Osteoporosis, another major cause of problems for women in the menopause, it is the major cause of morbidity in women, affecting millions of women, causing millions of fractures each year and costing billions of dollars to treat. It is estimated 25% of all Caucasian women will fracture their spines, 33 will fracture their hips sometime in their life time. These are very dramatic statistics, and we expect them to continue to increase based on the fact that the younger generation are not taking in the same quantities of calcium that most of us did when we were growing up. So we are anticipating these statistics to double or triple over the next 10 years. This is the most preventable type of morbidity that we as health care providers can actually intervene and make a big difference in a woman’s life. The peak age of bone mass is when a woman is 25 to 30. At that time, the bone resorption or bone loss processes, equilibrium to the bone formation process. By the time a woman is 40 and she starts to have some minor changes in her estrogen level, we start seeing that the bone resorption process begins to accelerate a little bit but it is usually not in excess of bone formation. Viagra professional online. By the time she is in the menopause, or primarily within the first five years of menopause, we see that bone resorption process accelerate 2 to 3 times that of the bone formation process. As a result, there is bone loss and often times osteopenia. If left untreated, that will progress to osteoporosis, hip fractures and once again a major source of morbidity for that woman. The bone on the right is a classic example of the deterioration in the micro architecture of the hip bone of a woman with osteoporosis. The two major bones that we look at when we are looking at osteoporosis in the postmenopausal woman, are the hip and the spine. You can see by this graft, over the age of 50, there is age rheumatic rise in the rate of fracture in women right up until the age of 85 and then it’s abruptly accelerated from there. Once again, there are things we cannot control such as race, ethnicity or body frame or family history, but there are some modifiable factors that we as health care providers can counsel patient’s about such as smoking cessation, alcohol, caffeine use, sedentary life style, and also optimizing medical conditions such as hypothyroidism, making sure that is under well control, if they are asthmatics on chronic steroid use or arthritis on chronic steroid use, probably adding agents to slow down the bone loss process because these are all conditions that would accelerate osteoporosis.
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There are lots of different ways to measure bone loss and if you find a woman in your practice that is at risk for bone loss, it would be useful to get at least a baseline measurement and our best way to do that would be through a DEXA scan, it is the most accurate and precise method that gives the least amount of radiation. It is performed with a woman in a supine position with elevation of her hips and lower extremities and various measurements are made through the right hip and through the spine, and then a score is calculated. It’s called a T sore, the T score is a measurement of peak bone mass as it is compared to a reference population, and that reference population is usually a group of women between the ages of 25 and 30 because that is the time that a woman’s peak bone mass is usually measured. A positive T score would obviously represent a bone mass density that is higher than the mean versus a negative which is lower, and when you have a negative T score of 1 to 2.5, that is considered osteopenia. When it is greater than 2.5 standard deviations and once again in the negative range, that is considered osteoporosis and then from there, there are various degrees of osteoporosis. We would like to intervene before it gets beyond osteopenia, and we can by just providing resources regarding diet, regarding supplements that can be given to slow down the bone loss process. Our treatment goal is to prevent fractures, but also it’s to stabilize and enhance bone mass density. If a woman has already had a fracture, it’s to try to relieve symptoms of the fracture and there are various medications useful for that, and to try to maximize physical function and deformity. Generic soma online 350 mg
There are various agents that can be used, by far the golden standard, if a woman can take it, would be estrogen, estrogen is not only useful in decreasing or preventing bone loss, but in treatment of bone loss. Fosamax is a very potent agent, an anti-resorptive agent that is useful in decreasing bone loss as well as treating bone fracture and further preventing bone fractures. Calcitonin is really reserved for more last resort treatment, however, just a word about calcitonin, it comes in a nasal spray now and it’s very useful in treating women who have already had a spinal compression fracture because there is an analgesic effect to it. The drawback with calcitonin is usually after two or three years, a woman will develop antibodies and there is very little change in bone mass density after that point. We are seeing limitations with the use of calcitonin so it is really reserved for last resort. Raloxifene we now know does decrease fracture rates, it is useful in enhancing bone mineral density, calcium alone is not useful for decreasing fractures, it is useful in slowing down bone loss, but it cannot be used alone in terms of decreasing fracture rate, and fluoride which is no longer available was one of the only bone formation agents that we had and it would build bone at the expense of the cortical bone. Sleepwell xanax without prescription. The bone that we were discussing today is trabecular bone or the weight bearing bone. The entire skeleton is made of cortical bone and how fluoride works, it will help take away from the cortical bone to build trabecular bone so it makes it very dense, the problem is, it is not very strong and one of the other effects is that it has severe gastrointestinal side effects. So it is no longer available, but over the next few years, along with the selective estrogen receptor modulators, we will be seeing new bone formation agents in terms of growth formation factor agents.

Cardiovascular disease, this is one of the long term consequences of being in the menopause. Cardiovascular disease is by far the most common cause of death in the postmenopausal woman, accounting for over 500,000 deaths each year. As you can see based on this pie graft, that it accounts for 45% of deaths versus breast cancer with which women are very concerned with, which only accounts for about 4% of deaths. About 1 in 9 women will develop some type of coronary artery disease during this time, and as I said, six times as many women die from heart disease versus those from breast cancer.
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There are certain things that we can do to change the risks for cardiovascular disease, however, things such as age, family history, race and ethnicity are something we can’t do much about, but smoking, alcohol use, the use of more than two alcoholic beverages on a daily basis, life style such as sedentary life style and weight loss are very important counseling tools for our patient’s in the prevention of cardiovascular disease. Some treatable medical conditions such as diabetes, hypertension, and dyslipidemia, elevation of the LDL and the triglycerides are also very important to get under control during this time. It’s also a very complex disease, we used to think years ago that it was just based on the lipids, we now know it’s not just lipid metabolism that’s involved in cardiovascular disease, but instead, based on changes in the coagulation factors, carbohydrate metabolism and the actual vascular tone of the vessels of the heart, so we now know that lipid metabolism and dysfunction of lipid metabolism only really accounts for 25% of the pathogenesis of cardiovascular disease. It’s important that we try to optimize our life style to enhance our lipid profiles, but there are other things that are also very important that can be affected by life style that can change, for example, insulin sensitivity, just weight loss alone would decrease a woman’s insulin sensitivity but coagulation factors and vascular tone are also very much affected by the lack of estrogen within the body. The Nurse’s Health Trial also found that estrogen versus estrogen and progesterone are both equally effective in decreasing cardiovascular disease, the mechanism being primarily through lipids and vascular tone. It was thought many years ago that the addition of progesterone would be a negative impact, but we have not found that to be true and many large scale studies have found that to be the case. Viagra Jelly at cheapest canadian pharmacy.
Overall survival, in studies looking at women who are at risk for cardiovascular disease or have early signs of cardiovascular disease that are treated with an estrogen replacement over a 10 year period, they have an overall increased chance of survival versus those who have been treated with a placebo. Now, there was a recent study called the Hearse study in which woman were enrolled who already had advanced cardiovascular disease, and we found a lot of problems with that study as well as many of the breast cancer studies that are now emerging into the media, one of which is that the population that was studied was very advanced in their heart disease, perhaps beyond anything that many medications can do for them. The other factor is that the women that were enrolled were of much older age than the average women that are studied, and then perhaps some of the statistics that were used were also a little bit flawed, so you have to be very careful when you look at some of these studies before you change the course of direction for a woman, particularly if she is already on hormone replacement, doing very well for that on the hormone replacement and is being given that for a specific purpose in life to decrease or reduce her risk of developing long term health problems. Instead, you look very closely at the studies, you see if there is a problem and if your patient would apply to that before withdrawing any kind of hormone replacement. Canadian viagra

It’s a vicious cycle, so as women develop more and more vasomotor symptoms, we also see that carry through into other changes that affect concentration, one may be having anxiety attacks, memory changes, particularly short term memory changes that affects mood and irritability, and then loss of libido becomes an issue as well. This is kind of a complicated slide, but very important because it’s the basis for a lot of current research. What we know is that as the active estrogen drops, that affects the neurochemistry of the brain, and in particular, it affects tryptophan and serotonin which we know is the hormone associated with depression and well being. What we see, even slight changes occur in the perimenopause with estradiol. We already see change in the sense of well being, so just the addition of estrogen has been found to increase or enhance well being, and as a result, alleviate depression. There is a certain group of women, that in spite of replacing the estrogen, the serotonin levels do not come up to their baseline, and in that group of women, probably they would need an SSRI or a serotonin re-uptake inhibitor that would increase the serotonin levels and enhance their sense of well being. The other important change in the change in the ratio of norepinephrine to dopamine. So this accounts for more anxiety, more inability to cope with daily activity or stresses of daily life, and it also interferes with sleep patterns. So what we see is that women during this time have an interruption in their sleep and as a result, they go night after night of restless sleep, they wake up tired, their inability to concentrate and to remember becomes enhanced, and as a result that can lead to further depression of the serotonin levels and further alteration in the stressors that we see here.
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So there have been many studies looking at sleep patterns, at memory, at different quality of life issues in women during this time and it has clearly been found that the addition of estrogen as well as estrogen and progesterone clearly enhance rem sleep, giving longer REM cycles and more restful sleep, so that a woman feels better, so that in term adds to overall well being. There are also less complaints during this time if a woman is on estrogen because indeed she does feel better and she is not so concerned about sleep anymore, unless of course there is a urogenital problem.
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Then we talk about mood and fatigue, and once again, we see women who have been treated with an estrogen or estrogen progesterone combination who have reported less anxiety, less depression, and overall better sense of well being. What about the urogenital tract, we know as the levels of active estrogen begin to decrease, we see changes in the urogenital tract and this may occur as early as the 40s before a woman actually progresses into her menopausal years. The vulva, vagina, urethra, and bladder are all very estrogen sensitive organs, and with the lack of estrogen, there is a lack of collagen and a subsequent lack of lubrication. This give rise to changes in bladder function, it gives rise to changes in sexual function. So as a result, we see very commonly, complaints of frequency, urgency, very common complaints of nocturia, and often times complaints of incontinence. Some of the other symptoms we hear about are burning, itching, painful intercourse and this again is due to lack of the tone within the vagina as well as decrease in vaginal secretions. Sexual dysfunction symptoms that we see, once again, decrease in sexual desire or sexual response, this may be associated with changes in the hormones as well as what is going on in the urogenital tract. These symptoms are very pronounced in women after a surgical menopause. What we do know about estrogen and estrogen replacement in this area is that just the addition of an estrogen topical cream would promote strengthening of the muscles, will enhance the blood flow and lubrication to this area. It promotes the return of the pH, so that women have less bladder infections, they have less symptomatology during this time.
Sexual functioning, although the studies are very limited, and they are based on very short term treatment with estrogen, has been found to increase estrogen replacement therapy in an oral form has been found to increase lubrication of this area and has enhance arousal and sexual response. Viagra professional at cheap Canadian pharmacy. Again, this is based on very short term studies and longer term studies need to be looked at to see whether this is a placebo effect or not.

Menopause is an essential phase that every woman is going to pass through. It is defined as 12 consecutive months of amenorrhea due to the lack of ovarian function and it’s associated with the inability to reproduce. It is estimated there will be some 35,000,000 women alone passing through the menopause this year. So we as OB-GYN physicians and other health care professionals, have an obligation to learn all about the menopause, the problems, the solutions, the options that are associated with the menopause so we can better counsel our patient’s. Some hundred years ago, the average life expectancy for women was 52 years. Currently, the average life expectancy is 82 years, and since the average mean of menopause has remained constant at 51, that equates to about 30 years of lifetime in the menopausal phase, or about a third of a woman’s lifetime. That is a lot of time and a lot of potential for problems and a lot of confusion during this time. It’s a complex event, not only characterized by changes, biologic and social and psychologic function, but it is rooted in changes in hormones. These hormones are very complex in that they affect various target organs as well as the brain, in terms of causing a chemical imbalance and changes in stress hormones and various other factors that affect the quality of life.
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It’s not as easy as we used to think that just passage through the menopause was associated with some hot flashes. We now know it affects every organ system within a woman’s body. The main hormones that we are concerned with during the menopause that are the basis for the changes, are primarily changes in the pituitary hormones, FSH and LH, FSH is the main marker that we use during the perimenopause and into the early stages of menopause to actually mark the menopause. During the reproductive years in the early follicular phase of a woman’s cycle, the FSH should be less than 10. As she is approaching the menopause or in the perimenopausal phase, which means that a woman is still having some menstrual cycles, although she may be having some vasomotor symptoms, but she is still having a menstrual cycle occasionally, the FSH will fluctuate, and it’s very important to measure that FSH in the first five days of the menstrual cycle because that is the time that it’s the most accurate. The FSH will fluctuate anywhere from 5 to 30. After the menopause, the FSH no longer is fluctuating, it is well over 50. That is associated with significant drops in other hormones, particularly the bioactive estrogen which is estradiol. During the reproductive phases and the early follicular phase, the estradiol states at low levels of 60 to 80, will rise up to 200 and back down to 60 or 80, where as during the perimenopause, it may start to fluctuate down into the 20 range and by the menopausal years, the active estradiol remains pretty constant between 20 and 40 picograms per ml. Progesterone is no longer being secreted in the menopause, so the levels will be extremely low. The adrenal hormones such as DHEA change very negligibly during this time, but the hormone testosterone which is the primary male hormone made by the ovary will drop to about half of what is normal, which accounts for some change in sexual function.
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As a result of the changes that we see primarily associated with a drop of estradiol, we see some of the early symptoms that are classified as the vasomotor symptoms, such as hot flashes, night sweats, subsequent changes in sleep patterns resulting in insomnia and lack of sleep resulting in irritability, mood disturbances, depression, and then further along we start seeing changes in the urogenital tract accounting for atrophy, changes in bladder function, and changes in overall skin texture, and then the long term sequelae of estrogen depravation can result in cardiovascular disease, osteoporosis, dementia of the Alzheimer’s type and also certain types of cancer. It’s a complex event that is occurring because during this time, we are weighing quality of life issues versus medical conditions versus various propensities for heart disease and cancers. Perhaps the most common or cardinal feature of the menopause is the hot flash. Viagra professional. This affects some 75 to 80% of women, usually occurring within the first year of the menopause, although it can occur earlier. We don’t quite understand it, we know it has to do with abrupt changes in estrogen that change the neural chemicals of the brain, or the catechol estrogens, it is a very brief event, lasting only 3 to 5 minutes and it’s associated with changes that occur at the nipple line and work their way up to the top of the head. It is associated with skin flushing, associated with palpitations, however, no change in the heart rhythm, and then a perspiration that occurs. Some women have one to two hot flashes, other women have 50 to 60 hot flashes and there are no factors that associate which woman will have more hot flashes versus others. We do know that there is a difference in vasomotor symptoms, and those women who undergo a natural menopause versus those who undergo a surgical menopause or those that have had both ovaries removed. In a surgical menopause, there is an abrupt drop in all of the estrogens as well as the testosterone. As a result, 100% of women who undergo a surgical menopause have some type of vasomotor symptomatology. Their symptoms tend to be much more severe, seeking medical attention much more frequently, and last a lot longer.
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During the natural menopause, duration of symptoms are usually three to four years. After surgical menopause, women will continue to have vasomotor symptoms up to 10 years, so leaving them on some type of hormone replacement for five or six years may not be enough. These women may require prolonged treatment with various agents such as hormone replacement, or estrogen alternatives. The estradiol levels and testosterones levels are characteristically much less in these patient’s, and often times, this is basis for the use of an estrogen androgen preparation, particularly in the surgical menopause patient.

We all know people who claim that ‘quitting smoking is easy.’ They typically say this as they are puffing on a cigarette. Sure — it’s easy to quit for an hour or a day. But it is the “quit smoking for good” part which is difficult.

Your Health is the Best Reason to Give Up Smoking for Good

Perhaps the best reason to quit smoking for good is knowing how it affects your health. According to the US Surgeon General’s report the advantages of giving up smoking begin almost immediately and increase the longer you keep away from smoking. After just 20 minutes of nonsmoking your blood pressure comes back to normal. Eight hours later your system has flushed out the carbon dioxide. During the first three months after quitting your lung capacity increases by 30%. One year after quitting your risk of heart attack has become half that of a steady smoker. After five years your risk of sudden stroke has normalized and after 10 years your expected risk of lung cancer is half that of a steady smoker.

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These health benefits are one and the same regardless when you quit smoking for good. Of course, if you quit when you are young you have a much better probability of regaining normal health within a shorter time. But even if you quit when you are 60 or older your life expectancy and primary standard of living will significantly increase.

If It Were Easy…

Of course, what is going to happen ten years in the future is often of little concern during a nicotine fit. The longer you quit smoking, however, the less often these cravings will occur. But smoking is more than just a physical addiction, it is also a behavioral habit and long after the physical need for nicotine has been finally overcome you may still feel the need to smoke in special circumstances.

Identifying the current circumstances which cause you to reach for a cigarette can be of great help in overcoming the inclination to smoke. If you recognize, for instance, that you feel like smoking at parties, you may need to avoid them for a while until you break the habit. Also, if current conditions of stress make you want to smoke, finding alternative ways to deal with stress will help you stay smoke-free.

What If I Relapse

Okay, despite all your best efforts, you may find that you have had a relapse and have taken up smoking again. If this happens, don’t let this discourage you — many people have to try four or five times before they successfully quit smoking for good. The most important thing is immediately to stop smoking again. Even if you are in the middle of a cigarette, put it out and discard the balance of the package. Don’t get down on yourself or think that you have failed. Each time you reaffirm your commitment to quit smoking for good it becomes stronger.

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Look for moral support from family and friends. If you desperately feel like smoking, talk to somebody about it and let them know what you are going through. Some communities have solid encouragement groups for people who are trying to quit smoking for good. With regular scheduled meetings and group members you can support one another and offer encouragement and expert guidance.

Some companies offer programs for employees who wish to quit. Take advantage of all of these services — your long-term commitment to quit smoking for good is helpful not only to you but also to your family, friends and associates.

There are some metabolic diseases we can do something about: PKU and a low phenylalanine, low-protein diets. You give them just enough proteins so that these patients can grow. Homocystinuria: we used to decrease their protein restriction a little bit but now betaine has sort of taken care of all of that, and we usually don’t restrict the diet in kids with homocystinuria. However, in the urea cycle disorders, regardless of which one it is, all those kids need protein restriction to decrease their ammonia load. In the more rare disorders, like maple-syrup urine disease there are a whole series of special formulas which you can buy, at great expense - which are usually covered by insurance - which are fine-tuned to the particular metabolic requirements of those patients. So for example, in maple-syrup urine disease the infant formulas have decreased branch chain amino acids, valine, leucine and isoleucine. The problem comes when these kids grow out of the formula age and you have to look at table foods, and keep them happy. So this usually requires the services of a well-trained nutritionist. And we have one that works part time in our metabolic clinic and she is very very useful. The advantages of Lorenzo’s oil are over-touted.
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We also have some pharmacologic weaponry to fight some of these disorders: betaine in homocystinuria, the ammonia scavengers, sodium benzoate and phenyl acetate, phenylbutyrate for urea cycle disorders. Many patients with MSUD are responsive to thiamin. Some of the organic acidemias are responsive to vitamin B-12. Biotinidase kids obviously need biotin. The MCAD kids benefit from carnitine, which aids in medium chain fatty acid oxidation.
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The successful management of inborn errors has many components to it. Early detection is the key. You can’t treat these diseases until you diagnose them. So you must have an index of suspicion. You have to educate the family, especially if there is a special diet involved or special medications involved, they must be compliant. The need financial and social support. If the medications or the formulas are expensive and if the family has to bear that burden, they may not be as compliant as you’d like. You have to anticipate that they may get very sick with trivial illnesses, colds, flu. Kids with urea cycle disorders or some of the organic acidurias can really go into a tailspin with just a very simple classroom illness. So these kids are admitted frequently to the hospital for acute management. You have to institute the treatment early, whether it is dietary or pharmacologic or both. Then they need to be followed periodically in a referral center to get complete nutritional assessment. To make sure that they have the right amount of protein for growing or to make sure that they are compliant with their medication.
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In terms of Hurler’s, the diagnostic test is to measure the enzyme iduronidase, which can be measured in blood as well as from a skin fibroblast cell line. The clinical features: progressive, coarse facial features. So-called gargoylism. Corneal clouding, loss of milestones, severe mental retardation, hepatosplenomegaly, hirsutism, hernias and these multiple bony changes. So dysostosis multiplex. Complications include recurrent pneumonia because of thick secretions, congestive heart failure because of valvular involvement, and in the case of Hurler’s, usually death by the age of ten. Note that there is a milder form of MPS-1, iduronidase deficiency, called Scheie syndrome which shares the same enzyme defect but does not present with mental retardation. Now biochemically you can’t distinguish between Hurler’s and Scheie’s because in both you have a gross deficit of iduronidase. But clinically they are different because Scheie’s is milder. Pink viagra
The mucopolysaccharidoses present sometimes with growth delay, with organomegaly, corneal clouding, joint stiffness. The more severe manifestations include hirsutism or increased body hair, loss of milestones and these gargoyle-like coarsening features.
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How do we treat urea cycle disorders, without going through all five of them? Three key points. First of all, we need to prevent protein catabolism because these infants, if they don’t get enough calories they break down their own muscle protein, and in the process of doing that generate more ammonia. That’s the last thing you want to happen. So you have to pump these kids full of calories in the form of fat and carbohydrates. If the urea cycle is impaired, arginine then becomes an essential amino acid and if you don’t supply the arginine they are going to break down their own protein to make new proteins. So that’s why you have to supplement them with arginine. You have to decrease the ammonia load going in. So again, you have to restrict the amount of protein in their diet to a reasonable amount. Lastly, we can utilize these pharmacologic ammonia scavengers - which were discovered serendipitously about 15, 20 years ago - in the form of sodium benzoate and sodium phenyl acetate. Benzoate actually binds to glycine, which is the smallest amino acid that has ammonia as part of it - nitrogen is part of it as do all amino acids - and conjugates with that and excretes it into the urine. Herbal Testosterone
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Tay-Sachs. The incidence used to be about 1:4,000 among Ashkenazi Jews because the carrier frequency is quite high. The screening test is to measure hexosaminidase A in the serum, and the clinical features you must be familiar with. Hyperacusis, or increased startle reflex, progressive weakness or hypotonia, visual loss, the cherry red macula, macrocephaly and usually early death, because this is untreatable. Primary defect we know is in the alpha _ and hexosaminidase A, and if you have a defect in the beta sub-unit, that knocks out both hex-A and hex-B and results in Sandhoff’s disease, which is another gangliosidosis. It used to be that Tay-Sachs was only seen in the Ashkenazi Jewish population, but in the late 1960s and early 1970s screening programs were set up which were centered in synagogues. The Jewish community and the leaders embraced this screening program and engaged in pre-conceptual counseling, prenuptial counseling, to the point where it was very successful. Because the Jewish community has embraced the screening program - and has even consented to terminating affected pregnancies, which was quite surprising - that we seldom see Tay-Sachs in the Ashkenazi Jews anymore because the screening program is so effective. So we see it in these other unusual populations. We see it in Hispanics, we see it in blacks, because there is a much lower carrier frequency in other populations. Probably in order of magnitude or two less than this. But there is still that chance that two carriers will get together.
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There was a treatment touted a few years ago, something called Lorenzo’s oil, which is a dietary supplement consisting of monounsaturated long chain fatty acids. The theory here was to decrease the amount of very long chain fatty acids by putting in not quite so long chain fatty acids into the diet and making them monounsaturated so they have a single double bond here. This was thought to decrease the amount of saturated very long chains. The problem with Lorenzo’s oil is it doesn’t cross the blood-brain barrier. So although if you measure in plasma, the very long chains, you may see an improvement. You really don’t have much affect on the CNS and that’s very often the case in many of these metabolic disorders which affect the central nervous system. You can make them look better on paper if you are measuring blood, but that’s not what’s going on in the brain. Also bear in mind that palliative treatment of course is to replace the corticosteroids which are deficient. Now there is also a neonatal form of adrenoleukodystrophy, which is autosomal recessively inherited, and it resembles Zellweger’s. Zellweger’s is not as common as ALD so in the interests of time, I chose to illustrate this case rather than a case of Zellweger’s. Although we’ve seen two cases of Zellweger’s in the last six months at Vanderbilt. Not a good thing to have.
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