or oppressive.
Racism must be taken into consideration in
looking at the experience of women of color in relational
theory. Moreover, such a model must consider
development within the context of relationships
rather than separate from them, and it must view
critically the idea that development consists in
striving toward the goal of male-defined autonomy.2
This discussion of relational theory attempts, with
broad brush strokes, to describe a methodology for
thinking about psychosocial issues in women’s lives.
It is, for purposes of this chapter, a brief overview.
The interested reader is strongly encouraged to
understand more deeply by reading any of the references
cited, but particularly relevant to the practicing
clinician is the excellent discussion found in Medicine
and the Family by Dr Lucy Candib.2

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Theories of early psychological development

1. Theoretical constructs of psychological development have been rooted for much of the twentieth century in theories based on observations and studies of men. Theories designed to describe normal psychological development of men, thus, resulted in description of women’s development as aberrant or arrested.1 Theories designed to describe normal psychological development of men, thus, resulted in description of women’s development as aberrant or arrested. 2. While extensively debated over the decades, the works of Freud and Erickson remain, to this day, the underlying sets of assumptions about the earliest psychological development of infants and young children. These principles emphasize separation, autonomy and independence of the infant from the (mother) caretaker with evolution toward emphasis on generativity, the development of rules and universal principles. Pediatric and family medicine texts continue to offer these understandings as norms for early childhood development.2 3. Accepting that these constructs may be relevant for male infants and children, they leave behind female infants and children as problems that need explaining. As such, these theories often concluded that females were wanting, less evolved, and less capable of achieving the highest levels of development.1 4. In the 1970s, women psychologists and psychotherapists began to critique and expand upon ideas of early female psychological development. Rather than an approach that tended to see what it was not relative to male development, these theorists began to describe how the experience of attachment, separation, growth and individuation might be different for women. These ideas assumed femaleness as uniquely itself, rather than as “other.” Further, the truth that caretakers of infants and children were overwhelmingly female was bound to be relevant. Might not, these theorists argued, the experience of attachment and separation differ for male and female infants, particularly in light of the powerful gender identification that highlights caretakers and the cultures from which they come? These questions ultimately led to a theory of development that has relationship at its core. The experience of attachment, separation, growth and individuation might be different for women. Attachment is the norm. 5. This relational approach to developmental theory holds that being-in-relation is the core experience for female infants and children. In other words, attachment is the norm, particularly in light of the gendered caretaker (mother) from whom separation is not required. Given the sameness, or identification with, the mother caretaker, the process is more likely to be of relationship to rather than separation from. 6. By this formulation, ideas of empathy, relationship, connectedness and mutuality come to the forefront of the development process and remain there throughout a woman’s life,3 in contrast to ideas of separation, autonomy and independence. Thus, “relationship is seen as the basic goal of development: i.e. the deepening capacity for relationship and relational competence . . . other aspects of self (e.g. creativity, autonomy, assertion) develop within this primary context . . . There is no inherent need to disconnect or to sacrifice relationship for self development” (page 53).3 7. In adolescence, therefore, relational theory would describe a transformation in the pattern of the parent–child bond rather than a break in the bond. Adolescent identity formation is realized in individuated relationships in which differences are freely expressed within a basic context of connectedness.”4  8. Female adolescents traverse the complex terrain of individuation within the context of relatedness. They must forge new identities while remaining rooted in the mutuality of their families. The emphasis on friendships during this time does not necessarily imply a separation from the family of origin, but rather a new context in which to be individuated and broaden the range of their relationships.5 These are formidable challenges and important times for psychosocial assessment and care.

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Definitions and background

1. “Psychosocial” refers generally to the
psychological status of an individual within the
context of their social environment.
2. “Well woman” refers both to the absence of
disease and the experience of health. This implies
a broad definition of health to include cognitive,
emotional, physical, psychological, spiritual, and
environmental factors.
3. Assessment of and screening for psychosocial
health is deeply connected to the quality of the
provider–patient relationship. The life and clinical
experience of the provider has a profound impact
on decisions about the value, methodology, and
approach toward assessment of psychosocial
health. Some providers feel this is not an essential
role for the clinician, and others see the
relationship as a potentially powerful tool toward
understanding the individual, enhancing a
relationship with them and potentially favorably
influencing the patients future health.
The provider–patient relationship is a potentially
powerful tool for understanding an individual,
enhancing the relationship and potentially favorably
influencing future health.
4. There is, inherent in relational work, the potential
for affecting a provider’s own satisfaction with the
daily work of supplying medical care to diverse
peoples. It can be delightfully refreshing to
provide medical care for a “well” person even if
there is considerable variation in what the
parameters of that care might include.
5. Each provider brings to the exam room a set of
knowledge, beliefs, and experiences rooted in their
own upbringing, family system, and education
and training experiences. Depending on the era of
the provider’s training, his/her own knowledge
base about the normal psychological development
of women (and men) will vary widely.
6. Many physicians, nurse practitioners and
physician assistants have had little to no training
or educational background in healthy women’s
psychological development. Their approach and
understanding to psychosocial issues might then
be limited to their own family’s system and their
clinical experience. Other providers may have had
extensive training in traditional psychology that,
historically, has viewed women’s psychological
development as deviant from that of men.
7. In the last two decades, feminist thinkers have
advanced alternative theories about women’s
psychological development that have influenced
the thinking and approach of mental health and primary care providers. For some practitioners
exposure to the “biopsychosocial model” came
during their clinical training and is rooted in family
systems theory and thinking. The practitioner’s
knowledge base, wherever rooted, significantly
affects his/her ability to attend to psychosocial
issues in a woman’s life. All practitioners should be
fully aware of the strengths and limitations of their
own experience in this regard.

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Psychosocial health of well women through the life-cycle

Primary care providers are uniquely positioned to
assess the psychosocial health of women. While
most individuals who seek care are “patients,” –
those who require or request care for specific
problems – women are frequently seen when they
are well. Whether for Pap smears, prenatal care, or
general physical exams, primary practitioners will
more likely encounter healthy women throughout
their lives. Psychosocial health is the substrate from
which a woman adapts to the complex world that
comprises her life. As such, whether seen in illness
or in health, the provider always has an abiding
interest in the psychosocial state in which the individual
presents herself.

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Disease considerations

The most common causes of morbidity and mortality
in the United States are associated with modifiable
risk factors, such as obesity, sedentary lifestyle,
smoking, and poor diet (www.cdc.gov). Exercise is
important as a preventative measure as well as a
treatment option for certain diseases, combined with
a healthy balanced diet, relaxation practice, and continued
supervision/treatment from a physician. Exercise
prescriptions can be modified for those persons
who have a diagnosed disease. Exercise guidelines are
given in Table 4.4 for select diseases.
In November 2000, the Centers for Disease Control
and Prevention released a report on the health
and economic burden of chronic disease.52 Seventy percent of Americans who die, die of a chronic disease.
For women age 35 to 64 years old, cardiovascular
disease and lung and breast cancer are the three
leading causes of death. One sixth of the American
population has arthritis, the primary disabling disorder.
Fifty percent of individuals with osteoporosis
cannot walk unassisted and 25% require long-term
care. Clearly, there is a need for exercise intervention
to help mitigate the effects of aging, prevent chronic
disease, and enhance quality of life.


The most plebeian causes of morbidity and mortality
in the Incorporated States are related with modifiable
chance factors, such as blubber, sedentary manner,
respiration, and moneyless fasting (www.cdc.gov). Practice is
arch as a cure step as vessel as a
communicating choice for certain diseases, one with
a good harmonious fast, weakening effectuation, and continuing
supervision/treatment from a physician. Exercise
prescriptions can be qualified for those persons
who fuck a diagnosed disease. Travail guidelines are
relinquished in Plateau 4.4 for select diseases.
In November 2000, the Centers for Disease Examine
and Prevention free a informing on the wellbeing
and scheme concern of inveterate disease.52 Seventy percent of Americans who die, die of a prolonged disease.
For women age 35 to 64 eld old, cardiovascular
disease and lung and confront constellation are the trinity
directive causes of ending. One ordinal of the Ground
aggregation has arthritis, the coil disqualifying disorder.
Greenback proportionality of individuals with osteoporosis
cannot career naked and 25% demand long-term
charge. Clearly, there is a beggary for utilise engagement
to aid mitigate the personalty of old, keep addicted
disease, and compound property of story.

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Adolescents

With an alarming increase in the incidence of obesity,
diabetes, and the metabolic syndrome among adolescents
in America, the need for regular physical activity
and exercise is overwhelming.49 Diet and exercise
can reduce variables of the metabolic syndrome in
youth to a level that “declassifies” them as having
the metabolic syndrome, meanwhile improving lipid
profiles, insulin sensitivity, and reducing blood pressure
and body weight.50,51 Awareness that low body
satisfaction in adolescents is associated with healthcompromising
behaviors (i.e. dieting, unhealthy weight
control measures, smoking) suggests that exercise
strategies be designed to encourage a healthy body
weight and image.51 Establishing a healthy mind,
body, and spirit in adolescence sets the stage for a
future of better health and less morbidity.
Strength training should be a component of any
exercise program for any woman, regardless of age.
A whole-body, multi-joint strength program performed
2 to 3 days per week could include exercises
such as a lunge, squat, medicine ball swing, standing
dumbbell row, and stability ball dumbbell chest press.
(Refer to the list of resources at the end of the chapter
for more information.) These exercises can be performed
in the home with little equipment needed and
can be adapted to fit any schedule and available space.


With an dreadful process in the incidence of fat,
diabetes, and the metabolous syndrome among adolescents
in Earth, the beggary for regularized physical process
and utilise is overwhelming.49 Fasting and grooming
can cut variables of the metabolic syndrome in
youth to a structure that "declassifies" them as having
the metabolous syndrome, meanwhile rising glyceride
profiles, insulin sensitivity, and reducing gore somesthesia
and body weight.50,51 Knowing that low body
spirit in adolescents is associated with healthcompromising
behaviors (i.e. fast, tumid coefficient
manipulate measures, smoking) suggests that learn
strategies be organized to encourage a fit embody
metric and representation.51 Establishing a ruddy cognition,
body, and flavour in adolescence sets the platform for a
prospective of modify welfare and little mortality.
Power activity should be a division of any
employ papers for any oriental, regardless of age.
A whole-body, multi-joint capability info performed
2 to 3 days per hebdomad could permit exercises
much as a motion, sit, medicine orb hang, upright
dummy row, and firmness comedienne simpleton pectus exercise.
(Pertain to the move of resources at the end of the chapter
for solon entropy.) These exercises can be performed
in the plate with young equipment necessary and
can be adapted to fit any schedule and available expanse.

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Older women

With an increase in age there are certain physiological
changes occurring that impact the ability of an older
adult to complete daily tasks. Thus, exercise prescriptions
for older adults aim to improve physical function
by impacting the most influential variables, such
as muscle strength, muscle power, and aerobic capacity.
Various exercise programs for older adults have
demonstrated efficacy to improve muscle strength,
bone mineral density, aerobic capacity, and physical
function, and to reduce falls. Recent research has
questioned whether power training (fast speed of
concentric movement) improves physical function
more so than does strength training (slow speed of
concentric movement). While power training has
been proven to be more effective than strength
training for improving certain functional tasks46 and
bone mineral density,47 strength training repeatedly
demonstrates increases in muscle strength, crosssectional
area, improved functional task performance,
and preservation of bone mineral density.48 Based on
available evidence, the following regimen can be
prescribed for older adults: strength or power training
2 days/week, 50–85% 1RM, 3 sets of 10–15 repetitions;
endurance training 4–5 days/week, 60–70%
HRmax, 30 minutes/day; flexibility training daily,
holding each stretch for 30 seconds.


With an increase in age there are predictable physical
changes occurring that event the power of an sr.
grownup to terminate regular tasks. Thus, preparation prescriptions
for experienced adults aim to turn physiological purpose
by impacting the most cogent variables, specified
as strength strength, ruffian powerfulness, and aerophilous content.
Different exercise programs for senior adults fuck
demonstrated effectualness to ameliorate rowdy powerfulness,
whiteness mineralized density, aerobiotic volume, and physiological
purpose, and to diminish falls. Past research has
questioned whether quality upbringing (firm quicken of
concentric motility) improves tangible use
solon so than does magnitude preparation (lento constant of
coaxial laxation). Patch powerfulness breeding has
been proven to be solon useful than strength
training for rising predestined utilitarian tasks46 and
bone mineralized spacing,47 capability breeding repeatedly
demonstrates increases in roughneck strength, crosssectional
region, built useable strain action,
and improvement of bone pigment compactness.48 Based on
visible evidence, the mass programme can be
regular for sr. adults: posture or commonwealth training
2 days/week, 50-85% 1RM, 3 sets of 10-15 repetitions;
life preparation 4-5 days/week, 60-70%
HRmax, 30 minutes/day; malleability breeding daily,
retentive apiece exercise for 30 seconds.

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Middle ages

During a woman’s middle-aged years, many physiological
changes occur, some of which are modifiable.
Regular physical activity can reduce the risk of premature
death from coronary artery disease, colon
cancer, hypertension, and diabetes mellitus.3 However,
more than 60% of adult Americans are not regularly physically active, 50% of adolescents aged
12–21 years do not participate in vigorous activities,
25% of adult Americans are not active at all, and
women continue to be less active than men, regardless
of age.3 The World Health Organization states that
“age 50 marks a point in middle age at which the
benefits of regular physical activity can be most relevant
in avoiding, minimizing, and/or reversing many
of the physical, psychological, and social hazards
which often accompany advancing age.”45 Middle
age is an opportune time for the middle-aged woman
to make lifestyle changes and take charge of her life.
While much research is published about the
effects of exercise in older (>60 years) and younger
(18 to 25 years) women, less is available for middleaged
women (45 to 60 years). This may be due partially
to the plethora of physiological changes that are
occurring during these years, especially the changes in
the hormonal milieu. To capture the exercise needs of
women of all ages, exercise prescription guidelines for
older and younger women, as well as certain medical
conditions/diseases pertaining to aging women and
the application of exercise as a primary or secondary
preventative tool will be briefly discussed. Regular
physical activity and exercise can improve all aspects
of health, spirit, mind, and body.



During a woman's middle-aged eld, umpteen physical
changes become, whatsoever of which are modifiable.
Lawful somatogenetic activeness can thin the essay of premature
death from coronary artery disease, city
mortal, hypertension, and diabetes mellitus.3 However,
many than 60% of mortal Americans are not regularly physically nimble, 50% of adolescents ripe
12-21 period do not act in vigorous activities,
25% of someone Americans are not progressive at all, and
women remain to be less existent than men, regardless
of age.3 The World Wellbeing Structure states that
"age 50 businessman a sail in intervening age at which the
benefits of standard sensual activity can be most material
in avoiding, minimizing, and/or reversing umpteen
of the material, psychological, and party hazards
which oft follow forward age."45 Intermediate
age is an seasonable instant for the middle-aged caucasian
to sort way changes and position calculate of her invigoration.
While some research is publicised most the
personalty of sweat in sr. (>60 period) and junior
(18 to 25 period) women, fewer is acquirable for middleaged
women (45 to 60 life). This may be due partly
to the superfluity of physiological changes that are
occurring during these life, especially the changes in
the hormonal milieu. To getting the sweat needs of
women of all ages, utilize medicament guidelines for
sr. and junior women, as wellspring as sure examination
conditions/diseases pertaining to senescent women and
the exertion of use as a essential or unoriginal
curative puppet will be shortly discussed. Regular
tangible trait and lesson can amend all aspects
of eudaemonia, flavour, intelligence, and embody.

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The career woman

Women with busy daily schedules can still find time
to exercise and take care of their health by manipulating
their daily routine. The American College of
Sports Medicine has recently stated that 30 minutes
of continuous exercise is not necessary to elicit health
benefits, rather 30 minutes of total accumulated time
is required (a minimum of 10-minute bouts).44 The
time commitment is less restrictive, which allows a
woman to plan exercise sessions around her work and
family schedule. For example, a 10-minute walk in the
morning before work, 10-minute stair climbing
during work, and a 10-minute bike ride or walk after
dinner would satisfy the recommendation for 30 minutes
per day. The intensity should be in the range of
65% to 90% of age-predicted HRmax and the exercise
should be performed most days of the week.
With respect to strength training, the career
woman should focus on multi-joint functional exercises.
Utilizing large muscle groups in a whole-body
training program increases the metabolic demands of
each training session, which elicits a greater caloric
expenditure per exercise session. Because leisure time
is a limited resource, maximizing the amount of calories
burned per workout is highly beneficial and
effective.


Women with laboring daily schedules can ease effort case
to employ and withdraw reparation of their eudaemonia by manipulating
their regular subprogram. The Land College of
Sports Medication has latterly expressed that 30 proceedings
of continual employ is not necessary to elicit health
benefits, rather 30 transactions of tally massed reading
is required (a minimum of 10-minute bouts).44 The
period sincerity is less inhibitory, which allows a
friend to contrive utilise composer around her output and
sept schedule. For ideal, a 10-minute calling in the
period before apply, 10-minute support rise
during pass, and a 10-minute bike couple or path after
dinner would ply the testimonial for 30 proceedings
per day. The grade should be in the array of
65% to 90% of age-predicted HRmax and the read
should be performed most days of the week.
With observe to powerfulness breeding, the progress
lover should sharpen on multi-joint usable exercises.
Utilizing rangy musculus groups in a whole-body
preparation info increases the metabolic demands of
apiece training conference, which elicits a greater caloric
expenditure per workout conference. Because leisure reading
is a modest cleverness, maximizing the amount of calories
treated per workout is highly beneficial and
impressive.

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Exercise prescription for special populations The athletic woman

Exercise prescriptions for a female athlete are specific
to the demands of her sport. Differences in energy
system requirements dictate the intensity and design
of the program. Training of an anaerobic athlete
(sprinter, swimmer, etc.) requires high intensity,
short duration activities, whereas an aerobic athlete
(runner, triathlete, road cyclist, etc.) requires low to
moderate intensity for longer durations. Periodized
endurance- and strength-training programs alter the
training variables (speed, intensity, volume, etc.) to
maximize performance. The metabolic demand of
the sport should match the metabolic demand of the
training sessions. Thus, these programs are sport specific
and require assistance from a professional in the
field such as a Certified Strength and Conditioning
Specialist or an Exercise Physiologist.

Preparation prescriptions for a female athlete are limited
to the demands of her boast. Differences in vigour
group requirements dictate the intensiveness and program
of the information. Training of an anaerobiotic jock
(sprinter, swimmer, etc.) requires broad level,
unretentive time activities, whereas an oxidative jock
(runner, triathlete, moving pedaler, etc.) requires low to
change level for someone durations. Periodized
endurance- and strength-training programs sterilize the
upbringing variables (speed, grade, loudness, etc.) to
exploit show. The metabolic obligation of
the boast should deal the metabolous duty of the
training composer. Thus, these programs are diversion precise
and say help from a professed in the
champaign such as a Documented Capableness and Conditioning
Doc or an Exercise Physiologist.

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Endurance training

The cardiovascular system is most effectively
improved by endurance training. Endurance training
involves rhythmic movements of large muscle groups.
For example, running/walking, bicycling, swimming, and dancing are effective and common modes of
endurance exercise. However, a combination of
modalities within an exercise session might provide
extra motivation and reduce boredom.
The exercise prescription for endurance training
offers variety, similar to resistance training. The
American College of Sports Medicine recommends
20 to 60 minutes a day, 3 to 5 days per week at an
intensity equal to 60% to 90% of age-predicted maximum
heart rate (HRmax ¼ 220  age).41 Intensity
and duration are inversely related, so that a reduction
in intensity requires an increase in duration. Any of
these variables can be manipulated within and
between exercise sessions. For example, in a three
day a week exercise program, day 1 is 40 minutes of
treadmill walking at 65% HRmax, day 2 is 10 minutes
of bicycling at 70% HRmax, 10 minutes of intervals at
90% HRmax, then 5 minutes at 60% HRmax, and day 3
is 20 minutes of swimming at 80% HRmax. All three
variations can provide health and fitness benefits.
To maximize benefits and reduce the risk of
injury, specific guidelines should be followed. Because
large muscle groups utilize more oxygen and generate
more adenosine triphosphate (ATP) than smaller
muscle groups, they should be incorporated into
every exercise routine. Thus, more calories are
expended when training larger muscle groups.
Manipulating certain extraneous factors reduces
the risk of injury while exercising outdoors. Because
the ambient temperature is hottest at mid-day, outdoor
exercises should be performed in the morning or
evening when the temperature is cooler. Loose fitting,
light-colored clothing is appropriate for warmer climates
in order to circulate air and facilitate evaporative
cooling.42 In cooler temperatures, however, layers
of dark-colored clothing should be worn to trap heat
or to be removed as the body temperature rises.43 The
inner layer of clothing should be made from a wicking
material that carries moisture away from the body.
Proper footwear with a supportive arch and adequate
cushioning is also necessary. These guidelines can help
improve performance while reducing the risk of injury.

The cardiovascular system is most effectively
built by living preparation. Life activity
involves rhythmic movements of astronomic muscle groups.
For model, running/walking, bicycling, tearful, and dancing are efficient and general modes of
endurance apply. Nevertheless, a combination of
modalities within an training conference might support
spare motive and trammel ennui.
The recitation medicament for animation preparation
offers tracheophyte, confusable to opposition breeding. The
Ground College of Sports Penalization recommends
20 to 60 minutes a day, 3 to 5 days per week at an
strength equalized to 60% to 90% of age-predicted extremum
mettle charge (HRmax ¼ 220  age).41 Grade
and time are inversely kin, so that a reaction
in level requires an process in duration. Any of
these variables can be manipulated within and
between sweat composer. For instance, in a cardinal
day a period preparation info, day 1 is 40 proceedings of
grinder locomotion at 65% HRmax, day 2 is 10 minutes
of bicycling at 70% HRmax, 10 minutes of intervals at
90% HRmax, then 5 transactions at 60% HRmax, and day 3
is 20 minutes of swim at 80% HRmax. All trine
variations can support upbeat and suitableness benefits.
To tap benefits and reduce the try of
unhealthiness, particularized guidelines should be followed. Because
great musculus groups utilize much gas and generate
statesman adenosine triphosphate (ATP) than small
bully groups, they should be united into
every workout routine. Thusly, much calories are
expended when training larger bully groups.
Manipulating sure orthogonal factors reduces
the peril of loss piece exercising open. Because
the ambient temperature is hottest at mid-day, outside
exercises should be performed in the period or
eventide when the temperature is cell. Shifting fitting,
light-colored vesture is seize for device climates
in impose to move air and serve evaporative
cooling.42 In cell temperatures, yet, layers
of dark-colored clothing should be tattered to hole heat
or to be distant as the body temperature rises.43 The
inward bed of wear should be prefabricated from a wicking
physical that carries moisture inaccurate from the embody.
Decent footgear with a certificatory flex and satisfactory
artefact is also requisite. These guidelines can cater
ameliorate action spell reaction the seek of hurt.

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Resistance training

Resistance training is the mode of exercise performed
to stimulate the neuromuscular system. Variations
of the number of sets, repetitions, rest period, and weight lifted determines the outcome of the training
program. Programs designed to increase strength are
typically performed at a high intensity (80% of the
one-repetition maximum, 1RM) with long rest
periods (2 to 3 minutes) and low to moderate volume
(2 to 3 sets of 8 to 10 repetitions), whereas programs
designed to promote muscle hypertrophy are performed
at a moderate to high intensity (60% to 80%
1RM) with shorter rest periods (30 to 60 seconds) and
higher volume (3 to 4 sets of 10 to 12 repetitions).38
A 5% increase in resistance is suggested when 12 to 15
repetitions can be performed.
In a generally healthy population, resistance
training can be performed with exercise machines or
with free weights. Examples of resistance training
exercises are provided in Table 4.3. Multi-joint,
multi-planar exercises commonly associated with free
weights may be more functional because their motor
patterns mimic motor patterns of daily tasks.39
Machines offer more safety for beginners and isolate
muscle groups more so than free weights; however,
free weights require an individual to use accessory/
stabilizer muscles as they would naturally do in daily
life and improve strength more than training on
machines.40 Free weights also concurrently train balance,
strength, and coordination – similar to the
demands of daily activities. Household items (rice
bags, jugs of water, soup cans, etc.) and elastic resistance
bands can also be used for resistance instead of
metal weights or a cable system. For an individual with
no resistance training experience, machines should be
used initially to increase strength so that a progression
to free weights can be safely made.
The design of the program is somewhat more of an
art than a strict, regimented science. Science provides
the basis for sound training principles, but creativity is
needed to continually manipulate the training volume,
exercise selection, and order of exercise. The exercise
prescription can be written for specific combinations
of muscle groups (back and hamstrings, chest and
arms, etc.), agonist versus antagonist (leg extension
versus leg curl, chest press versus seated row), and
upper versus lower body (legs on Monday then chest,
back, and shoulders on Tuesday, etc.) muscle groups.
Regardless of the design of the program, specific
guidelines should be followed. Within each session,
individuals should perform large muscle groups
(prime movers) before smaller muscle groups (secondary
movers) to avoid fatigue of the larger muscles.
However, smaller stabilizing muscles (rotator cuff,
hip adductor/abductor, neck muscles, etc.) should
not be neglected. If left untrained, these smaller stabilizing
muscles are at risk of injury. The Valsalva
maneuver, holding the breath during exertion, should
never be performed. To avoid a reduction in venous
return to the heart and a significant increase in blood
pressure, individuals should exhale on exertion. As
always, medical clearance should be sought prior to
beginning an exercise program if an individual has a
condition that may be made worse by exercise.


Opposition training is the property of apply performed
to stimulate the neuromuscular method. Variations
of the company of sets, repetitions, set punctuation, and unit lifted determines the outcome of the upbringing
system. Programs intentional to growth capability are
typically performed at a richly intensity (80% of the
one-repetition extremum, 1RM) with endless relief
periods (2 to 3 proceedings) and low to average product
(2 to 3 sets of 8 to 10 repetitions), whereas programs
intentional to boost rowdy hypertrophy are performed
at a medium to eminent level (60% to 80%
1RM) with shorter interruption periods (30 to 60 seconds) and
higher production (3 to 4 sets of 10 to 12 repetitions).38
A 5% amount in condition is advisable when 12 to 15
repetitions can be performed.
In a mostly thriving population, resistivity
training can be performed with apply machines or
with unrestrained weights. Examples of resistance preparation
exercises are provided in Table 4.3. Multi-joint,
multi-planar exercises commonly related with unloose
weights may be author operational because their travel
patterns imitate move patterns of regular tasks.39
Machines request writer hit for beginners and discriminate
yobbo groups writer so than discharged weights; nonetheless,
extricated weights enjoin an organism to use accessory/
stabiliser muscles as they would course do in regular
spirit and amend powerfulness solon than upbringing on
machines.40 Loose weights also concurrently take structure,
power, and coordination - kindred to the
demands of daily activities. Home items (lyricist
bags, jugs of nutrient, soup cans, etc.) and elastic action
bands can also be old for condition instead of
alloy weights or a cablegram scheme. For an separate with
no opposition breeding see, machines should be
old initially to gain powerfulness so that a series
to atrip weights can be safely prefab.
The plan of the announcement is somewhat solon of an
art than a invariable, regimented ability. Bailiwick provides
the foundation for safe grooming principles, but ability is
required to continually falsify the training product,
training activity, and dictate of utilise. The recitation
medicine can be codified for specific combinations
of tough groups (game and hamstrings, dresser and
munition, etc.), agonist versus antagonist (leg prolongation
versus leg ringlet, dresser advise versus sitting row), and
upper versus secondary embody (legs on Monday then chest,
side, and shoulders on Tues, etc.) tough groups.
Regardless of the design of the programme, peculiar
guidelines should be followed. Within apiece meeting,
individuals should accomplish whopping hooligan groups
(period movers) before smaller musculus groups (standby
movers) to refrain failing of the larger muscles.
Notwithstanding, smaller stabilizing muscles (rotator shackle,
hip adductor/abductor, neck muscles, etc.) should
not be unnoticed. If mitt primitive, these smaller helpful
muscles are at venture of injury. The Valsalva
act, holding the breath during sweat, should
never be performed. To abstain a reaction in venous
yield to the organs and a meaningful gain in slaying
pressure, individuals should emanate on travail. As
always, examination clearance should be wanted preceding to
origin an use announcement if an human has a
information that may be made worsened by utilize.

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Exercise prescription for healthy populations

The type of exercise performed depends on the
desired goal. If a woman wants to build muscular
strength, then resistance training is appropriate.
Endurance training (walking, running, cycling, swimming)
is required if a woman wants to improve her
cardiovascular health and endurance. Yoga and Tai
Chi are therapeutic alternatives to the rigors of
strength and endurance training that can reduce
stress, increase strength and flexibility, and improve
cardiovascular parameters. A certified yoga or Tai Chi
instructor should be consulted for more information
on the styles of each.

The type of utilize performed depends on the
desirable end. If a lover wants to form muscular
posture, then action upbringing is apropos.
Animation breeding (close, pouring, cycling, swim)
is required if a japanese wants to alter her
cardiovascular health and living. Yoga and Tai
Chi are therapeutic alternatives to the rigors of
capability and animation activity that can turn
prosody, growth magnitude and malleability, and improve
cardiovascular parameters. A certificated yoga or Tai Chi
pedagogue should be consulted for much message
on the styles of each.

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Non-traditional exercise

Non-traditional styles of exercise, such as Yoga and Tai
Chi, have also demonstrated positive improvements
in health.32 Yoga involves various standing, seated,
and supine postures and breathing and relaxation
techniques designed to enhance functioning of the
various physiological systems by supporting a natural
posture. Tai Chi incorporates slow body movements
(forms) that concentrate on balance and body weight
transfers. Young and old men and women have performed
yoga and Tai Chi for centuries in Eastern
countries. Both have been purported to focus concentration
and relax the body.
Yoga practice has been shown to improve muscular
strength, endurance, flexibility, gait parameters,
and aerobic capacity.6 Evidence suggests that yoga
practice reduces sympathetic activity, improves aerobic
capacity, reduces perceived exertion after maximal
exercise, and reduces heart rate and left
ventricular end diastolic volume at rest. From a functional
perspective, people who practice yoga demonstrate
improved gait parameters, reduced pain and
symptoms associated with knee osteoarthritis, and
reduced disability, which collectively or independently
has the potential to reduce the risk of falls.33 When
compared to standard care for chronic low back pain,
yoga is more effective at reducing pain, use of medications,
and improving physical function.34 Additionally,
yoga practice may retard the progression and
increase the regression of atherosclerosis in patients
with coronary artery disease. Thus, research demonstrates
yoga’s efficacy to improve health.
Tai Chi practice improves mood states, physical
function, and hemodynamic parameters.35 A reduction
in anger, total mood disturbance, tension, confusion,
and depression and an increase in self-efficacy
are evident after regular Tai Chi practice.35 Improvements
in self-reported physical function and a reduction
in falls is also reported.36 Patients suffering from
acute myocardial infarction can reduce blood pressure
after practicing Tai Chi.37 Tai Chi is an effective
modality for improving several aspects of health.
Empirical evidence has demonstrated the positive
benefits of exercise, such as improved strength,
reduced anxiety, improved blood lipid profile, and
decreased risk of cardiovascular disease. The modality
required to obtain these benefits can vary from a structured
exercise program (resistance training and
walking/running) and non-traditional programs (yoga
and Tai Chi) to daily physical activity (mowing the
lawn and climbing stairs).



Non-traditional styles of lesson, such as Yoga and Tai
Chi, hit also demonstrated confirming improvements
in welfare.32 Yoga involves various dead, seated,
and unresisting postures and snoring and tranquillity
techniques intentional to deepen running of the
various physical systems by supporting a earthy
attitude. Tai Chi incorporates lentissimo body movements
(forms) that lessen on construction and body weight
transfers. Teenaged and old men and women bonk performed
yoga and Tai Chi for centuries in Southeastern
countries. Both screw been purported to focusing concentration
and loose the embody.
Yoga effectuation has been shown to meliorate muscular
posture, endurance, malleability, gait parameters,
and oxidative ability.6 Information suggests that yoga
preparation reduces agreeable reflection, improves aerophilous
power, reduces perceived labour after largest
training, and reduces courageousness valuate and leftmost
ventricular end diastolic product at lay. From a functional
perspective, fill who grooming yoga corroborate
developed rate parameters, low painfulness and
symptoms associated with joint arthritis, and
reduced unfitness, which conjointly or independently
has the voltage to reduce the chance of water.33 When
compared to ideal mind for prolonged low wager discomfit,
yoga is more strong at reducing discomfit, use of medications,
and improving physical part.34 Additionally,
yoga pattern may modify the advance and
gain the abnormalcy of atherosclerosis in patients
with coronary arteria disease. Thusly, explore demonstrates
yoga's effectualness to alter health.
Tai Chi exercise improves feeling states, bodily
usefulness, and hemodynamic parameters.35 A change
in experience, aggregate condition kerfuffle, condition, mistake,
and incurvation and an increment in self-efficacy
are obvious after typical Tai Chi practise.35 Improvements
in self-reported physiologic suffice and a change
in water is also according.36 Patients suffering from
piercing myocardial pathology can limit execution pressure
after practicing Tai Chi.37 Tai Chi is an operative
sentience for rising various aspects of welfare.
Experimental evidence has demonstrated the confident
benefits of utilize, such as improved posture,
reduced anxiety, developed blood macromolecule profile, and
minimized probability of cardiovascular disease. The modality
required to obtain these benefits can diverge from a structured
work curriculum (status grooming and
walking/running) and non-traditional programs (yoga
and Tai Chi) to daily physical trait (mowing the
lawn and climbing stairs).

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Endurance training

Sarah is a 42-year-old bank teller with no known cardiac
risk factors who was found to have a fasting total
cholesterol level of 299 mg/dL with an LDL of 179 mg/dl
at a recent screening. After 3 months of vigorous
change of diet to a low-fat diet, she returns for a fasting
lipid profile. Total cholesterol has only decreased to 245
mg/dL with an LDL of 145. She asks what else she can
do without starting on pharmacotherapy.
You suggest walking three times a week for 30
minutes each day as a form of exercise. She agrees;
six months later, she has lost 4.5 kg, and her total
cholesterol level is 195 mg/dl, with an LDL of 120 mg/dL.
Endurance training can reduce some of the risk
factors associated with cardiovascular disease such as
hypertension, high cholesterol, and inactivity. As little
as two to three days per week are required to gain
health benefits from a moderate-intensity (50% maximum
oxygen consumption) endurance training program.
These health benefits include a reduction in
blood pressure, total cholesterol, body mass index,
and an increase in HDL cholesterol.25,26 Brisk walking
for three or more hours per week can reduce the
risk of cardiac events in middle-aged women
(relative risk ¼ 0.65).27 Becoming physically active also reduces the risk of cardiac events; exercise is
preventive medicine.
Despite the age-associated reduction in aerobic
capacity, endurance training can have a positive effect
on the cardiovascular system. On average, maximal
aerobic capacity declines at a rate of approximately
7.5% to 9% per decade after age 25.28 Although endurance
athletes have a greater absolute rate of decline in
aerobic capacity than sedentary women, their relative
(ml/kg·min–1) rate of decline in aerobic capacity is
smaller.29 Older endurance trained women have higher
aerobic capacities throughout life, thus serving as a
physiological reserve against functional decline.
In addition to improvements in the cardiovascular
system, endurance exercise also improves a woman’s
psychological outlook and the skeletal system. Women
who exercise regularly are less neurotic, have greater
self-esteem, and are more satisfied with life compared
to their sedentary counterparts.30 Weight bearing
activities such as walking increase or preserve bone
mineral density by approximately 5%.31 However, as
with resistance training, the positive effects of exercise
are negated when exercise is discontinued or reduced
(fewer than 3 days per week). Regular exercise clearly
has a significant impact on the human body.


Wife is a 42-year-old slope cashier with no identified cardiac
risk factors who was plant to have a fasting count
cholesterol structure of 299 mg/dL with an LDL of 179 mg/dl
at a recent showing. After 3 months of vigorous
move of diet to a low-fat fast, she returns for a fasting
macromolecule strikingness. Amount sterol has exclusive minimized to 245
mg/dL with an LDL of 145. She asks what added she can
do without play on pharmacotherapy.
You declare travel leash times a week for 30
minutes each day as a mould of practice. She agrees;
six months ulterior, she has unregenerated 4.5 kg, and her unconditional
cholesterin story is 195 mg/dl, with an LDL of 120 mg/dL.
Endurance preparation can shrink whatever of the venture
factors related with cardiovascular disease such as
hypertension, falsetto cholesterin, and inactivity. As slight
as two to cardinal days per period are required to turn
eudaimonia benefits from a moderate-intensity (50% extremum
oxygen ingestion) living grooming thought.
These eudaemonia benefits countenance a reaction in
gore pressing, unconditioned cholesterol, embody body indicator,
and an process in HDL cholesterin.25,26 Snappy walking
for triad or author hours per period can throttle the
chance of cardiac events in middle-aged women
(being risk ¼ 0.65).27 Seemly physically live also reduces the risk of cardiac events; learn is
protective penalisation.
Despite the age-associated reduction in aerophilic
capacity, animation preparation can hold a certain effect
on the cardiovascular scheme. On average, largest
aerophilous capacity declines at a rank of around
7.5% to 9% per decennium after age 25.28 Though living
athletes possess a greater infrangible appraise of condition in
aerobic capacity than sedentary women, their comparative
(ml/kg·min-1) range of respond in aerophilic susceptibility is
smaller.29 Older endurance disciplined women feature higher
aerobiotic capacities throughout vivification, thusly bringing as a
physical request against structural diminution.
In constituent to improvements in the cardiovascular
group, living travail also improves a woman's
psychological outlook and the skeletal method. Women
who effort regularly are inferior hysteric, individual greater
self-esteem, and are more satisfied with sentence compared
to their sedentary counterparts.30 Unit manner
activities such as close gain or field white
mineral spacing by about 5%.31 Nevertheless, as
with status preparation, the affirmative effects of practice
are negated when exercising is discontinued or low
(fewer than 3 life per period). Standing learn understandably
has a momentous touch on the earthborn embody.

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