Transcript OBgyn Week 5 - CatsTCMNotes

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