Natural Menopause Relief Secrets

Holistic Hormone Balance

Every woman experiences hormonal imbalance at one point in life. The Holistic Hormone Balance is an essential guide that provides women with the information that they need to know on how to balance their hormones and reduce stress levels, fatigue, excessive weight gain, skin problems and increase desire in intimacy. In addition to that, the book provides women with steps to follow to identify any symptoms of hormonal imbalance and how to create an original and personalized treatment plan that works best for their body. A combination of natural hormone treatment has also been provided in the guide, making it easier for women to choose their best plan, that works best for them. Hormonal imbalance affects the female body and most of the time; they take the issue lightly, thinking that other people have more significant problems than theirs. Imbalance affects moods and creates discomfort in women. The frustration comes from the fact that they cannot do anything to change their situation, and always remain suffering in silence. The Holistic Hormone Balance book works towards helping women with hormone imbalance feel amazing again, by identifying the root cause of their problem and treating the symptoms when they occur. More here...

Holistic Hormone Balance Summary

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Signs of Natural Menopause

The three classic short-term symptoms of menopause erratic periods, hot flashes, and vaginal dryness are caused by a decrease in estrogen. The emotional symptoms of menopause, such as irritability, mood swings, melancholy, and so on, are actually caused by a rise in follicle-stimulating hormone (FSH). As the cycle changes and the ovaries' egg supply dwindles, FSH is secreted in very high amounts and reaches a lifetime peak as much as fifteen times higher it's the body's way of trying to jump-start the ovarian engine. Every woman entering menopause will experience a change in her menstrual cycle, discussed later. However, not all women will experience hot flashes or even notice vaginal changes, particularly true if a woman is overweight. Estrogen is stored in fat cells, which is why overweight women also tend to be more at risk for estrogen-dependent cancers. What happens is that the fat cells convert circulating male sex hormones into estrogen, creating a type of estrogen reserve that...

Management of Premature Menopause

Female survivors who develop premature menopause should be referred to a gynecologist for management and consideration for hormone replacement therapy. The decision to proceed with hormone replacement therapy, and the form that it should take, involves a careful evaluation of many competing healthcare factors, a subject that is beyond the scope of this chapter. However, it is imperative that patients be managed by a team of physicians who are well versed in this area and can assist in carefully weighing the risks and benefits of various hormonal replacement strategies.

HRT Menopause and Thyroid Disease

The average woman will live until age seventy-eight, meaning that she will live one-third of her life after her menopause. Since thyroid disorders affect women so much more frequently, particularly as they age, balancing thyroid hormone replacement with the confusion surrounding traditional estrogen and progesterone hormone replacement is challenging. Since heart disease can be a major complication of hypothy-roidism or thyrotoxicosis, in the 1980s and 1990s, women with thyroid disease were encouraged to seriously consider hormone replacement therapy after menopause, In July 2002, a study by the U.S. National Heart, Lung, and Blood Institute, part of a huge research program called the Women's Health Initiative (WHI), suggested that HRT should not be recommended for long-term use in fact, the results were so alarming, the study was halted before its completion date. It was found that Prempro, a combination of estrogen and progestin, which was a standard issue HRT formulation for...

Natural Menopause

When menopause occurs naturally, it tends to take place anywhere between the ages of forty-eight and fifty-two, but it can occur as early as your late thirties or as late as your Menopause or Thyroid The following menopausal symptoms may also be signs of hypo- or hyperthyroidism mid-fifties. When menopause occurs before age forty-five, it is technically considered early menopause, but just as menarche is genetically predetermined, so is menopause. For an average woman with an unremarkable medical history, what she eats or the activities she engages in will not influence the timing of her menopause. However, women who have had chemotherapy or who have been exposed to high levels of radiation (such as radiation therapy in their pelvic area for cancer treatment) may go into earlier menopause. In any event, the average age of menopause is fifty to fifty-one. Other causes that have been cited to trigger an early menopause include mumps (in small groups of women, the infection causing the...

LH or FSH Deficiency

Bertal hormones in a short or slowly-growing adolescent can cause fusion of bony growth centers and shorter-than-expected adult height. Such therapy should be provided only in coordination with the pediatric endocrinologist after an assessment of growth potential and treatment of GH or thyroid deficiencies. Initiation of sex steroid therapy in a short adolescent may be delayed until age 15 years to permit response to GH or thyroid hormone therapy and taller adult height. In short adolescents with delayed puberty, a few years of therapy with low-dose sex steroid therapy is preferable to full replacement. Such doses simulate the sex steroid levels observed in the first year or so of puberty and are less likely than full sex steroid replacement to cause inappropriate maturation of bone age. Girls can be treated with the conjugated estrogen tablets Premarin (0.3 mg every other day) or ethinyl estradiol (5 mcg daily, one quarter of a 20-mcg tablet daily) 47 . Menstrual spotting can be...

Allowing Graves to Run Its Natural Course

Many with Graves' disease have mild symptoms and wonder whether they should refuse active therapy and allow Graves' disease to run its natural course, which might normally result in the thyroid gland burning out and failing on its own, leaving you hypothyroid anyway. This approach is commonly recommended for the small group of people who have such low degrees of thyrotoxicosis that ablative therapy with RAI, surgery, or risks of drug effects of antithyroid medications seem unnecessary. These people often do well with beta-blockers however, they must be carefully monitored since thyrotoxicosis may worsen without warning. Also, the risks of worsening of osteoporosis and chronic effects of excess thyroid hormone on the heart should be considered. For these reasons, post-menopausal women with brittle bones (see Chapter 14) and people with irregular heart rhythms (see Chapter 25) are appropriately directed toward RAI treatment.

Regulation of ER Function

In normal nonpregnant, premenopausal human breast, only about 5-10 of the total luminal epithelial cell population expresses ERa, and this expression tends to be highest in the follicular phase of the menstrual cycle. The highest percentage of ERa-expressing cells are found in undifferentiated lobules type 1 (Lob1), with a progressive reduction in the more differentiated Lob2 and Lob3 types. The highest level of cell proliferation is also observed in Lob1, but expression of ERa occurs in cells other than these

Transcriptomic Approaches

Analysing messenger RNA (mRNA) has always been an important and technology-enabled approach to examine the expression of genes. As an alternative to classical low-throughput Northern technologies, different high-throughput processes such as serial analysis of gene expression (SAGE) and microarray analysis have been developed to analyse global gene expression at the transcriptomic level (Velculescu et al. 2000 Schena et al. 1998). Both screening techniques provide the possibility to simultaneously evaluate the relative expression levels of large numbers of different mRNA transcripts in a panoramic view. Thereby, entire expression profiles themselves become a tumour marker that mirrors the polygenic nature of carcinogenesis. The increasing list of microarray experiments published each month reflects the straightforwardness of this technology, which is based on relatively inexpensive and easy-to-synthesize but sensitive and specific nucleic acid sequences. These can be arrayed into...

Prediction of ovarian damage

Young ovary can be lost as a consequence of treatments without unduly compromising the future fertility of the individual. In support of this concept, there are numerous reports ofyoung women who suffer a transient loss of reproductive cyclicity following cancer treatment before their hormonal and reproductive cycles are re-established and their natural fertility is restored (Meirow 2000). The ability to assess accurately the ovarian reserve in these individuals, both before and after their cancer treatment, would provide these patients with reassurance that their cancer treatment has not induced a premature menopause.

Few Words About the Dangers of Alcohol

I am not suggesting that all non-drinking women should rush out and start consuming alcohol. Because other studies have shown an increase in risk of breast cancer from even moderate drinking, younger women and women who may be at increased risk for breast cancer should discuss their decision regarding drinking with their own doctors before making changes in their lifestyle. We must keep in mind, however, that a post-menopausal woman in the United States is much more likely to die from heart disease or stroke diseases for which she would be at a lower risk if she consumed a little alcohol than she is to die of breast cancer.

Female Sexual Arousal Disorder

Female sexual arousal disorder (FSAD) is operationalized as the difficulty in reaching and maintaining vaginal lubrication or genital swelling until the completion of the sexual activity (ApA, 2000). Recently, theorists have argued that diagnosis of FSAD should consider not only the physiological dimension of sexual arousal (i.e., lubrication) but the psychological experience as well. Women of all ages may experience difficulty lubricating, although it tends to be more of a problem in later life, typically after menopause. Female sexual arousal disorder is generally assessed and treated in conjunction with female orgasmic disorder or HSDD. To date, there are no validated treatments that focus exclusively on treating female arousal problems, although a number of pharmacological agents for enhancing vaginal engorgement and lubrication are currently under investigation. Techniques are often employed to help the patient become aware of her anxiety or her sexual turn-off thoughts,...

Personal Characteristics

Because the incidence of most cancers increases rapidly with age, exceptions to this pattern may have aetiological significance. Acute leukaemia, for example, shows both an early and a late peak, which led investigators to consider intrauterine carcinogenesis. The subsequent discovery that intrauterine exposure to ionizing radiation may increase the risk of childhood leukaemia provided empirical support to this hypothesis. Similarly, the bimodal incidence pattern of Hodgkin disease in many countries (Figure 5) led to the prevailing hypothesis that the early peak is due to an infectious agent. Finally, the slowing of the rate of increase of the incidence of breast cancer after menopause has underlined the importance of ovarian oestrogens in the aetiology of this disease.

How Much RAI Is Used for Graves Disease

Different methods are used to decide upon the dosage of RAI. Some physicians give arbitrary doses of I-131, knowing that most people will have some good results as long as the dose is reasonable (often around 10 millicuries). I (Ken) prefer to make measurements that permit the dose to be individually adjusted. It is nearly impossible to reliably give such a precise dose of RAI that a person ends up with normal thyroid gland function and, ultimately, the ongoing autoimmune processes of Graves' disease usually cause the thyroid gland to eventually fail anyway, resulting in hypothyroidism. For this reason, I feel that it's better to aim to give enough RAI to make a person hypothyroid reasonably soon, so that thyroid hormone replacement therapy can be started, which will allow that person to resume his or her usual quality of life faster. First, I estimate the size of a person's thyroid in grams, knowing that a normal-sized thyroid weighs around eighteen to twenty grams. Then I obtain the...

Belief Versus Knowledge in Healthcare

Notion that the interventions we have developed for the benefit of our patients can do harm. Nevertheless, harm is often done. Well-meaning physicians, through ignorance, injure their patients commonly. The administration of cutting and bleeding in earlier centuries, and the use of strong purgatives in this century are only two of the most notorious examples. The administration of potent hormone replacement therapy for menstrual symptoms, and the use of surgical lavage and debridement as palliative therapy for osteroarthritic knees are only two of the most recent examples of the well-meaning community of physicians treating patients under mistaken and untested assumptions. What will they say 200 years from now about our current oncologic treatments

Hearing about the diagnosis

The following account is based on semi-structured discussions with the six individual hospital endocrinologists and one gynaecologist with whom I work. Girls are referred to the paediatric endocrinologist with symptoms such as puffy hands or feet in infancy, short stature in childhood, or delay in signs of puberty in teen years. The degree of focus on fertility in the initial appointments depends on the reason for the referral, the age at diagnosis, and whether or not there are other serious health features that need immediate treatment. In childhood, the medical focus is usually growth hormone treatment through daily injections to increase height, which is monitored by measurement of linear growth every three months. The mean untreated Caucasian adult height is 143-147 cm, approximately 4 ft 9 in (Elsheikh et al. 2002). With treatment many girls grow to a height in the low normal range. From around the age of puberty, the medical focus turns to the use of sex hormone replacement...

Postoperative Estrogen in Women Patients

Women undergoing CABG are likely to be postmenopausal because coronary artery disease is more prevalent in post-menopausal women (young diabetic women are the exception). Many studies suggest that women at high risk for coronary artery disease or those who already have the disease will benefit from estrogen therapy. This group includes women who have undergone CABG or angioplasty. Another large study is currently testing these results, but, in the meantime, physicians should strongly consider treating all of their postmenopausal CABG patients with estrogen unless they are at very high risk for breast or uterine cancer.

Case study continued Investigating sources of heterogeneity

Several of the studies include women who were receiving hormone replacement therapy (HRT). The Littenberg-Moses summary ROC curve method can investigate whether the diagnostic accuracy of EVUS is similar in studies that did or did not include women receiving HRT. A hypothesis of equal diagnostic odds ratios can be tested formally by adding a term to the weighted regression indicating which studies included women receiving HRT

Effects of Radiotherapy on Ovarian Function

In considering the risk of ovarian failure related to radiotherapy, other fields than the abdomen and pelvis must be considered. Direct or scattered irradiation from the spinal component of craniospinal radiotherapy may also produce ovarian damage 6,17 . With the expanded use of hematopoietic stem cell transplantation in pediatric oncology, it is important to recall that total body irradiation (TBI) utilized in the conditioning regimen is commonly associated with primary ovarian failure or premature menopause, with prevalence rates as high as 90-100 18-22 .

What Causes Bone Loss Anyway

Our bones are always regenerating (known as remodeling). This process helps to maintain a constant level of calcium in the blood, essential for a healthy heart, blood circulation, and blood clotting. About 99 percent of all the body's calcium is in the bones and teeth when blood calcium drops below a certain level, the body will take calcium from the bones to replenish it. But by the time we reach our late thirties, our bones lose calcium faster than it can be replaced. The pace of bone calcium loss speeds up for freshly postmenopausal women (three to seven years beyond menopause). One of the most influential factors on bone loss is estrogen it slows the loss of bone mass by directly affecting cells that make bone (osteoblasts) and cells that digest bone (osteo-clasts). In men, testosterone does the same thing, but unlike women, men never reach a particular age when their testes stop producing testosterone. If they did, they might be just as prone to osteoporosis as women.

Thyroid Disease and Osteoporosis

Once your thyroid hormone levels are restored to normal, the risk is gone. But, as discussed in Chapter 10, finding the right dosage can be tricky. Women who have had a thyroidectomy to treat thyroid cancer or for other reasons need to be on a slightly higher dosage of thyroid hormone to suppress all thyroid stimulating hormone (TSH) activity. So they may live in a state of mild thyrotoxicosis. Essentially, postmenopausal A long list of other factors affect bone loss. One of the most obvious contributing factors is calcium in our diet. Calcium is regularly lost to urine, feces, and dead skin. We need to continuously account for this loss in our diet. In fact, the less calcium we ingest, the more we force our body into taking it out of our bones. Exercise also greatly affects bone density the more we exercise, the stronger we make our bones. In fact, the bone mass we have in our late twenties and early thirties will affect our bone mass at menopause.

Other Potential Roles As A Neuropeptidase

It has been long known that estradiol plays a very large role in neural remodeling and cognition. Studies of post-menopausal women who are given estradiol exogenously routinely fare better on tests for cognitive function and decline. Pertinent to our own research in AD, women who received estradiol post-menopausally demonstrated an increased age of disease onset and a slower rate of progression towards dementia89. The role of estradiol is still unclear but the effect is pronounced.

How Much Calcium Do You Need

According to the National Institutes of Health Consensus Panel on Osteoporosis, premenopausal women require roughly 1,000 milligrams of calcium a day for peri-menopausal or postmenopausal women already on HRT or ERT, 1,000 milligrams and for peri- and postmenopausal women not taking estrogen, roughly 1,500 milligrams per day. For women who have already been diagnosed with osteoporosis, the Panel recommends 2,500 milligrams of calcium a day. Foods that are rich in calcium include all dairy products (an eight-ounce glass of milk contains 300 milligrams calcium), fish, shellfish, oysters, shrimp, sardines, salmon, soybeans, tofu, broccoli, and dark green vegetables (except spinach, which contains oxalic acid, preventing calcium absorption). It's crucial to determine how much calcium you're getting in your diet before you start any calcium supplements too much calcium can cause kidney stones in people who are at risk for them. In addition, not all supplements have been tested for...

Staying Alert About Heart Disease

If you are past menopause, you must educate yourself about the signs and symptoms of heart disease, since you are at higher risk. Other risk factors, such as smoking, obesity, high blood pressure, and high cholesterol, can be reduced with lifestyle changes. For example, women who are physically active have a 60 to 75 percent lower risk of heart disease than inactive women. Heart disease is currently the number-one cause of death in postmenopausal women more women die of heart disease than lung cancer or breast cancer. Half of all North Americans who die from heart attacks each year are women.

Prevention and Treatment

Nonpharmacological therapy for prevention and treatment of osteoporosis includes adequate dietary intake of calcium and vitamin D, weight-bearing exercise, fall precautions, no smoking, and avoidance of excessive alcohol intake. These steps should be started early in life and continued through menopause because BMD peaks at about age 35 and then begins to decline with accelerated bone loss after menopause. According to the National Institutes of Health (NIH) Consensus Development Conference, the optimal recommended dose of elemental calcium is the amount that each person needs to maintain adult bone mass and minimize bone loss later in life (Table 8.3). The recommended dose for postmenopausal women

Evaluation of Nutritional Status using Biochemical Assessment

Assessment of serum lipid is strongly recommended in subjects that practice fitness regularly 1,32,33 . Prior to assessment, it is important that subjects abstain from alcohol for a 48-h period and from food for 12 h, and it is suggested that they abstain from strenuous exercise in the 48 h preceding the measurement 1,3,32,33 . Finally, factors that must be taken into consideration when interpreting the results include medication use, menopausal status, age, and smoking status 33 .

Obstructive sleep apnoeas and gender

Obstructive sleep apnoeas, upper airway resistance syndrome and snoring are all at least twice as common in men as in women. The risk in women is five times greater after the menopause and twice as great while taking hormone replacement treatment, compared to before the menopause.

Sexual Steroid Hormones

Several epidemiological studies have shown a higher prevalence of RLS in women than in men (59,62,207). Elderly women seem to be particularly affected (207), which points to the postmenopausal hormonal status as a possible cause. Prospective (208,209), concurrent (210,211), or retrospective assessment (18) of RLS occurrence during pregnancy consistently indicates that approximately 25 of females will experience RLS symptoms, with the highest prevalence during the last trimester (see Chapter 20). In many females, RLS symptoms during pregnancy are mild and infrequent (18,208,210) and disappear shortly after delivery (18,208-210). Hormonal changes during pregnancy predominantly manifest by increases in plasma estrogen, progesterone, and prolactin. A recent study (212) that followed pregnant women with and without RLS from the 35th week of gestation to approximately 12 weeks postpartum has found markedly elevated estradiol levels in pregnant women with RLS during late-term pregnancy but...

Obstructive sleep apnoeas in the elderly

Snoring is less commonly reported in the elderly, possibly because of the partner's deteriorating hearing, because the partner is in a separate bed or bedroom, or because the snorer lives alone. Obstructive sleep apnoeas, however, appear to become progressively more common in older age, although over the age of 60 the gender difference between males and females is less than in younger adults and obesity is less important. The familial association of OSA persists into old age. In women there is an increased prevalence of OSA after the menopause.

Promotion of Physical Activity in Adults

Overall, available evidence discourages educational interventions on the general adult population to prevent obesity through the increase of physical activity. In fact, although several governments have launched mass media campaigns, it is unlikely that these will produce any relevant results. It would be more rational to invest available resources in community and workplace facilities for physical exercise, while concentrating educational interventions on specific groups with a greater awareness of benefits of weight control (e.g., first-degree relatives of patients with diabetes or cardiovascular disease). Some groups of subjects with a high risk for weight gain (e.g., menopausal women, or patients treated with antipsychotic drugs) could be the target of more complex, and expensive, programs for weight control.

Further Comment on Risk Factors

Hormones There is a very substantial literature on the relationships between hormone levels and thrombosis. The vast majority of this literature pertains to sex hormones used e.g. for oral contraception or hormone replacement therapy, and this matter was discussed briefly in Chapter 3. However, perturbed thyroid hormone levels also appear to increase the likelihood of DVT (as well as atherosclerosis) the mechanisms remain elusive (Squizzato et al. 2005), but protein C levels may be abnormally low (Nagumo et al. 2007). According to an intriguing recent paper, leptin increases TF production by peripheral monocytes, suggesting a possible reason why obesity is a 'risk factor' for DVT (Napoleone et al. 2007).

Hypoactive Sexual Desire Disorder

There are currently no empirically validated treatments for HSDD. Sex therapy techniques generally consist of 15 to 45 sessions of cognitive therapy aimed at restructuring thoughts or beliefs that may adversely impact sexual desire (e.g., women should not initiate sexual activities, sex is dirty ) and to address negative underlying relationship issues. Behavioral approaches are utilized to teach patients to express intimacy and affection in both nonsexual (e.g., holding hands, hugging) and sexual ways, to incorporate new techniques into their sexual repertoire that may enhance their sexual pleasure, and to increase sexual communication. Testosterone is effective in restoring sexual desire in women with abnormally low testosterone levels (e.g., secondary to removal of the adrenal glands, bilateral removal of the ovaries, menopause).

Sexual Pain Disorders Dyspareunia

Dyspareunia refers to genital pain associated with intercourse (ApA, 2000). Vulvar vestibulitis is the most common type of premenopausal dyspareunia, whereas vulvar or vaginal atrophy is mostly reported by postmenopausal women. Women with these types of dyspareunia complain of pain in the vulvar area or anterior portion of the vagina upon penetration. The assessment of the type of dyspareu-nia should include information on the location, quality, intensity, time course, and meaning of the pain. The few studies that have examined treatment efficacy showed a moderate success rate of cognitive-behavioral techniques and biofeedback. The cognitive-behavioral approach includes

Who Is Most Likely to Suffer from Dry Eyes

Dry eyes are often a woman's problem since so many autoimmune diseases, which plague women in particular, are associated with dry eyes. Aside from Graves' disease, women can also be plagued with Sjogren's syndrome, which impairs lacrimal gland function and the formation of watery tears (90 percent of Sjogren's syndrome sufferers are women). Hormonal changes during pregnancy and menopause can also cause dry eyes, while in the general population asthma, glaucoma, blepharitis (chronic inflammation of the eyelids), cornea surgery, and corrective surgery for nearsighted-ness are other causes.

Years old ten weeks into my fourth pregnancy

Early menopause is now becoming a recognized long-term complication of chemotherapy given in adolescence (Marsden and Hacker 2003). Young adult cancer survivors are often advised to wait two years following the completion of treatment before trying to conceive, when health prospects become brighter. There is also evidence to suggest that teen-cancer-survivors exhibit delayed sexual maturity and first sexual experiences occur later than their peers (Kokkonen et al. 1997). These factors combine to limit duration of potential childbearing years. Communication concerning a shortening of reproductive years could serve to decrease psychological distress in the future by giving a survivor the correct facts to make an informed choice.

Complications with Amiodarone

On the other hand, there is an unusual situation when the amiodarone seems to poison the thyroid gland, causing an intense irritation that releases stored thyroid hormones from the gland. Many medical treatments have been tried, most to no avail, to alleviate this problem. If this occurs, most of the time, the two treatment options are to either provide sufficient beta-blockers and medical support for the person to survive the thyrotoxicosis or to have a surgeon remove the thyroid gland, then start thyroid hormone replacement therapy. Determination of the proper approach requires the consultation of expert thyroid specialists and cardiologists.

Night sweats sleep hyperhidrosis

Night sweats may be a physiological response to a rise in temperature, but many normal subjects complain of excess sweating at night without any demonstrable fever. This is probably due to an increased sympathetic stimulation of sweat glands and is often related to anxiety or stress, or is a response to sleep disorders such as obstructive sleep apnoeas. Menopausal night sweats are related to fluctuations in blood oestrogen levels. Night sweats also occur in thyrotoxicosis, with infections such as pulmonary tuberculosis, in lymphomas, particularly Hodgkin's disease, and occasionally in hypothalamic lesions. Sweating at night can lead to frequent awakenings from sleep. Treatment is unsatisfactory, except for the sweats related to the menopause which respond to oestrogen replacement treatment. If night sweats are drenching and require frequent changes of night-clothes, either extensive tuberculosis or a lymphoma, such as Hodgkin's disease, should be suspected.

Building on enthusiasm while avoiding duplication

Because it is unlikely to make sense from the perspective of someone using a review to make a practical decision. For example, someone deciding about hormone replacement therapy is likely to be interested in all its important effects, including possible benefits, such as reducing the risk of fractures and cardiovascular disease, and possible adverse effects, such as increasing the risk of breast cancer. From this perspective, it would be unhelpful, as well as inefficient, for each of the many review groups with an interest in this intervention to focus only on the outcomes that they consider within their scope.

Genital Tract Infections

The normal anatomy, physiology and microbial etiology of the vagina are age-dependent (Cruickshank and Sharman, 1934). There are also obvious age-dependent differences in the source of vaginal infections. These factors account for different etiologies of vaginitis in neonates, infants, prepubertal girls and pre- and postmenopausal adults (Table 3.1). TABLE 3.1 Etiology of lower urogenital tract sexually trans' mitted diseases in adult premenopausal women.

Types of cardiovascular disease

Types Cardiovascular Diseases

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

Localized pruritic dermatoses

Lichen Simplex Chronicus Scrotum

It is very common to see localized neurodermatitis of the posterior neck in menopausal women. Other clinical types of neurodermatitis are seen in any age. VULVAR PRURITUS. Etiologically, vulvar pruritus is due to candida or trichomonas infection contact dermatitis from underwear, douche chemicals, contraceptive jellies, and diaphragms chronic cervicitis neurodermatitis menopausal or senile atrophic changes lichen sclerosus et atrophicus or leukoplakia. Pruritus vulvae is frequently seen in patients with diabetes mellitus and during pregnancy.

Pathophysiology of DHEA deficiency

More recently, a DHEA deficiency state has been reported in young, healthy, regularly menstruating premenopausal women presenting with decreased libido 297 . The regular menstrual periods support normal cyclical ovarian function and ovarian testosterone production. However, since adrenal DHEA contributes to almost half of a premenopausal woman's circulating androgens, such a deficiency

Screening for late onset hypogonadism LOH

In women, age-related hormonal changes are well recognized, generally with a rapid onset and progression, leading to the characteristic menopausal symptoms. In males, the changes in the hypo-thalamic-pituitary-gonadal axis in general have an insidious onset and a slow progression, do not have clinical manifestations in all men, have a great variability from man to man with the clinical picture of hypogonadism being mild or even nonexistent in many of them 159 .

Abnormalities of Secretion by the Ovaries

When the ovaries of a fully developed woman are removed, the sexual organs regress to some extent so that the uterus becomes almost infantile in size, the vagina becomes smaller, and the vaginal epithelium becomes thin and easily damaged. The breasts atrophy and become pendulous, and the pubic hair becomes thinner. The same changes occur in women after menopause. Hypogonadism. As pointed out in the preceding discussion of menopause, the quantity of estrogens produced by the ovaries must rise above a critical value in order to cause rhythmical sexual cycles. Consequently, in hypogonadism or when the gonads are secreting small quantities of estrogens as a result of other factors, such as hypothyroidism, the ovarian cycle often does not occur normally. Instead, several months may elapse between menstrual periods, or menstruation may cease altogether (amenorrhea). Prolonged ovarian cycles are frequently associated with failure of ovulation, presumably because of insufficient secretion of...

Initiation of treatment and followup

The second annual Andropause consensus meeting recommended performing DRE and serum PSA before treatment, at three and six months, and yearly thereafter 215 . In addition to that recommendation, a PSA level could be obtained one month after initiation of therapy to capture the patient with a previously undiagnosed prostate cancer that may be behaving in a very aggressive fashion following T-replacement. ISSAM and WHO guidelines also recommend periodic hematologic assessment, i.e.

Diagnosing Thyrotoxicosis andor Hyperthyroidism

The challenge for diagnosing either hyperthyroidism and or thyrotoxicosis is similar for hypothyroidism the symptoms can overlap with stress, anxiety, panic disorder, low blood sugar, and cardiovascular diseases. For women, PMS and perimenopause can mask, or be mistaken for, thyrotoxicosis miscarriage or infertility can also result from thyrotoxicosis.

Normal Organ Development

Hormonal function and potential for fertility are synchronous in females, as the ovary both produces oocytes and secretes steroid hormones. Prepubertal females possess their lifetime supply of oocytes with no new oogonia formed after birth. Active mitosis of oogonia occurs during fetal life, reaching a peak of 6-7 million by 20 weeks of gestation, and then rapidly declining to 1-2 million at birth. At the onset of puberty, only 300,000 remain 1 . The cortices of the ovaries harbor the follicles within connective tissue. These follicles arise from the germinal epithelium, which covers the free surface of the ovary. Through involution, atresia and, to a much lesser extent, ovulation, the follicles disappear entirely at menopause. The normal pre-menopausal ovary contains degenerating ova and follicles in varying stages of maturity. Ovarian hormones also have critical physiologic effects on other organs and bodily processes, including the stimulation of libido, the maturation and function...

Table 9 Aspects of chemoprevention at major cancer target sites3

Age 50 years, familial history of breast cancer or genetic syndrome (e.g. Li-Fraumeni, BRCA1), previous breast, endometrial or ovarian cancer, atypical hyperplasia, DCIS, LCIS oestrogen exposure (e.g. early menarche, late menopause, late age at first full-term pregnancy) life-style factors (e.g. diet)

Felida x 1887 Azam 1892

Now in 1891, Felida is forty-seven years old. Her general health is bad, for she has an ovarian tumor. Her intellectual condition at present is as fol-lows -For the last nine or ten years the periods of the second condition have diminished in time of duration to lasting a few hours only, and appearing only every twenty-five to thirty days. So that Felida is almost cured, and will be perfectly so at the epoch of the menopause.

Thyroid Hormone Replacement

Since we are all individuals, dosing may vary greatly from one person to the other. Indeed, people of the same gender, age, and weight may require different doses. The goal of thyroid hormone replacement therapy is to restore thyroid hormone levels to a level that results in a normal TSH value. That said, some pharmacologic studies to date indicate no significant differences between the four most commonly dispensed brands of levothyroxine. In clinical speak, they were found to be pharmacologically equivalent (absorbed in the blood in precisely the same way) and are considered equivalent under current FDA guidelines. This means that the brands studied were found to be interchangeable in the majority of patients receiving thyroid hormone replacement therapy. But disagreement persists regarding bioequivalency among thyroid brands. This is because many thyroid experts believe that bioequivalence requires comparing TSH responses, rather than just T4 levels. One manufacturer had to recall...

Prevention Strategies

A critical component to prevention is health counseling for females at risk. For females treated during the prepubertal period, parents should be counseled regarding the risk of primary ovarian failure. Normal gonadal development should be reviewed with recommendations for monitoring of growth and development. Reproductive counseling should be made cautiously and preferably, in conjunction with a specialist in reproductive endocrinology. The effects on the female gonadal system from radiotherapy and chemotherapy may demonstrate significant inter-individual variation, even with identical exposures at identical ages. Post-pubertal females who have normal menstrual function should be counseled about appropriate contraception should they currently not wish to conceive a child, and they should also be made aware of their potential risk for premature menopause. Not inconsequential for young adults is the impact of ovarian failure or impending failure in sexual drive or libido, an effect...

Cardiovascular function

Steroids and vascular risk factors Premenopausal women suffer significantly less from cardiovascular disease than men, and traditionally it has been thought that the relationship between sex steroids and cardiovascular disease is predominantly determined by the relatively beneficial effects of estrogens, and by the relatively detrimental effects of androgens on lipid profiles 101 . Nevertheless, the vast majority of cross-sectional studies in men are not in agreement with this assumption they show a positive correlation between FT levels and HDL cholesterol 111-113 , and a negative correlation, with fibrinogen, plasminogen activator inhibitor-1 105 , and insulin levels as well as with coronary heart disease 115,116 , but not with cardiovascular mortality 117-119 . Low testosterone level in coronary artery disease Premenopausal women, in comparison to men, are felt to be protected against cardiovascular disease by estrogens. It is then paradoxical that in cross-sectional studies of...

The Female Athlete Triad

Disordered eating, estrogen deficiency, and menstrual dysfunction predispose women to the third component of the triad, osteoporosis 89 . Reduced BMD in premenopausal women appears to be irreversible, despite weight gain, resumption of menses, or estrogen replacement 6,7 . One study found that, with the resumption of menses, there was a significant increase in vertebral BMD. However after 2 years of normal menses, BMD remained below the age-normative level. Slemenda and colleagues 97 have shown that the low estro-genic state associated with amenorrhea has a more profound effect on cancellous bone than on cortical bone. Cancellous bone is found in a higher percentage in the pelvis, sacrum, and femoral neck areas where female athletes tend to have a higher occurrence of stress fractures. These factors put the female athlete who is experiencing the triad complex at a significant risk for stress fractures. Although some investigators have found that weight-bearing exercise has a...

Effect Of Botanicals On The Breast

The role of food in health and disease is of immense and ongoing interest. One of the most studied botanicals is soy. Soy has been reported to have protective effects against breast cancer in Asian women. At least two studies have evaluated the effect of soy isoflavones on the breast using NAF, one (Hargreaves et al., 1999) short term (2 weeks) and the other (Petrakis et al., 1996) for a longer duration (6 months). The short-term study administered 45 mg soy isoflavones to 84 healthy premenopausal women. They found that the isoflavones genistein and daidzein were concentrated in NAF compared to matched serum, both before and after soy supplementation, and that apolipoprotein D (apoD) levels were significantly lowered and pS2 levels were raised in response to soy ingestion (pS2 levels rise and apoD levels go down in response to estrogen Harding et al., 2000). NAF cytology did not significantly change. In the longer-term study, which evaluated both pre- and postmenopausal white...

Two Dimensional Polyacrylamide Gel Electrophoresis

Were analyzed using enzyme-linked immunosorbent assay (ELISA), a high-throughput method of evaluating protein concentration. Considering all subjects, GCDFP-15 levels were significantly lower and AAG levels significantly higher in breasts with cancer. This was also true in pre- but not postmenopausal women. GCDFP-15 levels were lowest and AAG levels highest in women with DCIS. Menopausal status influenced GCDFP-15 and AAG more in women without than with breast cancer. ApoD levels did not correlate significantly with breast cancer.

Initial Studies Of Naf Focus On Feasibility

In order for NAF to be useful as a screening tool, it is essential to collect a sample in the vast majority of women. As a result, increasing the success rate continued to be an important area of investigation for the next 30 years. Early studies indicated that the ease of collecting NAF was related to the ethnicity of the individual, with NAF being more difficult to collect from Asians than African Americans or Caucasians (Petrakis et al., 1975). This was presumed to be due to the physiology of the breast, a modified ceruminous gland and is probably related to the secretory pattern in the breast and other ceruminous glands, which provide less secretions in most Asians (Petrakis, 1971) and American Indians (Petrakis, 1969) who are thought to have come from Asia than in Caucasians and African Americans. Other variables (Petrakis et al., 1975) found linked to success in NAF collection included age (late premenopause had the highest yield) and menopausal status (premenopausal subjects...

Effects of Chemotherapy on Ovarian Function

Due to improved survivorship from childhood cancer noted as early as the 1970s to 1980s, large cohorts of female survivors have reached the 3rd and 4th decades of life, where the risk for infertility and premature menopause has been examined. Two large studies of these survivors demonstrated elevated risks for infertility and premature menopause 9,24 . A study of 2,498 female survivors, treated between 1945 and 1975, showed a 7 deficit in fertility, compared with siblings. Between ages 21 and 25 years, survivors had a risk of premature menopause four times greater than that of siblings. Treatment-related risk factors included radiotherapy alone (RR 3.7), alkylating agents alone (RR 9.2) or a combination of both (RR 27). By age 31,42 of these women had reached menopause, compared with 5 of siblings 9 . In a study of 719 survivors treated between 1964 and 1988,15.5 of women were unable to conceive. Women treated with abdominopelvic radiotherapy alone had a fertility deficit of 23 ,...

Life stages and the skin

Common physiologic changes in the skin of women during menopause include hot flashes, increased perspiration, increased hair growth on the face, and varying degrees of scalp hair loss. Other skin conditions associated with menopause are chloasma, pedunculated fibromas (skin tags), lichen simplex chronicus, vulvar pruritus, keratoderma climacterium (palmar psoriasis), and rosacea.

Autoimmune Endocrine Diseases

The potential of HSCT for treatment of autoimmune diseases is dependent on both the pathogenesis and severity of the underlying disorder. For example, hormone replacement therapy is both effective and well tolerated in patients with thyroiditis and (after destruction or removal of the thyroid gland) Graves' disease. Prognosis for these diseases is excellent, and complications related to hormone therapy are minimal therefore, HSCT for these diseases cannot be justified. Moreover, HSCT is effective only for diseases in which the primary defect is expressed through hematopoietic stem cells. For example, autoimmune polyendocrine syndrome type 1 results from a defect in central (thymic) toler

Endogenous Substances Single Protein Analysis 9411 Hormones and Growth Factors

Leptin is a hormone that plays a central role in food intake and energy expenditure (Macajova et al., 2004). Systemic levels of leptin are increased in obese individuals, and have been found to stimulate the growth of breast cancer cells in vitro. Leptin levels in NAF were more readily measured in post- than in premeno-pausal women and were significantly higher in postmenopausal women with a body mass index (BMI) 25 (Sauter et al., 2004a). While NAF leptin levels were not associated with pre- or postmenopausal breast cancer, they were associated with premenopausal BMI.

Why Do I Still Feel Hypothyroid

Other potential causes of these ailments include physical and emotional stress, sleep deprivation, normal aging (including menopause), sedentary living (the older we get, the less active we become), poor diet, obesity or obesity-related diseases (such as diabetes or cardiovascular disease), and other diseases we should be managing. Remember, too, that bouts of hypothyroidism seriously interfere with your normal activities. Many people become more sedentary, gain weight, and may consequently feel bad even after their thyroid hormone levels are restored. Bouts of hypothyroidism can leave us out of the loop at work and socially, and we may feel the consequences of having to catch up or the long absence of engagement in our community or our social network, in turn, that can trigger real depression. (See Chapter 24.) In that way we can feel worse or unwell in spite of normal thyroid hormone and TSH levels.

Organ Damage Induced by Cytotoxic Therapy

Radiotherapy and chemotherapy each may cause transitory or permanent effects on hormonal function, reproductive capacity and sexual function. Primary ovarian failure, impaired development of secondary sexual characteristics, menstrual irregularities, including oligomenorrhea and amenorrhea, or premature menopause may occur. The menopausal state, when it occurs prematurely, is associated with the same physical symptoms as are seen with normal aging,including hot flashes,loss oflibido and osteoporosis 2,3 . Such effects are not simply physically bothersome to survivors, but adversely impact their quality of life 4 . The specific effects are dependent on the ovarian dose of radiation and the chemotherapeutic agents and their doses. They also depend on the developmental status of the patient at the age of treatment.

Inhibitors of Bone Resorption

Hormone Replacement Therapy (HRT) In the PEPI trial, HRT increased BMD at the hip by 1.7 and at the spine by 3.5 to 5.0 over a 3-year period compared to placebo. HRT inhibits bone loss for the duration of the therapy, which recurs once therapy is discontinued. In premenopausal women with osteoporosis secondary to hypoestrogenic stages, early intervention with estrogen to achieve return of menses, is critical since bone loss may be irreversible. Observational studies consistently suggest that postmenopausal HRT reduces the risk of hip and other types of fractures.30 Evidence from randomized controlled trials (RCTs), especially for vertebral fracture prevention, is less available. In a Danish RCT, HRT reduced forearm fracture incidence in recent postmenopausal women.31 In another randomized trial, HRT and vitamin D prevented nonvertebral fractures in postmenopausal women.32 A meta-analysis published in 2001 suggests that estrogen reduces risk of nonvertebral fractures by 27 . Estrogen...

Neurotransmitter Correlates

Another means of making inferences about brain serotonin in humans involves neuroendocrine challenges. For example, researchers have infused serotonin agonists such as fenfluramine into subjects' veins, which bind to serotonin receptors in the hypothalamus and cause release of the hormone prolactin from the pituitary gland into the peripheral circulation. Thus, the prolactin response to d,l-fenfluramine is thought to provide an index of brain serotonergic function. A number of studies conducted on this topic (but not all) have revealed inverse relationships between fenfluramine-induced prolactin release and indices of behavioral aggression and hostility in personality-disordered patients. Studies utilizing other serotonin agonists such as meta-chlorophenylpiperazine and ipsapirone have also revealed inverse associations with prolactin release and ratings of hostility in personality disordered subjects (Coccaro, 1998). Although comor-bid alcoholism was a potential confounding factor in...

Human Studies of Behavioral Effects of Androgens and Estrogens

Estrogen also affects behavior later in life. Cognition changes with variations in estrogen levels resulting from the menstrual cycle, oral contraceptives, menopause, and estrogen treatment. Estrogen facilitates aspects of motor function, perhaps by modulating left-hemisphere regions involved in praxis. Estrogen also facilitates memory, so that postmenopausal women receiving estrogen supplementation have better memory than women not taking estrogen. There are associated changes in brain activity, especially in regions involved in memory, including frontal lobes and hippocampus.

Breast

The third phase of mammary development occurs during pregnancy and lactation and at this stage the breast can be considered to be morphologically mature and functionally active. The alveolar buds and lobes subdivide further, giving rise to large clusters of alveolar lobes. During lactation, the clusters of alveolar lobes become distended and form secretory alveoli lined with alveolar cells which produce milk. After cessation of lactation, involution of the breast occurs where the secretory cells of the alveoli degenerate and disappear. Similarly, after the menopause, there is progressive involution of the ductal and glandular components of the breast. The connective tissue supporting the breast also degenerates with loss of stromal cells and collagen fibres.

Tamoxifen

D profile and is administered orally at a dose of 20 mg day. It improves survival in postmenopausal and premenopausal patients whose tumors are estrogen receptor positive. Tamoxifen has also been shown to decrease further the recurrence rate in patients receiving chemotherapy. There may be a small benefit for women with estrogen receptor negative tumors. Tamoxifen should be given for at least 2 years and is usually given for 5 years. Studies indicate no survival benefit for use of Tamoxifen beyond 5 years.

High Cholesterol

Hypothyroid people often have high cholesterol that can lead to a host of other problems, including heart disease. This should be controlled through diet until your thyroid problem is brought under control. It's generally recommended that anyone with high cholesterol be tested for hypothyroidism. Cholesterol-lowering medications should not be started unless the high cholesterol levels persist a few months after sufficient thyroid hormone replacement therapy. We discuss cholesterol more in Chapter 25.

Hypothyroidism

Unlike primary hypothyroidism, it is not useful to monitor TSH in patients with central hypothyroidism. In a prospective study of 37 patients with central hypothyroidism, free T4 and free T3 were monitored during therapy and adjusted to achieve free T4 in the midnormal range without free T3 elevation and without symptoms of hypothyroidism or hyperthyroidism 14 .We usually adjust thyroid hormone replacement therapy in patients with central hypothyroidism to maintain the level of free T4 just above the middle of the normal range (for example, free T4 of 1.4-1.6 ng dl if the normal range is 0.781.85 ng dl).

History

The factors of age group and gender are also important, for several diseases are often related to age or gender. The autoimmune disorder known as Sjogren's syndrome, for example, is common in menopausal women, while mumps, parotid swelling due to paramyxoviral infection, usually occurs in children between the ages of 4 and 10 years.

Silent Thyroiditis

This kind of thyroiditis was not discussed until the 1970s and was possibly mistaken for transient Graves' disease before then because of thyrotoxicosis. Again, the thyroiditis runs its course and the thyrotoxicosis clears up. In the course of the diagnosis, a silent thyroiditis sufferer may be given a radioactive iodine uptake test, showing almost no uptake, to distinguish it from Graves' disease with high uptake. Often, no treatment is necessary, and the condition clears up by itself. At other times, beta-blockers provide relief from some thyrotoxic symptoms. If a period of hypothyroidism follows the transient episode of thyrotoxicosis, it may require thyroid hormone treatment unless it is very brief. Some people with this thyroiditis become permanently hypothyroid, requiring lifelong thyroid hormone replacement therapy.

Alopecia Areata

Another new scarring hair loss reported in Australia termed postmenopausal frontal fibrosing alopecia may in fact be a frontal variant of lichen planopilaris (Kossard, 1997). This was described as progressive, asymptomatic, marginal scarring hair loss extending to temporal and parietal areas in menopausal women.

Menstruation

Struation (menarche) at about age 12, although between 10 and 14 years is normal. Menstruation continues cyclically for several decades until the final menstrual period at an average age of 51. A woman is menopausal once she has had a year without menstrual flow. The menopause transition (or perimenopause) occurs during the final years of menstruation and lasts about four years from the start of irregular periods. Perimenopause is a time of change with high or variable estrogen levels, ovulation disturbances, and consequent changes in flow, unpredictability of menstrual cycles, and more intense premenstrual experiences. between the LH peak and flow or fewer than 10 days between temperature rise and the next menstruation. Short luteal phase cycles are associated with early miscarriages and infertility. In addition, short luteal phases are associated with risks for low bone density (and subsequent osteoporosis). Short luteal phase cycles are common during the first 12 years following...

Mood Swings

Mood swings can be an especially tricky symptom of both menopause and thyroid disease. While irritability and depression can be symptoms of menopause, they may also be signs of thyroid disease. The following menopausal symptoms can also be confused with symptoms of hypo-or hyperthyroidism

Osteoporosis

Postmenopausal women are at highest risk of developing osteoporosis (bone loss), which can be aggravated by thyrotoxicosis (see further). Eighty percent of all osteoporosis sufferers are women as a direct result of estrogen loss. Maintaining bone mass and good bone health is your best defense against osteoporosis. Although osteoporosis can be disfiguring, it is a relatively silent disease in that there are often no immediate symptoms, pain, or suffering that occur with it. The problem is not osteoporosis itself but the risk of fractures. One out of two women over fifty will have an osteoporosis-related fracture in her lifetime. If you have osteoporosis and fall down, a fracture can dramatically affect the current and future quality of life. If you've ever experienced reduced mobility, or you've been dependent on someone else to prepare meals, shop, or run errands, you may have some idea as to how debilitating being bedridden and immobile can be. A full 70 percent of all hip fractures...

Summary

Both chemotherapy and radiotherapy can affect ovarian function in female survivors of childhood cancer. The effects are varied and dependent on the chemotherapeutic agents and doses, radiotherapy doses,techniques,volumes and fields and the age and pubertal status of the female. There is also considerable individual variation, the reasons for which remain largely unknown. Problems may include primary ovarian failure, reduced libido, pregnancy complications and premature menopause. Preventive strategies remain limited. Avoidance or reduction in the dose of gonadal toxic therapies should be attempted where possible. Where this is not possible, advances in reproductive medicine may ultimately allow for ovarian cryopreservation and similar techniques. Survivors should receive health counseling about risks, annual physical examinations with attention paid to endocrine and reproductive function, close monitoring of gonadal function and referral to pediatric endocrinologists, reproductive...

Genetic Issues

The prevalence of osteoporosis varies by sex, ethnicity, and race.12 Decreased bone density is more common in women of Northern European or Asian descent. Women and men experience age-related decrease in bone mass density starting at midlife, but women experience more rapid bone loss after the menopause.13 Genetic syndromes like Turner's (45,X0) syndrome patients have streak ovaries and decreased estrogen production leading to the early development of osteoporosis.14

Lifestyle

To prevent osteoporosis, the physician should attempt to establish early detection of low bone mineral density (BMD). Currently there is no accurate measure of bone strength, but BMD is the accepted method to establish a diagnosis of osteoporosis and predict future fracture risk.22,23 The World Health Organization (WHO) defines osteoporosis as a BMD 2.5 standard deviations (SDs) below the mean for young white adult women. This definition does not apply to other ethnic groups, men, or children.7,24 The U.S. Preventive Services Task Force suggests that the primary reason to screen postmenopausal The most thoroughly studied and most widely used technique to measure BMD is the dual-energy x-ray absortiometry (DEXA) scan. This is considered to be the gold standard screening test to measure the BMD of the hip and spine. It is less expensive and involves less radiation exposure than the quantitative computed tomography (CT). Since some patients don't respond to therapy for osteoporosis, the...

Management

And magnesium disrupt the normal metabolism of bone, which has significant effects on the internal structure and strength of bone 41 . Part of this treatment option is determining the appropriate use of hormone replacement therapy in amenorrheic females. A critique of the athlete's diet is also important to ensure adequate caloric intake and appropriate vitamins and minerals to maintain adequate bone density. Psychologic assessment may be needed in athletes with eating disorders. A supervised, graduated physical therapy program is required to define and control the duration, frequency, and intensity of activity as the athlete moves closer to full competition. The correction of training errors that led initially to the stress fracture is essential to the rehabilitation process. Athletes are allowed to continue conditioning exercises such as swimming or cycling during the period of rest for their injured femur. In some patients, the use of unloader braces may be appropriate to decrease...

Estrogens

17 -Estradiol is the main estrogen synthesized and secreted by normal female ovaries. Its oxidized analog, estrone, is secreted to a significantly lesser degree by premenopausal ovaries. The hormonal effect of estrogens on target tissues is based on a complex mechanism that includes their reaction with specific estrogenic cytoplasmic receptors. After binding with these receptors, a conformational change occurs, which results in the estrogen-receptor complex penetrating into the nucleus, where it disassociates and returns to its native condition. Estrogens are used for insufficient ovary function. Estrogen replacement therapy is used in agonadal, menopausal, hypothalamic, and amenorrheal conditions (i.e. in cases of primary hypogonadism and hormone therapy in postmenopausal women). Estrogens are also recommended for other clinical endocrine diseases if hypoestrogenism has been established. Estrogens are most widely used in combination with progestins in a number of oral contraceptive...

Risedronate Actonel

Risedronate is a newer biphosphonate approved in 2000 by the FDA for treatment of postmenopausal osteoporosis. While the indications are the same as alendronate, it has fewer gastrointestinal side effects. Both agents cost over 50 a month. In a randomized, double-blind, placebo-controlled trial of 2458 ambulatory postmenopausal women younger than 85 years with at least 1 vertebral fracture at baseline, risedronate decreased the relative incidence of new vertebral fractures by 41 over 3 years. The absolute risk reduction was from 16.3 to 11.3 . The cumulative incidence of nonvertebral fractures over 3 years was reduced by 39 (5.2 vs 8.4 ). The overall safety profile of rise-dronate, including gastrointestinal safety, was similar to that of placebo. The most effective dose was 5 mg day.39

Battling the Bloat

Good sources of soluble fiber include oats or oat bran, legumes (dried beans and peas), some seeds, carrots, oranges, bananas, and other fruits. Soybeans are also high sources of soluble fiber. Studies show that people with very high cholesterol have the most to gain by eating soybeans. Soybeans are also a phytoestrogen (plant estrogen) that is believed to lower the risks of estrogen-related cancers (for example, breast cancer), as well as lower the incidence of estrogen-loss symptoms associated with menopause.

Breast Cancer

Another international study of 3,817 women diagnosed with HD before age 30 reported that 105 developed breast cancer at a mean of 18 years after diagnosis and at a mean age of 40.7 years 57 . Increased risk of breast cancer was observed in patients who had received more than 40Gy to the chest, and there was a dose-response relationship. Overall, women who became menopausal before age 40, either as a result of radiation or alkylating agent chemotherapy, experienced significant reductions in risk, compared with women who retained ovarian function. Among those patients who did not become menopausal, the number of alkylating agent cycles received was inversely related to the risk of breast cancer, also implying decreased risk when ovarian function is lost. Regarding the possible role of genetic susceptibility in survivors of HD, Nichols et al. found that TP53, BRCA1 or BRCA2 were not frequently mutated in a cohort who had developed SMNs 44 . Many reports have documented that the risk of...

Definitions

Late onset hypogonadism (LOH) is the term recommended by the International Society for the Study of the Aging Male (ISSAM), the International Society of Andrology (ISA), and the European Association of Urology (EAU), to replace the previous terminology of andropause, androgen deficiency of the aging male (ADAM), and partial androgen deficiency of the aging male (PADAM) 2 . It is a clinical and biochemical syndrome associated with advancing age and is characterized by typical symptoms and a deficiency in serum T levels. It may result in significant detriment in the quality of life and adversely affect the function of multiple organ systems.

Acknowledgements

Cost-effectiveness scenario analysis for a proposed trial of hormone replacement therapy. Health Policy 1997 39 181-94. 19 Smith TJ, Hillner BE. The efficacy and cost-effectiveness of adjuvant therapy of early breast cancer in pre-menopausal women. J Clin Oncol 1993,11 771-6.

I1111012 1340 50

Months to a few years, the cycle ceases altogether, as shown in Figure 81-10. The period during which the cycle ceases and the female sex hormones diminish to almost none is called menopause. The cause of menopause is burning out of the ovaries. Throughout a woman's reproductive life, about 400 of the primordial follicles grow into mature follicles and ovulate, and hundreds of thousands of ova degenerate. At about age 45 years, only a few primordial follicles remain to be stimulated by FSH and LH, and, as shown in Figure 81-10, the production of estrogens by the ovaries decreases as the number of primordial follicles approaches zero. When estrogen production falls below a critical value, the estrogens can no longer inhibit the production of the gonadotropins FSH and LH. Instead, as shown in Figure 81-9, the gonadotropins FSH and LH (mainly FSH) are produced after menopause in large and continuous quantities, but as the remaining primordial follicles become atretic, the production of...

Psychic functions

The assumption that postmenopausal women enjoy protection from Alzheimer disease when they receive estrogen replacement therapy has been challenged by the recently discontinued Women's Health Initiative (WHI) study. The WHI Memory Study showed that the combination of conjugated equine estrogens and progestagens increased the risk of probable dementia in postmenopausal women aged 65 years or over 149 . This could be due to the antagonistic effects of medroxyprogesterone acetate on the positive effects of estrogens on cognitive functions 150 , and not to estrogenic effects per se. There is evidence that androgens confer protection from Alzheimer disease in their own right 151 . So there may be an advantage in supplementing androgens in aging men whose T levels have fallen below a certain limit, thereby in fact substituting both androgens and estrogens. Not all studies in aging men are in agreement, however. A recent study 152 found only a link between cognition and estrogens in...

Hip Fractures

The best treatment for osteoporosis is prevention. Preventive measures include hormone replacement therapy, exercise, alendronate, increased calcium intake, and calcitonins (see Reference 56, Chapter 122). Recently, combination therapies of estrogen and alendronate have yielded even greater increases in bone mineral density and are tolerated quite well.5 Certain facts are important to remember when considering the prescription of preventive measures short-term intervention late in the natural course of osteoporosis may have significant effects on the incidence of hip fractures 6 hip fracture may be associated with reduced muscle strength rather than reduced body mass or fat 7,8 long-term heavy activity reduces the risk of hip fracture in postmenopausal women 9 and height appears to be an important independent risk factor for hip fracture among American women and men.10 Factors that are protective relative risk (RR)

Conclusions

DHEA is one of the most abundant circulating hormones. DHEA has been shown to exert its effects via downstream conversion to the steroid sex hormones, neuromodulation, improvement in en-dothelial function, and perhaps by means of action on a cell membrane-bound receptor. DHEA deficiency has been correlated with various endocrine, age-related, and other non-hormonal medical conditions. DHEA supplementation has been shown to be beneficial in patients with primary and secondary adrenal insufficiency. However, studies looking at the effects of DHEA supplementation on well-being, metabolism, and sexual function, in euadrenal subjects (including premenopausal and post-menopausal women with androgen insufficiency) have been inconsistent to date. Further research, in the form of randomized, blinded, placebo-controlled studies, is needed to better elucidate the efficacy and safety of DHEA supplementation for the treatment of androgen insufficiency in women.

Androgens

Methyltestosterone is a synthetic analog of testosterone that possesses all of the properties of testosterone, exhibiting stimulatory action on the development of male sex organs and secondary sex characteristics, although it is not degraded by enzymes in the gastrointestinal tract, and therefore it can only be taken orally. It is used for the same indications as testosterone for sexual underdevelopment, functional problems of the reproductive system, and the vascular nerve disorders associated with climacteric problems in men. It is also used for dysfunctional uterine bleeding in premenopausal and menopausal women as well as for breast and ovarian cancer. Synonyms of this drug are androral, testoral, oraviron, and others.

Sleep and obesity

The control of sleep is closely linked to feeding behaviour and energy expenditure. These determine the body weight and in particular the body fat and lean body mass. Body weight and body mass index (weight in kg height in m squared) are only indirect indicators of obesity because they do not assess body composition. Other measures, such as the waist to hip ratio and collar circumference, give an indication of the distribution of body fat and in particular whether it has a central rather than a peripheral location. Central fat deposition is more common in males and post-menopausal females, and peripheral fat is more common in pre-menopausal females.

Skeletal System

Osteoporosis is most typical in post-menopausal women, who have low blood levels of the hormones estrogen and progesterone. Men can get osteoporosis, too, but their testosterone supports building greater bone mass. Though their risk is less than women's, men can get osteoporosis as their testosterone levels decline with age.

Iron Losses

The low solubility of iron at physiologic pH precludes urinary excretion as a major mechanism of maintaining iron homeostasis. Thus, in contrast to most other trace minerals whose homeostasis in maintained by excretion, the primary mechanism of maintaining whole body iron homeostasis is to regulate the amount of iron absorbed so that it approximates iron losses. Iron losses can vary considerably with the gender of the individual. In male humans, total iron losses from the body have been calculated to be 1 mg day. For premenopausal female humans, this loss is slightly higher. The predominant route of loss is from the GI tract and amounts to 0.6 mg day in adult males (28). Fecal iron losses derive from shed enterocytes, extravasated red blood cells, and biliary heme breakdown products, which are poorly absorbed. Urogenital and integu-mental iron losses have been estimated to be greater than 0.1 mg day and 0.3 mg day, respectively, in adult males (27). Menstrual iron loss, estimated from...

Gender

As discussed in Chapter i, incidence of hypertension is influenced by gender. Basically, males exhibit higher incidence rates of essential hypertension than females until menopause. Following this stage in life, females' incidence rates increase and actually exceed incidence rates for males (Wolz et al., 2000). Naturally, this has alerted researchers to the importance of the menstrual cycle in protecting women from onset of In a meta-analysis of 12 studies that compared cardiovascular responses to stress between males and females, Stoney, Davis, and Matthews (1987) found evidence to support gender differences in acute physiological response to stress. Males, in contrast to females, exhibited significantly higher SBP and epinephrine responses, but lower heart rate responses to stress. Measurement of hemodynamic responses of males and females using impedance cardiography has also revealed consistent gender differences, with males showing more of a total peripheral resistance response to...

Fertility

Most research on fertility and pregnancy outcomes after treatment has reported primarily on the risks for infertility in cancer survivors. Current knowledge regarding reproductive effects in young adult survivors of adult-onset and childhood cancer focuses primarily on treatment-related risk factors for infertility and other reproductive organ gonadal effects, including early menopause (Byrne 1999a Kwon and Case 2002). Fertility preservation and pregnancy outcomes, including effects of treatment on progeny of childhood survivors and risks for congenital defects and cancer, also have been evaluated (Aslam et al. 2000 Blatt 1999 Byrne 1999b). Some reports go as far as to mention artificial insemination, in vitro fertiliza-

Background

There are a number of incidences where young patients may wish to protect and or preserve their future fertility. Fertility preservation may, for example, be advocated in girls and adolescents undergoing surgical interventions where the ovaries must be removed as a consequence of abdominal trauma. For adolescents and young women who have a familial history of premature ovarian failure, it may be foolhardy to delay child-bearing (Conway 2001 Davis etal. 2000). These patients may elect to preserve their oocytes or ovarian tissue to prolong their reproductive lifespan. Girls with Turner Syndrome have a very high risk of premature menopause or, in the most severe cases, they may be permanently sterile. The former group of individuals may elect to cryopreserve their ovarian tissue during their pre-pubertal or early teenage years before their ovarian reserve is completely lost and menopause ensues (Hreinsson etal. 2002 Saenger etal. 2001). The overwhelming application of fertility...

Puberty and Menarche

Total rates of secretion of gonadotropic hormones throughout the sexual lives of female and male human beings, showing an especially abrupt increase in gonadotropic hormones at menopause in the female. Figure 81-10 shows (1) the increasing levels of estrogen secretion at puberty, (2) the cyclical variation during the monthly sexual cycle, (3) the further increase in estrogen secretion during the first few years of reproductive life, (4) the progressive decrease in estrogen secretion toward the end of reproductive life, and, finally, (5) almost no estrogen or progesterone secretion beyond menopause.

Iron Metabolism

Blood loss in the menses is a major source of iron loss in females between menarche and menopause. Average iron loss in the menses is 0.6 mg d.6 However, about 10 of women lose more than 1.4 mg of iron per day in the menses.6 Total iron loss in menstruating females averages 1.4 mg d. It is estimated that the mean iron loss in men and in women who are postmenopausal is 0.9 mg d.1

Alendronate Fosamax

Alendronate was approved by the FDA in 1995 for treatment of post-menopausal osteoporosis. It reduces the risk of vertebral fractures by 30 to 50 and increases the BMD at the spine and hip.35 Alendronate also reduces the risk of fractures in men and women with osteoporosis secondary to the chronic use of steroids.36 One study evaluated the addition of alendronate to HRT in the treatment of postmenopausal women with low BMD despite ongoing treatment with estrogen.37 Compared with HRT alone, at 12 months alendronate plus HRT produced significantly greater increases in BMD of the lumbar spine (3.6 vs. 1.0 , p .001) and hip trochanter (2.7 vs. 0.5 , p .001). This study suggests that alendronate may be beneficial when added to HRT in postmenopausal women with low BMD despite ongoing treatment with HRT. However, it should be noted that the outcome measured was BMD and not fractures. The recommended starting dose for postmenopausal osteoporosis prevention is 5 mg day with a maintenance dose...

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