Hi, Friends.  I haven't been blogging much lately on integrative medicine because of our all-consuming green home remodel.  Check it out right here if you're interested!  David Gottfried, founder of the US Green Building Council, and fab husband of mine, also got us on the Discovery Channel, Renovation Nation, with Steve Thomas.  Should air in September, 2008 - will keep you posted!

A dear acquaintance just revealed that he has inflammatory bowel
disease. That together with the past week loaded with patients who
suffer from symptoms of hyperpermeable gut suggests today's topic.

What Is Leaky Gut?

Leaky Gut Syndrome is a group of problems associated with increased
intestinal permeability. This group is far ranging and includes:

- inflammatory and infectious bowel diseases
- food allergies and their accompanying triggered conditions such as irritable bowel, eczema and urticaria
- chronic inflammatory arthritis
- skin conditions like acne, psoriasis and dermatitis herpetiformis
- chronic fatigue
- chronic hepatitis
- pancreatitis and perhaps pancreatic cancer

Increased gut permeability or hyperpermeability is either a primary
cause in the evolution of each condition, or may be a secondary result
of it but then causes immune activation, liver dysfunction, and
pancreatic insufficiency, creating a vicious cycle. Unless tested, the
hyperpemeability often is unrecognized. We have safe, non-invasive, and
inexpensive tests to check for this – the tests make it possible for
clinicians to look for the presence of altered intestinal permeability
in their patients and to assess objectively the efficacy of treatments.

There are four vicious cycles to leaky gut: allergy, malnutrition, dysbiosis and hepatic stress.

What Triggers Leaky Gut?

Leaky Gut is triggered by substances that damage the integrity of the
intestinal mucosa, harming the binds between epithelial cells and
increasing passive absorption. Here’s the list of bad players:

- Infectious (viral, bacterial, protozoa/parasites)
- Alcohol
- Stress, stress and more stress
- Non-steroidal anti-inflammatory drugs such as advil or ibuprofen or their newer cousins
- Low oxygen in the bowel (such as after surgery or shock)
- Reactive oxygen metabolites (a.k.a., rust)
- Other drugs

How Can You Test?

Testing is relatively easy. You get a kit from an integrative lab or
our office. You drink a lactulose/mannitol cocktail (volume depends on
the test), which is made of innocuous sugars that are not metabolized
by humans. Most normal people absorb 14% (range 5-25%) of mannitol
but <1% of lactulose. We then measure the amount of both in your urine.
The test is performed after avoiding fruit juice for 24 hours, and after an
8-hour fast. You collect your urine for 6 hours drinking the cocktail,
and mail in to the lab a pre-test and post-test sample of your urine.

How to Heal?

More on this later, but we have a new protocol that is a powerful,
proven combination of nutrition, enzymes, permeability factors,
antioxidants, fiber and probiotics. If you test positive for leaky gut,
try the protocol for 3 months, then retest. We have been amazed by the
healing and reversal in our patients. Both Dr. Charlotte Massey, ND and
I are experienced with managing and reversing Leaky Gut.  You must be
a patient of ours for us to administer the test and/or protocol, but call us
for more information.

We are thrilled to announce that Dr. Charlotte Massey will be joining our practice at the Center for Integrative Medicine in July, 2008. She is a superb clinician, extremely bright, and facile with women's health issues as well as primary care for men, women, and children. I give her my highest recommendation! Read on....

"When I approach any health condition, my focus must be on the individual. I am committed to making a difference by optimizing my patients' health and providing them with a positive healthcare experience."

Dr. Charlotte Massey is a Naturopathic physician and as well as a licensed Acupuncturist. As a primary care provider, Dr. Massey provides healthcare that integrates the best of Western, Naturopathic and Chinese medicine. She is a skilled medical detective who specializes in uncovering difficult core issues that convention medicine overlooks. She is especially adept in treating complex digestion issues. She works with people of all ages and her areas of special interest include women's health, particularly gynecology and infertility, allergies and food sensitivities, and fatigue and stress.

Dr. Massey is a licensed Doctor of Naturopathic Medicine with a degree from Bastyr University. During her clinical training Dr. Massey specialized in integrative oncology at Highline Hospital in Burien, Washington and integrative HIV/AIDS care both at the Bastyr Center for Natural Health and Harborview Hospital in Seattle, WA. Her background includes humanitarian work in Africa as a Peace Corp volunteer.

To make an appointment with Dr. Massey or for more information, call 510.893.3907.

Another great article from Harvard Women's Health Watch.  I'm teaching a workshop next Wednesday on Yoga for Bones & Joints (at the Claremont Resort in Oakland, call 510.549.8512 to register - you don't need to be a member to come), and as you can see I am collating some good data to share at the workshop.  

Regarding hips: I find that women especially store emotions in their hips, and that yoga is a great way to release and process it constructively.

Happy hips, 

dr. sara gottfried, m.d.

Harvard Women's Health Watch | December 2005

		More strengthening exercises

 

Exercise sampler: Building hip strength

“What weight-bearing exercises do you suggest for strengthening the hipbones?” asks a reader. Here are some suggestions.

One of our greatest fears as we get older is that we will break a hip, an event that can cause permanent disability, depression, and the need for long-term care. Women are twice as likely as men to suffer a hip fracture, partly because we have a greater risk for osteoporosis, a condition that weakens bones.

The chances of developing osteoporosis vary with age, body type, estrogen levels, genetic makeup, ethnicity, lifestyle, level of physical activity, diet, and certain medical conditions. Women are especially vulnerable because they lose bone at an accelerated rate during the first few years after menopause. Along with adequate calcium and vitamin D, exercise is a cornerstone of osteoporosis prevention. It not only helps limit bone loss but also improves balance and coordination and strengthens the muscles we rely on to stay upright. This provides a hedge against falls — one of the main causes of fractures.

Weight-bearing and resistance exercise are especially important. This article highlights some exercises that are particularly good for building hip strength. Keep in mind that they work best as part of an overall program that includes a variety of aerobic, strength, and stretching activities.

Building bone strength

When you put demands on bone, it responds by becoming stronger and denser. Bearing or resisting weight — any activity that works against gravity — stimulates the growth of new bone tissue. Your weight-bearing bones are mainly in your feet and legs and they respond to such activities as walking, jogging, playing soccer, and climbing stairs. Swimming is good for overall fitness, but it isn’t weight-bearing and thus does not improve bone mass or density.

Resistance training, or exercising with weights (see “Working with weights,” below) or resistance bands, can have an even more pronounced effect on bone than weight-bearing exercise. It applies stress to the bones by way of the muscles and tendons. As muscles grow stronger, they pull increasingly harder on bone, which helps build bone mass.

The following exercises work on the muscle groups of the lower body and can help strengthen hipbones.

Working with weights To perform the exercises illustrated here, you need a sturdy chair with a back and a deep seat; athletic shoes with nonskid soles; an exercise mat (a clean rug or thick towel will do); and hand and ankle weights (for the ankle-weighted exercises, you can use a single ankle weight). Good free-weight designs include dumbbell-style hand weights with a padded center bar and screw-on end weights and Velcro-closing ankle cuffs with pockets for weight bars. If you have had hip surgery or have osteoporosis or any other bone or joint condition affecting the feet, ankles, knees, or hips, see your physician or physical therapist before attempting any of these exercises. How to get the most from working with weights: To start, take at least 5–10 minutes to get your muscles warm and loose. You can walk (outdoors, indoors, or on a treadmill) or use a rowing machine, stair stepper, NordicTrack, or other piece of indoor exercise equipment. For best results, do weight training two or three times a week, allowing at least 48 hours for your muscles to recover between workouts. If you have a regular aerobic weight-bearing routine (such as 20–30 minutes of walking or low-impact aerobics), do that first. Follow your resistance training with stretches (such as the hip stretch described here). Start with a weight you can lift 8 times. (You may need to start with 1 or 2 pounds, or no weight at all.) If you can’t comfortably do 8 repetitions of an exercise, the weight is too heavy. If you can easily do 15 repetitions, it’s too light. Move only the part of your body that you’re trying to exercise. Don’t rock or sway. Try to keep your hips even. When lifting a weight, allow three seconds to lift, hold the position for one second, and take another three seconds to lower the weight. Breathe slowly, inhaling as you lift a weight and exhaling as you lower it. Never hold your breath. Do one set of 8–15 repetitions (reps), rest for a minute or two, then do a second set. As you gain strength, you may want to add a third set. When you can perform 2 (or 3) sets of 15 repetitions easily, you’re ready to increase the weight. Add weight until you can lift it only 8 times. Add more weight each time you can easily do 2 or 3 sets of 15 repetitions in a row (don’t forget to rest a minute or two between sets).

Chair stand

Position a chair so that its back rests against a wall. Sit at the front of the chair, with your knees bent and feet flat on the floor, hip-width apart. Lean back in a half-reclining position with your arms crossed and your hands on your shoulders. Keeping your head, neck, and back in a straight line, bring your upper body forward, then stand up slowly. Pause. Slowly sit back down the same way you got up, returning to your original position. Do 8–15 repetitions. Rest, and do a second set. When you’re ready for more: Hold a weight in each hand and cross your hands over your chest.

Front lunge

Stand with your legs hip-width apart. You may want to hold on to a table or counter until you’re sure of your balance. Step forward with your right foot and plant the right heel on the ground. Your right knee should be directly above your right ankle, not in front of it. Roll your back foot forward onto its ball. Keeping your head, neck, back, and hips upright and aligned, lower your body until your right thigh is nearly parallel to the floor (the back knee will be lower). Do not allow the right hip to sink below the level of the right knee. Pause. Push back forcefully to return to the starting position. Alternate legs until you’ve done 8 repetitions on each side. Rest, and do a second set. When you’re ready for more:Hold your arms out to the side or in front of you. Or, try holding hand weights.

Dumbbell squat

Stand with your feet shoulder-width apart. Hold a weight in each hand, with your arms at your sides, palms facing inward. Slowly bend your knees and lower your buttocks 8 inches or more (but do not allow the hips to sink below knee level). Pause. Slowly return to the starting position. Do 8–15 repetitions. Rest. Repeat the set. When you’re ready for more: Increase the weight. You may also try this exercise holding the hand weights at ear level, just above the shoulders.

Hip extension

Wearing an ankle weight, stand 12 inches behind your chair. Holding onto the back of the chair for balance, bend your trunk forward 45 degrees and slowly raise your right leg straight behind you. Lift it as high as possible without bending your knee or pitching forward over the chair. Pause. Slowly lower the leg, returning to the starting position. Do 8–15 repetitions. Repeat with the left leg. Rest, and do a second set.

Side leg raise

Wearing an ankle weight, stand behind your chair with your feet together. Hold on to the back of the chair for balance. With both feet pointed forward, slowly raise your right leg to the side until it is about 8 inches off the floor. Keep your knee straight. Pause. Slowly lower your foot to the floor. Do 8–15 repetitions. Repeat with the left leg. Rest, and do a second set.

Hip flexion

Wearing ankle weights, lie on your back on a mat, with your knees bent and both feet flat on the floor. Rest your hands on your hipbones. Tighten your abdominal muscles and slowly lift your right knee toward your chest until the right foot is about 12 inches off the floor. Slowly lower it. Keep both hips level (it helps to engage your abdominal muscles and press your lower back into the mat). Do 8–15 repetitions. Repeat on the left side. Rest, and do a second set. When you’re ready for more: Do this exercise with a straight leg. With your right knee bent and right foot flat on the floor, extend the left leg so that it is resting on the floor. Keeping the left knee straight, lift the left leg upward until the straight knee is level with the bent knee.

Back extension

Lie facedown on your mat with your knees straight and the tops of your feet against the mat. Place your right arm alongside your body, palm up. Extend your left arm flat on the floor above your head, palm down. Keeping your nose pointed downward, slowly raise your right leg and left arm off the floor (reach out as well as up). Try to keep your head and neck in line with your arm. Pause, and then slowly return to the starting position. Do 8–15 repetitions. Repeat with the left leg and right arm. Rest, and do a second set. When you’re ready for more: Try raising your shoulders and upper chest as you lift your arm and leg.

Hip stretch

You should always stretch after weight-bearing or resistance exercise. Here’s a good stretch for the hips: Lie on your back with your knees bent and feet flat on the floor. Keep your shoulders on the floor at all times. Gently lower both legs to one side, keeping your knees together, and turn your head to the opposite side. You should feel this stretch along the muscles of your hip and side. Hold for 20–30 seconds. Bring your knees back to center, and repeat on the other side.

A new study shows that in menopausal women with Lupus, HT does not increase blood clots. Good news! SG In postmenopausal women with lupus, no increase in vascular thrombotic events with HT use Fernandez M, Calvo-Alen J, Bertoli AM, et al, for the LUMINA Study Group. Systemic lupus erythematosus in a multiethnic US cohort (LUMINA L II): relationship between vascular events and the use of hormone replacement therapy in postmenopausal women. J Clin Rheumatol 2007;13:261-265. Level of evidence: II-2. Menopausal hormone therapy (HT) does not predispose postmenopausal women with systemic lupus erythematosus (SLE) to vascular throm- botic events, found this substudy of LUMINA, a longitudinal, observational, multiethnic cohort study of outcome in SLE. The original cohort included women with SLE, aged 16 years or older, with disease duration of 5 years or greater. For the current study, perimenopausal women were drawn from the original cohort, excluding those with positive IgG or IgM antiphospholipid antibodies and/or the lupus anticoagulant, or vascular arterial events occurring before the use of HT. A total of 72 women were included (mean age, 53.7 y), of whom 32 were HT users and 40 were nonusers. The occurrence of vascular arterial and venous thrombotic events was compared between the two groups. available. Vascular arterial events considered in the analysis were myocardial infarction, angina, coronary artery bypass graft, stroke, inter- mittent claudication, and peripheral arterial thrombosis. Peripheral or visceral venous events were also considered. Vascular arterial events occurred more frequently in nonusers than HT users (P = 0.029). No difference was found for venous thrombotic events between the two groups (P = 0.725). Although HT use was negatively associated with vascular arterial events (odds ratio, 0.156; P = 0.021), this diminished to nonsignificance when a propen- sity score, which adjusted for baseline variables, was factored in. In women with SLE who are antiphospholipid antibody negative, with no previous thrombotic vascular events or other risk factors for such events, HT may be used in the immediate postmenopausal period, the study authors suggest. Comment. Contradictory findings exist re- garding estrogen and SLE. The Nurses’ Health Study1 demonstrated that the relative risk for SLE was increased by events that increase one’s lifetime exposure to estrogen, such as early age at menarche, oral contraceptive (OC) use, and the use of HT during perimenopause. The same study also demonstrated an increased risk for SLE with early age at menopause and surgical menopause. Like other autoimmune diseases, SLE has a varied disease course that waxes and wanes irrespective of medical therapy. Clearly there is a need for randomized controlled trials (RCTs) to evaluate the effects and safety of HT in patients with SLE. Prescribing HT to women with SLE is of particular concern because both SLE and HT have been associated with vascular events. To date, RCTs have found that neither the use of OCs nor HT leads to significant flares.2 Sanchez- Guerrero and colleagues3 performed a double- blind RCT of 106 women with SLE either in the menopause transition or in early or late postmenopause who received a continuous- sequential estrogen-progestogen regimen (n = 52) or placebo (n = 54). Disease activity remained mild and stable in both groups throughout the trial. There were no significant differences between the groups in global or maximum disease activity, incidence or probability of flares, or medication use. Thrombosis occurred in three patients who received HT and in one patient who received placebo. Thus, HT did not alter disease activity during 2 years of treatment. However, an increased risk of thrombosis was found in women with SLE who received HT. The largest RCT was conducted by Buyon and colleagues4 who evaluated the risk of 12 months of cyclic-combined HT in the Safety of Estrogens in Lupus Erythematosis National Assessment trial in 351 perimenopausal patients (mean age, 50 y) with inactive (81.5%) or stable-active (18.5%) SLE. The addition of HT was associated with a small risk for increasing the natural flare rate of mild to moderate flares of SLE although the risk for severe flare was not significantly increased compared with placebo. During the trial, they validated the Systemic Lupus Erythematosis Disease Activity Index (SLEDAI) of ongoing, recurrent, or new activity to capture persistent activity/flares. Neither Buyon nor Sanchez-Guerrero found an increased occurrence of arterial thrombosis with HT use in women with SLE. This lack of increased risk of arterial thrombosis in selected women with SLE was confirmed in this recent study by Fernandez et al. The strengths of their multiethnic, longitudinal, nonrandomized, observational cohort trial included the use of the SLEDAI and the process of pseudo- randomization using a propensity scale to take into account the fact that subjects using HT had less severe and less active disease. The trial is limited by the lack of information about precise doses, formulations, and length of time of HT. Their findings are not generalizable to women with high-titer anticardiolipin antibodies, lupus anticoagulant, or previous thrombosis as these women were excluded from the trial. The indications for HT in postmenopausal women include the treatment of menopause- related symptoms and the prevention of osteoporosis. Women with SLE are more likely to have premature menopause induced by chemotherapy as well as increased risks of osteoporosis and cardiovascular disease. Recent studies2,3 have shown that HT can induce mild to moderate SLE flares as well as cardiovascular or venous thromboembolic events. Therefore, at this time, we would not recommend giving HT to women with active SLE, lupus anticoagulant, antiphospholipid antibodies, or previous thrombosis. Candidates for HT might include young women with premature ovarian failure from chemotherapy for SLE or symptomatic women with SLE for treatment of vasomotor symptoms and prevention of osteoporosis. Nonoral admin- istration may be preferable because of potential decreased effect on coagulation. The increased risk for mild to moderate flares needs to be considered on an individual basis. JoAnn V. Pinkerton, MD Professor of Obstetrics and Gynecology Vice Chair for Academic Affairs University of Virginia Charlottesville, VA President-Elect, NAMS Board of Trustees Credentialed NAMS Menopause Practitioner Dale W. Stovall, MD Professor of Obstetrics and Gynecology Division Director, Reproductive Endocrinology and Fertility University of Virginia Charlottesville, VA References: 1. Costenbader KH, Feskanich D, Stampfer MJ, Karlson EW. Reproductive and menopausal factors and risk of systemic lupus erythematosus in women. Arthritis Rheum 2007;56:1251-1262. 2. Urowitz MB, Ibanez D, Jerome D, Gladman DD. The effect of menopause on disease activity in systemic lupus erythematosus. J Rheumatol 2006;33:2192-2198. 3. Sanchez-Guerrero J, Gonzalez-Perez M, Durand- Carbajal M, et al. Menopause hormonal therapy in women with systemic lupus erythematosus. Arthritis Rheum 2007;56:3070-3079. 4. Buyon JP, Petri MA, Kim MY, et al The effect of combined estrogen and progesterone hormone replace- ment therapy on disease activity in systemic lupus erythematosus: a randomized trial. Ann Intern Med 2005;142(12 Pt 1):953-962.

Here’s a good update on osteoporosis – not a lot of new information but a good and basic overview.  I would have put #1 – measure your Vitamin D level!  I find half of my patients are deficient!  SG

 

Harvard Women's Health Watch | December 2007

Eight for 2008: Eight things you should know about osteoporosis and fracture risk

Bone health is every woman’s concern. Resolve to make it a priority.

How strong are your bones? You may have no idea — until a bone breaks when you push on a stuck window or bend down to pick up something you’ve dropped. Fractures resulting from such seemingly innocuous activities — sometimes called fragility fractures — are usually the first symptom of osteoporosis, the skeletal disorder that makes bones vulnerable to breakage even without a serious fall or other trauma.

Osteoporosis is responsible for more than 1.5 million fractures each year in the United States, almost half of them vertebral (spine) fractures and the rest mostly broken hips and wrists. Hip fractures usually require hospitalization and surgery and often result in permanent disability or the need for nursing home care. Nearly 25% of hip-fracture patients die within a year. Vertebral fractures not only are painful but also cause a stooped posture that can lead to respiratory and gastrointestinal problems. Having any kind of low-impact fracture boosts the risk of having another.

Mostly a woman’s disease

Of the estimated 10 million Americans who have osteoporosis, 80% are women. Another 22 million women are at increased risk for the disease. In both sexes, certain medications (glucocorticoids, aromatase inhibitors, immunosuppressive drugs, chemotherapy drugs, and anticonvulsants) can lead to significant bone loss. So can certain medical conditions. Celiac disease and Crohn’s disease, for example, reduce the absorption of calcium and other nutrients needed for bone maintenance. Rheumatoid arthritis, hyperthyroidism, chronic kidney or liver disease, osteogenesis imperfecta, and anorexia nervosa are also associated with osteoporosis.

Currently, a woman’s odds of having an osteoporotic fracture are one in three. We can’t control all the factors involved, but we need to do all we can to strengthen and preserve our bones. To that end, here are eight important points to keep in mind.

1. Vital nutrients

A healthy diet preserves bone strength by providing key nutrients such as potassium, magnesium, phosphorus, and — of course — calcium and vitamin D. If you don’t get enough calcium, your body will take it from your bones. If your diet doesn’t supply enough calcium (1,000 to 1,200 milligrams per day), take a supplement. The same goes for vitamin D, which is needed to extract calcium from your food. Food sources of vitamin D are limited, and you may not get enough sun to manufacture adequate amounts through the skin. Experts recommend 800 to 1,000 IU of vitamin D per day (women being treated for vitamin D deficiency take much higher amounts). According to the National Osteoporosis Foundation, vitamin D₃ (cholecalciferol) is the form that best supports bone health. To learn more about other nutrients that affect bone health, visit www.niams.nih.gov/Health_Info/Bone/Bone_Health/Nutrition/other_nutrients.asp.

2. The exercise prescription

Two types of exercise — weight-bearing and resistance — are particularly important for countering osteoporosis. Weight-bearing activities are those in which your feet and legs bear your full weight. This puts stress on the bones of your lower body and spine, stimulating bone cell activity. Weight-bearing exercise includes running, jogging, brisk walking, jumping, playing tennis, and stair climbing. Resistance exercise — using free weights, rubber stretch bands, or the weight of your own body (as in sit-ups and push-ups) — applies stress to bones by way of the muscles. It’s especially helpful for strengthening bones of the upper body that don’t bear much weight during everyday activities. Merely occasional exercise won’t help, though. Aim for at least 30 minutes of bone-strengthening exercise most days of the week. If you have osteoporosis or another pre-existing health condition, consult a clinician about whether you should avoid certain activities, positions, or movements.

Bone turnover basics Bone continually undergoes a process called remodeling, or bone turnover, which has two distinct stages: resorption (breakdown) and formation. Bone is a storage depot for calcium. When the body needs calcium, bone cells called osteoclasts attach to the bone surface and break it down, leaving small cavities (A). Bone-forming cells called osteoblasts move into these cavities (B), releasing collagen and other proteins to stimulate bone mineralization and replace what was lost. The osteoblasts that become incorporated in the new bone (matrix) are called osteocytes (C).

Early in life, bone formation outpaces resorption. By age 20, most of us have the greatest amount of bone tissue we’ll ever have (peak bone mass). Bone mass declines very slowly until late perimenopause, when bone loss becomes more rapid, due in part to decreased estrogen, a crucial player in bone turnover. Also, after age 50 to 60 our bodies are less able to absorb calcium and produce vitamin D. We continue to lose bone, though more slowly, for the rest of our lives.

3. No smoking, please

Here’s yet one more reason not to smoke: Women who smoke lose bone faster, reach menopause two years earlier, and have higher postmenopausal fracture rates. The mechanism isn’t known; smoking may lower estrogen levels, or it may interfere with the absorption of calcium and other important nutrients.

4. Know your risk

To screen for osteoporosis, clinicians measure bone mineral density (BMD) — the amount of calcium and other minerals in bone. The best way to assess fracture risk is to calculate BMD at the spine and hip with low-dose x-rays (dual-energy x-ray absorptiometry, or DXA) and factor in a woman’s age. The World Health Organization’s definition of osteoporosis is based on a DXA value called a T-score, which compares the amount of bone a woman has to normal peak bone mass. A T-score of −2.5 or worse indicates osteoporosis. Women who have T-scores of −1.0 to −2.5 have osteopenia and are at increased risk for developing osteoporosis.

Most official guidelines recommend DXA screening for all women starting at age 65, and earlier for women who take medications or have health conditions that increase osteoporosis risk. But reduced BMD is only one risk factor for osteoporosis. You’re also at greater risk if you smoke or are older, Caucasian, or thin, or if you had a fracture after age 50 or have a parent who had a hip fracture. The World Health Organization has developed a formula that predicts 10-year fracture risk based on BMD and other risk factors. A calculator based on this formula is available at courses.washington.edu/bonephys/FxRiskCalculator.html.

Clinicians are also interested in bone quality — a complex characteristic that includes bone mineralization, microarchitecture, and the rate of bone turnover. So far, we have no way to noninvasively assess bone quality, but new imaging technologies are being developed that may allow clinicians to visualize the internal structure of bone and gain information that was once available only through biopsy.

5. Bone-preserving drugs

Postmenopausal woman who’ve had a fragility fracture or received a BMD T-score of −2.5 or worse should take an osteoporosis drug. Women with T-scores from −2.0 to −2.5 should consider drug therapy if they have a parent with a history of hip fracture or one or more other risk factors for osteoporosis.

Most approved osteoporosis drugs (see sidebar) are antiresorptive, that is, they slow resorption, the breakdown phase of bone turnover. Only one drug, parathyroid hormone (Forteo), is anabolic, meaning that it stimulates new bone formation. All medications have side effects, and dosing schedules vary from one to the other, so it’s important to explore all the options with your clinician. One adverse effect of bisphosphonates — death of jawbone tissue, usually after dental extractions or oral surgery — has occurred extremely rarely in women taking bisphosphonates for osteoporosis. It mostly has affected cancer patients, who take far higher bisphosphonate doses, usually intravenously.

Several osteoporosis drugs are under investigation, including the mineral strontium in the form of strontium ranelate, and denosumab, a monoclonal antibody that works by blocking osteoclasts, the cells that resorb bone.

Drugs approved for osteoporosis Antiresorptive drugs (slow bone breakdown) Bisphosphonates (prevention and treatment) 0.      alendronate (Fosamax); oral, daily or weekly 0.      risedronate (Actonel); oral, daily or weekly 0.      ibandronate (Boniva); oral, monthly, or intravenous every three months Bisphosphonates (treatment only) 0.      zoledronic acid (Reclast); intravenous once a year Selective estrogen receptor modulators (SERMs) (prevention and treatment) 0.      raloxifene (Evista); oral, daily Hormone therapy (prevention only)* 0.      various agents (Premarin, Prempro, Estrace, Estraderm, Climara, Menostar, Femring, Estring**); oral, transdermal, vaginal Other (treatment only) 0.      calcitonin (Miacalcin); injection or nasal spray Anabolic drugs (stimulate new bone formation) Parathyroid hormone (treatment only) 0.      teriparatide (Forteo); self-injection once a day for up to 18 months *Only for prevention in postmenopausal women at significant risk for osteoporosis after non-estrogen drugs have been considered. No longer a first-line therapy. **In a two-year study reported in Maturitas (Aug. 20, 2007), use of an estradiol-releasing vaginal ring produced a small but significant improvement in bone mineral density of the hip and lumbar spine.

6. Depression connection

Since the mid-1990s, researchers have investigated links between depression and bone loss. In 1996, a New England Journal of Medicine study found that women with a history of major depression had lower bone density at the hip and spine and higher levels of cortisol, a stress hormone associated with bone loss. Since then, many studies have found a similar relationship. Research has also linked selective serotonin reuptake inhibitor antidepressants with fractures, but cause and effect has not been established. It may be a long time before these connections are fully elucidated. In the meantime, women being treated for depression may want to talk to their clinicians about a BMD test.

7. Weight and weight loss

Weighing less than 127 pounds or having a body mass index under 21 is a risk factor for osteoporosis. Regardless of your body mass index, if you lose weight during the menopausal transition (late perimenopause and the first few years after menopause), you’re more likely to lose bone. Avoid ultra-low-calorie diets and diets that eliminate whole food groups. Be aware that bone loss accelerates during the menopausal transition, so if you’re trying to lose weight at that time, you may need to boost your calcium and vitamin D intake and bone-strengthening workouts.

8. Avoiding falls

Falling is one of the leading causes of fractures, especially among older women and those with low BMDs. Clear floors of anything that could trip you, including loose cords, stools, pillows, throw rugs, and magazines. Make sure stairways, halls, and entrances are well lit; install night-lights to help you see your way to the bathroom. Add grab bars to your tub or shower; make sure stairways have sturdy handrails. Don’t walk around in socks. Limit your alcohol intake. Have your vision and hearing checked regularly. If you take tranquilizers, sleeping pills, or any other medications that could impair your balance, talk to your clinician about reducing or eliminating them.

This is a helpful article from this month's Harvard Women's Health Watch on sleep.

Nighttime awakenings in menopause may be caused by sleep disorders, not hot flashes

Hot flashes aren’t anybody’s friend, but they may be getting an unfair rap for disrupting women’s sleep at midlife. Studies have often reported that sleep problems increase during the menopausal transition, reinforcing the idea that hot flashes (also called vasomotor symptoms) are to blame. But even under controlled conditions in sleep laboratories, the connection between hot flashes and sleep disruption remains unclear. Moreover, in certain circumstances, vasomotor symptoms may be the result — not the cause — of nighttime awakenings. Now, a study concludes that some of the sleep problems that women typically attribute to hot flashes may instead be caused by primary sleep disorders such as apnea. The findings suggest that women may not be receiving appropriate treatment for their sleep difficulties.

To determine the cause of poor sleep in peri- and postmenopausal women, researchers at Wayne State University School of Medicine in Detroit assessed the sleep of 102 women, ages 44 to 56, who reported having trouble sleeping. Participants were interviewed about their sleep histories, and they completed questionnaires to evaluate mood and sleep quality. In the sleep laboratory, subjects were hooked up for one night to recording devices, allowing researchers to collect data on participants’ skin temperature, skin conductance (a measure of sweating), blood flow, respiration, leg movements, eye movements, brain-wave activity, and muscle movements in the chin.

The researchers found that 31 women had periodic limb movements (PLM), 23 had sleep apnea, and six had both. In other words, 53% had a primary sleep disorder. Among the entire group, 56% had measurable hot flashes. A separate analysis of the data showed that while apnea, PLM, and brief awakenings were the best predictors of poor sleep in the laboratory, on the questionnaires completed beforehand, poor sleep was more likely to be associated with anxiety and hot flashes during the first half of the night. (In an earlier study, the Wayne State researchers, led by Dr. Robert R. Freedman, showed that hot flashes wake women in the first half of the night but not the second.)

PLM, a significant cause of daytime sleepiness, is characterized by contractions of the limb (usually the leg) at regular intervals during sleep and in roughly the same way: the big toe and ankle tighten and flex, sometimes followed by the knee and hip. Limb movements occur about every 20 to 40 seconds, typically during the first half of the night. Sleep apnea (also a major cause of daytime sleepiness) is shallow breathing or the cessation of breathing for brief periods during sleep. Untreated, it can boost blood pressure and lead to cardiovascular disease.

The Wayne State investigation is the first to examine menopausal sleep complaints using both objective and subjective measures. The study was small and may not be representative of all menopausal women with sleep complaints. But the finding that half the women in this sample had primary sleep disorders, not just hot flashes, bears further investigation. Sleep problems are often assumed to result from hot flashes, but treating hot flashes isn’t likely to resolve a serious underlying sleep disorder.

Here is a basic plan for all adults (kids in a future post!). Additional supplements should be based on your individual issues and goals (e.g., weight loss, insomnia, reversing insulin resistance, adrenal fatigue, underactive thyroid, etc.).

1. Good multivitamin. You need ample A, B, C, some E and minerals. Minerals vary depending on your health. My faves are on my website at www.doctorgottfried.com and, as with all of our supplements, 100% of after-tax proceeds support educational and environmental nonprofits.
2. Fish oil. Even if you are vegetarian, consider this supplement. 99% of Americans are deficient and flax oil does not suffice. You must use a safe brand that is molecularly distilled and tested to be free of mercury. I recommend 1000-3000 mg/day, depending on your health. Higher doses are sometimes needed in depression, inflammation, high cholesterol and insulin resistance. I prefer PurEFA (each soft gel is 1000mg). This is our most proven supplement based in high-quality data.
3. Calcium, magnesium and vitamin D. Most of us need more than nutrition, sunlight and a multivitamin provide. Check your vitamin D level – most of my patients are deficient even here in sunny California.
4. Greens formula. I recommend that everyone drink green juice as a start to the morning followed by protein. This alkalinizes your body. You can juice it yourself (wheatgrass, kale, celery, chard, etc.) or mostly use a powder. I prefer the taste of Designs for Health or Integrative Therapeutics.

I’ve had 5 requests in the past few hours that ask this question. While the Master Cleanse has many loyal fans, and there is little to data to say it is better or worse than any other cleanse, I squirm at the thought of depleted 30-, 40-, and 50-somethings drinking lemon, cayenne and maple syrup for days on end. I favor a cleanse that has sufficient, healthy oils, whole foods and protein to support you and your adrenals. Out of all the cleanses I’ve reviewed, my favorite and what comes closest to what I recommend to my patients is Mark Hyman, MD’s UltraSimple Diet (www.ultrasimple.com). If you are dying to lose a few pounds (or many) or just to cleanse the cabernet and sugar cookies of December out of your system, check it out! It is part of his new program, Ultrametabolism. I believe, unlike the Master Cleanse, this way of cleansing will not send your body into survival mode and lead to yo-yo eating and weight flux. Mark takes some complicated concepts, such as oxidative stress and the benefits of antioxidants, and makes them very understandable. He calls this “Get the Rust Out” or something like that. More on antioxidants later. I’ve got to go eat dinner with my husband at Café Gratitude and dust off my rust. Let me know if you've tried the Master Cleanse and how it went for you. Cheers, SG

Here is Christiane Northrup, MD's perspective on the HPV Vaccine. -- SG 

DOES YOUR DAUGHTER NEED THE HPV VACCINE? Earlier this summer (2006), Merck pharmaceutical received FDA approval to market the first Human Papillomavirus (HPV) vaccine Gardasil, a genetically engineered vaccine that helps prevents four types of HPV viruses, including type 16 infection, one of the most common HPV type viruses implicated in cervical cancer. Other HPV vaccines are in the pipeline. With the approval of Gardasil, HPV and its link to cervical cancer was suddenly front page news around the world with a barrage of media ads marketing the vaccine heavily for women. The CDC quickly recommended vaccinating all women age 9–26 and even beyond. Overnight women with virtually no risk for cervical cancer (the vast majority) were suddenly made to feel vulnerable, thus creating a huge market for the vaccine. Let me put the issue into much needed perspective. The risk of getting cervical cancer from HPV has been greatly overstated! Fifty to seventy-five percent of all people are exposed to HPV in their lifetimes. The virus clears spontaneously by the immune system within two years in over ninety percent of all women, posing no risk at all.[1-4] Though the vaccine undoubtedly has some value for some women, it is unnecessary, and may even be dangerous, to administer it to millions of girls and women in the United States. 
The Numbers Speak for Themselves There are an average of 9,710 new diagnoses of cervical cancer and 3,700 deaths from the disease in the United States each year, according to the CDC. Of these new cases, 70 percent are related to HPV. That’s about 6,797 cases per year. Over fourteen types of HPV are associated with cervical cancer. Gardasil protects against the HPV strains that are implicated in about 90 percent of cervical cancers, not 100 percent. That further reduces the number of cases of cervical cancer that might potentially be prevented with a vaccine to just under 6,200. And the vast majority of these cases could be prevented with improved nutrition, safe sex, and the kind of screening and early treatment that is already in place! The HPV vaccine media blitz has overshadowed the fact that the incidence of cervical cancer has already decreased dramatically through routine cervical screening with pap smears and HPV (DNA) testing. For example, the National Health Service of England reports that the incidence of invasive cervical cancer fell by 42 percent between 1988 and 1997 in the U.K because of cervical cancer screening programs. The NHS reports that in 2000, there were 2,424 new cases of invasive cervical cancer, most of which are not fatal. 
Abnormal Paps Are Common Surveys suggest that about four percent of all pap smears will show an abnormality associated with HPV infection, which is known as atypical squamous cells of undetermined significance (ASCUS).[5] In the vast majority, further evaluation will fail to show any abnormality, and no further action is required. (This occurrence of “false positives” with Pap smears led to the development of the ThinPrep® Pap Test, which is more reliable but still not 100 percent accurate.) But five to ten percent of patients initially diagnosed with ASCUS actually have more worrisome cellular changes, known as high-grade, which must be followed closely and treated in some women. [6, 7] The Department of Pathology, at the University of Alabama in Birmingham reviewed 39,661 pap and HPV tests from January 1, 2002 to December 31, 2003. Of these, 12 percent were diagnosed with ASCUS. High risk HPV (DNA) was detected in only 732 cases! Out of all of these, only six had persistent abnormal pap smears requiring repeat follow-up; five had evidence of cellular abnormalities; and four had low-grade cervical dysplasia or cellular changes associated with HPV. And only one had high-grade dysplasia (a more worrisome type of cellular change that is associated with a higher risk of actual cancer down the line if not treated). The remaining patients all had negative pap smears. In other words, only a very small percentage of those with high risk HPV were found to have cervical abnormalities—which are not invasive cervical cancer and are treatable! [8] 
Vaccines Aren't Entirely Safe According to the National Vaccine Information Centers (www.909shot.com), “The FDA allowed Merck to use a potentially reactive aluminum containing placebo as a control for most trial participants, rather than a non-reactive saline solution placebo."[9] Using a reactive placebo can artificially increase the appearance of safety of an experimental drug or vaccine in a clinical trial. Gardasil contains 225 mcg of aluminum and, although aluminum adjuvants have been used in vaccines for decades, they were never tested for safety in clinical trials. Merck and the FDA did not disclose how much aluminum was in the placebo 6.[10] Whenever you vaccinate an individual, you’re intervening with their immunity. And that’s exactly what happened with Gardasil in the clinical trials. According to the Merck product insert, there was one case of juvenile arthritis, two cases of rheumatoid arthritis, five cases of arthritis, and one case of reactive arthritis out of 11,813 Gardasil recipients. There was also one case of lupus and two cases of arthritis out of the 9,701 patients who received the aluminum containing placebo. Investigators dismissed the total of 102 Gardasil and placebo-associated serious adverse events, including 17 deaths, that occurred during the clinical trials, claiming that they were unrelated. (It’s also not clear how many girls received the Hepatitis B vaccine in addition to Gardasil. Giving a couple vaccines at the same time can increase the risk of adverse outcomes.) Regardless, there were 102 adverse events in 21,514 women and children who received the vaccine or the aluminum containing placebo. This translates to 474 adverse events per 1 million people getting vaccinated. Conservatively speaking, that’s 14,220 (474 x 30 million) adverse events expected if you were to give the vaccine as recommended to about 30 million women and girls—the approximate number of people in the target market for Gardasil. Is it worth it to make 14,220 girls and women sick in order to possibly prevent 6,200 cases of HPV-related cervical cancer? 
The Bottom Line About HPV Vaccines Remember, it is not HPV per se that causes the cancer. It’s the immune system’s inability to fight the virus that is the issue. The rapid, widespread, and unquestioning acceptance of the HPV vaccine as “the answer” to cervical cancer prevention speaks volumes about our cultural misunderstanding of the root causes of health and disease. On his deathbed, Louis Pasteur, the famous pioneer in the discovery of the role of germs in disease, said that Antoine Beauchamp, his rival, was correct. It was not the germ itself that caused disease, it was the environment, which Beauchamp had claimed all along. While it is certainly laudable to want to decrease the incidence of invasive cervical cancer even further, and while this vaccine may be useful for some high-risk women and girls, it is far too early to subject millions to yet another vaccine. Especially when there’s so much we can do to shore up an individual’s immunity safely and effectively. (For a complete program on how to do this, read Mother-Daughter Wisdom, Bantam, 2005.) Gardasil definitely isn’t cost free—it’s a staggering $360 per person. It’s administered in three shots, which must be given over six months. At this time, it doesn’t even guarantee immunity for longer than five years. Gardasil will not eliminate the need for routine pap smears. And whether or not a woman opts for the vaccine, she should still protect herself from getting a sexually transmitted disease by using condoms, abstaining from intercourse, being discerning about her sexual partners, and also making sure her diet is rich in antioxidant nutrients that help her resist infections of all kinds. Rather than relying solely on mass immunization programs that treat everyone as though they are at equal risk (which clearly isn’t the case), and which also promote the myth of universal vulnerability, it is far more prudent to optimize a woman’s nutrition and lifestyle so that her immune system is functioning optimally in the first place. This is especially true if she is one of the few who don’t clear HPV rapidly and spontaneously. Moreover, if a woman has a persistent HPV infection, she has a problem with her immune system. The bottom line is: The depression of her immune system is what's putting her at increased risk for cervical cancer. So while a vaccine might prevent cancer in one location, disease will manifest in another area if the root cause isn’t addressed. This is done by looking at her entire life—body, mind, and spirit.  

Money Talks So who really benefits by vaccinating approximately 30 million girls and women with a vaccine that costs about $360? Industry analysts point out that mandating the HPV vaccine for virtually all girls and women will make Gardasil the blockbuster that Merck needs to boost profits since it was forced to withdraw its arthritis drug Vioxx. I certainly agree. It is no secret that medical schools, researchers, the CDC, and even the FDA itself are increasingly controlled by drug company profits. So is the mainstream media. To learn the facts about this, I recommend the documentary film Money Talks: Profits before Patient Safety.
  

REFERENCES 

1. Ho, G.Y., Bierman R., Beardsley, L., et. al., 1998. Natural history of cervicovaginal papillomavirus infection in young women, N Engl J Med, 338:423-428.
 

2. Woodman, C.B., Collins, S., Winter, H., et. al., 2001. Natural history of cervical human papillomavirus infection in young women: a longitudinal cohort study, Lancet, 357:1831-1836.
 

3. Nasiell, K., Nasiell, M., Vaclavinkova, V., 1983. Behavior of moderate cervical dysplasia during long-term follow-up, Obstet Gynecol, 61:609-614.
 

4. Richart, R.M., Barron, B.A., 1969. A follow-up study of patients with cervical dysplasia, Am J Obstet Gynecol, 105:386-393.
 

5. Davey, D.D., et. al., 2004. Implementation and reporting rates: 2003 practices of participants in the College of American Pathologists Interlaboratory Comparison Program in Cervicovaginal Cytology. Arch Pathol Lab Med., 128:1224-1229.
 

6. Manos, M.M., et. al., 1999. Identifying women with cervical neoplasia: using human papillomavirus DNA testing for equivocal Papanicolaou results, JAMA, 281:1605-1610.
 

7. ASCUS-LSIL Triage Study (ALTS) Group. 2003. Results of a randomized trial on the management of cytology interpretations of atypical squamous cells of undetermined significance. Am J Obstet Gynecol. 188:1383-1392.
 

8. Adams, A., et. al., 2006. Negative colposcopic biopsy after positive Human Papillomavirus DNA testing: false positive HPV results or false-negative histologic findings, Am J Clin Pathol. 2006;125(3):413-418.
 

9. Merck & Co., Inc. 2006. Gardasil [Quadrivalent Human Papillomavirus Types 6,11,16,18 Recombinant Vaccine] product insert. Table 6.
 

10. Food and Drug Administration. May 18, 2006. FDA Background Document for Vaccines and Related Biological Products Advisory Committee: Gardasil HPV Quadrivalent Vaccine.