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Surviving Perimenopause

To give you an even better idea of just what kind of useful and practical information youll find in Perimenopause: Have It, Live It, Love It!, heres a partial list of the topics covered extensively in this ebook: Learn about the 26 signs of perimenopause both common and not so common symptoms. Find out what your symptoms are Not telling you 18 perimenopause symptoms that are linked to other serious medical conditions. Learn how you can treat your symptoms Without the use of drugs and pills. Over 50 home remedies with recipes and instructions to help you cope with various perimenopause symptoms. What you need to prepare Before your visit to your doctor, including how to make sure your doctor listens to you and takes your symptoms seriously, and reaches the right diagnosis. Get tips and techniques to re-ignite your sex life. Its not too late to bring passion back to the bedroom. Perimenopause pregnancy? Get your facts straight whether you are trying to conceive or prevent a pregnancy. Make sense of the changes that are happening to your body and the ones that are happening inside your head. Learn techniques you can apply today to get better sleep and to overcome perimenopause insomnia. Discover what you can do now to prevent osteoporosis which attacks women after they hit menopause and is easily preventable only if you start now! Identify if you are estrogen deficient or estrogen dominant and find out which remedies work for each type. Determine whats actually causing your irregular periods, Pms and heavy bleeding. Learn how to tell when youll hit menopause. Understand medical jargon so you dont come out of a doctor consultation more confused than before you went in. Understand the link between hormonal changes in your body and your mood swings and depression. Find out what to expect when you have perimenopause the common and not-so-common transformations that can really affect the way you live. Get access to information that your doctor may not be telling you. Realize that you can do something about that weight youre putting on around your waist and thighs and why old dieting methods that worked for you in the past are next to useless now. Learn about the different kinds of tests your doctor may ask you to get and actually know what theyre for.

Surviving Perimenopause Overview


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Menopause The Hormonal Hostage

I've often heard women say that the change of life is one of the touchiest times in their lives. The body and mind that they have become accustomed to for 40+ years are now different and often unpredictable. This change is a natural transition in a woman's life as fertility comes to an end. Menopause refers to a point when a woman stops ovulating and menstruating. Pre- or perimenopause lasts about five to ten years before the last period. This transition is marked by irregular menstruation, showing the decline in your body's ovary production of the reproductive hormones estrogen and progesterone. Typically, the last period occurs around age 50. Hormone replacement therapy, or HRT, is the only satisfactory therapy that conventional medicine offers to relieve such symptoms as hot flashes. When estrogens are contraindicated because of a family history of breast cancer, other medications are prescribed to control symptoms. HRT stands for hormone replacement therapy, which attempts to...

Menarche Pregnancy Menopause Do They Affect Seizures

Changes in reproductive hormonal status associated with menarche,19 pregnancy,20,21 and menopause22 may all affect clinical manifestation of seizures. Menopause The generally accepted belief is that menopause has little effect on epilepsy. Earlier this century, for instance, castration was used unsuccessfully to treat epilepsy in women.28 In some patients seizures may cease at the time of menopause, whereas in other patients seizures may worsen.22 The term menopause refers to a complex process and a variable end point that may differ significantly from person to person. Although estrogen levels decline as ovarian function diminishes, progesterone declines before estrogen, with resulting elevation of E P serum ratios.29 Early during menopause, for example, anovulatory cycles may develop and lead to increased E P ratios that would be expected to promote the occurrence of seizures. At the end of the process, estrogen production by the ovaries may become essentially undetectable and may...

Hormone Replacement Therapy

Hether she has a hysterectomy or not, every woman who lives to the age of menopause will confront the issue of hormone replacement. Hormone replacement therapy (HRT) has become one of the most discussed and debated issues related to women's health. The increased number of women encountering menopause as the baby boomer generation goes through middle age ensures that the discussion will continue and intensify. There are still many questions about the risks and benefits of hormone replacement, but a number of large studies are addressing those questions and perhaps will resolve controversies in coming years. Menopause occurs after a woman's last menstrual period. Since periods are apt to be irregular and widely spaced during perimenopause (the months and years preceding menopause), it can be hard to know exactly where you are. The wide age range (42 to 58) for menopause in healthy women indicates the wide variation in the number of eggs a woman has to begin with and their rate of loss....

Symptoms of Menopause

Eighty percent of women will experience hot flashes when they become menopausal. Other symptoms include night sweats, difficulty sleeping, memory loss, irritability, and mood changes. Later, most women will experience vaginal dryness. Sometimes urinary symptoms such as leakage, frequency, and urgency occur because of the loss of estrogen action on the urogenital tissues, which include the urethra and the supporting tissues around the bladder. Without estrogen these tissues may atrophy somewhat over time. The lack of ovarian hormones may also contribute to the development of osteoporosis, a gradual thinning of the bone that increases the risk of fractures. As estrogen decreases, blood lipids, especially cholesterol and LDL, increase. At one time it was thought that these changes contributed to the development of cardiovascular disease and that supplementation with estrogens in menopause would protect against heart disease. Recent data from large studies (WHI, HERS, which are discussed...

Hormone Replacement Therapy 183 Making the HRT Decision

Whether to use hormone replacement therapy after hysterectomy is a personal decision that you should make in consultation with a medical professional who knows your full medical history and your concerns. Most women who start HRT after hysterectomy find that the hormones are beneficial in improving the immediate symptoms of menopause and in improving their sense of well-being. Every woman has individual needs, but in general we recommend HRT for treatment of menopausal symptoms in women who Initially, estrogen therapy will significantly reduce the number and frequency of hot flashes and other symptoms of menopause. You may not notice full effects until you have been on the medication for one month. We know from our patients and from the considerable research that has been done that many women feel that their quality of life is improved when they take estrogen. Estrogen therapy also has been shown to prevent bone loss and fractures. Up until recently, ERT was thought to have many...

Press Acu Points to Pause Your Menopause

Acupoints For Menopuase

The natural process of menopause has been getting comforting help from Oriental Medicine for centuries. As you've already read, diet, exercise, and a healthy outlook are key components of any comprehensive treatment plan. Hot flashes, dry skin, vaginal dryness, increased thirst, insomnia, forgetfulness, and anxiety are part of the deficient heart yin pattern in Oriental Medicine. The term deficient yin in this case often refers to the reduction in estrogen. The term heart addresses not only the organ itself, but the accompanying forgetfulness, insomnia, palpitations, and mood changes. Stop smoking Premature menopause is the early shutdown of the ovaries before age 40. Smoking is assoa'ated with this premature reduction in the estrogen level. Because estrogen is important in bone formation, smoking also puts you at risk for osteoporosis and health-jeopardizing bone fractures. Pausing menopause. Pausing menopause. Stock up on soy The British medical journal Lancet reported that Japanese...

Perimenopause Menopause and Migraine

Perimenopause is described as the decade preceding menopause when hormonal fluctuations may begin. Menopause is defined as the absence of menstruation for 1 year. The average age of menopause is approximately 53, and an increase in migraine due to the fluctuating hormones of perimenopause may present a challenge to both the patient and physician. Following a natural menopause, approximately 60-70 of women have an improvement in their migraine. In contrast, 40-70 of women who undergo a surgical menopause causing an abrupt cessation of female hormones may actually experience a worsening of their migraine (see Table 18.18). Hormone replacement therapy (HRT) has a variable effect on migraine. The Women's Health Study, a population-based study of 17,107 postmenopausal women, reported that those using HRT were 1.42 times more likely to report migraine than non-users. Other studies have shown a variable response, with approximately 50 of women demonstrating no change and approximately 25 who...

About the Female Reproductive Organs

The rhythms of a woman's menstrual cycle and interruptions in this rhythm during pregnancy and menopause alert women to their bodily functions throughout their lives. When your reproductive organs change or malfunction, various tests provide clues to the problem. Imaging tests provide important medical information to your doctors and help you to understand your own anatomy and how your reproductive system functions.

Burden of Disease

Ovarian cancer is the fifth leading cause of cancer deaths in women, with an estimated 22,000 new cases and 14,600 deaths in 2009 (SEER, 2009). Most women have non-localized disease at diagnosis. Risk factors for developing ovarian cancer include having a first- or second-degree relative with ovarian cancer, being a carrier of the BRCA1 or BRCA2 gene mutations, and taking estrogens after menopause. Oral contraceptive use and parity have a protective effect, reducing the risk of disease (Nelson et al., 2004b).

Effectiveness of Early Detection and Intervention

Hormone replacement therapy does not prevent CHD in postmenopausal women (Anderson et al., 2004 Rossouw et al., 2002), and evidence does not support a benefit from vitamin supplements (Lee et al., 2005). There is good evidence that screening for CAS with an ultrasound leads to important harms, including strokes from confirmatory tests or surgery. For men at increased risk for CHD, aspirin prophylaxis decreases the rate of CHD events and for women at increased risk of strokes, aspirin decreases the rate of strokes (Berger et al., 2006 USPSTF, 2009). The ideal dose is uncertain, but low doses (75 mg) are as effective as high doses

See Your Doctor Within 24 Hours

Possible cause You may have a crush fracture of a vertebra as a result of osteoporosis, in which bones throughout the body become thin and weak. osteoporosis is symptomless unless a fracture occurs. The disorder is most common in women who have passed the menopause. However, a prolonged period of immobility will also lead to the development of osteoporosis. Action Initial treatment for the pain is with painkillers. Your doctor may also request bone densitometry (below). Specific treatment for osteoporosis depends on the underlying cause. However, in all cases, it is important that you try to remain active and take weight-bearing exercise, such as walking.

Beliefs on Which It Is Based

Oversensitivity to Influences and Ideas Centaury for difficulty saying no and neglecting one's own interests Walnut for stabilizing emotions during life transitions such as adolescence and menopause, for breaking past links and adjusting to new beginnings Holly for envy suspicion, revenge, and hatred.

Listing relevant outcomes

While all important outcomes should be included in Cochrane reviews, trivial outcomes should not be included. Authors need to avoid overwhelming and potentially misleading readers with data that are of little or no importance. In addition, indirect or surrogate outcome measures, such as laboratory results or radiologic results (e.g. loss of bone mineral content as a surrogate for fractures in hormone replacement therapy), are potentially misleading and should be avoided or interpreted with caution because they may not predict clinically important outcomes accurately. Surrogate outcomes may provide information on how a treatment might work but not whether it actually does work. Many interventions reduce the risk for a surrogate outcome but have no effect or have harmful effects on clinically relevant outcomes, and some interventions have no effect on surrogate measures but improve clinical outcomes.

Physiology Of Bone Remodeling And Bone Turnover

Based upon the varying influences of bone resorption and formation, osteoporosis is subdivided into two categories low-turnover and highturnover osteoporosis. The low-turnover state describes a situation in which normal bone homeostasis is altered by decreased osteoblast activity however, the osteoclast activity remains normal. Low bone mineral density (BMD) in this setting, therefore, is a result of reduced bone formation. Conversely, the high-turnover state is characterized by increased activity of both osteo-blasts and osteoclasts. However, osteoclasts are activated to a greater extent. The bone remodeling process is shifted toward bone resorption, resulting in an imbalance of bone turnover that causes osteoporosis. High turnover osteoporosis is the most common form and appears at menopause, while low turnover osteoporosis occurs following drug interventions including chemotherapy, steroids, and prolonged bisphosphonate use.

Influence of testosterone on sexual behaviour in women

The most powerful design for the study of the specificity of testosterone influence involves hormone replacement therapy in women who are oophorectomized. It is common clinical practise to treat these patients with estrogen replacement, but substitution of testosterone is also sensible as the women are deprived of ovarian androgen production as well. Several studies on naturally or surgically menopausal women have shown - without contradictory evidence - that administration of testosterone, either alone or in addition to an estrogen replacement regimen, is more effective than estrogens alone or a placebo. In particular, an increase in sexual

Female Reproductive System Big Picture

The female reproductive system consists of the ovaries, uterine tubes, uterus, vagina, and external genitalia. These organs remain underdeveloped for about the first 10 years of life. During adolescence, sexual development occurs and menses first occur (menarche). Cyclic changes occur throughout the reproductive period, with an average cycle length of approximately 28 days. These cycles cease at about the fifth decade of life (menopause), at which time the reproductive organs become atrophic.

Diagnosis and Treatment

You should be certain that you receive notification about the report on your Pap smear. If you receive a report of an abnormal finding on a Pap smear, or if your doctor observes anything abnormal in the internal examination, it means you need a biopsy to obtain further information. If you are diagnosed with ASCUS, we recommend having the Pap smear repeated. If there is any indication of inflammation, it's a good idea to treat the cervical or vaginal infection before the smear is repeated. In women who are menopausal and are not receiving hormone replacement therapy, before repeating the Pap smear we recommend treatment for several weeks with estrogen, using a vaginal insert or cream or sys

Postmenopausal estrogen replacement therapy

Until menopause women generally suffer from a lower rate of vascular diseases, including ischemic stroke. This has been attributed to a protective effect of estrogen and thus research has focused on the beneficial effect of postmenopausal hormone therapy for the prevention of cardiovascular diseases and stroke. However, a meta-analysis of nine observational studies indicated an increased risk of stroke -especially of ischemic stroke - in women using hormone replacement therapy, with RR for overall and ischemic stroke respectively of 1.1 (95 CI 1.0-1.2) and 1.2 (95 CI 1.0-1.4) 82 . Another meta-analysis including 28 randomized controlled trials found a significant increase in total stroke RR of 1.3 (95 CI 1.1-1.5) and ischemic stroke RR of 1.3 (95 CI 1.1-1.6) for women using hormone replacement therapy 83 . A Cochrane systematic review came to the same conclusion and found hormone replacement therapy to be associated with an increased risk of stroke in primary prevention trials (RR 1.4...

Theoretical Issues

Two mutually informing analytic frameworks have been central to much recent fertility research the life course and the proximate determinants frameworks. The biological nature of fertility determines the structure of each framework. In fact, both frameworks rest on very straightforward observations. The life course perspective adopts a sequential model because children tend to be born one at a time, not in lots (Namboodiri 1972 198). Moreover, because women are biologically restricted to having children only between menarche and menopause, fertility may be considered as an irreversible, time-limited sequence.

The role of 5areduction and aromatization of testosterone in the muscle

After menopause, women tend to gain weight and experience an increase in body mass index (Gambacciani etal. 1997) mostly due to fat mass accumulation (Burger et al. 1995 Dallongeville et al. 1995) this weight gain is attenuated in women who receive estrogen replacement therapy. These data contradict the widely held notion that hormone replacement therapy is associated with significant weight gain. Taken together, the collective body of experimental data suggests that aroma-tization of testosterone might also be important in mediating androgen effects on body composition. Further studies are needed to determine the important role of estrogens in regulation of body composition.

Pleasant Summer

Taken hormone replacement pills ever since the onset of her menopause and continued them for twelve years. Two months prior to her discussion with me, Joan had discontinued hormone replacement because she had learned that the treatment increases the risk of breast cancer.

Investigation of topical and transdermal delivery in human subjects

While the majority of emulsion dosage forms are intended for localized delivery and treating skin conditions, there is an increasing interest in developing emulsion-type formulations for transdermal drug delivery. As shown in Table 3.1, an emulsion containing estradiol has been commercialized as a transdermal delivery system for hormone replacement therapy (HRT).

Longitudinal perspective

The experimental evidence on the possibility of increasing bone strength by exercise in older adults is still weak compared to the 'training effects' indirectly obtained in the athlete studies. Several exercise interventions have shown positive changes in BMD, but the magnitude of these changes (on average 1-2 per year vs. controls) 63 , at least in the short term, remains low in terms of bone strength and fracture prevention. The question remains as to whether more strength-demanding, fast and unusual loading patterns which have been suggested to be osteogenic in pre-menopausal women and early postmenopausal women with hormone replacement therapy are at all feasible for most older people, or whether outcomes other than BMD (e.g. moment of inertia and mass distribution, see 30 , or collagen structure and metabolism) would be more relevant and sensitive to the effects of exercise.

Clinical use in osteoporosis

Bones, which leads to an enhanced fragility of the skeleton and therefore to a greater risk of fracture. It is defined as present in women when the bone mass is more than 2.5 SD below that of the young woman (t score). It is a very common disorder which will become even more common with the increase in life expectancy. It is also frequent in men, although less so than in women. Its main cause is the continuous loss during life of both cancellous and cortical bone, which is exacerbated in women after the menopause. The second contributory factor is failure to achieve adequate peak bone mass during adolescence. The causes of these changes are not yet clear, although genetic factors are involved, at least for the latter. sphonates, was estrogen replacement after the menopause. However, it has recently been shown that estrogens increase the risk of breast cancer, and increase instead of decrease cardiovascular insults 20 . Calcitonin is sometimes used, but parenteral administration can...

Conservative Followup in Clinically Detected Primary Hyperparathyroidism

Silverberg and coworkers44 reported a 10-year prospective follow-up of 121 HPT patients, 61 of whom were subjected to parathyroidectomy (according to indications established at the National Institutes of Health Consensus Conference Statement, 1991, concerning diagnosis and management of asymptomatic HPT4), whereas 60 patients did not undergo surgery. The majority of nonoperated patients were asymptomatic, but in some patients surgery was not undertaken despite the presence of kidney stone disease. All nonoperated symptomatic patients with kidney stones experienced progressive disease with recurrent stone attacks during follow-up, whereas none of the operated patients had such recurrences. Among nonoperated, asymptomatic patients, 27 had progressive disease with worsened hypercalcemia, increased hypercalciuria, and decrease in bone mineral the remaining patients had apparently stable disease. The authors concluded that women with HPT seemed to be at risk for disease progression with...

Progression of Symptoms

Cortical bone of nearly 20 among current patients with primary HPT, and the bone loss tends to be most pronounced in postmenopausal women.4449 Total and trabecular bone mass is often significantly but less markedly reduced.4446 Bone density measurements are recommended at the distal radius, hip, and lumbar spine because a subset of patients have more apparent reduction in the spine than other sites.46 The risk for fracture appears to be increased for the vertebra, distal leg, and forearm and returns to normal after parathyroid surgery.50 51 The bone loss may be most evident at the time of menopause and may constitute an important indication for surgery in female patients.44 No bone loss has been detected in postmenopausal women with borderline hypercalcemia, but losses were significant when the serum calcium level was higher than 2.74 mmol L.47

Variation in the estrogen receptor

Several polymorphisms of intronic sequences of the estrogen receptor a gene which are in linkage dysequilibrium with each other were previously found to modulate the response of HDL-cholesterol levels to estrogen replacement therapy in menopause (Herrington etal. 2002). We did not find any significant association of ER polymorphisms with cardiovascular risk factors or the presence of coronary artery disease in men (Hersberger and von Eckardstein, unpublished data). In an autopsy study, a pvuIpolymorphism in the estrogen receptor a was found associated with the extent of complicated coronary artery atherosclerotic lesions in men older than 53 years (Lehtimaki etal. 2002).

Historical Perspective

Herbal remedies continue to play a significant role in human medicine. Chemical investigations have identified many of the active principles in many commonly used products. These products are often sold as dietary supplements rather than ethical pharmaceutical products. Because these products are complex mixtures of many natural products there is a need to establish criteria for their standardization. This situation is complicated by the natural variation in secondary metabolites produced by closely related species of medicinal plants. Owing to the possibility that variations in the composition of the products will result in unpredictable potency, the herbal products industry has been developing quality control standards. Black cohosh, for example, which is taken for the relief of menopausal symptoms, has a number of signature triterpenoid constituents including, actein, 23-epi-26-deoxyactein, and cimigenol-3-O-arabinoside (Figure 6.2). These compounds can be identified by coupled...

Distribution and Incidence

Peptic ulcer dyspepsia is rare in people under the age of 20, but by age 30, 2 percent of the males and 0.5 percent of the females in a population have developed the condition. For men, the incidence increases steadily with age, reaching a peak of around 20 percent in the sixth decade of life. The incidence for women remains low, about 1 percent, until menopause, after which it climbs as rapidly as in men. A morbidity rate of nearly 14 percent has been re

Epidemiology and etiology

The prevalence of osteoporosis varies by age, gender, and race ethnicity. The risk of fracture increases exponentially with each decade in age over 50.8 Residents of nursing homes may be at an even higher risk of fracture. Both men and women lose bone as they age. However, women have accelerated bone loss surrounding menopause due to loss of estrogen. Men have some protection from osteoporosis due to their large bone mass and size and the absence of menopause. Fragility fractures of the hip and spine are common among men, especially as age increases. Men comprise

Structure and Physiology

The nodularity, density, and fullness of the adult breast depend on several factors. Most important is the presence of excess adipose tissue. Because the mammary gland consists mainly of adipose tissue, women who are overweight have larger breasts. Pregnancy and nursing also alter the character of the breasts. Often, women who have nursed have softer, less nodular breasts. However, because the glandular tissue is approximately equal in all women, the size of the breast is unrelated to nursing. With menopause, the breasts decrease in size and become less dense. There is an associated decrease in elastic tissue as women age.

Demographic Characteristics

Examination of age and gender effects continues to be an important topic of research. To the extent that there are gender differences in age of onset, questions arise about the disease process itself. If schizophrenia has an earlier onset in males, and this onset tends to be more insidious than in females, then what biologic factors might account for this For example, some studies have shown that the gender difference in age of onset is more often found in sporadic cases rather than familial schizophrenia (e.g., DeLisi et al., 1994). Another hypothesis tested by the Mannheim research program was that an elevated vulnerability threshold for women until menopause'' could be due to the sensitivity-reducing effect of estrogen on D2 receptors in the central nervous system'' (Hafner et al., 1998). Identification of these factors might provide clues about disease-promotion mechanisms.

What do you do now

The RCVS syndrome most often affects young women, especially during the puerperium, but also occurs at menopause and is found at all ages. Many of the patients have had a history of migraine. Some patients have developed this syndrome after carotid endarterectomy. The use of serotonin reuptake inhibitors prescribed for depression, and cannabis especially smoked in a binge can provoke the syndrome. Drugs such as phenylpropanolamine, cocaine, and amphetamines can also precipitate identical syndromes.

The Oestrus That Never

Place throughout the monthly menstrual cycle, after ovarian cycles cease at the menopause, or as a result of ovariectomy. This is not to imply that the menstrual cycle and ovarian hormones have no effects upon human sexual behaviour I shall return to this subject later in this chapter. However, since women do not experience circumscribed periods of sexual receptivity, anthropologists have sought to explain how and why, there has been loss of oestrus during human evolution. Nor is it obvious when ovulation is likely to occur during the human menstrual cycle, as women do not exhibit external cues, such as the oestrogen-dependent sexual skin swellings found in chimpanzees and some Old World monkeys. Thus, in addition to searching for the reasons why oestrus was lost in human ancestors, scientists have sought to explain the origins of concealed ovulation. Symons (1979), for example, proposed that 'estrus was lost some time after humans last shared a common ancestor with any living...

Possible MCI Therapies

Despite promising basic science research, estrogen has not consistently shown benefits in treating or preventing cognitive disorders. The data currently do not support the use of this agent for the treatment of AD. In one meta-analysis (LeBlanc et al., 2001) examining nine randomized controlled trials and eight cohort studies with respect to the role of estrogen and cognition, women with menopausal symptoms showed improvement in verbal memory, vigilance, reasoning, and motor speed but no benefit in other cognitive domains. Asymptomatic women did not improve. Likewise, clinical trials have failed to demonstrate benefits for coronary artery disease, cerebrovascular disease, osteoporosis, and cognition. Further, its long-term use may be contraindicated in women with intact uteruses due to the potential risk of endometrial hyperplasia, endometrial cancer, gallstones, and breast cancer.

Primary Prevention Trials

Thus, several strategies can be considered for primary prevention trials. In the first strategy, healthy individuals would be treated in an attempt to delay the onset of disease. The main advantage of this design is that the results would be gener-alisable to other healthy individuals. Because of the large sample size and high costs associated with this strategy, enrichment strategies should also be considered. These include enrolling older subjects, subjects with a positive family history of AD, and subjects at risk because of the presence of an apo E4 allele. Several primary prevention trials for AD are currently preparing to get underway utilising some of these strategies. A second strategy would be to find subjects who are already randomised to compounds of interest in trials for other indications to which cognitive endpoints could be added. This has already been successfully accomplished within the framework of the Women's Health Initiative (WHI) where approximately 8000...

Abdominal Hysterectomy

Leslie, in her own words, freaked out when her doctor told her it was time for her to have a hysterectomy. Her doctor had been monitoring Leslie's fibroids for seven years, and as Leslie went through menopause, she expected them to shrink. She never had any symptoms, but even after menopause, the fibroids continued growing, and her doctor told her they would soon interfere with the functioning of some of her organs.

Additional clinical variables

Endogenous bio-available testosterone levels were reported to be inversely associated with depressive mood assessed with the Beck Depression Inventory in older men in the Rancho Bernardo Study (Barrett-Connor et al. 1999). In a study of selected men aged 50 to 70 years, who participated in a screening program on prostate cancer and 'andropause', there was an inverse correlation between free testosterone and depressive symptoms assessed on the Carroll Rating Scale, but serum free testosterone was not related to the prevalence of a significant score for depression (Delhez et al. 2003). In contrast others reported that declining bio-available testosterone levels were associated with lower levels of depressive symptoms on the Hamilton Depression Scale in men 55 to 76 years old (Perry et al. 2001).

Who should be considered for treatment

There exist a number of questionnaires that are being used in clinical or epi-demiological settings to help describe and semi-quantify symptoms in different areas that are of relevance to elderly men, such as questionnaires on self-perceived health status, on depressive mood, on urinary symptoms, on erectile function, or on coping with activities of daily living. Morley et al. (2000) proposed a dedicated instrument, the ADAM screening questionnaire for androgen deficiency in aging males. The available information suggests that this questionnaire, although relatively sensitive to detect men with decreased free or bio-available testosterone, lacks the required specificity to be a valid instrument for diagnosis in the individual subject (Delhez etal. 2003). The Aging Males' Symptoms Scale (AMS) was developed by Heinemann et al. (1999) in Germany to help describe and quantify the clinical syndrome of'andropause', but was not intended to screen for low serum testosterone and was not...

Tightfitting and nona bsor bent clothing

Estrogen enhances Candida adherence to vaginal epithelial cells and yeast-mycelial Transformation this is supported by the fact that infection rates are lower before menarche and after menopause except in women Taking hormone replacement therapy)r while rates are hiyher during pregnancy

Subarachnoid Hemorrhage SAH

The incidence of SAH increases with age (mean age of approximately 50 years) and is higher in women than in men. Blacks are at higher risk than whites. Population-based mortality rates for SAH have progressively declined, and the survival rate after SAH has improved since the 1970s. The risk of SAH is increased during the third trimester of pregnancy. SAH due to aneurysm rupture is a leading cause of maternal mortality, contributing to between 6 and 25 percent of maternal deaths. Significant risk factors for SAH include smoking, hypertension, and heavy alcohol use. Use of oral contraceptives, hormone replacement therapy, hypercholesterolemia, and physical activity are not significantly related. During pregnancy, there is also a greater risk of AVM rupture y , y

Patient Encounter Part 1

BB is a 65-year-old woman who presents with a history of a small, hard lump in the upper outer quadrant of her right breast. This lump has been there for at least 3 months. She reports having mammograms in the past that were normal, but she has not had one in about 3 years. The lump in her breast is not painful. She has no nipple discharge or drainage from that breast and the skin appears normal. The left breast is normal. She has a history of hypertension and has been postmenopausal for approximately 10 years. She does not smoke and drinks an occasional glass of wine. She has no family history of breast cancer, but does have a sister with ovarian cancer at age 58 and her father had prostate cancer at age 85. She began menses at age 10, had two pregnancies (first at age 25) with two healthy daughters, and has taken Prempro since menopause at age 55 (for 10 years).

Unifocal Langerhans Cell Histiocytosis Intracranial

Occurrence of LCH as a unifocal intracranial lesion is very rare. When reported, the regions involved included the hypothalamus (although this more commonly occurs with multifocal involvement), cerebellum,15 or cerebral hemispheres.7,18 In the absence of multifocal lesions, the diagnosis is virtually impossible to predict based on the nonspecific imaging findings alone. Therefore these lesions are usually subject to the treatment algorithm applied to suspected brain tumors, which would involve either an attempt at open resection or biopsy. This can be a particularly difficult task for hypothalamic lesions, which usually need to be accessed by either an open craniotomy or, if feasible, an endoscopic transventricular route. However, once the diagnosis of LCH is confirmed, the treatment options can be better defined. Following a gross-total resection of an intracranial LCH lesion, most patients should be observed without any further therapy.7,8,18 In the setting of a biopsy or incomplete...

A lternatives to Hormone Replacement

Other medications may alleviate some the symptoms of menopause. None are as effective as estrogen in reducing hot flashes, however. These medications include selective serotonin reuptake inhibitors (SSRIs, often Many advocates of alternative medical approaches have publicized the use of soy products to alleviate menopausal symptoms. However, the few studies that have been done so far have shown that most of these soy preparations have little or no effect on symptoms of menopause in most women. But a diet rich in soy protein has been shown to reduce total cholesterol, LDL cholesterol, and triglycerides. And eating a diet containing large amounts of soy protein doesn't seem to have any adverse side effects.

Mecanism Of Centripetal Lipid Accumulation Supraclavicular Fat And Face

Hypogonadism is separated into primary (dysfunction of the testis or ovary) or central (pituitary or hypothalamic). Clinical manifestations of hypogonadism in prepubertal children cause no symptoms, whereas in adolescents hypogonadism leads to delayed or absent pubertal development. In adult women, hypogonadism causes amenorrhea, infertility, loss of libido, vaginal dryness, and hot flashes. In men, hypogonadism leads to loss of libido, erectile dysfunction, and infertility. Causes of primary hypogonadism include genetic disposition, menopause, autoimmune reactions, viruses, radiation, and chemotherapeutic agents. Central hypogonadism is most often caused by pituitary adenomas. Through compression of the gland, these tumors can cause destruction of pituitary tissue or interference with GnRH input from the hypothalamus. Gonadotropin dysfunction is the second most common hor

Patient Encounter 1 Part 1

A 67-year-old female with history of coronary artery disease, diabetes, and GI reflux presents to your clinic complaining of persistent flatulence, bloating, and feels she is getting fat. After discussing the symptoms with her, you learn that her reflux symptoms are recent onset and her proton pump inhibitor is working. However, for the past 3 or 4 months, she also has irregular bleeding and occasional cramping, which has been frustrating for her because she thought that ended years ago when she went through menopause. She reports her menses began when she was 9 and lasted all way until she was 61. She has two sisters in good health and a brother with diabetes. She has been married for 25 years with no children. The physician orders a CA-125 and CT scan that both come back positive and suggestive of ovarian cancer.

Accreditation Commission for Acupuncture and Oriental Medicine AGAOM

Menopause, 171-172 eight directions, 55-56 pulse, 13-15 tongue, 12-13 dianhea, 189-190 dysmenonhea, 167-170 ear infections, 142-144 eczema, 195-197 electro-acupuncture, treatments, 104 endometriosis, 177-179 facelifts, 197-199 fibromyalgia, 65-66 headaches, 59-61 healthful lifestyle tips, 251-252 herbal medicine, 47-49 HIV AIDS, 218-219 hypertension, 220-221 IBS, 186-187 indigestion, 191-193 infertility, 156-158 injuries, 101 insomnia, 225-227 jumper's knee, 88-89 knee pain, 87-88 licenses, 244 magnets, 45-46 Margaret Naeset, 75 medical histories, 14-15 menopause, 170-172 moxibustion, 41-42 nasal congestion, 126-127 infertility, 157-158 insomnia, 227 insurance, 261-262 magnetics, 9 menopause, 171-172 migraine headaches, 61 nasal congestion, 126-127 nausea, 152 neck pain, 64-65 Oriental Medicine, 94-96 palm pressure, 30 postpartum depression, 163-164 pressure types, 32-34 Q , 8

Definition Advantages and Disadvantages of Hemithyroidectomy

The advantages of this surgical approach are that, when compared with total thyroidectomy, surgical complications including permanent hypoparathyroidism and bilateral recurrent laryngeal nerve palsy are lower, even when an inexperienced surgeon performs the operation. In patients treated in this manner, only one of the two recurrent nerves and two or three of the four parathyroid glands are at risk. Most patients are also euthyroid postoperatively, so that lifelong thyroid hormone replacement therapy is unnecessary. When we recently examined thyroid function by measuring serum thyroxine (T4), triiodothyronine (T3), and TSH concentrations in 150 patients who had hemithyroidectomy, 95 (63 ) of all patients examined were euthyroid, 31 (21 ) had subclinical hypothyroid (low T4 and normal T3 with abnormally high TSH), and 24 (16 ) were hypothyroid.

Valerian Root Valeriana Officinalis

Use Three decades of extensive research have shown that valerian root is like a minor tranquilizer. It is known as a sleeping aid, and it might be useful for insomnia, mild anxiety and restlessness, lowering blood pressure, and reducing symptoms of menstruation and menopause. To date, it has not been proven to be habit-forming.

Acu Points to Block the Bleeding

Many women who come to my practice are opting to use acupuncture and Oriental Medicine to stop the pain and excessive bleeding from fibroids and cysts. I make sure that they have been properly examined and diagnosed by their conventional physician to rule out any malignant growths. Over 30 percent of all hysterectomies (removal of the uterus) in the United States are done to remove uterine fibroids. Since these growths shrink after menopause, avoiding surgery is an option some women are choosing, and Oriental Medicine is a helpful partner.

Levocarnitinein Libido

In cystic fibrosis, 303, 304, 306, 308, 309 in sickle cell anemia disease, 1145t Lung transplantation. See also Solid-organ transplantation acute rejection, signs and symptoms of, 944t epidemiology and etiology of, 941 Lupus erythematosus, allergic drug reaction, 929t Luteinizing hormone at menopause, 870-871 in menstrual cycle, 843, 856, 856f Luteinizing hormone-releasing hormone, 1546 Luteinizing hormone-releasing hormone agonists in breast cancer, 1485, 1486t in cancer, 1468

What are some of the side effects of hormonal therapy and how are they treated

Significant impact on bone mineral density. Low testosterone levels affect bone mineral density in men almost the same as low estrogen levels in women. The use of androgen deprivation therapy, whether it is via orchiec-tomy or LHRH analogue or LHRH antagonist with or without antiandrogen, causes decreased bone mineral density. There is an average loss of 4 per year for the first 2 years on hormone therapy and 2 per year after year 4, which is similar to the loss in women after removal of the ovaries or natural menopause. This loss of bone mineral density in men taking hormone therapy occurs for at least ten years and probably accounts for the increased incidence of fractures 5 to 13.5 of men taking hormone therapy have fractures compared to 1 in men with prostate cancer who are not receiving hormone therapy. The cause of hot flashes and sweating (vasomotor symptoms) associated with hormone therapy (shots or orchiectomy) is not well known. The symptoms are similar to those that women...

Impulse Control Disorders in Parkinson s Disease

There have been very few studies that examine the impact of PD on sexual functioning in women with PD. What little evidence that exists suggests that women with PD often experience a decline in sexual desire and a reduced ability to experience orgasm during sex. Sex can be uncomfortable due to lack of lubrication and desire. For women with PD who have experienced menopause, the decline in sexual interest may be due to both menopause and to PD.

What if my testosterone level is low What are the risks and benefits of testosterone therapy

Hypogonadism is a condition in which low levels of testosterone are found in association with specific signs and symptoms, including decreased desire (libido) and sense of vitality, erectile dysfunction, decreased muscle mass and bone density, depression, and anemia. When hypogonadism occurs in an older male, it is referred to as andropause, or androgen deficiency of the aging male. Hypogonadism is estimated to affect 2 to 4 million men in the United States, and its incidence increases with age. Only about 5 of affected males are being treated.

Treatment and Consideration of Womens Issues in Headache

Abstract At menarche the incidence of migraine in girls increases. Migraine also changes at other key times in a women's life during menses, with the use of oral contraceptive therapy, and with pregnancy, lactation, and menopause. Each of these hormonal milieus is discussed in this chapter with relation to headache. The chapter includes sections on diagnosis of menstrual migraine, followed by discussion of acute, preventive, and miniprevention strategies. The impact and controversies of contraception in female migraineurs are considered, with special discussion on stroke risk. An extensive set of parts on migraine and pregnancy and lactation, with emphasis on practical treatment follows. The chapter ends with clinical pearls on treatment during perimenopause and menopause.

Longlived Monkeys Have Life Spans Proportional To Human Centenarians

Post-reproduction expected from primate patterns. Hammer and Foley (1996) use body and raw brain volume estimates from fossil crania to predict early hominid longevity using a multivariate regression of log body weight and brain volume. Estimates based on regressions ofanthropoid primate subfamilies, or limited to extant apes, indicate a major increase in longevity between Homo habilis (52 to 56 years) and H. erectus (60 to 63 years), occurring roughly 1.7 to 2 million years ago. Their predicted life span for small-bodied H. sapiens is 66 to 72 years. From a catarrhine (Old World monkeys and apes) comparison group, Judge and Carey (2000) predict 91 years when contemporary human data are excluded from the equation. For early hominids to live as long or longer than predicted was probably extremely rare the important point is that the basic Old World primate design resulted in an organism with the potential to survive longer than a contemporary mother's ability to give birth. Notably,...

Patient Encounter 1 Part 1 Patient History

In osteoporosis, an imbalance in bone remodeling occurs. Most commonly, osteo-clastic activity is enhanced resulting in overall bone loss. However, a reduction in os-teoblastic activity and reduced bone formation can also occur in certain types of osteoporosis. Due to a decrease in endogenous estrogen, bone remodeling accelerates during menopause and up to 15 of bone is lost during the first 5 years after menopause. After this initial decline, bone loss continues to occur but at a much slower rate of up to 1 per year. The resultant bone loss and change in bone quality predispose patients to low-impact or fragility fractures.

Androgen deficiency states in women

Estrogen And Androgen Over Time Women

A core precept of endocrinology is that of an endocrinopathy, defined as a hormonal deficiency state with clearly defined adverse sequelae. This paradigm is best illustrated by hypothyroidism and subsequent replacement, or by male hypogonadism with testosterone replacement. In the previous section, we have hypothesized that a clear androgen deficiency state does not exist in women undergoing natural menopause, but there are several conditions that are associated with decreased levels of androgens in women. These include the use of postmenopausal hormone replacement therapy (HRT), (particularly orally administered), oral contraceptive use, pre-or postmenopausal oophorectomy, and adrenal suppression. Combined, these iatrogenic causes are prevalent enough to makeandrogen deficiency in women an extremely common condition. Perhaps the most prevalent cause of androgen deficiency in women occurs with surgical menopause. The postmenopausal ovaries clearly remain active androgenic secretory...

Agerelated bone loss and osteoporosis

Primary osteoporosis related to aging has been classified as type II, or senile, osteoporosis. The type I disorder is related to the onset of menopause, and is thus termed postmenopausal osteoporosis. Other causes of osteoporosis can be secondary, such as that caused by long-term corticosteroid use or endocrinopathy. Peak bone mass is achieved between the ages of 16 to 25 years in most people. After this age, bone mass slowly, but continuously, decreases. The greater the amount of bone achieved during the peak period, the lower the chance that a person will develop osteoporosis later in life. Normal rates of bone loss are different in men and women. In men, bone mass is lost at a rate of 0.3 per year, while for women this rate is 0.5 . In contrast, bone loss after menopause, in particular the first 5 years after its onset, can be as high as 5-6 per year 17 . Because women live longer than men, it is believed that increased longevity places women at higher risk of senile osteoporosis.

Epidemiology And Risk Factors

Spinal osteoarthritis has been demonstrated through radiographic and cadaver studies to affect every adult age group.2,3 The prevalence of clinical spinal osteoarthritis increases with age, with elderly patients having the highest radiographic and symptomatic prevalence.1,3 There is also a significant gender difference in prevalence. Females are more likely than males to suffer from osteoarthritis in general. The gender difference is exacerbated after menopause and therefore greater in the elderly.1

Female breast anatomy

With increasing age, and especially after the menopause, the glandular elements of the breast become less prominent and tend to be replaced by adipose tissue (fat). Fat attenuates the beam less than glandular breast tissue as a result, fatty breast is darker. Significant disease (which tends to be dense and produce high attenuation or bright areas on the film) is detected more easily. Younger breast tissue is denser (whiter), and the sensitivity of mammography in patients under 50 years of age is thus reduced. The younger breast is also more sensitive to the adverse effects of ionizing radiation, so ultrasound is often used as the first-line investigation in younger patients, especially under 35 years of age.

Summary and future directions

Androgens circulate in appreciable amounts in women. Female serum testosterone levels rely on a complex interplay of hormonal secretion and bioconversion of peripheral prehormones. Testosterone levels are proportional to ovarian and adrenal secretion and peripheral bioconversion of the adrenal androgens DHEAS and DHEA, the predominant circulating androgens. Adrenal androgen secretion attenuates with age in a cortisol-independent fashion due to involution of the reticularis zone of the adrenal cortex. As a result, as women age, less testosterone is produced from peripheral bioconversion of DHEAS and DHEA. With the onset of menopause, while ovarian folliculogenesis ceases, the remaining theca and stroma respond to the elevated, menopausal levels of LH by greatly increasing ovarian testosterone secretion. This compensatory mechanism attenuates the age decline in serum testosterone levels from declining adrenal androgens. The combined effects create a subtle decline in serum testosterone...

Genetics vs Lifestyle

Central obesity suggests increased visceral fat deposits, likely caused by increased production of peptides and other metabolic messengers. Hormonal influences most likely play a role in the distribution of fat. Central obesity is believed to result partly from increased androgenic effects, which is why men have a greater tendency for central obesity. Central obesity is also associated with hyperandrogenic states in women, such as polycystic ovary syndrome (PCOS). The increase in visceral deposition of fat that can occur after menopause in women may be related to a decrease in growth hormone and estrogen production (see Chapter 35).

Physiologic Effects of Corticosteroids

The physiologic effects of DHEA-S, DHEA, and androstene-dione are relatively weak, and they undergo conversion to testosterone in peripheral tissue. In females, androgens produced by the adrenal glands sustain normal pubic and axillary hair growth, and after menopause the adrenal glands are a major source of estradiol. However, in males, the high amount of androgens produced by the testis exceeds that produced by the adrenal glands.1

Clinical implications

Some clinicians argue that androgen replacement in the elderly male, in addition to possible benefits on muscle, bone, sexual and mental functions, has the potential to prevent atherosclerotic vessel diseases. However, androgens have such an extraordinary array of effects in vivo that it is hazardous to extrapolate isolated experimental findings to the wider clinical setting. It is premature to assume clinical benefits from manipulation of the sex steroid milieu based on biologically plausible mechanisms, or indeed on cross-sectional risk factor observational data in a complex multifactorial condition such as coronary artery disease. Interpretations of effects of pharmacological doses of androgens on arterial compliance and flow-mediated dilatation in particular must also be treated with circumspection. The lessons from estrogen hormone replacement in postmenopausal women are especially salutary. Despite the overwhelmingly positive but indirect evidence on risk factors and disease...

Treatment options in androgen insensitivity syndromes

Risk of a malignancy of the gonads should not be underestimated however, to date there is no report of a prepubertal or pubertal AIS-patient with a gonadal malignancy. In female patients with partial AIS caused by a mosaic mutation of the AR gene or decreased, albeit distinct, receptor activity due to a point mutation of the AR gene, the gonads should be removed before the beginning of puberty (Holterhus etal. 2002). Hormone replacement therapy in female patients with AIS will always include estrogens. However, when and if gestagens should be replaced and a cyclic replacement be given is debatable in these patients without Mullerian structures.

Exogenous androgen treatment in women

There is increasing interest in the use of testosterone as part of postmenopausal hormone replacement therapy, in particular to improve reportedly impaired sexual function (Davis and Tran 2001). Whether the concurrent use of testosterone will impact on the perceived benefits of estrogen hormone replacement therapy on the cardiovascular system is currently unknown. In a 20-year (1975-1994) retrospective survey ofthe Amsterdam Gender Dysphoria Clinic (vanKesteren 1997),293 female-to-male transexuals aged 17-70 years (mean 34) were treated for two months to 41 years (total exposure of 2418 patient-years) with oral testosterone undecanoate 160 mg daily or testosterone (Sustanon) 250 mg i.m. every 2 weeks. There was no excess of cardiovascular (or all cause) mortality or morbidity compared with the general female Dutch population.

Upon completion of the chapter the reader will be able to

Explain the pathophysiologic changes associated with menopause. 2. Identify the signs and symptoms associated with menopause. 5. Recommend nonpharmacologic therapy for menopausal symptoms. 11. Recognize that alternative, nonhormonal therapies for menopausal symptoms exist and should be considered in some circumstances for women unable to take HT.

Treatment Desired Outcomes

HT remains the most effective treatment for vasomotor symptoms and vulvovaginal atrophy and should be consideredfor women experiencing these symptoms. The goals of treatment are to alleviate or reduce menopausal symptoms and to improve the patient's quality of life (QoL) while minimizing adverse effects of therapy. The appropriate route of administration should be chosen based on individual patient symptoms, and therapy should be continued at the lowest dose for the shortest duration consistent with treatment goals for each patient.

Stress Urinary Incontinence Related to Urethral Underactivity4

Urethral underactivity are incompletely understood, although the loss of the trophic effects of estrogen on the uroepithelium at menopause is thought to be important. The peak of SUI prevalence in the perimenopausal years supports this hypothesis. Clearly established risk factors for SUI include5 Menopause

Outcome evaluation

Evaluating the outcomes of any therapy for menopausal symptoms focuses primarily on the woman's report of symptom resolution. Ask women to report the resolution or reduction of hot flashes, night sweats, and vaginal dryness, and any improvement or change in sleep patterns. Also ask women taking hormonal therapies to report any breakthrough bleeding or spotting. If abnormal or heavy bleeding occurs, refer the woman to her primary care provider. Monitor subjective parameters such as adverse effects and adherence to the therapy regimen, as well as monthly breast self-examinations. In addition, monitor objective parameters, including blood pressure, at every outpatient visit encourage yearly clinical breast examinations, mammograms, and thyroid-stimulating hormone (TSH) determination, particularly for women with hypothyroidism on thyroid therapy, and conduct a BMD test every 5 years. Also perform endometrial studies, as necessary, in women with undiagnosed vaginal bleeding. Lastly,...

Nonpharmacologic Therapy

Nonpharmacologic therapies for menopause-related symptoms have not been studied in large randomized trials, and evidence of benefit is not well documented. Owing to minimal adverse effects with these types of interventions, it is prudent for patients to try lifestyle or behavioral modifications before and in addition to pharmacologic therapy. The most common nonpharmacologic interventions for vasomotor symptoms include the following 3,8,9

Clinical Manifestations

Fully 90 to 95 percent of patients are male, and gout rarely develops in women before menopause. The first attack most often occurs in the fifth decade in men and in the sixth decade in women. The rate of production of uric acid and, related thereto, the onset of primary gout, thereafter diminishes.

General Considerations

Once breast cancer has occurred in a family, the risk that other women in the same family will have breast cancer is significantly higher. First-degree relatives, such as sisters or daughters, have more than twice the risk for development of breast cancer if the original patient developed cancer in one breast after menopause. Women with a family history of premeno-pausal breast cancer in one breast have three times the risk. If the original patient had post-menopausal cancer in both breasts, the first-degree relatives have more than four times the risk. First-degree relatives of patients with cancer in both breasts before menopause have nearly nine times the risk.

Breast Self Examination

Advise the woman that the best time to perform breast self-examination is 2 to 3 days to a week after the end of her menstrual period. At this time the breasts are less tender or swollen. Women taking oral contraceptives are encouraged to do their breast self-examination each month on the day they begin their new package of pills. A woman past menopause should be advised to pick a particular day of the month and then perform the examination monthly.

Radiologic Investigations

Bone densitometry studies are currently being performed more frequently and may be utilized in assessing the effects of primary hyperparathyroidism on bone. Primary hyperparathyroidism mainly leads to loss of bone at cortical sites such as the distal radius. Bone density is relatively preserved at sites such as the lumbar spine, which is rich in cancellous bone.39 This is in contrast to the bone density changes seen in menopause. In the latter, the lumbar spine is the major target of bone mineral loss. Despite these findings, lumbar spine density improves after parathyroidectomy.40,41

Indications for Parathyroidectomy

Primary hyperparathyroidism is a common disease in nontropical areas of the world. It is found in 1 in 2000 men and in 1 in 500 women after menopause and is more common in elderly people. Because hypercalcemia is frequently detected by routine laboratory studies and because of the availability of specific, sensitive, and accurate assays for intact PTH, most patients are diagnosed now at an early stage. Thus, it is uncommon to see patients with severe

Indications for Operative Treatment

The panel also cautioned against the use of neuropsychological abnormalities, cardiovascular disease, gastrointestinal symptoms, menopause, and elevated serum or urine indices of increased bone turnover as sole indications for parathyroidectomy. Rather, these factors should be weighed in the context of the individual patient. Although bisphosphonates and cal-cimimetics show promise, data are insufficient to recommend medical management in patients with asymptomatic primary hyperparathyroidism and only parathyroidectomy offers curative treatment. The new recommendations for follow-up of patients not undergoing surgery are compared with the previous recommendations in Table 40-4.

Prospective studies in women

The accelerated bone loss in postmenopausal women due to the decrease in reproductive hormones at menopause is a powerful contributor to the observed decrease in bone mass during life in females. Aloia et al. 65 were among the first to report bone mass benefits of exercise in postmenopausal women, measuring the total body calcium before and after exercise an increase from 781 95 g to 801 118 g was reported. Since that time several exercise studies investigating the effect of either moderate training or muscle-building training on BMD have been performed. Most studies of moderate training programs have used non-randomized exercise interventions to investigate the effects with varying results. Krolner et al. studied women with a previous distal radius fracture and demonstrated that the BMC of the lumbar spine increased in response to a program of walking, run ning, standing and rest 66 . BMC of the forearm was stable in patients as well as in controls. Nelson et al. 67 studied the...

Pathways involved in the spreading of the mechanical signal to neighboring cells

Estradiol and dihydrotestosterone both amplify the response of bone to mechanical stimulation via a mechanism which is independent of prostanoid formation 16 . The mitogenic effects of estrogen and EGF involve the estrogen receptor, whereas those of FGF and the IGFs do not 17 . Thus, antiestrogens like tamoxifen and ICI 182780 prevent osteoblastic proliferative responses to strain, while estradiol enhances strain-induced mitogenesis. The reduced ability to maintain the structural strength of bone after the menopause could be explained by less effective strain-related remodeling when estrogen is absent and or the estrogen receptor could be down-regulated. Recent studies indicate that strain may di

Osteoporosis Introduction

While osteoporosis, or loss of bone mass, is a well-known effect of menopause and aging in adults, it is also a significant problem among younger individuals. Hypothalamic amenorrhea in young women is associated with reduced bone accretion or premature bone loss during adolescence 40-49 , which places women at high risk for fractures, significant osteopenia (diminished bone mass) and severe osteoporosis at menopause. Amenorrhea in athletic women affects trabecular and cortical bone. Weight-bearing physical activity does not completely compensate for the side-effects of reduced estrogen levels even in weight-bearing bones in the lower extremities and the spine 50 . The most recent research suggests that poor nutrition or an energy deficit with an adaptation to large caloric needs is fundamentally linked not only with a prolonged amenorrheic state, but with osteopenia as well 51-54 .

What is peak bone mass PBM

Peak bone mass (PBM) is defined as the highest level of bone mass achieved as a result of normal growth. Bone mineral density (BMD) increases rapidly during adolescence until PBM is reached between 16 and 25 years of age. After age 30, men normally lose bone at a rate of 0.3 per year. After age 30, women normally lose bone at a rate of 0.5 per year until menopause, at which time the rate of bone loss accelerates to 2 to 3 per year over a 6- to 10-year period. The greater the PBM, the better the chance of avoiding osteoporosis later in life.

Mghr on for 1214 hours off for 101 hours

Pharmacotherapy With No Benefit or Potentially Harmful Effects Hormone Replacement Therapy Hormone replacement therapy (HRT) has favorable effects on lipoprotein cholesterol concentrations. Data from several observational studies suggested that HRT might reduce the risk of cardiovascular events in women with IHD. However, subsequent randomized, controlled, clinical trials failed to demonstrate a reduction in the risk for

Secondary prevention after ischemic stroke in young adults

The main characteristics of ischemic stroke occurring in young patients, i.e. their causes, the overall good outcome and interference with hormonal life in women (contraception, pregnancy and future menopause), influence secondary prevention after stroke. As for elderly subjects, secondary prevention measures mainly depend on the presumed cause. For this reason, an extensive and early diagnostic work-up is required, as well as an extensive evaluation of risk factors. The overall management of secondary prevention is based on principles similar to those in elderly subjects, i.e. an optimal management of vascular risk factors, an appropriate antithrombotic therapy (oral anticoagulation and antithrombotic agents depending on the cause) and removal of the source in specific cases (severe internal artery stenosis, cardiac The specificities of stroke prevention in young adults are the following (i) oral contraceptive therapy should be avoided in most cases (ii) in the absence of...

Types of cardiovascular disease

Blood clots in the leg veins, which can dislodge and move to the heart and lungs. Riskfactors Surgery, obesity, cancer, previous episode of DVT, recent childbirth, use of oral contraceptive and hormone replacement therapy, long periods of immobility, for example while travelling, high homocysteine levels in the blood.

Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a common disorder that is often unrecognized, affecting 4 of middle-aged white men and 2 of middle-aged white women.15 In women, the frequency of OSA increases after menopause. OSA is as common or more common in African Americans and less common in Asian populations. The risk of OSA increases with age and obesity. Individuals with OSA experience repetitive upper airway collapse during sleep, which decreases or stops airflow, with subsequent arousal from sleep to resume breathing. The severity is determined by nocturnal polysomnography (NPSG) and is graded by the number of episodes of apnea (total cessation of airflow) and hypopnea (partial airway closure with blood oxygen desaturation) experienced during sleep. The severity is expressed as the respiratory disturbance index (RDI), quantified in events per hour. Mild sleep apneics have an RDI of between 5 and 15 episodes per hour moderate, 15 and 30 and individuals with severe OSA can exhibit more than...

Understanding the Statistical Significance of Study Results

The following equations show how to take a summary rate commonly reported in published studies (i.e., relative risk) and calculate a summary measure (e.g., number needed to treat, number needed to harm) that may be more useful in describing the results to clinicians and patients. The example considers the average annual incidence rates and relative risk for coronary heart disease (CHD) events in the WHI study on the effects of hormone replacement therapy (HRT)

Ovarian and Testicular Disorders

Sexual development in both males and females is driven by the hypothalamic-pituitary axis. The normal process is the result of pulsatile release of GnRH from the hypothalamus, which stimulates the pituitary to release FSH and LH (GHRH and GH also play a role). Release of FSH and LH activates the ovary and testis to produce estrogen and testosterone and is responsible for stimulation of gametogenesis. This process is assisted by conversion of adrenal androgens from the adrenal cortex into androstenedione and subsequently into potent androgens (testosterone) or estrogens (estradiol) in the peripheral tissues (see Adrenal Glands). Errors can occur along this complex pathway, resulting in early sexual development (precocity), delayed sexual development (delayed menarche), errors of translation (male feminization syndrome), early loss of reproductive function (premature menopause), and inappropriate response to stimuli (polycystic ovary syndrome).

Case Example

Table 8-4 Examples of Reference Materials on Hormone Replacement Therapy for the Busy Physician Table 8-4 Examples of Reference Materials on Hormone Replacement Therapy for the Busy Physician A PubMed search (http entrez q uery static clinical.html) was performed using the clinical queries home page. Using the field therapy as the clinical study category and emphasis broad, sensitive search were chosen. The search terms were hormone replacement therapy and vasomotor symptoms. An excellent, evidence-based summary from Women's Health (Pinkerton et al., 2009) reviews the use of estrogen and other hormonal replacement therapies, various antidepressants, clonidine, gabapentin, and dietary and herbal supplements. The search and review of this article took approximately 3 minutes. Another PubMed reference found by doing a search using the keywords hormone replacement therapy and the limit, Meta-Analysis, uncovered a recent Cochrane review. Long-term hormone therapy for...

Eligibility criteria

One of the features that distinguish a systematic review from a narrative review is the pre-specification of criteria for including and excluding studies in the review (eligibility criteria). Eligibility criteria are a combination of aspects of the clinical question plus specification of the types of studies that have addressed these questions. The participants, interventions and comparisons in the clinical question usually translate directly into eligibility criteria for the review. Outcomes usually are not part of the criteria for including studies a Cochrane review would typically seek all rigorous studies (e.g. randomized trials) of a particular comparison of interventions in a particular population of participants, irrespective of the outcomes measured or reported. However, some reviews do legitimately restrict eligibility to specific outcomes. For example, the same intervention may be studied in the same population for different purposes (e.g. hormone replacement therapy, or...

Surgical Treatment

Important factors affecting recurrence in patients with Cushing's disease are the presence of tumor on MRI and tumor size. Transsphenoidal surgery for Cushing's disease results in a 70 to 90 rate of remission of hypercortisolism.3 Recurrence rates following surgery are generally between 5 and 10 , and are directly proportional to tumor size, with 36 of patients with macroadenomas developing recurrence in one series.3 Patients in whom refractory hypercortisolism occurs after surgery may be offered total hypophysectomy. These patients must be aware that they will require lifelong hormone replacement therapy. Occasionally, bilateral adrenalectomy may be performed, which sometimes results in Nelson's syndrome, caused by excessive circulating ACTH from the pituitary adenoma.

Transplanted Hairs

Possible cause Male-pattern baldness (which can also affect women) typically causes this type of hair loss. In this condition, which often runs in families, hair follicles are oversensitive to the male hormone testosterone. In women, the levels of these hormones in the body often rise after the menopause.


That the contraceptives prompted no change in BMD 97 . Research has not yet consistently demonstrated the efficacy of hormone replacement therapy or oral contraceptives in increasing the bone mass of women with hypothalamic amenorrhea 96 (Tables 4.6.5 & 4.6.6). A lack of response to estrogen-progestin therapy in replacement doses has also been reported when given to anorectic women with hypothalamic amenorrhea 74,86 . Treatment of osteoporosis in anorexia nervosa includes weight normalization and supplemental calcium and vitamin D. Unlike postmenopausal osteoporosis, estrogen replacement does not prevent or correct the osteoporosis that occurs in anorexia nervosa 83 . Even after recovery, studies have found conflicting data about weight gain and changes in bone mineral density, and there is still uncertainty about the restoration of bone density with complete and sustained clinical recovery from anorexia nervosa 81,82,86,103,104 . The effect of estrogen supplementation differs from...

Treatment options

An interdisciplinary approach is substantial not only in diagnostic, but also in therapeutic strategies. The aim of treatment of osteoporosis is to halt bone loss, to reduce pain and to prevent the occurrence of future fractures through osteoinduction. Pharmacological treatments for bone loss include the bisphosphonates, hormone replacement therapy, selective oestrogen receptor modulators, calcitonin, the 1-34 fragment of parathyroid hormone, calcium and vitamin D supplements, and calcitriol. Long acting strategies for patients with secondary osteoporosis must include effective treatment of the primary disease. In rheumatoid arthritis, this aims to reduce risk factors by inhibiting inflammatory activities of the disease by avoiding glucocor-ticoids and applying physical therapy.


Osteoporosis and osteopenia and fractures are potential complications in postmenopausal women and in patients with immobile limbs. Patients at risk for a decline in bone mineral density, especially in the vertebral bodies and the femoral head and neck, should ingest approximately 1500 mg of calcium and 800 IU of vitamin D daily. Postmenopausal women may benefit from hormone replacement therapy, although the effect in mobile older women is modest. Prevention in mobile women appears best using the selective estrogen receptor modulators such as raloxifene and biphosphonates such as alendronate or risedronate.154 Exercise is the best way to maintain mineralization. However, even high intensity resistance training that increases strength may not improve vertebral bone density over 24 weeks of training.


Generally speaking, men tend to have higher homocysteine levels than women the same age. And in women, homocysteine levels often increase after menopause, which can lead to a heightened risk of cardiovascular disease. Furthermore, homocysteine increases with impaired metabolism of homocysteine by the kidney. For this reason, total homocysteine levels are much higher in patients with chronic kidney disease.


Recently, Haddock and associates have shown an overall morphometric vertebral fracture weighted prevalence of 11.2 in a population-based study in a female population 50 years and older in the city of San Juan40,41. Of the 48 females out of 398 who had fractures, 19 had an early menopause at mean age 39 4.7 years. Although the asssociation did not reach statistical significance, an early menopause at age less than 45 years is an important risk factor for fractures and osteoporosis, more so if patients do not receive estrogen replacement. Cooper and associates42 found that women with vertebral fractures had an earlier menopause, fewer births and higher prevalence of clinically diagnosed hyperthyroidism. Thus, women with Sheehan's syndrome who develop the disease in their reproductive years are more prone to develop osteoporosis and fractures, for they are diagnosed late in the course of the disease and have not received hormonal replacement therapy.


With the possibility of a 20 bone mass loss in the 5 to 7 years following menopause, the best treatment for osteoporosis (reduction in amount of bone mass) is the prevention of bone loss. The following three steps are recognized as most helpful for women (80 of osteoporosis population) Peak bone development occurs throughout adolescence, with smaller bone gain during the 20s and less calcium needed at this age. Bone loss starts with menopause for women, which increases the need for calcium and vitamin D to prevent bone loss. High dietary intake of calcium does not seem to present any risk previous concern about kidney stone formation with increased calcium intake appears to be unfounded (Curhan et al., 1997). Side effects of high calcium supplement intake include constipation and dyspepsia, and calcium supplementation with more than 2000 mg day of vitamin D may lead to soft tissue calcification.

Black Cohosh

Use Some women take this for PMS and menopausal symptoms, but nothing has been clinically verified in humans. (However, it is big in Europe.) It suppresses the leutinizing hormone and therefore helps control hormone surges that cause discomforting menopausal symptoms. Relieving physical symptoms can lead to improving the emotional symptoms. In other words, some women get entirely depressed because they feel so physically lousy. Improve the hot flushes, bloating, etc., and the depression can sometimes improve.

Brittle Nails

Nail brittleness causes several clinical symptoms including splitting, softening, lamellar exfoliation and onychorrhexis. Brittle nails are a common complaint. It is often an idiopathic condition, but can also be a symptom of a large number of dermatological nail disorders. Although brittle nails have been linked with many internal diseases, the high frequency of nail fragility in the general population makes it difficult to prove the validity of any such association. Environmental and occupational factors that produce a progressive dehydration of the nail plate play an important part in the development of idiopathic nail brittleness. The lipid content of the nail is influenced by sexual hormones and decreases after menopause. This explains the high prevalence of brittle nails in postmenopausal women.