WHERE ARE WE GOING

The story of menopause is very long. It has been going on for centuries. Currently scientists have started GENERATIONAL research on it. The first book on it was written by Robert Wilson in 1966. There are different views on it, that it was to improve the sale of drugs and earn money, however many women benefitted from it. It came to a tragic end when a lot of women started to developed  endometrial cancer and it was recognised that they needed progesterone along with oestrogens to prevent it. Many other problems started such as breast cancer, heart disease, deep venous thrombosis (DVT), but women suffering osteoporosis and many genitourinary problems continued.  In 2001 it was decided to instigate a research program called THE WOMENS HEALTH INITIATIVE and this started in the USA. This was not a great scientific study as the women selected belong to all age groups. The study was halted half way and when published almost 80 percent of women did not want to take HRT and suffered in silence. However further research has clarified that the HRT should be started early in menopause, before the age of 60 or within 10 years of menopause. This is called window of opportunity. A fair bit of help is now available in this area. Great concern remained about prevention of breast cancer and osteoporosis. There were a new group of drugs that came into play; they act both as oestrogens and anti-oestrogens, with oestrogen receptors at different sites in the body. There called selective oestrogen receptor modulators (SERMS). Tamoxifen is one such drug, it was first described in 1987. It has proven to be very useful for the chemo prevention of breast cancer. However one drawback of this is that it is oestrogenic on endometrial tissue causing to grow, thus increasing the risk of endometrial cancer.

Raloxifene is another SERM which is useful for the treatment of osteoporosis. It does not harm breast tissue or endometrial tissue. The risk of DVT is there. There are many SERMS for the treatment of osteoporosis.  

In the management of menopausal years, HRT helps with symptoms of hot flashes, prevents colon cancer, osteoporosis but there is risk of breast cancer, DVT, stroke, CHD, alzhiemers and poor cognitive function. The few most important SERMS are Tamoxifen , Raloxifene and Ospemifene. They help with breast cancer, and osteoporosis. They can cause stroke, hot flushes, musculoskeletal problems and DVT.

Soon I hope the world’s scientists and researchers can produce an ideal SERM that can help with hot flushes, no stroke or DVT, reduce CVD, no breast cancer, cure osteoporosis and fracture risk and no endometrial cancer. The SERMS that we have now, TAMOXIFEN, RALOXIFENE, DUVAVEE, OSPEMIFENE, TIBOLONE, and many others; will continue to help the ever growing population of post menopausal women.

SEXUAL ACTIVITY DURING MENOPAUSAL YEARS

Many couples seem to have difficulty in sexual relations during and after menopause. This depend to some extent, as to how their relationship was in earlier years and what else is going on along with menopause, such as heavy and /or irregular bleeding problems. The other important thing is that two people are involved and it can be a problem with either of them. If a woman has had a hysterectomy this alone is often not a problem. However some gynaecologists think that removal of the cervix does interfere with the pleasure of sexual function, others think it does not matter. If one woman has had her ovaries removed it is a sudden withdrawal of ovarian hormones then they need help. If there are no contraindications for HRT, an ovarian implant is done at the same time. In early peri menopausal time women need to consider contraception, deal with hot flushes and a dry vagina. Their partner should understand and educate himself with these problems. If her desire to have sex is gone down perhaps more intimate time is required, gentle approach is necessary. If there is pain due to dry vagina there are many water soluble and silicone based moisturisers and lubricants available, which can make the sexual activity happy. Never give up, as sexual activity keeps the vagina healthy. It is said use it or lose it. Always pay attention to each other’s problems. You may consider MHT (HRT) if menopausal symptoms particularly hot flushes are making life difficult. When a woman starts having sex with a new partner always protect yourself from STD’s as your vagina is no longer protected and it may also be injured. The commonest infections are HIV, HERPES, and CLAMYDIA. There is a new SERM called Ospemifene is useful to protect from painful sex. Laser treatment is being tried but FDA has put up some warnings against it. Sexual activity in peri menopausal years requires personal, social, psychological and medical help.

PREMATURE OVARIAN INSUFFICIENCY (POI)

Premature ovarian insufficiency is defined when the ovaries fail to function before the age of 40.  This can happen very young, when a young girl fails to show the signs of puberty, or any time in her life before the age of 40. There are different names given to this problem, but the internationally accepted name is POI.  There is no ovulation and hormones, oestrogens, progesterone and testosterone are not produced. Besides reproduction these hormones are required for many functions in the human body, so the body suffers. I will explain this as we go along.

POI happens in 1% of women and 1 in 1000 women between the ages of 15 to 28. This is caused by chromosomal disorders, one of commonest being Turner’s syndrome. These women have only one X chromosome instead of two. These women have a fairly normal life when treated, except for fertility; the other chromosomal disorder is Fragile X mutation. The other causes are autoimmune diseases as in when the antibodies destroy the ovarian follicles, previous cancer treatments, metabolic disorders, toxins and viral infections. The special test required when these women or girls present to us are follicular hormone, oestrogens, chromosomes, genetic testing, thyroid function test, and antibodies. It is often very traumatic when women come to you hoping that they are pregnant and it is found that they have POI. In the management of young girls, once the diagnosis is established for sure; hormones are given in increasing doses to bring a period on and help with breast development. If they are really young growth hormones can be tried especially in girls with Turners Syndrome as they are short in height. This may help them to gain some height. Girls with Turners Syndrome need to be seen by a cardiologist who can look after any congenital heart lesion, as they often have them. Pregnancy can be tried with an Oocyte donation (a young egg from a donor) but this requires great care both during pregnancy and labour.  They are maintained on HRT at least until the age of menopause. These women with POI should be advised on general life style factors such as weight, cholesterol, smoking, as they have a higher risk of CVD due to lack of oestrogens. They can also try to get pregnant with an Oocyte donation. The age of the donor should be considered and screening should be carried out for any foetal abnormalities. If a woman is lucky to have a spontaneous pregnancy with POI, there are no special risks. Osteoporosis is another risk factor in women with POI; again due to lack of oestrogens, they should be having HRT, or a combined oral contraceptive pill, which will prevent any unexpected pregnancy if they do not want to be pregnant. If they have osteoporosis and require special treatment besides HRT, calcium, vitamin D and sunshine, it is best for them to be seen by an osteoporosis expert. HRT has not been shown to increase the risk of breast cancer under the age of 50. If any of these women are positive for BRCA12 (increased risk of breast cancer, and ovarian cancer) and there is no personal history of breast cancer they can have HRT but only after removal of both ovaries and tubes. Migraine headaches, fibroids, endometriosis, and blood pressure are not a contraindication of HRT in women with POI.  If obese it is better to use transdermal HRT. These women require a fair bit of psychosexual, psychological, cognitive, and life style intervention advice. Because of risks of CVS there life expectancy is shorter in women with POI. If they need help with genitourinary syndrome, they can be offered, local oestrogen creams, moistures and lubricants. They can read my previous posts on HRT and genitourinary syndrome. In short POI is perhaps a very premature menopause.

However it can be made very comfortable with all the modern treatments and in future we can achieve even more with regards to pregnancy.

CARDIO VASCULAR DISEASES IN PERIMENOPAUSAL AND POSTMENOPAUSAL YEARS AND ABOUT MHT(HRT)

We the clinicians as well as the women, all worry about hot flushes , night sweats , bladder problems, insomnia and mood swings, but do not think about heart problems in peri and post menopausal women .  However the fact remains that the highest cause of death in women after 50 is cerebrovascular disease (CVS) and stroke. These account for 75-76% deaths in western society as compared to deaths due to breast cancer which is 6-8%. Out of every 3 deaths in women 1, is due to CVS. We have to start paying attention to this and prevent them, from happening. There is a 10 years lag time when this happens in women as compared to men, unless women have a premature ovarian failure, premature menopause or early surgical menopause. Women lose oestrogen, this causes the blood vessels to become stiff, lose their elasticity, blood pressure increases and this increases the strain on the heart. The LDL (Low Density Lipoproteins) and Triglycerides (bad cholesterols) increase. HDL decreases (good cholesterol). Insulin resistance increases leading to, pre diabetes and diabetes as time goes on. Oestrogen also effects fat stores slows metabolism, this leads to weight gain and an increase in BMI and increase in abdominal girth. These are not ideal to prevent heart disease. The coagulation factors are altered, such as antithrombin3, factor 7c and plasma fibrinogen are all increased, leading to increased risk of thrombosis. So the risk of heart disease becomes multi factorial, there is increased blood pressure, strain on the heart, diabetes, obesity, changed cholesterol, increased thrombotic factors and increased sympathetic tone. All these lead to, metabolic syndrome and CVD. Some research has indicated that changes in cholesterol, apoproteins B, happen within the one year after the final menstrual period where as most other changes are related to chronological age.

What are the symptoms of CVS and heart disease? Heart Palpitations, Shortness of Breath, Light Headedness, Headaches, Diabetes, Swelling of the Feet, (change in the rhythm of the heart) Fibrillation, Pain in the Chest and Stomach. Women often do not have a chest pains when they have a heart attack. For neurological problems (Stroke); a women may not be able to smile put her tongue out and cannot lift her arms above her head (these are very simple test for the public to work out what is happening). Take them to a hospital immediately if this is happening. If stroke sufferers are treated within 4 hours they suffer very little residual damage. It has been shown that if treatment for prevention of long term CVS is started soon after menopause or within 10 years of menopause, these can be prevented.                        Most women need treating for hot flushes, night sweats, lack of sleep, mood swings, dry vagina and psychosexual problems, why not give them MHT (Menopausal Hormone Treatment) and not let them suffer and also prevent them from long term  effects of oestrogen deficiency such as increased risk of CVS and osteoporosis. This early period of menopause is called Xperiod of opportunity. Later on after many years of menopause, changes in women’s blood vessels have already occurred and oestrogen is not helpful. If a woman has a uterus and she needs oestrogen, she needs progesterone as well for uterine protection from cancer; a form of progesterone called micronized progesterone is recommended. This has fewer side effects and is better tolerated. For prevention of thromboembolic problems, dermal oestrogens are prescribed in the way of oestrogen patches and or jelly.  Women should watch their weight, abdominal girth, exercise, nutrition and quit bad habits such as smoking, excessive drinking of alcohol and soft drinks and being a couch potato.

It is very important to start MHT (HRT) during the WINDOW of OPPORTUNITY to prevent cardiovascular disease, which is the main cause of death in older postmenopausal women. The window of opportunity is considered to be within 10 years of menopause, or under the age 60.

There are many ways in which a woman can be relieved of her peri menopausal problems during the transitional phase or post menopausal phase. The most important thing is do not suffer in silence or follow the odd or non scientific, unauthorised, unproven solutions. MHT or HRT is probably the best solution for a long time or for the future prevention of complications and deaths from CVD or complications of Osteoporosis. Women who want to self manage their peri menopause can do this to some extent. They can watch their lifestyle factors, diet, exercise and yoga. Some selected antidepressants also help with hot flushes and sleep disturbances, these also can be tried. They need medical input if there periods are all over the place, too heavy and they are worried about contraception. When a medical care giver starts to look after peri and postmenopausal problems he/she takes a history in detail. This includes age, period history, your personal history of any medical disorders, DVT, CVS, liver and kidney disease, any operations, does she have a uterus or ovaries, does she need contraception, any family history of problems such as CVD, DVT or cancer. There will be a focus on women’s symptoms, irregular bleeding, anxiety, hot flushes, night sweats, sleeping problems, lack of interest in sex, dry and painful vagina, urinary problems such as urgency, incontinence and or repeated bladder infections. The clinician will do a detailed clinical assessment and look at a woman’s stature,   walking, vision and hearing. This can all be observed as she enters the clinic and says hello. He /she will take your weight, blood pressure or may be test your blood sugar. A breast examination is done, along with listening to the chest, abdominal examination and above all a vaginal / pelvic examination to find or exclude any local problem. Not many tests are required to make a diagnosis of menopause except in situations where there is a question of premature ovarian failure. It is not very rare if women came to you with a diagnosis of early pregnancy, (before the advent of such good pregnancy tests) ,the care giver finds, the woman in fact  is not pregnant and is suffering from premature ovarian insufficiency (PIF).  These situations are extremely distressing both for the care giver and the woman. Some of the tests that are ordered in peri and menopausal  are to assess ,her health such as FBE , ferritin (iron level in the blood), cholesterol ,thyroid function tests, liver and kidney function, mammogram, blood in stool, human  papilloma virus, now  instead of a smear test, pelvic ultrasound and any other tests if required in particular cases. With all this information the care giver is in a very good situation to discuss MHT with a woman depending on her wishes and symptoms. If you are under 60 or within ten years of menopause, this is what is called window of opportunity. It is the best time to start MHT if you so desire. It helps with your initial symptoms and prevents future problems such as CVD, osteoporosis and genitourinary syndrome of menopause. If a woman has had a hysterectomy the MHT (HRT) is easy to prescribe and take.  Normally women need two hormones, oestrogens for symptom relief and long term protection from CVD, osteoporosis and late onset genitourinary problems and progesterone is required for protection of the uterine lining the endometrium from cancer. Progesterone can be difficult to take for many women because of side effects, and it also increases the risk of breast cancer. When there is no uterus, progesterone is not required. It is easy to take oestrogen only. It can be used as oral, transdermal (on the skin) as a patch or jelly. It can also be used as an implant. Implants (deposited just under the skin for slow release) are used 6monthly or 12 monthly depending on the strength as to how long they will last).  Transdermal methods are very good if there is any history or risk factors for thromboembolic problems. In the early pre menopausal phase, if a woman needs MHT and her period is overdue always exclude pregnancy. One of the best MHT is combined oral contraceptive pill, especially if contraception is required and if there are no contraindications, for the pill such as high blood pressure, history of thromboembolic (DVT) problems or smoking. They come in different strengths depending on what is required to relieve a woman’s symptoms safely. For progesterone, what is currently used is called micronized progesterone. This progesterone is very safe and easy to tolerate. It decreases the risk of breast cancer. It can be used orally or vaginally, either continuous or 12 days in each cycle. However this regime is not a contraceptive and also does not help if a woman’s periods are heavy. For these situations an oral contraceptive pill which is good. If oral oestrogens are not suitable, transdermal oestrogens combined with a progesterone realsing intrauterine device is used, releasing a progesterone called levonorgestrel . This stops heavy periods or in fact periods all together and is a contraceptive as well. It is cost effective. This does not help with cyclical symptoms such as PMS, mastalgia, mood swings and fluid retention.

This works for nearly 5 years.  For more information on these you can refer to my previous post on bleeding problems, and contraception after 40. Women, who have early menopause, benefit from MHT. If they have an intact uterus, MHT with different types of Oestrogens and Progesterone is required, as already explained.

Combined oestrogen and progesterone patches are also available in varies forms.  They are useful if transdermal oestrogens are required. They can be cyclical or continuous.

Tibolone is another HRT often used for treatment in post menopausal women. It should not be used if a woman has not had a period for at least 1 year. It is a synthetic drug made from the Mexican yam. It can be used both in women with or without a uterus. It has oestrogenic actions on the brain relieving hot flushes, on the bone preventing bone loss and fractures and on the vagina improving vaginal dryness. It works like testosterone and improves sexual function and mood swings. There is some controversy about its risk on breast cancer. It is best to have regular breast examinations and mammograms. It has a slightly increased risk of stroke in women over 60. It is best not to use it in women who are over 60 or have risk factors for stroke eg: smoking, obesity, and high blood pressure.

IT should not be used, in women with a history of breast cancer or, for cardiovascular protection. Its data on LDL, HDL, and thrombosis risk are also inconclusive. Its side effects are headaches, nausea and swollen feet. Some women may have some bleeding in the initial 1-3 months, if it does not settle it should be investigated. The role of Tibolone on breast cancer is still under research.

One of the latest drugs approved by FDA for post menopausal women is a combination of combined   Estrogens and Bazedoxifene. Bazedoxifene, is a selective oestrogen modulator (SERM), this means that these oestrogens act differently in different organs. It is used for vasomotor symptoms and osteoporosis. This drug cannot be used if a woman has a heart disease, stroke, breast or uterine cancer, liver and kidney disease, dementia, blood clot, eye problems, migraine headaches, epilepsy, risk factors for coronary heart disease, thyroid function or high calcium levels in blood. Every woman should discuss with her care giver in detail that it’s safe for her to take this drug. Some side effects are diarrhoea, nausea, neck pain and upper abdominal pain. One of the serous side effects reported is sudden loss of vision. This is thought to be due to retinal vascular thrombosis.  Breast, ovarian and endometrial cancer may occur but this risk is unknown. Bioidentical hormones are promoted by many people instead of MRT. But these are not truly tested. This may be a euphemism for uncontrolled activity.

Non Hormonal Treatments of menopause

Some recent anti depressant called SSRIS (selective serotonin reuptake inhibitors, and selective norepinepinephrine reuptake inhibitors) and SNRIS are found very helpful for management of vasomotor symptoms of menopause, particularly in women who cannot take oestrogens. These drugs help to increase our levels of serotonin and noradrenalin in the brain; they are useful in transmitting messages from one cell to another. They are useful for vasomotor symptoms and mood swings. There are many such drugs. Your care giver will be able to give these to you. They are venloxifene, escitopram, praoxitin, prebgablin and many others. These normally are anti depressants, but when used for VMS of menopause they are used in a much smaller dosage. There is another drug called Gabapantin which is very helpful if there is pain as well with VMS. Normally it is used for chronic pain and epilepsy. Side effects can be dizziness, light headaches and drowsiness.  Clonidine is another useful drug, normally it is used for blood pressure or migraine headaches. All these drugs are particularly used for women who have suffered from breast cancer or any others cancers and these are non hormonal. They can use local moisturisers for the vagina, they last longer than lubricants. Silicone based lubricants are best.

There are many plant based remedies and food, however women who have had a history of cancer should stay away from them as they have not been evaluated. Other helpful counselling can be on sexual problems, bone health, life style changes, relaxation, no smoking and acupuncture is supposed to help some women. In very difficult cases Stellalate Ganglion Block is done, by injecting sympathetic nerves in the neck. A new class of drug is being studied in the Imperial College in London which may revolutionise the management of menopause. There are many new treatments for genitourinary syndrome of menopause, please refer to my previous post on this. Women who have had breast cancer cannot use Ospemifene, a drug mentioned there for dyspareunia. There are special situations when HRT should not be used. These are Oestrogen dependent cancers, high risk of DVT/VTE, personal wish not to use hormones, undiagnosed genital bleeding, severe liver disease, and untreated high blood pressure.  When any one uses a drug always read the information on side effects.

CONCLUSION:  This post discusses the prevention of CVD in older post menopausal women, which is the main cause of death in menopausal years. Various treatments of menopause are also mentioned. The most important thing is not to suffer in silence. There is a lot of help available in various forms and it is always discussed with every woman in detail. It is offered to women in total agreement with them. The most important scenario is to start it during the window of opportunity. Stay away from treatments which are not scientifically proven.

POSTMENOPAUSAL YEARS

We the clinicians as well as the women, all worry about hot flushes , night sweats , bladder problems, insomnia and mood swings, but do not think about heart problems in peri and post menopausal women .  However the fact remains that the highest cause of death in women after 50 is cerebrovascular disease (CVS) and stroke. These account for 75-76% deaths in western society as compared to deaths due to breast cancer which is 6-8%. Out of every 3 deaths in women 1 is due to CVS. We have to start paying attention to this and prevent them from happening. There is a 10 years lag time when this happens in women as compared to men, unless women have a premature ovarian failure, premature menopause or early surgical menopause. Women lose oestrogen, this causes the blood vessels to become stiff, lose their elasticity, blood pressure increases and this increases the strain on the heart. The LDL (Low Density Lipoproteins) and Triglycerides (bad cholesterols) increase. HDL decreases (good cholesterol). Insulin resistance increases leading to, prediabetes and diabetes as time goes on. Oestrogen also effects fat stores slows metabolism, this leads to weight gain and an increase in BMI and increase in abdominal girth. These are not ideal to prevent heart disease. The coagulation factors are altered, such as antithrombin3, factor 7c and plasma fibrinogen are all increased, leading to increased risk of thrombosis. So the risk of heart disease becomes multi factorial, there is increased blood pressure, strain on the heart, diabetes, obesity, changed cholesterol, increased thrombotic factors and increased sympathetic tone. All these lead to, metabolic syndrome and CVD. Some research has indicated that changes in cholesterol, apoproteins B, happen within the one year after the final menstrual period where as most other changes are related to chronological age.

What are the symptoms of CVS and heart disease? Heart Palpitations, Shortness of Breath, Light Headedness, Headaches, Diabetes, Swelling of the Feet, (change in the rhythm of the heart) Fibrillation, Pain in the Chest and Stomach. Women often do not have a chest pains when they have a heart attack. For neurological problems (Stroke); a women may not be able to smile put her tongue out and cannot lift her arms above her head (these are very simple test for the public to work out what is happening) . Take them to a hospital immediately if this is happening. If stroke sufferers are treated within 4 hours they suffer very little residual damage. It has been shown that if treatment for prevention of long term CVS is started soon after menopause or within 10 years of menopause, these can be prevented.                        Most women need treating for hot flushes, night sweats, lack of sleep, mood swings, dry vagina and psychosexual problems, why not give them MHT (Menopausal Hormone Treatment) and not let them suffer and also prevent them from long term  effects of oestrogen deficiency such as increased risk of CVS and osteoporosis. This early period of peri menopause is called period of opportunity. Later on after many years of menopause, changes in women’s blood vessels have already occurred and oestrogen is not helpful. If a woman has a uterus and she needs oestrogen, she needs progesterone as well for uterine protection from cancer; a form of progesterone called micronized progesterone is recommended. This has less side effects and is better tolerated. For prevention of thromboembolic problems dermal oestrogens are prescribed in the way of oestrogen patches and or jelly.  Women should watch their weight, abdominal girth, exercise, nutrition and quit bad habits such as smoking, excessive drinking of alcohol and soft drinks and being a couch potato.

It is very important to start MHT during the WINDOW of OPPORTUNITY to prevent cardiovascular disease, which is the main cause of death in women in later years.  

NUTRITION DURING PREGNANCY

When a woman starts thinking of getting pregnant, she should start a good pre pregnancy health regime. If she wishes to get pregnant in the near future she should make sure that she is not overweight, obese or too thin. Her blood pressure should be normal and thyroid function tests, blood sugars as well as basic bloods are within normal range. Besides all these it is very important to take 400 mcg of folic acid every day. This has been proven without doubt that this prevents occurrence of neural tube defects (abnormalities  of brain and spinal cord) in the new born. This is able to prevent it by almost 70%. These are far more common in the Asian population. I feel folic acid pre pregnancy and the first three months of pregnancy is recommended all over the world. In fact many foods are fortified with folic acid. Women may continue to take it for the rest of the pregnancy. When pregnancy begins many women feel that it is happening very quickly, within two weeks, some start getting sick and get a feeling of liking or disliking certain foods (This is called pica of pregnancy).The sickness of pregnancy is called morning sickness, as it is worse in the mornings. The medical word for this is nausea and vomiting of pregnancy. This usually settles down after 12 weeks, however it can continue throughout the pregnancy in a small number of women. If it is severe then the care givers, have to watch for dehydration, too much weight loss and rarely liver failure in women who were already malnourished in poorer socioeconomic countries. These women are often admitted to the hospital for supervised treatment of morning sickness.   The morning sickness happens during pregnancy  due to hormones; Chorionic- gonnadotrophins hormone of pregnancy, increased levels of oestrogens, increased sense of smell and taste, sensitive stomach, stress and unhappy surroundings. In general it can be controlled by a gentler life style, dry snacks, cooled food, less fat, small and frequent meals and adequate rest. Vitamin B6 is very useful. Ginger and its preparation; such as tea, candy, ginger ale, are all excellent. In fact in very ill women we use ginger injections in a hospital setting and for some women there are tablets which help with day to day work. I have used a preparation like a balm which had Vitamin B6, lemongrass, ginger, and women inhaled the balm and found it to be very useful. Acupressure on the wrist points and an acupressure wrist band is also useful. It is just like the one used for travel sickness. If you are well eat normal food like grains, complex carbohydrates, protein, lean and cooked, fish free of mercury, cheeses’ made from pasteurised milk, not soft  cheese, and not processed meats, small quantity of good fats. A good range of assorted fruits, vegetables and dark green leafy vegetables; depending on the seasonal growth in your country. Avocado and spinach are two of the best foods both for vegetarians and non-vegetarians. Avocado has Omegas 3 fatty acids, Vitamin B5 (pantothenic acid), Vitamin K and C, phosphors, iron and fibre. Half an Avocado per day is very useful, however more than that, you may put on weight. Please do not fall into the mindset of thinking that you need to eat for two.   Women need to increase their calories by 300 for a single pregnancy and 600 for a twin in the first trimester. 300 calories are equal to a glass of fat free or low fat milk and a medium sized half a sandwich. Please do not eat food full of calories and have no food value. Women need many vitamins and minerals, Iodine and Selenium for foetal thyroid and brain development. Calcium and Vitamin D for bones, Iron, Copper, Zinc, Vitamins B1, B6, B12, C , K, E, are required for immunity and other developments.

Nuts, beans, and lentils, are also very important particularly for vegetarians.  Try to keep your weight gain to about 2 -4 kgs in the first trimester. A weight gain of 25 -35 kgs is best for the whole pregnancy. If a woman has a balanced diet she may get all her vitamins and minerals, however inmost countries there are special pre natal capsules which provide all the nutrients. It is worth while taking a capsule or a tablet daily throughout the pregnancy. If you put on too much weight in the second or third trimester, a woman runs the risk of diabetes or blood pressure (Preccelamsia) of pregnancy.  Both these conditions, make the pregnancy complicated and can also cause long term problems. Do not eat for 2 as already mentioned and be aware of the following points: - Do not eat shellfish which is raw, raw eggs, refrigerated and smoked food as it can have Listeria.

Women must abstain from alcohol, limited caffeine intake (one medium cup in 24 hrs), over the counter food from take away places, unwashed fruits and vegetables. Make sure that your hands, cutlery and crockery are clean.

Generally in the first trimester women can have 1800 calories, in the 2nd trimester 2200 and the 3rd trimester 2800 calories.

During lactation women have to worry about her nutrition as well as baby’s nutrition. Please maintain the calories required. Do not start funny diets to lose weight in a hurry, gently do it with restricting too much sugar, fat, and increased exercise levels. Most important nutrients required are, calcium, iron, Vitamin D, vitamin B12 and Iodine. Stick to your diet rich in protein, whole grains, nuts and seeds. Avoid too many juices, as they produce a change in the taste of breast milk and babies do not like it. Do not drink too much coffee (may be just 1-2 cups in a 24HR period) as this makes the baby’s restless and upsets their sleep. For women who may not get enough, Vitamin D and B12 they can take supplements. Iodine is also very important for the baby’s brain development. These can all be obtained from prenatal supplements. Iodised salt can also provide the iodine. Please watch your food intake and notice the baby’s behaviour, avoid foods that upset the baby. Many foods can improve your milk supply; these include Fenugreek seeds, oats, nuts, fennel, and many local healthy food items.  Grandmothers and lactation consultants can be of a great help with a woman’s lactation problems, depending on where they live in the world. A woman must take care of calcium, vitamin D, B12, Iron, and Iodine intake. Avocado is an excellent food for lactating mothers.

OSTEOPOROSIS

Are you at risk?
The biggest osteoporotic risk factor is simply being a woman. You are ten times more prone to suffer from osteoporosis at an earlier age than your male counterpart.

Osteoporosis means, fragile bones, these bones break easily by slightest trauma. One in four women suffer from osteoporosis with increasing age after menopause 

Women suffer more

1) They have an initial lower bone mass

2) Have a higher bone loss with age particularly at menopause when oestrogen is decreased, as they are the most important hormones in keeping the bone mass.

3) Women live longer.

It is estimated that about 56% of women suffer from a fracture after the age of 60.These fractures include spine, hip, wrist, ribs and upper arm. This makes life difficult and painful.

Osteoporosis is somewhat difficult to treat but easy to prevent. This prevention should start early in childhood with good nutrition, plenty of milk and calcium as this is required for bone formation, sports activities, and sunshine as this gives us vitamin D. This should continue in adolescence. The maximum bone mass is achieved in our late 20s to early 30s, after which it begins to decline. Fractures are the main side effect of osteoporosis and they should be prevented. However besides osteoporosis there are many other risk factors which can cause fractures.

These include:-

1) Being a female

2) Age

3) Weight and height

4) Parental hip fracture at a young age

5) Smoking

6) Alcohol

7) Glucocorticoid drugs

8) Antidepressants called serotonin uptake inhibitors

    For example- Prozac

 9) Drugs for acidity called proton pump inhibitors

10) Vitamin D and K deficiency

11) Personal history of soft trauma fracture

12) Rheumatoid arthritis

13) Ethnicity-(Caucasians have the highest risk for fractures.)

14) Premature menopause

15) Lactose intolerance and bowel problems

When we talk about osteoporosis we always wonder how to make this diagnosis. There are many tests to make this diagnosis, which I will talk about in the next few lines. However it is clear from the above list that assessing the fracture risk is even more important than making the diagnosis of osteoporosis. Many women have fractures without osteoporosis.  There are several tools by which fracture risk assessments are done .The tools WHO: uses are called FRAX, WHO does not always include BMD in their risk assessment. These tools depend on local factors, such as facility for bone density, local economic factors, reimbursement by insurance and people willing to pay for health issues. There is no unified strategy to use. Basically if fracture risk is high, the individual is treated pronto, if intermediate do BMD and reassess, if low follow the normal protocol. Bone is a living tissue it is constantly being made and destroyed this keeps a balance. It is under the control of many chemicals and hormones. It consist of a mesh if proteins called collagen in which minerals are deposited mainly calcium. The tough outer wall of the bone is called cortical bone; the inner tissue is called trabecular bone or spongy bone or cancellous bone it is, porous and contains bone marrow, produces blood cells.

Normal Bone                          Osteoporotic Bone

It is this part of the bone that loses its minerals; it is mainly calcium and becomes thin, thus causing osteoporosis.  99% of our body calcium is stored in our bones. There are two types of cells involved in our constant bone remodelling. They are called osteoblasts which form the bones and osteoclasts which destroy the bone. A fine balance is maintained in this activity to keep the bones well tuned, maintain body calcium levels, as this is very important for the activity of the heart and muscles. As already mentioned this is controlled by various hormones and chemicals in the body. Bone modelling and remodelling is done at the same time. The bones are also sculpted. The maximum bone mass is achieved at around the age of 30, after which it slowly starts to decrease. The adult skeleton is replaced about every 10 years. The oestrogens keep the bone destroying cells osteoclasts under control, and maintain the beneficial role of vitamin D.

So why does osteoporosis happen?

Many of these reasons overlap with fracture risks:

1) Oestrogen deficiency in women which happens at menopause, testosterone deficiency in men which happens with aging.

2) Under activity of adrenal glands (a hormone producing gland in our body).

3) Under activity of a hormone Calcitonin (produced by the Thyroid Gland)

4) Over activity of another hormone called Parathyroid.This drains the calcium from the bones.

5) Under activity of the pituitary gland. This is the most important hormone producing gland in our body. It is often called the band master of the body orchestra.

6) Prolonged absence of periods which results in oestrogen deficiency caused by: anorexia nervosa, excessive exercise ,high Prolactin level, a hormone which comes from the Pituitary gland, surgical removal of ovaries or prolonged suppression of ovaries for medical treatment). All these cause oestrogen deficiency

6) Hypogonadism (poor functioning sex glands or may come from the poor activity of the Pituitary ) again Oestrogen is depleted in women and likewise Testosterone in men.

7) Brittle bone disease (Osteogenesis imperfecta) .

This is a genetic disorder where the bones are fragile due to defective collagen, and break easily. It can be mild to severe. 

8) Malabsorption syndrome, chronic inflammatory bowel disease

9) Drugs, corticosteroids, heparin, antidepressant and proton pump inhibitors (used for acidity of the oesophagus and stomach)

10) Chronic diseases, diabetes, renal, arthritis, liver, multiple myeloma, Systemic lupus Erythematosus (these two are complex diseases) and HIV.

11) Prolonged immobilization.

DIAGNOSIS OF OSTEOPOROSIS AND FRACTURE RISK

The thoughts on diagnosis of osteoporosis should start with a woman’s personal history and risk factors which have been enumerated in the previous few lines for example long term use of corticosteroids, smoking weight below BMI of 21. However X-rays play a most important role in the gold diagnosis of osteoporosis. The best of these tests is called DEXA; in simple words we can call it bone densitometry. The test measures what is called BONE MINERAL DENSITY (BMD), it measures a certain amount of minerals and tissues in a certain volume of bone (W/G/CM2). This tells us if the bone is normal or a certain amount of bone is lost. This is expressed on 2 measurements, T score, which compares it to a young white young woman 30 years of age. The other is called Z score, which compares it to the bone density in the same age group. 

A T score of -1 is considered osteopenia, a T score of      -2.5 or below is considered osteoporosis. This is an expensive test costing approximately $125 American dollars, and also it is not available in many parts of the world, nor is it advocated routinely.  At the time of bone density assessment you do not need any preparation you just lay on a machine with your clothes on, the machine then scans your body, it takes about 15 minutes and reports are calculated.

The fracture risk is expressed at the same time. Different fracture risk tools are used in different countries. Bone density is not always used to assess fracture risk.

Besides DEXA scan, different types of x-ray studies are used, QCT, (quantitative computerised axial tomography), ultrasound of the heel, plain lateral x-ray of the thoracolumbar region of the spine, this is often useful when we cannot do BMD.

Several basic blood tests are required to exclude many other problems:-

1) Normal Full Blood Examination.

2) Hormones, Thyroid, Parathyroid, Oestrogens, Pituitary and Testosterone in men.

3) Alkaline phosphatase, Homocysteine a congenital problem in causation of osteoporosis.

4) Serum calcium and vitamin D

5) Bone turnover markers, are a recent tool which measure the end products of osteoblastic and osteoclastic activity of bone in serum, blood or urine, which gives us what is happening to the bones. These are rapid, reliable and cost effective tests. One has to understand its biological analytical and standardization process. At this stage these are very useful for fracture risk assessment independent of B.M.D. In clinical practice it is useful to assess the progress of people on osteoporosis treatment particularly those who are on a given treatment to prevent bone reabsorption. One can also check on patients to see if they are compliant to the treatment.

What is the treatment of Osteoporosis and who should be treated with what?

Osteoporosis (OP) is a silent disease; hence it is under treated in most countries of the world.  The other problem is poor patient compliance due to forgetfulness, side effects and not understanding the consequences of the problem. We have to overcome these problems with education, good reminder methods, minimizing the side effects or changing over to a drug more acceptable to a woman.  Prevention of OP starts in childhood with good nutrition exercise and sunshine. This should continue at all ages, a woman needs to take about 1000 to 1300 mg of calcium daily. Too much calcium can cause some cardiac problems; hence there is some international debate on this issue. This should be accompanied by 800 international units of Vitamin D (1 microgram of Vitamin D is = to 40 INU); this can be taken as a lump sum once a month. One of the main roles of Vitamin D is to absorb calcium from the gut, allowing calcium and phosphorus levels to control bone formation. It also keeps the parathyroid gland under control. Sunshine for a few minutes in summer is adequate to make up your Vitamin D, may be a short walk at lunch time, prolonged sun exposure does not keep increasing your vitamin D; however it increases your risk of skin cancer. If the UV index is more than 3, sun exposure should be avoided. This is to prevent the risk of skin cancer.

Lifestyle factors should be improved, such as; stop

smoking,  limit alcohol intake, along with soft drinks, tea, coffee and sugar. Try and decrease your weight, if you are very overweight and see if some of the drugs you take for other diseases can be readjusted. Some studies have shown a role of vitamin K, but at this stage it is not recommended for the treatment of OP.

Pharmacological treatment is recommended in almost all pre and post menopausal women under the age of 60. Initially they were prescribed a drug called PROFOX (a combination Prozac and Fosamax) which in my opinion was no good. Fosamax has its own side effects and Prozac is no good for OP. In the first 5 years of menopause not only do women lose 1% of their bone density, they lose collagen from the skin thus losing its thickness, losing intervertebral discs which make one fifth of the length of the spine, there are emotional changes due to lack of oestrogens, at times of life cycle as postpartum, premenstrual, so in my view hormone replacement treatment will be the best treatment before the age of sixty. It will take care of all other symptoms for example: hot flushes, poor sleep, depression and all that goes with menopause and prevent losing bone. Many clinicians are reluctant to use HRT because they have not familiarised themselves with its use. Depending on if the woman has a uterus she can have oestrogens and progesterone, otherwise if she has no uterus oestrogens alone do very well. Many different types of oestrogens and progesterone can be taken by different routes to prevent side effects. They decrease risk of hip and spinal fracture, bowel cancer, heart attacks and mortality. After 5 years of treatment bone density has been shown to rise by about 10 %. The only risk is a very small risk of increase in breast cancer. The Thromboembolic risk (Thrombus) can be managed by using Transdermal (on the skin) oestrogens. The breast tenderness and vaginal bleeding problems are easily managed.

Bisphosphonates is the main group of drugs used by most clinicians as the first line of treatment.

Who should be given these drugs?

1) Those that have had a minimum trauma fracture have a high fracture risk with or without using BMD

2) Those with a T score of -2.5 or lower.

3) On high doses of corticosteroid for more than 3 months

4) High risk factors for OP

Various Bisphosphonates

Alendronate: 70 mg orally once weekly.  On the remaining 6 days women can take vitamin D and calcium in the usual dosage

The other Bisphosphonate often used is Risedronate: 35 mg orally once a week or 150 mg once a month.

Ibandronate: 150mg orally once a month or it can be given 3 mg IV every 3 months.

Zoledronic acid (another Bisphosphonate) is given

5 mg in 100mls IV slowly once a year.

Bisphosphonates are advised to be taken on an empty stomach first thing in the morning with a glass of water, after that keep standing, do not eat or drink anything else. Bisphosphonates attach to the surface of the bone thus slowing the activity of osteoclast cells. Bisphosphonates have many serious side effects. The main side effect of these is gastric upset and esophageal burning, nausea, vomiting, joint and muscle pains, fever, loosing of teeth, jaw pain, constipation and fatigue. One of the two very rare complications quoted are osteonecrosis of the jaw and atypical fracture of the femur. These usually, only happen if they are used in very high doses for bone cancer. There is no definitive date as to how long this therapy should be used. No therapy is indefinite, after 1-3 years or if there is another fracture it should be reassessed. It is believed that the benefit of Bisphosphonate treatment can last up to 5-10 years, however it is worth while repeating BMD , BTM , and fracture risk after 1-3 years.  During this time calcium and vitamin D should be continued. Combination therapy with other drugs does not provide any benefit.

Denosumab, is the latest achievement in the treatment of osteoporosis. It is used as a first line of treatment in some countries. It is a monoclonal antibody (like a vaccine) and attacks only one type of cell. It works by disabling the maturation and activity of osteoclasts, and the only problem is that its effect does not last when the drug is stopped. Before starting Denosumab assess the oral cavity to decrease the risk of osteonecrosis of jaw (this is very rare), and make sure there is no hypocalcaemia. There is some concern about its effect on the immune system (increased risk of infections) and its use after bisphosphonates, on the bone after treatment is stopped. The dose of Denosumab is 60 mg in 1ml given every 6 months subcutaneously, (meaning under the skin). It can cause side effects like any other drug and you can get this list from your caregiver. A 5 year trial with Denosumab has been very successful. Its use decreased the risk of spinal fractures by 70%, hip fractures by 40%. It does not have a cancer risk. The cap on the syringe is latex so let your caregiver know, that you have a latex allergy. There is a special programme called Provital, which can keep reminding you when your next treatment is due.

The other very simple treatment for OP is Raloxifene. This is a special oestrogen which has different actions in different organs, hence effective with bones; it does not cause breast cancer. The dose is 60 mg daily, taken orally and you do not have to fast. It should not be given to people who have a history of deep venous thrombosis or have been immobilised for a long time.

Teriparatide: Is a synthetic form of Parathyroid hormone and acts by decreasing bone resorption and improves bone formation. 20 micrograms are given daily by subcutaneous injection. Its use is restricted to 18 months as its long term use caused bone cancer in animals. It is recommended that it is followed by Bisphosphonates.
Abaloparatide is the latest drug that is being used in place of Teriparatide.

It is recommended that any treatment is followed every 1, 3, 5 years depending on the individual situation. Treatment should be offered for various disorders, which cause secondary osteoporosis.
There are many new drugs and treatments now available in different situations.

So much on osteoporosis why is it such a significant problem? Life expectancy is increasing hence the risk of osteoporosis is increasing. There are almost 200 million women in the world who have osteoporosis, may be many more about whom we do not know. There are 8.9 million known fractures caused in the world annually. It costs 70 -20 billion US dollars to treat them. Do not forget that in most parts of the world many are never treated. It was estimated that a fracture occurs in the world every 3 seconds. Osteoporosis is a silent disease, it causes untold problems to the individuals, pain, disability, poor quality of life, and death, too much cost to the nations, too much cost to the world. The good news is that health providers and the public are both becoming aware about it, so let us start with education, information and prevention. The new technologies are providing us with better and better treatments. Even surgery is used for correction of spinal defects caused by osteoporosis. The main prevention should start in childhood, good nutrition sunshine and exercise. Later focus on lifestyle factors, nutrition, calcium, vitamin D measures for fall prevention,(do not walk in the dark or cluttered spaces, be aware of the drugs that can cause dizziness), exercise and regular medical advice on your health. Do not ignore the treatment that is offered to you.

KEY POINTS:-
Start prevention early in life rather than later.
Regular exercise.
Good Nutrition.
Sunshine.
Vitamin D and Calcium.
Stop Smoking
Limited Alcohol