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OBgyn Week 5 PMS, PMDD, Chronic Fatigue, Normal Sexuality, Menopause Premenstrual Syndrome • PMS is a group of symptoms, both physical and behavioral, that occur in the second half of the menstrual cycle, and that often interfere with work and personal relationships. • Estimated 40% of women are significantly affected at one time or another • Severe symptoms occur in only 2- 3% of women between 18-48 • PMS is complex, not simply a biomedical entity • Cultural image of women’s reproductive health – “The Curse” Premenstrual Syndrome • Common findings in PMS patients: – – – – History of maternal PMS Low levels of exercise Younger age Higher parity Premenstrual Syndrome • Symptoms: – – – – – – – – Bloated feeling Feeling of weight increase Breast pain or tenderness Skin disorders Hot flushes Headache Pelvic pain Change in bowel habits Premenstrual Syndrome • Psychologic symptoms Irritability Aggression Tension Depression Insomnia Crying Anxiety Lethargy Change in appetite Change in libido Loss of concentration Clumsiness, poor coordination Premenstrual Syndrome • Depression – Often felt during luteal phase – Not as severe as depression noted by endogenous depression patients Premenstrual Syndrome • Positive symptoms may also be experienced premenstrually: – – – – Increased libido Enhanced creativity Intellectual clarity Feelings of happiness and well-being Premenstrual Syndrome four subcatagories • PMT-A (anxiety) – Most common; 66-80% – Predominant symptoms are anxiety, irritability, insomnia, and general nervous tension – Proposed etiology: elevated estrogen in relation to progesterone • PMT-H (hyperhydration) – Second most frequent group of symptoms; 60-66% – Characterized by weight gain, abdominal bloating, breast tenderness, engorgement and edema of face, hands, feet – Associated with deficient dopamine Premenstrual Syndrome subcategories con’t • PMT-C (craving) – Approx. 20% – Characterized by increase in appetite, craving for sweets followed by symptoms of hypoglycemia (headache, fainting, fatigue, dizziness, palpitations, trembling) – Abnormal glucose tolerance curves • PMT-D (depression) – Least common; 1.7-23% – Characterized by depression, suicidal tendencies – Associated with elevation of progesterone in relation to estrogen Premenstrual Dysphoric Disorder (PMDD) • 3 to 5 percent of menstruating women experience a more severe form of PMS • PMDD has a significant negative impact on life: work, relationships, etc • To be diagnosed with PMDD, a woman must experience at least five PMS symptoms during the period between ovulation and menstruation, and one of the five symptoms must be: PMDD Must include one of the following: • Markedly depressed mood • Noticeable anxiety or tension • Sudden sadness or tearfulness • Persistent anger or irritability PMDD • Other symptoms may include: Lack of interest in activities Lack of energy Change in appetite Headache Bloating Breast tenderness Insomnia or fatige Joint or muscle pain Weight gain PMDD • Possible genetic link: – Seen in members of same family – Variant in estrogen receptor alpha gene – Variant in COMT gene • Involved in regulating prefrontal cortex (which regulates mood) Premenstrual Syndrome Etiology • Possible etiologies • Neurotransmitter imbalance – Serotonin – GABA – MAO (monoamine oxidase) • Hormonal imbalance, including stress hormones • Increase in inflammatory prostaglandin synth • Nutritional deficiencies Premenstrual Syndrome etiology • GABA: – Neurotransmitter: gamma-aminobutyric acid A – Bimodal action on GABA receptor • Low and high levels has anti-anxiolitic, anesthetic effects • In between is associated depression, anxiety, agitation – GABA agonists include: • Progesterone metabolites • Alcohol, benzodiazapenes, barbituates Premenstrual Syndrome etiology Serotonin • Low levels associated with depression, anger, irritability, poor impulse control, carbohydrate cravings • Regulates mood, sleep, creates feeling of wellbeing • Decreases in estrogen lead to decreases in serotonin Premenstrual Syndrome etiology • Stress hormones – Catecholamines released • Influences blood pressure, heart rate, mood – Dopamine and epinephrine trigger glucocorticoid release, producing cortisol • Low cortisol associated with depression, lethargy • Cortisol excess associated with anxiety, insomnia, belly fat Premenstrual Syndrome etiology Increase in inflammatory prostaglandins – Omega-3 fatty acids EPA and DHA drive the production of anti-inflammatory prostaglandin PGE-3 series – GLA (omega-6) from borage, evening primrose oil drives PGE-1 series, also antiinflammatory • Decrease myometrial contractions • Decrease uterine vasoconstriction Premenstrual Syndrome etiology Nutritional deficiencies: B6 (active form: pyridoxal 5 phosphate) • Co-factor for dopamine, serotonin, and GABA production • Needed for conversion of linoleic acid to GLA, which is converted to PGE1 series • Needed for estrogen metabolism • 200-600mg/day decreases serum estrogen and increases serum progesterone • May have positive effect on symptoms of depression, irritability and fatigue Premenstrual Syndrome etiology • Magnesium – Relieves premenstrual migraine, nervous tension, mastalgia, weight gain, headaches – Most common mineral deficiency (negatively affected by tobacco and caffeine) – Deficiency causes depletion of dopamine – Required for fatty acid metabolism – Synergistic effects with B6 (needed for cellular uptake) Premenstrual Syndrome etiology • Other helpful nutrients/ possible deficiencies – – – – – Vitamin E Vitamin A Zinc Flavonoids Calcium Premenstrual Syndrome • Diagnosis – Symptom diary – Extensive history – Rule out psychiatric disorders (depression, anxiety, psychosis) • PMS patients will experience above symptoms ONLY during luteal phase • Symptoms come and go in a predictable fashion Premenstrual Syndrome • Management Diet • Avoid caffeine, refined sugar (increases urinary magnesium excretion), alcohol Exercise • • • Significant decrease in anxiety, distress, concentration, pain, water retention Important to have regularity as well as diversity in exercise program (flexibility, strength, cardiovascular, stretching) Equally important is to enjoy the exercise chosen Premenstrual Syndrome • Management continued – Diuretics • Relieve bloating and perceived change in body • Lowest dose possible, potassium-sparing – Dandelion leaf is in this category (Dandelion root aids in liver detox/ estrogen metabolism) Premenstrual Syndrome • Management – Psychoactive drugs • Alprazolam (Xanax) significantly relieves severity of premenstrual nervous tension, mood swings, irritability, anxiety, depression, fatigue, forgetfulness, crying, carbohydrate/ sugar cravings, abdominal bloating, headaches • Prozac (SSRI) – Low dose follicular phase, higher dose luteal phase – Marketed as Serafem (for PMDD) by Eli Lily once patent for Prozac ran out Premenstrual Syndrome • Other medications: – Danzol • Low dose days 20-28 of cycle • Will not inhibit ovulation • Should not be used in case pregnancy desired – Bromocriptine • Relieves breast tenderness – NSAIDs Premenstrual Syndrome • Surgical management – Involves hysterectomy and bilateral salpingo-oopherectomy – Last resort for women with debilitating symptoms Chronic Fatigue Syndrome • Refers to an illness characterized by persistent and relapsing fatigue, often accompanied by numerous symptoms involving various body systems • Relatively common – Affects 522 women/ 100,000 – Affects 291 men/ 100,00 – Gender is not a proven risk factor • • More women seek doctor’s help; tendency to report more Men and women deal differently with disease Chronic Fatigue Syndrome • Predominantly in women in 40s and 50s but may occur at any age • Onset typically after period of emotional stress and/or viral infection (usually EBV/ mononucleosis) • Onset may be sudden with flu-like symptoms • Etiology unknown – Likely multifactorial Chronic Fatigue Syndrome International CFS Study Group Definition: • Clinically evaluated, unexplained persistent or relapsing chronic fatigue that: – – – – Is of new or definite onset (has not been lifelong) Is not the result of ongoing exertion Is not substantially alleviated by rest Results in substantial reduction in previous levels of occupational, educational, social, or personal activities Chronic Fatigue Syndrome • The concurrent occurrence of four or more of the following symptoms, all of which must have persisted or recurred during six or more consecutive months of illness and must not have predated the fatigue: • • • • • • • • Self-reported impairment in short-term memory or concentration severe enough to cause substantial reduction in previous levels of occupational, educational, social, or personal activities Sore throat Tender cervical or axillary nodes Muscle pain Multi-joint pain without joint swelling or redness Headaches of a new type, pattern, or severity Unrefreshing sleep Post-exertional malaise lasting more than 24 hours Chronic Fatigue Syndrome • Suspected etiologies – Viral infections and the post-viral fatigue syndrome – Fibromyalgia – Neurally-mediated hypotension – Psychogenic biological dysfunction – Low natural killer cell syndrome Chronic Fatigue Syndrome • Factors suspected of promoting CFS: Hypoxemia Immune dysfunction Endocrine dysfunction Stress-related dysfunction Somatoform disorder Marginal nutritional deficiencies Dysbiosis Chemical toxicity Intestinal hypermeability Food and chemical sensitivities Heavy metal toxicity Chronic Fatigue Syndrome • Observed Pathological Changes – – – – – – White matter lesions in CNS Cerebral hypo-perfusion Vestibular dysfunction Gait abnormalities Impaired immune response Oxidative damage to DNA and lipids in biopsy samples – Increase in activity of antioxidant enzyme systems Chronic Fatigue Syndrome • It is a diagnosis of exclusion – Need to rule out disorders that cause fatigue (and other symptoms): • • • • • • Hypothyroidism Anemia Diabetes Multiple Chemical Sensitivities Celiac disease Psychological disorders Chronic Fatigue Syndrome • Co-morbidity with many other disorders: – – – – – – – Depression Fibromyalgia Irritable Bowel Syndrome TMJ pain Multiple Chemical Sensitivities Chronic pelvic pain syndrome Endometriosis Chronic Fatigue Syndrome • CFS sufferers carry a heavy psychosocial burden – Difficulty in being recognized as a “real disease” – Lack of true diagnosis – Social stigma • Hyperchondriac tendencies • “yuppie flu” Chronic Fatigue Syndrome • Progression – Symptoms peak and then stabilize – Symptoms may come and go – Patients may recover completely or may get progressively worse • Management – Cognitive behavioral therapy- replaces negative beliefs and behaviors with positive ones – Physical therapy - supervised gradual exercise regime Chronic Fatigue Syndrome • Possible medications: – – – – – Pain: NSAIDs Depression: SSRI, TCA antidepressants Allergy symptoms: antihistamines Hypotension: tenormin CNS symptoms: clonazepam for dizziness, Xanax for anxiety • Experimental medications: – Ritalin, Concerta as psychostimulants – Steroids – Anti-viral drugs Chronic Fatigue Syndrome • Implicated nutrient deficiencies: Folic acid Vitamin B12 and other Bs Vitamin C Sodium (hypotension) Magnesium Zinc L-tryptophan CoQ10 L-carnitine EFAs Chronic Fatigue Syndrome • These patients may be our modern “canaries in the coal mine” • Likely a multitude of environmental, genetic, psychosocial factors involved • You will see patients with this diagnosis – Any experiences so far? – TCM explanation for sx? Normal Sexuality • How would you define this? • What does “sexuality” involve? Normal Sexuality • Some factors to consider: – – – – – – Health of sexual organs and whole body Mental health Cultural norms, personal beliefs Age Relationship status Sexual orientation Not all sex is penetrative, heterosexual sex! – Sex drive – Orgasmic function • There is no universal “normal” Normal Sexuality - Libido • Libido is a term for sex drive popularized by Freud • Big market - aphrodisiac industry • May be affected by numerous factors – Physical: loss of privacy, environmental stressors, menstrual cycle, circulating levels of androgen hormones, during or after illness or surgery, weight gain or loss – Emotional: stress, loss of intimacy or attraction to partner – Psychosocial: depression, body/sexual image issues, childhood sexual trauma or neglect, PTSD – Iatrogenic: medications such as antidepressants, finasteride, OCPs, beta blockers – Inborn lack of sexual desire Normal Sexuality - TCM • Chinese medicine Sui dynasty recommendations for appropriate sexual behavior (male ejaculation) by age: Age 20 30 40 50 60 70 In good health 2x day 1x day Every 3 days Every 5 days Every 10 days every 30 days Average health 1x day Every other day Every 4 days Every 10 days Every 20 days None Normal Sexuality • Four phases of female sexual response (Masters and Johnson) – Excitement • • • Mental or physical stimuli Deep breathing, increase in heart rate and BP, total body feeling of warmth, generalized vasocongestion (breast, clitoris and labia engorgement), vaginal lubrication, nipple erection, sex flush Under control of the parasympathetic system – Plateau • • • Marked degree of vascular congestion and tissue engorgement In lower 1/3rd of vagina, decrease in diameter of as much as 50% (“orgasmic platform”) Upper 2/3 of vagina lengthens and dilates Normal Sexuality • Sexual response phases continued – Orgasm • • • Release of sexual tension Contractions of perivaginal muscles, anal sphincter, and uterus control of the sympathetic autonomic nervous system – Resolution • • • Return to pre-excitement physiological state No or less refractory period compared to men Feeling of satisfaction and well-being Normal sexuality • Normal progression/ duration of phases interrupted in: – Vulvectomy – Excisions in vulva – Pelvic radiation (vulvar carcinoma) – Desire and behavior patterns may remain the same Normal Sexuality • Sexual dysfunction – Defined as a psychologic or physiologic problem or condition that prevents the full participation and enjoyment of coitus – Decreased libido is the most common dysfunction • Communication between partners is important – Estimated that it exists to some degree in 50% of marriages (Masters and Johnson) • Higher degree of dysfunction seen in couples presenting for marital therapy Normal Sexuality • Sexual response problems may be due to: – – – – – Previous negative sexual experience Secondary to emotional or physical illness Medications Distractions Alcohol/ drug abuse • Alcohol may release inhibitions but decreases vaginal lubrication and ability to reach orgasm Sexual Dysfunction • Vaginismus: involuntary spasm of vaginal introital and levator ani muscles • Penetration is either painful or impossible • Pain and/or fear of pain during coitus, inserting a tampon or vaginal medication • Seen in rape victims (vaginal pain during coitus), women with painful episiotomy repairs, severe yeast vaginitis Sexual Dysfunction • Orgasmic dysfunction – 25-35% of women will have difficulty reaching orgasm on any particular occasion – 10-15% of women have never reached an orgasm through any means of sexual stimulation Menopause • Physical changes during menopause that may lead to decreased libido/ sexual dysfunction: • Progressive vaginal atrophy • Decrease in vaginal secretions • Pelvic relaxation (cystocele, rectocele, uterine prolapse) • General loss of vaginal tone Menopause • Libido changes • Total estrogen production decreases by 70-80% • Total androgen production decreases ~50% • Adrenal glands will produce small amount of sex hormones better if ovaries intact • Over 80% postmenopausal women will experience some form of decreased libido Menopause • Emotional or psycho-social factors that may affect libido: – – – – Woman is no longer society’s youthful ideal Changes in self-confidence Changes in priorities Embarrassment from hot flashes, incontinence, etc. Menopause • Definition? • (technically a date, but usually thought of as a time period) Menopause • May be considered a second puberty, milestone in life – Different cultural attitudes • Described as “the change” – Role of caregiver redefined – Role of partner redefined Menopause • Time for inwardness, introspection – Many people develop a deeper spirituality practice at this time in their lives, or rediscover religion – Many women want to be “left alone” – Focus on “inner beauty” and wisdom – Preparation for journey to “golden years” Menopause • Physical symptoms – – – – – – – – Menstrual cessation (and irregularity prior) Incontinence Vaginal atrophy/dryness Cardiovascular changes Osteoporosis Thyroid disturbances Memory loss/ concentration issues/ dementia Changes in sleep patterns Menopause – Acne, Facial Hair, and Hair Loss • • • Relative increase in testosterone Individual sensitivities to androgen Excess hair growth occurs in areas where hair follicles are the most androgen-sensitive (face, chin, along mandible, upper lip, sideburns, cheeks, nipples, umbilical, low back) • Vasomotor symptoms – Hot flashes, night sweats, insomnia, palpitations – About 75% women will experience hot flashes • About 15% will be severely affected – For most women hot flashes last about 2 years • Some women experience them for 5-10 years – Frequency is variable Menopause - Incontinence • Urinary incontinence – Occurs in approx. 40% menopausal women – Statistics hard to come by because it is an under-reported condition – Urinary incontinence can have devastating psychological, social, emotional consequences as women may avoid friends and family and live in shame and fear Urinary incontinence – Bladder and urethra lining atrophy with absence of estrogen • • • Similar process to vaginal wall atrophy Declining estrogen levels, vulva and urethra lose collagen, fat, and water-retaining ability Mucosa becomes flattened, thin, dry, and loses its tone – Low estrogen decreases blood flow to pelvis • Causes general decrease in muscle tone Urinary incontinence – Stress incontinence: leakage of urine due to increased pressure from sneezing, coughing, laughing Due mainly to weak pelvic floor muscles and low sphincter tone – Urge incontinence: sudden urge to urinate, most common type Often caused by involuntary and inappropriate detrusor muscle contractions (spasticity) – Mixed incontinence: both stress and urge Urinary incontinence • Overflow incontinence • Detrusor muscle hypoactivity • Rare in women • Worsened by anticholinergic drugs as well as calcium channel blockers • Early symptoms include a hesitant or slow stream of urine during voluntary urination Urinary Incontinence anatomy Urinary incontinence anatomy Urinary incontinence - mgmt • Management: – Diet: decrease in caffeine, possible avoidance of food allergies/ intolerances – Kegel exercises: to improve pelvic floor tone; 3 sets of 15 per day is general recommendation; may be used in conjunction with Biofeedback therapy to ensure proper technique Urinary incontinence - mgmt • Bladder Retraining: Retrain bladder to encourage less frequent urination. Drink 6 to 8 glasses of water and delay urination for five minutes. Every day, drink more water and delay urination by a little bit longer, working up to a delay of 15 minutes. Bladder should begin to hold more urine and you will need to urinate less frequently. Urinary incontinence - mgmt • Pessary – Designed to hold pelvic organs up and in place – Easily inserted via vagina (no surgery) – Come in a variety of shapes and sizes. May be made of rubber, plastic, or silicone-based material – Must be fitted and prescribed – Cleaning schedule determined by degree of organ prolapse and brand/ material it is made from – Most can be worn during intercourse Pessaries QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. Pessaries Urinary incontinence - mgmt Neuromuscular Electrical Stimulation – Electrical stimulation of the pudendal nerve causes pelvic floor and urethral sphincter muscles to contract – A probe is inserted into the vagina and a current is passed through the probe at a level below the pain threshold, causing a contraction. – The patient is instructed to squeeze the muscles when the current is on. After the contraction, the current is switched off for 5 to 10 seconds. – Treatment sessions lasts approximately 20 to 30 minutes. Urinary incontinence - mgmt Vaginal cone therapy • • • • • • Small plastic cone is inserted into vagina Reflex contraction keeps it in place; requires very little effort on part of patient Repeated 2x day for 15-20 minutes As muscles get stronger, cones of progressively increasing weight can be used Pelvic floor muscles become stronger in 2-3 weeks Mild to moderate stress incontinence improved in 8-12 weeks Urinary incontinence - mgmt Magnetic therapy – Beneficial for women with stress, urge, or mixed urinary incontinence caused by weak pelvic floor muscles – Patient sits in a specially designed chair where magnetic pulses are aimed at pelvic floor muscles – Muscles contract and relax with each magnetic pulse – Approx. 8 weeks of therapy to achieve some degree of continence Urinary incontinence - mgmt Injection therapy (for stress incontinence) – Material injected around urethra to bulk area, this improves sphincter function – Collagen – Autologous fat – Synthetic compounds polytetrafluoroethylene (PTFE) and Durasphere® Urinary incontinence - mgmt • Medications – Detrol • anticholinergic, suppresses involuntary contractions – Tri-cyclic antidepressants • Exact mechanism of action unknown – Ditropan • • Inhibits action of acetylcholine on smooth muscle and has direct antispasmodic effect on smooth muscle Causes increase in bladder capacity and decrease in involuntary contractions – HRT • • Systemic if patient also has other generalized symptoms Local if symptoms confined to vagina/ urethra Urinary incontinence - mgmt • Surgical management: – Bladder swing or sling is surgically implanted to support bladder – Two types: • percutaneous, which requires a small abdominal incision – Hammock- like sling made from patient’s fascia • transvaginal, which is performed through the vagina – "tension-free vaginal tape” – not attached to the pubic bone or abdominal wall – remains in place by your body's tissues growing through the mesh material Urinary incontinence - mgmt • Surgical managment Urinary incontinence - mgmt • Surgical Management – Surgical slings may help women regain bladder control for up to 10 years – Complications include: accidental bladder injury or injury to surrounding organs, infection, and prolonged urinary retention, which may require chronic intermittent selfcatheterization • Or, surgery may not relieve symptoms at all Menopause - UTIs • Urinary Tract infections – Changes in vaginal and urethral mucosa make more prone to infection and damage • Symptoms • Pain or burning with urination • Increased urinary frequency or urge • Malodorous or cloudy urine • WBCs seen on UA *Pain symptoms often present differently in older pts* • If left untreated, infxn can travel to kidneys • • • Fever Low back pain CVA tenderness UTIs • Prevention – Hygiene – Hydration and freguent urination – Avoid food allergens, coffee, alcohol, sweets • Some treatment options for UTI – – – – Lots of water Cranberry juice (unsweetened) General immune support Uva ursi herb (works in alkaline environment -do not use in conjunction w cranberry or Vit C) – Antibiotics if necessary Menopause - hot flashes • Vasomotor symptoms - “hot flashes” – Common ~90% of women in U.S. experience them – Sx may include sweating, anxiety, palpitations, flushing, night sweats and sleep disruption – Theorized to be body’s response to a downward resetting of the hypothalamic set point – Specific role of estrogen in thermoregulation unknown – May have cultural and environmental factors Hot Flashes • Conventional tx = HRT • Natural tx options – Vitamin E – Phytoestrogenic botanicals (red clover, black cohosh) and soy – Homeopathic glonoinum Menopause - cognition • Hormonal changes affect memory and cognition – – – – Hypothyroidism Low adrenal function Pregnancy/ Lactation Menopause • Short-term memory loss most common • Difficulty concentrating • Lack of mental clarity Alzheimer’s disease is most common cause of dementia Affects women 1.5-3x more than men Osteoporosis • Osteoporosis – Bone mineral density 2.5 standard deviations below peak bone mass (age 20) – Can lead to an increased risk of fracture – Bone mineral density is reduced – Bone microarchitecture is disrupted, as is the amount and variety of non-colagenous proteins Osteoporosis • Osteoporosis – Childhood: bone formation far exceeds bone remodeling – Adulthood: bone resorption and formation are in balance • Are interdependent processes – Increased bone resorption continues w age • • 5-10 years after menopause bone loss is accelerated Around age 65 this bone loss rate slows Osteoporosis • Osteoporosis – Estimated 1 in 3 women (1 in 12 men) over the age of 50 worldwide have osteoporosis – In US, > 250,000 hip fractures annually attributed to osteoporosis – Between 35-50% of all women over 50 have at least one vertebral fracture Osteoporosis • Symptoms – Asymptomatic until bone fracture or seen under DEXA scan – Osteoporotic fractures occur in situations where healthy people would not normally break a bone – Typical fragility fractures occur in • • • • Vertebral column Rib Hip wrist Osteoporosis • Fractures – Vertebral fractures lead to stooped posture, loss of height, chronic pain, reduction in mobility – Long bone fractures require surgery, impair mobility – Hip fractures most associated with deep vein thrombosis and pulmonary embolism • • • • • Risk of fat embolism 50% higher within first year Mortality rate increased up to 20% during first year 25% of survivors will be confined to long-term care facilities one year post fracture Hip fractures 2x more common in women than men Approx 200,000 occur each year in US Osteoporosis • Osteoporosis risk factors: – Increased age – Estrogen deficiency following menopause – European, Asian ancestry • African ancestry has highest bone density – Personal history of fracture (2x risk) – Family history of fracture/ osteoporosis • At least 30 genes known to be associated with development of osteoporosis Osteoporosis • Modifiable risk factors: – Chronic heavy drinking (> 2 drinks/ day) • Alcohol increases estrogen metabolism – Vitamin D deficiency – Tobacco smoking (inhibits osteoblasts) – Low body mass index (being overweight protects against osteoporosis - constant weight-bearing) – Malnutrition – Inactivity and excessive physical activity – Heavy metals (cadmium, lead) – Soft drinks (phosphorous) Osteoporosis • Osteoporosis – Predictions from risk factors cannot pinpoint all persons who will be affected – Risk factors account for only 20-40% of bone mass variance – Are important guides for clinical assessment of osteoporosis but do not provide adequate assessment of low bone mass Low bone mass alone does not cause fractures! Osteoporosis • Hormones involved in bone metabolism – – – – – – – Estrogen Progesterone Testosterone Parathyroid hormone Calcitonin Growth hormone insulin Osteoporosis • Medications associated with osteoporosis: – – – – – – – Steroids (> 3 month use) Barbiturates Anticonvulsants L-thyroxine over-replacement Anticoagulants (decrease bone density) Proton pump inhibitors Thiazolidenediones (diabetes meds: increase fracture risk) – Chronic lithium therapy – Aromatase inhibitors and anti-estrogen meds Osteoporosis • Osteoporosis diagnosis: – DEXA (dual energy x-ray absorptiometry) – Investigations of underlying causes • DEXA results translated as T-scores: – Normal: T-score of =1.0 or greater – Low bone mass/ osteopenia: =1.0 and =2.5 – Osteoporosis: =2.5 or below • Screening recommendations – Varies – Women 60-64 at risk Osteoporosis DEXA Osteoporosis • Pathogenesis – Constant bone remodeling (10% of all one mass may be undergoing remodeling at any point in time) – Lack of estrogen increases bone resorption, decreases deposition of new bone – Calcium and Vitamin D deficiency leads to impaired bone deposition – Parathyroid may react to low calcium by secreting PTH, which increases bone resorption • Once blood calcium levels are low, know this has been long-standing Osteoporosis • Low bone density by itself does NOT cause increase in fractures • According to American College of Physicians, “most women with hip fractures have hip bone density within the normal range” Osteoporosis -mgmt • Medications – Fosamax, Actonel, and Boniva are biphosphonate drugs that inhibit osteoclast activity, reducing bone resorption and turnover • Make bones denser, but not necessarily stronger • Processes of osteoclasts and osteoblasts interdependent; these drugs do not promote osteoblastic activity Osteoporosis - mgmt • Biphosphanate side effects may be serious: – – – – – – – – Increased risk of ulcers Liver damage Gastric and esophageal inflammation Renal failure Skin reactions Hypocalcemia (low serum calcium) Osteonecrosis (especially of mandible) Serious eye inflammations and possible blindness Osteoporosis - mgmt • Fall-prevention: • Increase muscle tone, especially small mm used for balance • Magnesium may aid in mm response and increase balance • Proprioreception- improvement exercises • Equilibrium therapies • Weight-bearing exercise (anabolic effect in general) Osteoporosis - mgmt • Osteoporosis prevention: – Adequate calcium intake • • • • Dark, leafy greens Unprocessed dairy Fermented dairy (yogurt, kefir) Herbal teas and vinegars with highly absorbable calcium/ minerals: » Nettles, Equisetum/horsetail/ mu zei, seaweeds • *Must also have good digestion/absorption Osteoporosis • Adequate vitamin D intake – Best is from sun • • Apply sunscreen only when risk of burn is high and then only to areas prone to burn Exercise outdoors – Foods • Mushrooms, healthy animal fats, liver Vitamin D supplementation should be monitored by blood tests if over ~2000 IU daily (every 3-6 months) Osteoporosis - mgmt • Supplements - Calcium – Calcium carbonate is cheapest form of calcium, but not very absorbable – Best if from whole food – Isolated/ concentrated/ synthetic minerals have a brittle quality/ energy – Should be in conjunction with Vitamin D (cod liver oil) and Vitamin K, boron, vanadium Osteoporosis - mgmt – Phytoestrogens (soy, flax seed) • • • One study has shown increase in postmenopausal women’s lumbar spines after taking 55-90mg isoflavones from soy for 6 months No studies on phytoestrogenic herbs and osteoporosis Ipriflavone is a synthetic derivative of isoflavones – Appears to have a direct ability to inhibit osteoclastic activity Osteoporosis prevention – Regular check-ups – Appropriate exercise – Avoid: • • • • • • Carbonated beverages: sugar and phosphorous deplete body stores of calcium Excessive alcohol Smoking Excessive weight loss/ gain White/ refined wheat and grains Antacids/ proton pump inhibitors – Stomach acidity needed for mineral absorption!