Friday, February 29, 2008

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

1. Costenbader KH, Feskanich D, Stampfer MJ, Karlson
EW. Reproductive and menopausal factors and risk of
systemic lupus erythematosus in women. Arthritis Rheum
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.

Thursday, February 28, 2008

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.
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
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
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
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.

Saturday, February 16, 2008

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 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.

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I'm an organic gynecologist, yoga teacher + writer. I earn a living partnering with women to get them vital and self-realized again. We're born that way, but often fall off the path. Let's take your lousy mood and fatigue, and transform it into something sacred and useful.