Lower Your CRP

From Virginia Hopkins Health Watch -- nutritional ways to lower your C-Reactive Protein, an independent risk factor for cardiovascular disease and marker for inflammation.

1. Vitamin C (1000 mg/day) lower CRP in humans by 25%

2. Vitamin E & CoQ10 reduce CPR in baboons by 30%

3. Krill oil (300 mg/day) taken for two weeks by humans reduced CRP by 30%

4. Eat more fruits and veggies: 30% reduction

5. This one's for Jo: regular, small amounts of dark chocolate lower CRP by 20%

PMS: Why, Why, Why?

I see a lot of women in our practice who suffer the 3 to 10 days before menstruation with irritability, rage and crazy mood swings. Many of these women have needlessly been started on an anti-depressant such as Prozac or Zoloft or Paxil. We have myriad natural ways of easing Premenstrual Syndrome (PMS), from raising serotonin more naturally (without derailing libido) to nutritional changes to supplements that re-balance the underlying hormonal causes.

Eckhart Tolle, the luminous spiritual guide of Oprah and millions of others, has a great take on PMS. I am excerpting his text from A New Earth, p 154.  See if it resonates with you.

The Collective Female Pain-Body

The collective dimension of the pain-body has different strands in it. Tribes, nations, races, all have their own collective pain-body, some heavier than others, and most members of that tribe, nation or race have a share in it to a greater or lesser degree.

Almost every woman has her share in the collective female pain body, which tends to become activated particularly just prior to the time of menstruation. At that time many women become overwhelmed by intense negative emotion.

The suppression of the feminine principle especially over the past two thousand years has enabled the ego to gain absolute supremacy in the collective human psyche. Although women have egos, of course, the ego can take root and grow more easily in the male form than in the female. This is because women are less mind-identified than men. They are more in touch with the inner body and the intelligence of the organism where the intuitive faculties originate. The female form is less rigidly encapsulated than the males, has greater openness and sensitivity toward other life-forms, and is more attuned to the natural world.

If the balance between male and female energies had not been destroyed on our planet, the ego's growth would have been greatly curtailed. We would not have declared war on nature, and we would not be so completely alienated from our Being.

Nobody knows the exact figure because records were not kept, but it seems certain that during a three-hundred year period between three and five million women were tortured and killed by the "Holy Inquisition,"an institution founded by the Roman Catholic Church to suppress heresy. This surely ranks together with the Holocaust as one of the darkest chapters in human history. It was enough for a woman to show a love for animals, walk alone in the fields or woods, or gather medicinal plants to be branded a witch, then tortured and burned at the stake. The sacred feminine was declared demonic, and an entire dimension largely disappeared from human experience. Other cultures and religions, such as Judaism, Islam, and even Buddhism, also suppressed the female dimension, although in a less violent way. Women's status was reduced to being child bearers and men's property. Males who denied the feminine even within themselves were now running the world, a world that was totally out of balance. The rest is history or rather a case history of insanity.

Who was responsible for this fear of the feminine that could only be described as acute collective paranoia? We could say: Of course, men were responsible. But then why in many ancient pre-Christian civilizations such as the Sumerian, Egyptian, and Celtic were women respected and the feminine principle not feared but revered? What is it that suddenly made men feel threatened by the female? The evolving ego in them. It knew it could gain full control of our planet only through the male form, and to do so, it had to render the female powerless.

In time, the ego also took over most women, although it could never become as deeply entrenched in them as its men.

We now have a situation in which the suppression of the feminine has become internalized, even in most women. The sacred feminine, because it is suppressed, is felt by many women as emotional pain. In fact, it has become part of their pain-body, together with the accumulated pain suffered by women over millennia, through childbirth, rape, slavery, torture, and violent death.

But things are changing rapidly now. With many people becoming more conscious, the ego is losing its hold on the human mind. Because the ego was never as deeply rooted in woman, it is losing its hold on women more quickly than on men.

CSK: Filling the Gap between Farmer's Markets & Your Table

Do you feverishly buy lots of produce at your local farmer's market only to watch sadly as it composts in your fridge a few days later? Or maybe what's rotting is your weekly box of Community-Sponsored Agriculture (CSA) fruits and vegetables? I find that there's a huge gap between my desire for local, sustainable food and my ability to find the time to process and cook it all.

Community Sponsored Kitchens (CSK) to the rescue! We are blessed in the Bay Area with Three Stone Hearth, an amazing CSK based on the Wise Traditions of Weston Price and Nourishing Traditions movement of Sally Fallon. Founded by Jessica Prentice and four other visionaries, Three Stone Hearth sources the CSA food and translates it for you into yummy dishes that you heat-and-serve. Every week they feature a different region for food inspiration.

I'm in a cluster for the Rockridge area, and my clustermates and I take turns picking up the goods on Wednesday 5-7pm from the Berkeley location of Three Stone Hearth. Last night I came home to Hui Beef Stew with chick peas and bok choy, peanut curry with chicken and vegetables, and Thai minced pork with galanga, lemongrass and mint. Served with sprouted mung bean salad and steamed Massa rice with coconut oil - you have a nutrient-rich meal that kids love too, and it takes very little time.

Check it out. Their eggs, dried majorum and cheeses are amazing too.  And their bone-broth based soups have helped raise my ferritin (iron) levels higher than any supplement, and also are rich in glucosamine.

Thyroid: Is Yours Working Optimally?

Here is a great thyroid questionnaire, modified from the Hotze Health and Wellness Center. If the question addresses a concern that applies to you, record the number. When done, total the numbers.

1. Do you experience fatigue (4)?
2. Is your cholesterol elevated (4)?
3. Do you have difficulty losing weight (2)?
4. Do you have cold hands and feet (2)?
5. Are you sensitive to cold (2)?
6. Do you have difficulty thinking (2)?
7. Do you find it hard to concentrate (2)?
8. Do you have poor short-term memory (2)?
9. Are your moods depressed (2)?
10. Are you experiencing hair loss (2)?
11. Do you have fewer that one BM per day (2)?
12. Do you have dry skin (2)?
13. Do you have itchy skin in winter (1)?
14. Do you have fluid retention (2)?
15. Do you have recurrent headaches (1)?
16. Do you sleep restlessly (1)?
17. Do you experience afternoon fatigue (2)?
18. Are you tired when you awaken (2)?
19. Do you experience tingling in hands or feet (2)?
20. Have you had infertility or miscarriages (2)?
21. Do you have decreased sweating (2)?
22. Do you have muscle aches (2)?
23. Have you had recurrent infections (2)?
24. Do you have joint pain (2)?
25. Do you have thinning of your eyebrows or eyelashes (2)?

Score < 11? You are unlikely to have a thyroid problem.
Score 11-30? Low thyroid function is a possibility.
Score >30? Low thyroid function is probable. Get tested if your score is > 11, including a free T3 and TSH.

Love Wine?

Let’s chat about how much you drink. I have lots of patients who are working at demanding jobs, either in the corporate/non-profit sector or at home, and when dinnertime rolls around, a glass of wine just hits the spot. Many of my patients, blessed by proximity to sumptuous wine-growing regions, don’t stop at one glass: they have one while making dinner, one with dinner, and maybe one more after. They don’t see a problem with it. “But I have my liver checked every year, and my internist says I’m fine,” one patient confided.

The problem is the accumulated effect on the body: 2 glasses of wine 7 days per week is excessive. We know that the threshold for a problem is 12+ drinks per week. For every alcoholic, there are 4 problem drinkers. We know that 10% of us or more have a sticky relationship to alcohol. I’m interested in trying to prevent people from becoming problem drinkers, or if you are already, how to reverse the path toward alcoholism and/or over-consumption.
One glass of wine feels good. You’re relaxed -- more calm, open and loving. Two glasses – yum! But some of us get tipsy with more than one glass. When you’re tipsy, you’re at a greater risk of addiction, emotional problems, including irritability and depression, obesity or overweight, gastritis or ulcers, nerve and brain problems, hepatitis, cirrhosis, pancreatitis, hypoglycemia, immune suppression, injury and death. Even if you do not notice the white of your eyeballs turning yellow from hepatitis, you may still be doing some damage. Alcohol is what we call “empty calories” – that is, you are not getting essential vitamins, minerals or other nutrients. It can cause deficiencies over time. Alcohol causes rapid changes in blood sugar, which can cause mood swings, inconsistent energy and very commonly, sleep disruption.

I find that many perimenopausal or menopausal women or andropausal men can no longer tolerate wine on a regular basis – adrenal fatigue or fluctuating sex hormones increase your chances of intolerances or allergies to grains, grapes, sugar and yeast, all of which are contained in wine. And you already know that sulfites are bad for you.

Recently a study showed that the “healthy” limit of alcohol is 80 ounces/month (that’s 20 ounces per week, or 5 servings of 4 ounces – you’d be surprised with our increasing larger wine glass capacities how small a 4 ounce serving really is!). I recommend to my patients who are drinking too much to start measuring their wine (or even better, get your partner to do it for you) and stop at 20 ounces per week or less.

I was taught in medical school that the two ways to raise your good cholesterol or HDL were exercise and alcohol. In our sedentary culture, wine seems a lot easier than regular exercise! The problem is that not all people raise their HDL with alcohol: in 25% of the population with the ApoE4 genotype, moderate alcohol actually lowers HDL and raises the bad type of cholesterol (LDL).

For those of us who are battling the bulge, any excess alcohol gets stored as fat. Not good! Right around the time your liver stores those extra calories as fat, the calming effects of alcohol downslide toward numbness, flatness, delayed reflexes and poor coordination and judgment. If you slur your words – even mildly – you have overconsumed.

How do you know if you have a problem with drinking?
1. Intense craving. This is a sign of alcohol withdrawl.
2. Problems with your blood sugars: either hypoglycemia or pre-diabetes.
3. Difficulty with skipping your alcohol for 10-14 days at a time. I strongly recommend a periodic cleanse at a minimum of twice per year.
4. Drinking alone.
5. Drinking before a social outing or business function.
6. Drinking in the morning or late at night.
7. Drinking in place of meals or real nutrition.
8. Episodes of amnesia or blackouts. These are more common than you think. Do you get into fights with your spouse, and then forget the next day what you fought about?

What helps?

• Cut back or stop drinking. Keep to the 80 ounce/month limit or less. Have 2 days per week where you do not drink at all, and notice truthfully how you feel on those days versus the morning after you drink.

• Consider a 1-2 week cleanse. Stopping alcohol consumption for this length of time without difficulty is a good sign that you are not yet in serious trouble.
  

• Talk to your practitioner about getting help. We know acupuncture and massage are both helpful. Some people benefit from use of glutamine, topamax or antabuse.
  

• Alcoholics Anonymous or one of the moderate drinking groups can be helpful. Check out Moderation Management, a program aimed at helping early-stage problem drinkers and prevention of alcoholism.
  

Madonna Rocks Oakland!

She's my favorite Dominatrix. And she's FIFTY.

Went to the Madonna "Sweet & Sticky Tour" concert last night and still buzzing from the beauty, performance and sheer spectacle. Loved "Get Stupid" best for the call to action (check it out right here) but "Like A Prayer" with the juxtaposed Hebrew and Arabic was completely different from the old Catholic rant. Mostly her concert was super fun, inspired and energizing. Has there ever been a better live performer?

Who knew that Madonna was a master of double dutch?

I haven't had this much fun at night in a long time, in fact, not since Michelle Cordero's 40th birthday party at S Factor in San Fran. Well, Madonna is the original S girl. Check out those SOCKS!

Above: Does she shop at Serrahna on College Avenue? We all need some of these boots....

Shameless Plug for Husband, David Gottfried

My husband, David Gottfried, was just the cover story for a newspaper in Dubai. Here it is. He's my favorite green rock star.

Eat food. Not too much. Mostly plants.

In his introductory sentences to In Defense of Food:  An Eater's Manifesto, Michael Pollan has captured the essence of sound nutritional advice. Here is a link to his book jacket and a PDF of his intro. He gets it, and he writes brilliantly about a difficult subject:  what's so bad about the American way of eating, and how to change it.  Yet somehow he manages to stay chatty and engaging as he writes about depressing subjects such as the 32-billion dollar  "Food Marketing Machine" and the shifting sands of nutritional science (or the reason my patients are so confused).

I believe women need more than this to get back on track when they are 35+ and having trouble figuring out what to eat without developing middle-age spread, but it's the finest and most eloquent place to begin.

See you at the farmer's market.

Hormone Imbalance: Symptoms

After many requests, I am re-posting this from my other blog as it is consistently the most popular and my patients seem  to love it. It does not include enough questions related to leptin- and insulin-resistance... more on this in future blogs.

-- SG

How do you know if your hormones are out of balance? I combine a careful history of what my patients are experiencing, their nutritional status, level of activity/lifestyle and sleep along with symptom questionnaires and testing. If any part is left out, we may miss the root cause of the hormone imbalance.  Dr. John Lee's books are helpful with understanding symptoms, and I will provide those below with some modifications I've made.  If you are taking the questionnaire, check off any symptoms that you experience from each symptom group, then we'll integrate at the end.

Symptom Group 1: 

PMS?

Anxiety?

Cyclical headaches (menstrual or hormonal migraine)?

Insomnia?

Early miscarriage?

Lumpy or painful breasts?

Infertility?

Symptom Group 2:

Vaginal dryness or irritation?

Painful sex?

Bladder infections?

Night sweats

Hot flashes

Poor memory?

Depression, especially with lethargy?

Low libido?

Symptom Group 3:

Bloating and/or puffiness?

Abnormal paps?

Rapid weight gain?

Breast tenderness?

Mood swings?

Heavy bleeding?

Depression with anxiety?

Migraines?

Insomnia?

Brain fog?

Red flush on face?

Gallbladder problems?

Weepiness?

Symptom Group 4:

Number of checked symptoms for Group 1 & 3 combined

Symptom Group 5:

Acne?

Polycystic Ovary Syndrome?

Excess hair on face/chest/or arms?

Hyper- or hypo-glycemia and/or unstable blood sugar?

Thinning head hair?

Infertility?

Ovarian cysts?

Midcycle pain?

Symptom Group 6:

Low libido?

Debilitating fatigue?

Unstable blood sugar?

Brain fog?

Low blood pressure?

Thin or dry skin?

Intolerance to exercise?

Brown spots on skin?

For assessment, tally the total number of symptoms in each category.  If you have 2 or more symptoms from a grouping - you may have the following diagnosis. I recommend you sort this out with an integrative physician.

Group 1:  Progesterone deficiency.  This is the most common hormone imbalance of all ages.  Best approaches are to optimize diet, reduce synthetic hormones if you are taking any (including birth control pills) and add bioidentical progesterone if appropriate.

Group 2:  Estrogen deficiency.  This is most common in menopausal women, especially skinny minnies.  Dietary changes and herbal therapies are often helpful as a first approach.

Group 3:  Excess estrogen. We see excess estrogen when women are taking synthetic estrogen, too much bioidentical estrogen (estradiol, estriol, tri-est), or are exposed to environmental xenoestrogens.  Xenoestrogens refer to the 700+ chemicals in the environment that act like endrocrine disruptors in the body, usually by binding the estradiol receptor.  Xenoestrogens have estrogen-like effects such as fertilizers, pesticides and lauryl sulfates.

Group 4:  Estrogen dominance.  Usually caused by not having sufficient progesterone to balance estrogen.  Causes vary from not enough progesterone to too much estrogen, or as is common in premenopause (age 35-50):  low estrogen but superlow progesterone.

Group 5: Excess androgens or male hormones.  Often this is caused by insulin and/or leptin resistance, and we can reverse this with dietary changes and supplements, but other approaches are effective as well.

Group 6:  Cortisol excess or deficiency.  Most people need a laboratory test to differentiate.  This is caused by adrenal fatigue which results from chronic stress.

I find very few women survive work and kids without some degree of adrenal fatigue.

There also is interdependence among these different hormonal systems with each other as well as with neurotransmitters.  For instance, estrogen acts like a selective serotonin reuptake inhibitor and helps mood in many women.  Also, if adrenal hormones are off, this can interfere with conversion of T4 (inactive thyroid hormone) to T3 (active form of thyroid hormone).

For all of these conditions or for further information, I recommend consulting an integrative physician in your area such as those in this database.

Pre-Conception Counseling: Role of Mercury

Suddenly I am seeing lots of women who want to conceive or are pregnant already.  I am also seeing scary numbers of women with high mercury levels.  When I was getting pregnent, the brilliant advice of the CDC was "limit how much fish you eat to once per week or less."  I don't find that satisfying.

If you have metal fillings in your mouth or you eat seafood regularly, there's a good chance you might be mercury toxic.  I was and didn't know it.  You see - I have a great love for sashimi.  I ate it once/week for about a year when my office was near a glorious sushi restaurant, and since I have no metal fillings, I wasn't too concerned. Then I tested and found I was toxic.

Symptoms? Fun things such as:

emotional rage

depression

mood swings

irritability

anxiety

brain fog 

dementia

Alzheimer's disease

senior moments

memory loss

heart irregularity

shortness of breath

blood pressure problems

dizziness

numbness tremors

vision/hearing problems

MS or ALS

recurring infections autoimmune conditions

chronic fatigue

allergies/asthma

gum problems

low thyroid function

cold extremitities

unexplained weight gain

low libido (for men - poor erections)

infertility

birth defects

headaches

insomnia

lack of energy

metallic taste

As my thinking about pre-conception counseling evolves, I am integrating the importance of assessment and detoxification from heavy metals such as mercury and toxins such as xenoestrogens, chemicals in the environment that act like estrogen in your body.

I tried a lot of different mercury detox programs over the past two years since I was first diagnosed and have a few favorites.  More on that later....

I am teaming up with two other extraordinary physicians to try to raise awareness among women especially of reproductive age -- Drs. Marsha Nunley, MD and Bruce Dooley, MD.  We are planning some educational programming in San Francisco for the fall.  Stay tuned!

Shameless Plug for Green Home Remodel

Hi, Friends. One reason I've not been blogging so much (beyond two beautiful young kids, a great husband and a thriving practice) is our eco-craftsman green home remodel. Check it out here if you're interested!

Leaky Gut: What Is It? How to Heal?

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 your test kit), which is made of innocuous sugars that are not metabolized by humans. Most normal people absorb 14% (range 5-25%) of mannitol but <1% style="font-weight: bold;">


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. Call us for more information.

Wonderful New Physician Joining Us!

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.

Sleep Less?

I cannot believe how long it has been since my last post! We had a transformative trip to San Miguel de Allende in Mexico where I taught yoga, and time has gotten away from me. I've got some new content coming, but as that gestates, check out this good info from Harvard's Health Beat (May 8, 2008 edition) on how to deal with insomnia -- sleep less!

Surprising advice for insomniacs — sleep less

Changing your behavior, rather than medication, may be the first step to a better night’s sleep. And surprisingly, for chronic insomnia, the best treatment may be to cut back on the time you spend trying to sleep.

People with insomnia often find that spending less time in bed promotes more restful sleep and helps make the bedroom a welcome sight instead of a torture chamber. As you learn to fall asleep quickly and sleep soundly, the time in bed is slowly extended until you obtain a full night’s sleep.

Some sleep experts suggest starting with five or six hours at first, or whatever amount of time you typically sleep at night. Setting a rigid early morning waking time often works best. If the alarm is set for 7 a.m., a five-hour restriction means that no matter how sleepy you are, you must stay awake until 2 a.m. Once you are sleeping well during the allotted five hours, you can add another 15 or 30 minutes, then repeat the process until you’re getting a healthy amount of sleep.
Reconditioning

In the 1970s, a Northwestern University professor developed a technique to recondition people with insomnia to associate the bedroom with sleep. These are the rules:

* Use the bed only for sleeping or sex.
* Go to bed only when you’re sleepy. If you’re unable to sleep, get up and move to another room. Stay up until you are sleepy; then return to bed. If sleep does not follow quickly, repeat.
* During the reconditioning process, get up at the same time every day and do not nap.

The idea is to train your body to associate your bed with sleep instead of sleeplessness and frustration.
Relaxation techniques

For some people with insomnia, a racing or worried mind is the enemy of sleep. In others, physical tension is to blame. Fortunately, there are ways to release physical tension and relax more effectively. Relaxation techniques that can quiet a racing mind include meditation, breathing exercises, and progressively tensing and relaxing your muscles starting with your feet and working your way up your body — a technique known as progressive muscle relaxation.

In biofeedback, people use equipment that monitors and makes them aware of involuntary body states (such as muscle tension or hand temperature). Immediate feedback helps people see how various thoughts or relaxation maneuvers affect tension, enabling them to learn how to gain voluntary control over the process.

Biofeedback is usually done under professional supervision. Other relaxation techniques — such as progressive muscle relaxation or meditation — can be learned in behavior therapy sessions or from books, tapes, or classes.
Progressive muscle relaxation

Looking for a drug-free method to help you relax, free your mind of worries, and fall asleep? Progressive muscle relaxation is a tried and true technique for achieving both physical and mental relaxation.

* Lie down on your back in a comfortable position. Put a pillow under your head if you like, or place one under your knees to relax your back. Rest your arms, with palms up, slightly apart from your body. Feel your shoulders relax.
* Take several slow, deep breaths through your nose. Exhale with a long sigh to release tension.
* Begin to focus on your feet and ankles. Are they painful or tense? Tighten the muscles briefly to feel the sensation. Let your feet sink into the floor or the bed. Feel them getting heavy and becoming totally relaxed. Let them drop from your consciousness.
* Slowly move your attention through different parts of your body: your calves, thighs, lower back, hips, and pelvic area; your middle back, abdomen, upper back, shoulders, arms, and hands; your neck, jaw, tongue, forehead, and scalp. Feel your body relax and your lungs gently expand and contract. Relax any spots that are still tense. Breathe softly.
* If thoughts distract you, gently ignore them and return your attention to your breathing. Your worries and thoughts will be there when you are ready to acknowledge them.

Build Strong Hips

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

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.

Lupus & Hormone Therapy

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.

Trauma Worsens Menopause Transition

When I first started caring for women 19 years ago, I noticed that women with a history of trauma as children had a much rougher transition in perimenopause. This is a recent article documenting this finding. SG

Childhood abuse or neglect is associated with increased vasomotor symptom reporting among midlife women.
Articles
Menopause. 15(1):16-22, January 2008.
Thurston, Rebecca C. PhD 1,2; Bromberger, Joyce PhD 1,2; Chang, Yuefang PhD 2; Goldbacher, Edie MA 1; Brown, Charlotte PhD 1; Cyranowski, Jill M. PhD 1; Matthews, Karen A. PhD 1,2
Abstract: 
Objectives: This study tested the hypothesis that women exposed to childhood abuse or neglect would have an increased likelihood of reporting hot flashes and night sweats during the menopausal transition.
Design: This hypothesis was evaluated in 332 white and African American women participating in the Study of Women's Health Across the Nation Mental Health Study, a prospective investigation of women transitioning through menopause. Childhood abuse and neglect were measured once with the Child Trauma Questionnaire. Vasomotor symptoms (any/none hot flashes, night sweats) were reported annually over 8 years. Associations between maltreatment and vasomotor symptoms were estimated with generalized estimating equations.
Results: Childhood abuse or neglect was associated with increased reporting of hot flashes (odds ratio = 1.73, 95% CI: 1.23-2.43) and night sweats (odds ratio = 1.75, 95% CI: 1.26-2.43) in age-adjusted models. Results persisted in multivariable models and across several types of abuse and neglect.

Bones: 8 Tips for Strong Bones

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.

Sleep Problems in Women near Menopause

The following was published in Harvard Women's Health Watch.

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.

Supplements 101

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.

Rhodiola for Mild-Moderate Depression

This is a recent article that shows benefit in treating mild-moderate depression. Rhodiola is used by many alternative providers for improved response to stress. SG

Swedish Rhodiola rosea Extract Effective in Treating Mild to Moderate Depression in New Clinical Trial
( Austin , TX , December 19, 2007).

This is the first double-blind, randomized, placebo-controlled study of Rhodiola rosea in patients diagnosed with depression. Patients given the Swedish-made Rhodiola rosea extract showed significant improvements in depression compared to those given placebo.

The trial, published in the Nordic Journal of Psychiatry, utilized a proprietary Rhodiola rosea root extract called SHR-5, a standardized extract used in the product Arctic Root® produced by the Swedish Herbal Institute in Gothenburg, Sweden.*

The 6-week trial was conducted on 89 subjects, aged 18 to 70, who were assessed with clinically significant depression according to two different standard measurements used in psychiatry: the Beck Depression Inventory (BDI, scores greater than or equal to 13) and the Hamilton Rating Scale for Depression (HAMD, scores greater than or equal to 21). Patients were randomly assigned to one of three groups. The first group received 2 tablets once daily (340 mg/day) of SHR-5, the second group received 2 tablets twice daily (680 mg/day) of SHR-5, and the third group was given 2 placebo tablets once daily. (Placebos were described as being identical in appearance to the treatment tablets and contained inactive ingredients with 170 mg of lactose.)

There were no statistically significant differences in the average HAMD and BDI scores among the subjects in the three groups before the herb extract or placebos were given. Following treatment, both groups given SHR-5 experienced statistically significant declines in mean total HAMD scores (from 24.52 to 15.97 in the lower-dose group and from 23.79 to 16.72 in the higher-dose group), as well as statistically significant declines in mean BDI scores (from 12.23 to 7.09 in the lower-dose group and from 10.38 to 4.75 in the higher-dose group). The subjects in the placebo group did not show statistically significant decreases in either the HAMD or BDI scores by the end of the trial.

The study’s authors also measured other effects of the treatment, called secondary efficacy variables. At both dosage levels of SHR-5, people in the HAMD subgroups experienced statistically significant improvements in insomnia, emotional instability, and levels of somatization (the conversion of anxiety into physical symptoms), while such measures did not significantly change in the placebo group. Also, the group given the higher dose of SHR-5 experienced a statistically significant improvement in regards to low self esteem, while the lower-dose group and the placebo group did not experience changes in low self esteem.

The authors concluded that SHR-5 demonstrates clear and significant anti-depressive activity in patients suffering from mild to moderate depression, evident from both overall depression levels as well as from specific symptom levels of depression. They further noted that no adverse effects could be detected in either of the groups given the Rhodiola rosea extract.

Alexander Panossian, PhD, research director of the Swedish Herbal Institute and a co-author of the study, noted that all synthetically-derived, conventional pharmaceutical antidepressant drugs have adverse effects. He added that St. John’s wort (Hypericum perforatum), a popular herbal antidepressant, has been associated with herb-drug interactions, particularly with the pharmaceutical blood-thinner warfarin.

“Because of this drug interaction problem, there is a big demand for new natural antidepressants,” stated Dr. Panossian (e-mail to C. Cavaliere, December 2, 2007). “We have found that our SHR-5 extract of Rhodiola has a significant anti-depressive effect in human and animal studies, with no effect on the pharmacological activity and concentration of warfarin in blood after their oral administration together with SHR-5. It is a very safe extract.”†

Richard P. Brown, MD, associate professor of clinical psychiatry at Columbia University College of Physicians and Surgeons, and a co-author of a comprehensive review of Rhodiola rosea2 and a book on the subject3 likewise commented on the need for new, safe anti-depression medications. “At least 50% of patients given prescription anti-depressants stop them within 3 months due to unpleasant side effects,” said Dr. Brown (e-mail to M. Blumenthal, November 19, 2007). He cited a recent National Institutes of Health-funded multi-center study in which only 30% of patients responded to citalopram, a standard antidepressant medication.4 “Many patients have partial responses and are left with residual symptoms,” he said.

Dr. Brown stated that this clinical trial on SHR-5 has shown promising results: “Two dose levels of Rhodiola rosea [SHR-5 extract] were found to significantly reduce symptoms of depression in patients with mild to moderate depression compared to placebo in this randomized clinical trial. In addition to mood elevation, evidence indicates that R. rosea has numerous other benefits, including enhancement of cognitive function, sexual function, and both mental and physical performance under stress. Additional studies are needed to explore and establish the potential applications of this herbal extract. In the meantime, phytomedicinal researchers and consumers can be encouraged by these findings.”

According to Dr. Panossian, the SHR-5 Rhodiola rosea extract is already widely used and trusted in some areas of the world. “Four hundred million daily doses have been sold in the last 20 years in Scandinavia , where Rhodiola (notably SHR-5) is used as an adaptogen in cases of decreased performance, such as fatigue and sensation of weakness.”

This study was funded by the Swedish Herbal Institute.

About the American Botanical Council

Established in 1988, the American Botanical Council (ABC) is the leading nonprofit, member-based international organization working to educate consumers, healthcare professionals, researchers, educators, industry, and the media on the safe and effective use of herbs and medicinal plants products. ABC is located on a 2.5 acre site in Austin , Texas , where it publishes HerbalGram, a peer-reviewed quarterly journal; HerbClip, a twice-monthly scientific literature review service; and HerbalEGram, a monthly electronic newsletter. ABC is also the publisher of The ABC Clinical Guide to Herbs, a continuing education and reference book, which contains extensive monographs on the safety and efficacy of 29 popular herbs, and the recent The Identification of Medicinal Plants: A Handbook of Morphology of Botanicals in Commerce, a guide to the macroscopic identification of botanical materials for industry quality control laboratories that ABC published in cooperation with the Missouri Botanical Garden. More information is available at http://www.herbalgram.org/. An extensive review of Rhodiola rosea, its traditional uses, and its scientifically-supported modern medicinal properties and uses was published in HerbalGram in 2002.

References

1.
Darbinyan V, Aslanyan G, Amroyan E, Gabrielyan E, Malstrom C, Panossian A. Clinical trial of Rhodiola rosea L. extract SHR-5 in the treatment of mild to moderate depression. Nord J Psychiatry. 2007; 61(5):343-348.
2.
Brown R, Gerbarg P, Ramazanov Z. Rhodiola rosea—a phytomedicinal overview. HerbalGram. 2002;56:40-52.
3.
Brown D, Gerbarg, P. The Rhodiola Revolution. Emmaus , PA : Rodale Press, 2004.
4.
Trivedi MH, Rush AJ, Wisniewski SR, et al. Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D: implications for clinical practice. Am J Psychiatry. 2006;163(1):28-40.

Master Cleanse: Yes or No?

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

HPV Vaccine: Alternative View

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.