Editor: Michelle P. Warren, MD – Medical Director; Professor of Medicine and Obstetrics and Gynecology; Wyeth Professor of Women’s Health
Presented by: The Center for Menopause, Hormonal Disorders and Women’s Health, Columbia University and Sloane Hospital for Women
Preparation for Aging: Hormones, Eating Disorders, and Other Factors
Many of the health issues that women face in their later years are influenced by their reproductive health during adolescence and in the premenopause. Irregular periods (deviating from the average menstrual cycle of approximately 28 days) during adolescence can be a predictor of health problems later in life, and prolonged absence of periods can predict osteoporosis.
Irregular periods may occur at the beginning or end of the reproductive years and appear to be very common in women less than 15 years old. This is because the hormonal axis involving the brain, hypothalamus, pituitary gland, and the ovaries is maturing at this time. Menstrual irregularities are fairly uncommon after the age of about 20. As menopause approaches, irregular periods again become more common. Menstrual irregularity should be taken into consideration when evaluating a woman’s risk for osteoporosis. However, health problems that occurred in adolescence are often discovered only when a bone scan reveals low bone density at menopause.
Some women have irregular periods of a different sort. This is often associated with being overweight and puts women at risk for heart disease.
Women may be at risk even if they have had normal periods for most of their lives. During osteoporosis screening, women with low bone mass often give health histories that reveal menstrual problems in their adolescence or early adulthood–underscoring the importance of adolescence in the development of healthy bones. The average woman attains 40% of her bone mass during the first 20 years of her life–after peak bone mass is reached. The body draws on these deposits (the “foundation” for bone resorption and remodeling) for the remainder of life. The level of bone mass is approximately 80% related to genetic factors and 20% influenced by environmental factors such as nutrition, athletic training, calcium intake, and sex steroids.
Eating Disorders: Silent Risk Factors for Osteoporosis
Low bone density in menopausal women may be a result of poor adolescent nutrition associated with heavy athletic activity or due to eating disorders including dieting. In early adolescence, competitive athletic training, combined with eating irregularities, may cause skipped periods. The age of the first period may also be delayed until as late as 15 years of age (the normal age for the first period in the United States is around 12 1/2 years). Absence of periods for at least 3 months may result from high-mileage weekly training by long-distance runners. These factors help explain why surveys of the menstrual irregularities among various athletes can reveal associated osteoporosis or osteopenia (excessively low bone density in the absence of any structural damage to the bone).
Osteoporosis is especially common among participants in activities where it is advantageous to be below normal weight, such as ballet dancing or figure skating. In these activities, heavy physical training is often accompanied by dieting to maintain low body weight. These diets tend to be low in calcium (below the recommended daily calcium intake of at least 1200 mg for adolescents in competitive sports). In addition, adolescents often consume large quantities of diet soda–which is high in phosphates that interfere with calcium absorption–and low quantities of milk.
Other Osteoporosis Risk Factors:
There are several risk factors that, alone or in combination, increase the risk of osteoporosis in later life. These risk factors include:
Small, thin frame (low peak bone mass) Low body weight (less than 127 lbs.)
Ethnic background (Whites and Asians are more prone to osteoporosis than Blacks)
Drug therapy (particularly steroids and glucocorticoids such as Prednisone or cortisone)
Elevated levels of thyroid hormone
Lifestyle (smoking, excessive drinking)
Thyroid disease (associated with a marked overproduction of thyroid hormone)
Low calcium intake throughout life
Vitamin D deficiency
Individuals at risk for osteoporosis should act before menopause to reduce their risk factors, if possible. Five percent of bone mass per year is lost during the first 2 years after menopause. For almost all individuals, moderate exercise and improved calcium intake are good ways to protect against bone loss. Other interventions, when necessary, should be done before menopause, particularly since perimenopause may also be associated with significant bone loss. Remember also that while studies have shown that it may be possible to increase bone mass with HRT or other therapies, when peak mass is compromised during adolescence, it is never re-attained.
Hormonal Disorders: PCOS, the Most Common Hormonal Imblance for Women
Menstrual cycle dysfunction (experienced by 30% of women during their reproductive years) can be associated with metabolic complications, posing a silent yet serious health risk. Polycystic ovarian syndrome (PCOS) is the most common hormonal/endocrinal disorder in women of reproductive age (22% experience a mild form; 10% experience the “full blown” syndrome). In this syndrome, a number of follicles form a “necklace” around the periphery of the ovary. An imbalance of hormones occurs, resulting in menstrual irregularity, lack of ovulation, and possible infertility. Increased hair growth (on the face, chest, thighs, and abdomen) and obesity (50% gain) may also occur, as can skin changes (the development of a black pigment under the armpits and around the neck). At the same time, a mild increase in male hormones occurs, along with a decreased sensitivity to insulin, resulting in a condition called insulin resistance. The higher insulin levels that ensue may stimulate the male hormones occurring in the ovaries and are associated with metabolic abnormalities, including atherosclerotic heart disease and diabetes. Diabetes is more common in Hispanics, Blacks, and women of Mediterranean origin.
PCOS becomes worse with weight gain and may in fact first become apparent when a woman experiences a large weight gain. However, the development of PCOS is usually foreshadowed by problems during puberty including menstrual irregularities, acne, hair growth, and weight gain–largely cosmetic issues with psychosocial complications that negatively affect body image and self-esteem. Other problems related to PCOS include:
Pre-cancerous changes of the endometrium (uterine lining) due to lack of ovulation and constant stimulation by estrogen. Among women with these changes, the mean age for developing endometrial cancer is 32. Pre- cancerous endometrial changes can be pre- vented by progesterone or a progestin intake on a regular basis.
The incidence of heart disease with the approach of menopauseis 6 to 7 times greater in women with PCOS than in the normal population.
Women with PCOS often have high cholesterol, triglycerides, and LDL (low density lipoprotein).
The risk of diabetes mellitus is three times greater among women with PCOS than in the average population (20% have impaired glucose tolerance). Among women who have PCOS or diabetes, there is often a history of diabetes in the family or a history of gestational diabetes (diabetes during pregnancy).
The risk of hypertension is three times greater than normal among women who have PCOS.
Individuals with PCOS should be counseled and considered for therapy, which may after menopause include HRT (hormone replacement therapy), SERMS (selective estrogen receptor modulators), and statins. Treatment with insulin sensitizing agents may reverse the syndrome and is very promising. In addition, PCOS-related problems increase significantly with weight gain and can often be reversed by losing weight. Exercise is extremely important, since even if there is no weight loss, insulin resistance will be reduced, helping to prevent coronary artery disease. This reduction in insulin resistance may be associated with a reduction in acne and a return of regular menstrual periods.
Early menopause (occurring during or before a woman’s early 40s) mayalso be associated with health problems.
Women who experience early menopause have a greater incidence of heart disease. Lack of sex hormones may prevent relaxation of the coronary arteries, or occlusion may occur due to a build up of atherosclerotic plaque. Even with normal heart function test results, women may experience angina or they may have coronary artery disease due to abnormal functioning of the arteries.
Premature osteoporosis may also develop. Exercise and calcium (at a dose of 1500 mg daily) help prevent excessive loss of bone during menopause, but these are usually not enough to reduce the risks associated with below-normal bone mass, and other therapy is recommended. Estrogen therapy, which has been shown to protect against excessive bone loss, can also improve vascularity of the vagina and treat vaginal dryness in estrogen deficient women. Male hormones given in addition to estrogen may improve libido, particularly in women with early menopause.
Menopause: A Third of Life?
Experts predict that the number of people over 65 in the U.S. will more than double in the next 20 years. Many women in the U.S. can now expect to live until their late 80s or early 90s, but the age of menopause is not changing. These women are living a third of their lives in the menopausal state, which can have a substantial impact on their health and lifestyle.
Menopause, while a natural occurrence, is an important risk factor for women, as it is associated with an acceleration of aging changes, urogenital and sexual changes, and neuropsychiatric changes. Depression may surface in the perimenopause. Hot flashes, night sweats, chills and insomnia often occur, resulting in a significantly impaired quality of life. Additionally, in some cases, cognitive function may deteriorate. In women afflicted with these perimenopausal problems, hormone replacement therapy (HRT) has shown great benefits in improving quality of life. Many tissues in the body are affected by HRT, including the brain, skin, muscles, gastrointestinal tract, breasts, uterus, and reproductive organs. The use of HRT has resulted in relief of hot flashes, improvement in depression, and prevention of chronic disease such as osteoporosis, cardiovascular illness, and Alzheimer’s disease (the brain appears to be protected by estrogen). In addition, a significant decrease in macular degeneration (a disease of the elderly and the most common cause of blindness) and colon cancer has been observed among patients on HRT.
In addition to the conventional method of HRT administration, hormones can also be taken locally with the use of vaginal creams or a ring inserted and left in the vagina; this ring releases estrogen but is not absorbed in circulation. This treatment improves vaginal lubrication, sexual function, and urinary continence. Progesterone gel administered vaginally is an excellent way to provide progesterone to the uterus locally with little systemic circulation.
Progesterone is used to counteract the effects of estrogen on the uterus, since continuous use of estrogen leads to overgrowth of the endometrium and can cause precancerous changes.
Studies show that hot flashes can also be minimized through the use of some soy derivatives called isoflavones. These soy derivatives, taken in 40 mg to 60 mg daily doses, are useful in dealing with hot flashes, but are not as effective as estrogen and must be taken for 5 to 6 weeks versus only 1 to 2 weeks for estrogen therapy.
The possible link between estrogen therapy and breast cancer risk has been extensively studied. Estrogen therapy appears to be associated with a very small increase in breast cancer risk. The nurses’ health study shows a slightly increased relative risk of 1.3 (normal risk = 1). This means that 6 of 100 women of 50 years of age will develop breast cancer if they are not on estrogen for 20 years versus 7.5 in 100 who are on estrogen. The breast cancer that develops in women on estrogen tends to be benign in more cases than when it occurs in women not on hormones.
SERMs (selective estrogen reception modulators) show great promise in providing benefits similar to those of conventional estrogen therapy but without some of the potential risks. SERMs act like estrogen at certain receptors in the body but are antagonists (blocking the receptors) at others such as the breast and uterus. One SERM has been approved for prevention and treatment of osteoporosis. This therapy does not increase the risk of breast and endometrial cancers; there is no vaginal bleeding as there is no stimulation of the uterine lining; and there is also an improvement to the lipid profile. However, SERMS can cause an increase in hot flashes and leg cramps.
Estrogen is not for everybody, and counseling is suggested if there is a positive family history of breast cancer.
The Prevention and Treatment of Osteoporosis
Ethel S. Siris, MD
Madeline C. Stabile
Professor of Clinical Medicine
College of Physicians and Surgeons of Columbia University
Director, Toni Stabile
Center for the Prevention and Treatment of Osteoporosis
Columbia-Presbyterian Medical Center New York, NY
Osteoporosis commonly affects women after menopause. Osteoporosis is a systemic skeletal disease characterized by 2 factors: 1) Abnormally low bone mass–not enough bone density (osteopenia). 2) Microarchitectural deterioration of the bone structure–because bone is being broken down (resorbed) by the body to a greater extent than it is being rebuilt–leading to damage.
The process of replacing bone consists of bone resorption where bone is resorbed at microscopic levels by cells called osteoclasts. After a small segment of the surface bone is removed by osteoclasts, a group of different cells (osteoblasts) lays down new bone. After menopause the osteoclasts become overactive, resulting in increased bone resorption and potential bone damage. The osteoblasts are unable to renew the lost bone cells completely, resulting in a net loss of bone, eventually leading to osteopenia (low bone mass). The combination of low bone density and excessive bone resorption leads to an increase in bone fragility and susceptibility to fracture (Osteoporosis). The process of bone loss also damages the remaining bone, resulting in fragility. Although awareness of this condition has increased in recent years, many people remain confused about what this disease is and how it can be prevented and treated.
In the United States today, more than 1.5 million fractures occur each year due to osteoporosis, causing pain, loss of independence and function–along with enormous health care costs. In the U.S., more than 20 million people, 80% of whom are women, have osteoporosis or will develop it. Statistics show that an average 50-year old woman today has a 40% to 50% chance of suffering a fracture (with a 15% chance of hip fracture) in her remaining lifetime unless this issue is addressed.
The most worrisome fractures are spine and hip fractures. Spine fractures occur in the vertebral bodies, most commonly without women realizing that they are experiencing subtle chronic fracturing–bone damage too subtle to be noticeable when it occurs. Over time, this leads to deformity, associated with chronic back pain, without a specific moment of severe pain.
If there is a curvature of the back, the rib cage can be displaced downward, overlapping the pelvis and compressing the abdomen, and keeping the woman from eating big meals. Additionally, due to the spinal curvature, the head cannot be positioned straight up.
Lifting the head to look upwards may be painful or impossible.
Hip fractures can be even more devastating. If a 75-year old woman with osteoporosis falls, she is likely to fracture her hip (the part of the femur that connects to the hip bone snaps). Surgery has to be performed, to either replace the hip or to insert a plate. For the average patient, there is a 20% chance of dying within one calendar year after a hip fracture.
Until recently, osteoporosis was usually not diagnosed until the condition was so advanced that fractures occurred. Today, however, the risk of osteoporosis–and future disabling fractures–can be determined by measuring a perimenopausal woman’s bone mineral density. Bone density is typically evaluated at the spine and hip, giving information about the risk of future fracture at two very important regions of the skeleton. Newer devices now found in many primary care offices can also estimate the bone density at the arm, heel or finger to screen for overall fracture risk. In both cases the test is simple, non-invasive (no pain or injections), and requires only a few minutes.
The measurement of the bone density in each patient is compared with the average measurement found in healthy younger women at their maximum or peak bone density. The result is a number that is called a T-score. When the T-score number is positive, it means that the patient has a bone density higher than that of the average 30-year-old. If the score is a negative number (for example, -1, -2, -3, etc.), it means that the postmenopausal patient has a bone density lower than that of healthy younger women, and the diagnosis is based on how much lower. T-scores can be used to determine normal bone density, low bone density, or osteoporosis.
It should be emphasized that osteoporosis diagnosed by bone density measurement does not mean that a fracture will occur the next time there is a fall on an icy sidewalk, but it is a clear warning that the bone is sufficiently thinned that there is an increased risk of fracture as the woman ages. It is therefore important to take action to minimize that risk. Because all women are at some risk of osteoporosis, and data show that nearly one out of every two 50-year-old Caucasian women will actually experience a fracture in her remaining lifetime, this is a diagnosis to take seriously.
The National Osteoporosis Foundation recommends that every woman over 65 have a bone density test. For postmenopausal women under 65, the test is suggested if there are other risk factors for fracture, particularly thinness (weight under 127 pounds), cigarette smoking, a previous fracture in adulthood, or a history of fracture in a close relative such as a parent or sibling. Any postmenopausal woman who experiences a fracture needs a test to determine the role osteoporosis may have played in that fracture. Fortunately, Medicare generally provides reimbursement for this type of test, as do many other insurance companies and HMOs.
Preserving the skeleton begins with diet and exercise. All women regardless of age are in need of calcium, Vitamin D, and exercise. The blood level of calcium is essential to a person’s health. If enough calcium is taken daily by mouth, the body will primarily use this new calcium to maintain the blood level of calcium. If not enough calcium is taken orally, the body takes calcium out of the skeleton, resulting in a negative impact on bone density. To build and maintain a healthy skeleton, women of all ages need enough calcium, ideally from food eaten each day (dairy foods provide the bulk of the calcium in most diets in the U.S.), or from calcium pills to supplement the diet if necessary.
Recommended calcium intake needs tend to increase with age. For people under 50 years of age, 1000 mg of calcium should be taken daily (one quart of milk = 1000 mg; one glass of milk = 300 mg; a container of yogurt = 400 mg; most portions of dairy except cottage cheese = 300 mg). Postmenopausal women who are between 60 and 65 years old and taking estrogen still need 1000 mg of calcium daily; if they are not on estrogen and/or are older than 65 years old, they need 1200 to 1500 mg (2 calcium pills daily). Calcium carbonate (40% calcium) and calcium citrate (20% calcium) are well absorbed along with Vitamin D, another essential component for healthy bones (recommended dose: 400 units daily under 65 years; 800 units daily over 65 years).
Weight bearing exercise is also important. Exercise keeps muscles toned and strong as women age, supporting the bones and reducing the risk of falling and having a fracture if a fall does occur.
Finally, for postmenopausal women with T-scores below certain low levels, the National Osteoporosis Foundation advises the use of one of the prescription medications that have been scientifically shown to preserve or slightly increase bone density and decrease the risk of future fractures. Four such medications are approved by the Food and Drug Administration in the U. S. for the treatment and/or prevention of osteoporosis:
Estrogen, in the form of several estrogen preparations taken in pills or through a skin patch Alendronate, a potent non-hormonal tablet Calcitonin, a non-estrogenic hormone taken by injection under the skin or as a nasal spray for osteoporosis treatment Raloxifene, a non-hormonal tablet that mimics estrogen at bone but not at the breast or uterus
The very good news for postmenopausal women with, or at risk of, osteoporosis and fractures is that we have both an excellent and easy-to-use diagnostic tool–the bone density test–and a choice of effective therapies. The medications now available each have somewhat different characteristics in terms of how they are taken and their possible side effects. The treatment of choice is determined by the severity of the osteoporosis or the osteoporosis risk. This means that for every woman who would benefit from treatment, a medication can be selected that is tailored to her unique needs and personal concerns. We used to think of osteoporosis as an inevitable part of aging, but today we know that it is a preventable and treatable disease even among women at high risk.
Reprinted with permission from Newsweek Magazine, Winter Health and Fitnesss: Insight and Perspective.
Preventing Bone Loss Through Nutrition and Fitness
Gayle Reichler, MS, RD, CDN
If you have osteoporosis or are interested in reducing your bone loss asyou get older, you can help yourself maintain bone mass through proper diet and fitness. Once you are past the age of 30, your body does not form additional bone–in other words, osteoblasts do not produce new bone faster than osteoclasts tear down existing bone. From that point on, the focus must be on maintaining the bone you have by consuming adequate nutrients to nurture your bone’s natural “remodeling” process, the laying down of new bone cells. Learning about proper diet and weight bearing exercise is essential when you are trying to preserve the strength of your bone.
Proper Nutrition for Bone Health
Although calcium is often the nutrient we think of as the one most needed to protect our bone, there are several other nutrients that compliment calcium and that are just as important. A list of four things you can do to help maximize your bone density through diet and exercise follows:
1. Take enough calcium to support the bone rebuilding process. Calcium increases bone density, the most important measure of how well your bones will withstand impacts that can lead to fractures. Calcium is best absorbed from the foods you eat. The table below gives the best sources of calcium. Speak to your physician to determine your individual calcium intake goal.
2. Consume ample quantities of foods or vitamin and mineral supplements that enhance the absorption of calcium, including Vitamin D, Vitamin C, Vitamin K, magnesium, potassium, and soy-based foods. When eating calcium rich foods or taking calcium based supplements, try to consume them with foods or supplements rich in Vitamins D and C.
Vitamin D helps absorb and deposit calcium into bones. Our bodies begin to make Vitamin D upon exposure to sunlight for 10 to 15 minutes. However, as we age, our ability to make Vitamin D declines. If you do not spend time outdoors in the sun or are over 50 years of age, you should consider taking a daily Vitamin D supplement of 400 IU to 800 IUs, which can be part of your calcium supplement. Vitamin D is also prevalent in oily fish like salmon and fortified milk. One cup of skim milk has approximately 100 IUs of Vitamin D.
Vitamin C helps with the absorption of calcium and is also important in the production of collagen–connective tissue that forms a matrix to support calcium and other minerals and hold bones together. The goal should be 200 mg per day. Some of the best food sources for Vitamin C include citrus fruits, strawberry, tomato, bell pepper, and kiwi.
Vitamin K, found in dark green leafy vegetables, promotes the activation of a bone protein, osteocalcin, that increases bone strength. In a Harvard study of middle-aged women, it was found that those who had the highest intake of Vitamin K in their diet also had the lowest rate of hip fracture. For those taking a Vitamin K supplement, 80 mcg a day is recommended.
Potassium is a new addition to the list of substances for bone health. Fruits and vegetables are excellent sources of this mineral; the best sources include orange juice, cantaloupe, tomato juice, and carrot juice. A recent study found that older adults who ate the most produce faced fewer fractures. Always consult your physician before taking a separate potassium supplement.
Magnesium is also necessary for strong bones; 400 mg of this mineral is recommended daily. You can find magnesium in dark green vegetables, whole grains, nuts, seeds, legumes, and cocoa. The best sources of this mineral are amaranth (a grain), sunflower seeds, wheat germ and bran, and tofu.
Soy based foods contain isoflavones and phytoestrogens (plant estrogens) which may reduce bone loss. Recent studies indicate that bone building may be aided by 90 mg of isoflavones daily. The following table shows the soy foods that can help you meet your 90 mg/day isoflavone requirement.
3. Beware of substances that can rob strength from your bones. Sodium, protein, and caffeine are the three most important examples of such substances. You should limit your salt intake to the equivalent of approximately one teaspoon of salt per day (2400 mg/day). Try to limit your flesh protein intake as well, to 6 ounces per day of cooked meat, poultry or fish. You can substitute beans, tofu, or low-fat dairy for flesh protein at meals.
An excess of protein creates an acidic pH in your body. In order to neutralize the acidic pH, the body uses calcium as a buffer, drawing the needed calcium from the bone. This process means that if you consume 9 or more ounces of flesh protein a day, your calcium needs increase by about 250 mg per day.
Caffeine, when consumed in large quantities, also removes calcium from the bones. If you drink caffeinated beverages, try to limit your consumption to 16 ounces per day. Caffeinated beverages include not only coffee but tea, iced tea, decaffeinated beverages (they still have a small amount of caffeine), and many soft drinks. Try substituting non-caffeinated beverages such as mineral water (which often contains calcium), herbal teas, and grain coffees.
4. Focus on fitness (“Move it or lose it”). Along with proper diet, weight-bearing exercises have been shown to be effective in maintaining bone mass, and may even help build bone strength after menopause. Weight-bearing exercises can include walking, resistance band exercises, and weight lifting. No particular weight-bearing exercise is necessarily better than another. Find an activity you enjoy, and try to do it for about 30 minutes every other day.
If you have further questions, feel free to contact our nutritionist, Gayle Reichler MS, RD, CDN.