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Fibroids

Uterine fibroids, also known as uterine myomas, occur in up to 25% of females. They are more common in the 5th decade of life. They are a bit more common in black women but are found in women of various ethnic backgrounds.  Women may have only one fibroid, but more commonly they will have several. Fibroids may be located on the outer surface of the uterus, with the walls or on the inside surface.

The problems associated with fibroids vary from nothing to heavy bleeding, pelvic or abdominal pressure, frequent urination and abdominal swelling when they become large. The chance of one of these tumors turning into cancer is less than .01%.

In the 1970s, I worked with a research group at UCLA and we found that these tumors arise from a single cell. Why some women develop these benign growths is unknown but some clues are present. The age at which these tumors most comonly develop is the age when many women begin to develop hormonal dysfunctions. In other words, many of the women with uterine myomas have signs of a condition referred to as “ESTROGEN EXCESS”.

I did not truly appreciate this concept of estrogen excess until I began treating women with isoflavones and natural progesterone cream. Estrogen excess [EE] in women most commonly begins to develop in their middle to late thirties and often gradually worsens until menopause. It is chacterized by premenstrual breast tenderness, irritability, bloating weight gain, drop in sexual desire, headaches and an increase of menstrual flow. These women have an adequate estrogen but inadequate progesterone to balance the estrogen. Reasons for EE may be due to failure to ovulate, failure to develop an adequate number of cells to produce progesterone and the additional production of estrogen in body fat. Restoring the hormone balance will frequently eliminate the signs and symptoms of estrogen excess. Diet plays an important role since few Japanese have EE and my vegetarian patients seldom have the signs and symptoms of EE. When natural progesterone is combined with a change in diet, exercise and isoflavones (plant estrogens), over 90% of women with show marked improvement of these problems associated with EE.

So what’s the role of estrogen excess in myomas? Estrogen causes myomas to grow. A drug, Lupron[R], shuts off the production of estrogen by medically inducing a temporary state of menopause. Over 80% of women who receive this drug will have shrinkage of their myomas. However, when the Lupron is stopped and woman resumes her production of estrogen the myomas regrow, at times at a very fast rate. Women in  the menopause who have uterine myomas will experience a growth of these benign muscular tumors when given estrogen.

Estrogen is the nectar for myomas, but by modifying the estrogen environment naturally, it is possible to stop their growth and even cause them to decrease in size.

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There are a number of treatment options for women with these tumors. It is folly to think that they will not grow once they are diagnosed. Most are present because of estrogen excess. Doesn’t it make sense to first of all restore the hormone balance regardless of the size of these tumors? When a health care provider says “we’ll just watch them” what is really being said is we’ll watch them until it is time to surgically remove the myomas or the uterus. Why wait?  Act now!

For women who have myomas that require treatment because of symptoms such as heavy menstrual bleeding or pelvic pressure due to large size, the primary treatment option is myomectomy (surgical removal of the fibroid) either by an abdominal incision or laparoscopically (“band-aid” surgery). Most physicians recommend a hysterectomy: “You might as well have it out since it is essentially a worthless organ that can only cause problems.”

Another new treatment method is a technique called “Uterine Artery Embolization.” In this procedure, tiny beads are injected into the main blood supply of the uterus which shut off most of the blood supply to the myoma. The method is quite effective but many patients experience severe pain with this technique because of the sudden cessation of blood to the tissues. I personally do not recommend this method because of the severe side effects as well as because there are no long-term studies to determine the long-term side effects of this method.

Another technique currently being studied is the use of freezing to treat uterine myomas. The method is called “Cryomyolysis.” It was  developed by a Roman physician Errico Zupi. What he does is to locate the major blood supply of the fibroid and then he laparoscopically (“band-aid” surgery] freezes the myoma in a fashion that essentially destroys the major blood supply. In contrast to “Uterine Artery Embolization,” Dr. Zupi focuses on just the blood supply to fibroid. Women who have been treated with this method have a rapid diminution of the problems caused by the myoma. At six months after treatment, there has been an average shrinkage of 50%. Studies are ongoing but the preliminary results are exciting as none of the women treated have had any problems after “Cryomyolysis.”

Uterine myomas are found in three major areas of the uterus: within the uterine cavity, within the wall of the uterus and on the surface of the organ.  When these benign muscular tumors are found with the uterine cavity they are referred to as submucous myomas. They typically cause very heavy periods. Most of these lesions can be removed through the cervix or mouth of the uterus. This is referred as “resection of submucous myomas”. If a physician recommends this procedure, make certain that he/she has performed at least 15 of these procedures since in the hands of the neophyte there can be serious complications.

The most common location of myomas is within the wall of the uterus referred to as intramural myomas. They can cause heavy periods as well because they can interfere with normal contraction of the uterine muscles that is important is stopping menstrual flow.

The last major location is just beneath the lining that covers the uterus or serosa called subserosal fibroids. These tumors seldom cause heavy bleeding but when they became large they can cause pressure on the other pelvis organs such as the urinary bladder etc.

Uterine myomas seldom cause pain with sex.

To learn more about the management of your tumor with natural products, isoflavones and natural progesterone please see my book. If you desire a personal consultation about your particular problem either come visit me or contact me for an interactive session.

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Abnormal Pap Smears

George Papanicuou is the physican whose genius was responsible for developing the test that bears his name. The “Pap Test” is a simple but highly effective test that has saved thousand of lives. Since the pap test was introduced to medicine in the late 1940s a number of refinements and changes have been made to improve the quality of this technique.

Simply, the pap test is a test for the detection of cancer of the cervix. At one time, cancer of the cervix, mouth of the uterus or womb was the most common cancer in women worldwide. However, in those countries where the pap test is frequently used, the frequency of this cancer has dropped dramatically. Unfortunately there are still many countries where the pap test is not widely available (most African and many Asian and
South American countries), and cervical cancer remains as the most common malignancy in women in these areas. In many countries, the taboo of examinations limits the widespread use of the pap test. In most underdeveloped countries, there are inadequate resources.

The primary cause of cancer of the cervix is felt to be a virus called the human papilloma virus. This virus is spread by sexual intercourse so consequently cervical cancer is essentially a venereal disease, that is, a disease due to sexual relations.



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Abnormal Uterine Bleeding

Abnormal uterine bleeding [AUB] is one of the most common reasons for a woman to see her health care provider. It is also one of the most frequently listed indications for hysterectomy.

What is normal and abnormal bleeding from the uterus has been debated for decades. Fraser and others have attempted to quantify the volume of blood lost during a menstrual cycle and what should be considered excessive. However, few studies ever take into account what the patient considers “normal” or “abnormal.” Perhaps it might be appropriate to consider a women’s perspective of what she notes during a menstrual cycle. To a trained athlete, any bleeding may be excessive whereas a women who is running a household with children along with other stresses of life (ie job, finances, illness of loved ones) may ignore what many of us might consider excessive or abnormal.

A number of years ago when I was helping to introduce “Roller Ball Ablation” to medicine, a common thread was noted in the patients who came in seeking the procedure; to paraphrase what most said, “my bleeding really interferes with my life style”.  Unfortunately there is no ICD-9 code for this but this may be the single most important indication for the evaluation and treatment for AUB. 

There are a plethora of names attached to the various bleedings patterns referred to as “abnormal”. The most common subset of AUB is Dysfunctional Uterine Bleeding [DUB] DUB is broadly defined as abnormal uterine bleeding for which a cause cannot be found. However, in reality there is almost always a cause for BUD which will be discussed later.

The age of the patient is important in considering abnormal bleeding. Prior to puberty, trauma, foreign bodies and malignancies are the most common causes. With the initiation of menses, anovulation rules until the pituitary/uterine/ovarian axis becomes regulated. However, medical problems such as coagulation disorders, thyroid dysfunction and blood dyscrasias cannot be ignored. Nowadays because of the “sexual revolution,” pregnancy and its complications must be included in the differential diagnosis in the late teens.

Once the reproductive years are entered pregnancy-related disorders and poly-cystic-ovary syndrome are the most common causes of AUB. However, with our society’s propensity to swing from obesity to bulimia and back as well emotional challenges, more women with AUB are confronting the health care provider. The over-achieving woman both from a physical as well as emotional standpoint is becoming commonplace.

Malignancies, although relatively uncommon, become more important during the latter part of the reproductive years. AUB is most common in the latter part of the fourth and throughout the fifth decades of life (the perimenopause) and this is the age when hysterectomy for bleeding is most common. It seems that the uterus comes just before menopause. Complaints associated with AUB in this age group are headaches with menses, pre-menstrual breast tenderness, and weight fluctuations along with weight gain. Dysmenorrhea is common and moodiness is noted in up to 80% of women with menorrhagia.

 

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Patterns of Abnormal Bleeding

Amenorrhea:  Absence of bleeding for less than six months.

Menorrhagia:  Excessive bleeding at regular intervals.

Metrorrhagia:  Irregular frequent bleeding.

Menometrorrhagia:  Prolonged excessive bleeding at irregular intervals.

Intermenstrual Bleeding:  Bleeding that occurs between normal cycles.

Polymenorrhea:  Regular bleeding at less than 21 day intervals.

Postmenopausal Bleeding:  Bleeding occurring greater than one year following menopause.

Breakthrough Bleeding:  Unexpected bleeding in oral contraceptive and HRT users.

Postcoital Bleeding:  Bleeding after vaginal intercourse.

The most common organic causes of AUB are uterine myomas, endometrial polyps and adenomyosis. In the absence of a physical etiology, anovulation is most frequent although a surprisingly large number of women ovulate regularly but many still have the problems of estrogen excess [EE], sometime referred to as estrogen dominance [ED]. This concept  is supported by a study reported by Santoro et al, who found that perimenopausal women tended to be relatively hyper-estrogenic, associated with lower progesterone levels. The many signs and symptoms of EE are listed below.  This maybe one of the most important causes of DUB in this age group.

Signs and Symptoms of Estrogen Dominance [ED]

Weight gain, particularly fat on hips and thighs.

Heavy and /or irregular menstrual flow.

Uterine fibroids.

Headaches particularly with menses.

Breast enlargement and tenderness.

PMS.

Fibrocystic breast disease.

Fluid retention.

Carbohydrate cravings.

Depression.

Fatigue.

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Clotting disorder such as VonWillibrands disease must be considered as well as thyroid dysfunction, particularly hypothyroidism. Ruling out malignancy becomes more important in this older age group of individuals.

AUB in menopause, post menopausal bleeding [PMB], requires the clinician to rule out malignancy although in less than 10% of women with PMB will cancer be found. More common causes are exogenous hormones [HRT], endometrial polyps and uterine fibroids. In many women who have PMB a diagnosis of atrophic endometritis is used in the absence of a specific etiology.

Evaluation.

A thorough history and physical examination including cytology is a mandatory. The most economical and accurate diagnostic test available to the clinician, after the appropriate blood tests have been performed which should include coagulation and thyroid studies, focuses on imaging of the pelvic organs and endometrial sampling when indicated. Pelvic ultrasound has proven invaluable and the trans vaginal [TVS] approach usually provides the most information. When sterile saline is instilled into the uterus, saline infusion sonohysterography [SIS] at the time of ultrasound, even more information is obtained.  SIS is the most accurate method to evaluate AUB.  SIS is somewhat time-sensitive and is best performed when the endometrium is likely to be thinnest. This is important since a premenstrual endometrium can on occasion be “folded” in areas to resemble polyps. In skilled hands uterine imaging can reduce the need for endometrial sampling to as low as 25% of women with AUB. Since many health care providers do not have ultrasounds in their office, they must rely on the radiologist to perform the ultrasound. If SIS is requested, many radiologists are not familiar with the technique and it is not always possible to have this valuable test performed. However, a careful explanation of what one is requesting will usually result in SIS being added to the radiological services.

Hysteroscopy

Office hysteroscopy has been used for years and is highly accurate. However, because of equipment costs and low reimbursement many physicians are reluctant to learn this highly beneficial technique.

Dilatation and Curettage [D&C]:

At one time, D&C was felt to be the gold standard for both diagnosing and even treating women with AUB.  In fact, some insurance companies today still require that a D&C be performed prior to approving any surgical procedure.  The inaccuracy of the D&C as well as its failure to treat AUB is well known, and it should be abandoned.   Simpler and more effective means of diagnosing and treating women with AUB are available.

Endometrial Biopsy [EMB]:

A 3mm vacuum Pipelle for sampling the uterine cavity is commonly used today.

Once the evaluation of an individual with AUB has been completed, a safe an effective method for controlling the bleeding can be initiated.

Management:

In the teenager, bleeding can usually be managed with short courses of monophasic oral contraceptives [OC].  If the bleeding is severe and an organic cause is not found, then the administration of intravenous conjugated estrogens 25 mg every four to six hours will often be effective.  In other cases, a cascade of oral contraceptives starting with four pills initially and then tapering off to a single tablet daily, will be effective.  Oral contraceptives should then be continued for at least three months.

During the reproductive years, oral contraceptives are the most effective treatment for AUB in absence of organic causes.  If submucous fibroids or polyps are present, most of the time they can be easily managed with operative hysteroscopy.

Hysterectomy begins to surface as an option during the latter part of the fifth decade of life.  However, the necessity of such a radical approach is seldom necessary with the newer alternative methods that will be discussed shortly.

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The Perimenopause:

Many women in this age group can be effectively managed by oral contraceptive therapy providing they do not have contraindications such as smoking and diabetes, etc. Correcting hypothyroidism and clotting disorders if present will often suffice.  Submucous myomas as well as polyps are more common and operative hysteroscopy becomes a more important tool in this age group.  Since many women in the perimenopause have as their cause of DUB estrogen excess, specific treatment for this condition should be initiated.  Oral contraceptives are often effective in these women because they stop the stimulation of the ovary by the pituitary hormones.  However, many women on oral contraceptives still have the signs and symptoms of Estrogen Excess and other measures should be tried.

Isoflavones, specifically Genistein as well as natural progesterone can be effective in many women with many of the signs and symptoms of Estrogen Excess.

Genistein is appealing because it competes with estrogen for estrogen binding sites.  Natural progesterone more closely resembles what the ovaries should be producing and is much more effective than progestins.  In addition, progestins in this author’s experience are associated with too many side effects, ie depression, additional weight gain and bloating, and should be avoided.

Recently approved is the Levonorgestrel Impregnated IUD.  Preliminary studies suggest that it is as effective as oral contraceptives.  It is well tolerated and was reported to be as effective as the thermal balloon and microwave ablation for AUB.  What its eventual role will be remains to be determined.   Currently, few insurance companies pay for this IUD, which has limited as implementation.

Hysterectomy:

The ultimate treatment of AUB is hysterectomy.  However, hysterectomy is seldom necessary for AUB in light of the various modalities that have recently been introduced to destroy the endometrial lining, but it is still the only method that can guarantee amenorrhea.  Many patients have remarked that “my life began with my hysterectomy”.  Unfortunately, there is also an equal number of women who feel just the opposite. Hysterectomy is the best alternative for certain conditions such as major prolapse, large myomas, pre-cancers and early cancers of the endometrium.   However, in the women who have failed hormone approaches, hysterectomy is not the next step.

Endometrial Ablation:

Endometrial ablation dates back to 1870 when a physician inserted a hot uterine sound into a woman’s uterus and noted a reduction of her bleeding. Cryosurgery was introduced as a method to destroy the endometrium in the 1970s and the YAG laser introduced a few years later stimulated some interest. However, it wasn’t until endometrial resection and roller ball ablation were introduced in the late 1980s that interest in endometrial ablation surged. Both techniques require substantial training and general anesthesia. Although complications are infrequent, when they do occur they can be serious. Consequently, few physicians took the time necessary to master these methods. With the introduction of newer and less skill dependant ablative techniques, interest in endometrial ablation is dramatically increasing.

Thermal Balloon:

More women have been treated for AUB by the thermal balloon than any other ablative method to date.  Although the amenorrhea rates are low, it has been fairly effective in reducing AUB to acceptable levels.  Since it uses very hot water that is circulated in a balloon which also distends the uterus there is a moderate amount of pain associated with the technique.  Consequently, it is best performed with IV sedation or light anesthesia.  Complications are small and it is not difficult to learn.   Its use is restricted to women with a normal size cavity and probably the best results would be obtained in a woman who has been pre-treated with a GNRH agonist.  The depth of ablation is around 3 to 4 mm.

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Hydrotherm Ablation:

This technique takes the balloon out of the uterus and uses the hot water which is circulated throughout the uterine cavity under hysteroscopic observation.   Proponents feel that since one is observing treatment, it has advantages over blind techniques.  A GNRH agonist is required prior to treatment.  The depth of ablation is between 2 and 4 mm.  The best results are in women with a normal cavity, although studies are underway to determine its utility in larger cavities as well as in women with submucous myomas.  It is associated with a considerable degree of pain and is best performed in a surgical center or hospital with IV sedation or light anesthesia.  Very good relief from AUB is reported. Complications are infrequent.

Novasure:

Another system recently introduced is the Novasure impedance controlled endometrial ablation system.  This method utilizes a bipolar electrode mounted on an expandable frame.  It does not require any preoperative preparation.   Best results are noted in a normal size cavity without fibroids or polyps. It uses an enormous amount of bipolar energy.  Once the probe has been positioned within the uterine cavity which takes between 10 to 20 minutes depending upon the skill of the operator, the actual treatment time is around 90 seconds.  Again, because of the heat that is generated, it best performed under IV sedation or light anesthesia.  Depth of ablation is reported to be between 3 and 4 mm and results similar to the other heat ablation techniques are noted.

Microwave Ablation:

Just approved by the FDA is the use of microwave technology.  It utilizes a wand that is “wiped” across the uterine cavity in a systemic fashion.  Again, a GRNH agonist will probably give the best results. It is best performed under IV sedation or light anesthesia. If one precisely follows the current labeling on the equipment, complications are rare.  Results are similar to those of the other heat techniques.

Cryosurgery:

Cryoendometrial ablation was first reported in the early 1970’s by Droegmueller.   However, as an ablative technique, it was ignored because there was no suitable system to deliver the cryogen to the cavity.  A closed circuit system was developed and introduced in the late 1990s.  It is the only technique that can easily be performed in a physician’s office with little or no sedation and local block. No preoperative medication is necessary.  Initial results were disappointing because an effort was made to make it “an auto-ablative” method, which it is not.  Newer studies whereby the duration of the  cryosurgical sessions are related to uterine cavity size and treatment results comparable to the other ablative techniques have been noted.  Complications are extremely rare.  It has the added advantage in that treatment is performed with real time ultrasound guidance which dramatically reduces the risk of injury to surrounding organs.

Although endometrial ablation is an attractive alternative to hysterectomy, scarring can have significant consequences.  In 1993, the post-ablation tubal syndrome was first reported associated with areas of hematometria following roller ball ablation.  Treatment of these problems usually results in hysterectomy, the procedure that was to be avoided by the ablation.  A recently published study on the thermal balloon and rollerball ablation reported a 25% hysterectomy rate at five years, many due to pain and bleeding.

McCausland has raised a more potentially serious complication of scarring that is hiding an occult endometrial cancer.  In fact, such a case has already been reported. All of the studies reported on hysteroscopic findings following endometrial ablation note significant scarring after several heat ablation techniques but none after  cryosurgery in which the uterine cavity is minimally altered.   The significance of occult endometrial cancer after endometrial ablation will not be known for decades since the average age of women undergoing ablation is at least 10 to 15 years younger than the peak age incidence of endometrial cancer. Many women undergoing endometrial ablation have many of the stigmata associated with endometrial cancer, i.e., obesity, hypertension, and diabetes.

Life-Style and Abnormal Bleeding:

Virtually all articles that deal with the treatment of abnormal bleeding focus on the use of drugs and some form of treatment to manage such patients.  Seldom is life-style emphasized.  My vegetarian patients and those individuals who pay more attention to diet as well as exercise seldom have complaints related to estrogen dominance.  There is no question that what we consume not only affects our risk of heart disease, cancer, etc., but also many “endocrine related problems”. Unfortunately, a healthy approach to life has not until recently been promoted. This problem is further compounded by our health care system that has become dependent on treating most problems with drugs.  Until our population begins to embrace the benefits of proper diet and exercise, we are going to continue to see a large number of women with medical problems, particularly abnormal bleeding.


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Vaginal Infections

During the course of my practice, I met a physician from Houston named Carl Karnaky.   He had the radical notion that vaginal infections could be treated naturally.  At that time, the conventional treatment for these infections involved using anti-fungal ointments.  Dr. Karnaky believed that using a special powder to make the vagina very acidic would cure the yeast infection. What we had here was a true alternative treatment and I liked the idea.

I began to use this acidifying powder. When a patient would come in complaining of a vaginal discharge, we evaluated her using what we call a wet nap technique (no fancy testing procedures were available yet). This was a potassium hydroxide screening test done with a good old fashioned microscope. If the patient had a yeast infection, we would apply a dose of this fine, flour-like powder to the area.  Its application often caused a small cloud of white mist that would float up from the end of the examining table.

Unfortunately, while the fine powder worked just fine,  it was virtually impossible to teach a patient how to use it herself. It was just too hard to handle.  The bottom line (excuse the pun) was that it was effective, but too difficult to administer. I later discovered the value of placing boric acid in capsules to acidify the vagina and immediately switched to this method because it was so easy for the patient to use.  Let me stress here that this acidification of the vaginal canal was incredibly effective and cost no more than 40 cents, in contrast to the expensive prescription creams used today. 

Yeast Infections Are Common

Vaginal yeast infections (vulvovaginal candidiasis) occur when the candida albicans fungus (a natural inhabitant of the vaginal canal) overgrows. Several things can cause this proliferation of yeast include:  using antibiotics, diabetes, pregnancy, intercourse, hormonal changes, nutritional deficiencies, and poor hygiene.  It is estimated that 75 percent of all women will experience at least one yeast infection during their lifetimes. If you’ve had a yeast infection (and chances are you have) you know the symptoms —  itching, burning, and a thick discharge. 

Practical Do’s and Don’ts           

I tell my patients with recurring infections to keep the vaginal area cool and dry by wearing loose clothing and cotton underpants. I also frown on the use of vaginal sprays, commercial douches and deodorants, which can alter the natural acid/alkaline balance of the vagina, predisposing it to more infection.  Douching can actually be dangerous.  It can force the infection up through the cervix which could eventually cause pelvic inflammatory disease.

Research shows that women who douche on a regular basis actually develop more vaginal irritations and infections, than women who don’t. These women also develop more cases of pelvic inflammatory disease (PID). In fact their risk is 73% greater. Keep in mind that PID can lead to serious problems during pregnancy,  infections in the newborn and problems with labor and delivery. Thatt being said,  it certainly makes sense to keep as close to nature as possible when it comes to treating vaginal infections.  Natural treatments for yeast infections involve directly targeting the ecosystem of the vaginal canal and boosting immune defenses.

Pharmaceutical Solutions: Putting the Horse Before the Cart

Have you seen the latest pharmaceutical campaign to treat yeast infections?  The newest approach is to take anti-fungal pills by mouth to treat a localized yeast infection. Instead of treating a local problem with a topical medicine, why not send a powerful anti-fungal chemical coursing through the bloodstream so it affects every organ in the body on its way to the vaginal canal? 

The promotion of an oral medication to treat a vaginal infection defies common sense. It is nothing less than opportunistic ploy by pharmaceutical companies. In other words, they want increase their vaginal infection medication sales.  One reason they may succeed is that vaginal creams are messy and inconvenient. Once again, popping a pill is so much easier.  This convoluted logic powerfully illustrates our obsession with magic pill therapy and the marketing prowess of the pharmaceutical industry. They would have women taking a handful of drugs daily whether they needed them or not.

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The Dangers of Oral Medications for Vaginal Infections

Yes, antifungal pills may get rid of your vaginal infection, but they also have the potential of causing liver disease. Pregnant women with vaginal infections should be especially careful. A new study shows that taking the drug metronidazole (Flagyl) for a vaginal infection (known as asymptomatic vaginal trichomoniasis) may cause premature delivery of their babies. A startling 19% of the women who received the drug delivered their baby before 37 weeks gestation. Moreover, over-the-counter preparations can contain antihistamines or topical anesthetics that only mask the symptoms of the infection and do not treat the underlying problem.  Moreover, prescription medications are so expensive that a single pill cost 3 times as much as using acidification. You maybe thinking, “no problem, my insurance pays for the drugs.” Don’t you believe it. You pay with higher premiums, etc.

How To Use Acidification

You don’t need a medical diploma to acidify your vaginal canal.  The process is easy, inexpensive and can be very effective.

1. Purchase a 4 oz. jar of boric acid powder. Cost: $3 to $4

2. Purchase 30 empty gelatin capsules (check your health food store). Cost $3 to $4

3. Pull apart about a dozen capsules and set on a tabletop.

4. Pour a small mound of boric acid powder into the cap of the boric acid bottle.

5. Scoop the boric acid into both halves of the empty capsules and put the full capsules aside.

The Treatment Protocol

1. Insert one capsule high into the vagina at morning and night. If sexual relations are planned, insert the capsule after sexual relations, when the semen has left the vagina.

2. Insert the capsules twice a day for one week, then once a day for a week at night.

3. For the  third week, insert one capsule every third night.

4. Insert one capsule weekly for an indefinite period of time as a preventive treatment.

NOTE: For less severe infections, go directly to one capsule once a night for seven days etc.

This program can be repeated as necessary.

If you notice any burning after applying the capsules, empty ½ of the boric acid out of the capsules so that you are using only ½ capsule full of the boric acid powder with each treatment. Not only is acidification effective for yeast but can be used for virtually any other vaginal infection. If your symptoms keep recurring it is important to have your health care provider evaluate your problem further.

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Other Natural Ways to Prevent Vaginal Infections

1. Avoid alcohol, white sugar and refined flour foods. The candida fungus feeds on simple sugars.

2. Cut Down on Dairy Products. Milk products may aggravate yeast infections although low-fat yogurt with active cultures is recommended.

3. Choose seafood and vegetable proteins over meat and poultry, and be careful of yeasted or fermented foods or those containing molds, such as aged cheeses, dried fruits, or mushrooms.

Additional  Supplements To Consider

1. Acidophilus and Bifidobacteria at 1/2-1 teaspoon or two capsules three times a day help to repopulate the beneficial intestinal flora

2. Transfer factor to boost natural killer cells to keep fungal growth in control.

3. Garlic (one to two raw cloves or capsules two to three times daily) may be more effective against yeast infections than Nystatin (a prescription medication).

Vulvar itch

Many woman with a vaginal infection also experience  vulvar puritis (itching). When a woman has vulvar itching without a vaginal infection, it is most commonly caused by some kind of topical irritation or surface reaction to a chemical irritant (i.e. contact dermatitis). Some women who are severely allergic to pollens can also experience vulvar itching when grasses and weeds are blooming. After all, the area is moist and warm, much like the mucosal tissue found in the eye and in the nasal passages. I prescribe a simple program to address vulvar puritis which is easy to use and does the job.

1. Avoid washing the area (the vulva) with all soaps including  so-called hypoallergenic varieties except for Aveeno soap. The only true anti-allergic soap is Aveeno, which is an oatmeal based cleansing agent.  Wash the affected area 2 times a day with Aveeno soap and then thoroughly rinse with soft water.  Pat dry, do not rub!!

2. Keep the area dry. Wearing loose fitting clothes is a MUST.  Form fitting or tight jeans or slacks are to be avoided. Wear a dress or skirt! Panties and under garments must be made of 100% cotton and not just cotton lined. When possible, go al fresco (no panties) for periods of time to let the vulvar tissue breathe. When sleeping, wear nothing below the waist.

NOTE: If the itching persists or if redness, ulcers, or lumps are present, consult your doctor. Certain types of cancers can cause itching in conjunction with the presence of a growth or ulcer.

I’ve used the above program with phenomenal success in hundreds of individuals from  youngsters to great grandmothers. Two recent patients expressed their amazement that this simple program succeeds when drugs and prescription medications that have cost women countless of dollars have failed.

Donna’s Dilemma

Donna was 33 when she was referred to me for a persistent vaginal discharge that had not responded to all available creams and prescription drugs (which I like to call “jams and jellies”).  Why?  Because most of them are messy, sticky, not very effective, and are expensive (averaging about $20 per tube).  In the course of our visit, Donna also told me that intercourse had become painful. The pain seemed to emanate from the tissue located at the entrance of her vagina. She remarked (with a pained expression on her face) that it felt like there were tiny cuts at the opening of her vaginal canal. She continued to have sex for her husband’s sake but cringed at the prospect, commenting that she thought it was her duty to do so.  (It’s no wonder that so many women who develop similar problems develop an aversion to sex. When a woman has this kind of condition, I don’t hesitate to tell her spouse to back off). 

What Bonnie had is referred to as “vuladynia” or “vestibulitis,” something I’ve been treating quite successfully for over 20 years.  Despite millions of dollars spent on researching this condition, its cause remains a mystery. Men are not afflicted with a similar condition.  Personally, I believe it’s related to some type of allergic reaction to yeast.  Why? Because in severe cases, using transfer factor both orally and topically dramatically improved the problem.

In Donna’s case, I suggested vaginal acidification and the vulvar hygiene program discussed earlier.  She came back in a month with a big smile on her face. She had no vaginal discharge and the pain that she had been having with sexual relations was gone. She thanked me. I was quick to point out, however, that she should give herself the credit for faithfully following my directions and I sent her back to her referring physician. I can assure you she is not the first woman who responded in this way. In fact I almost feel guilty using this treatment protocol because it’s so simple and seemingly “unmedical.”

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Nora’s Profile

Nora is currently still under my care. She’s 44 and came in with a history of extreme fatigue, chronic vaginal infections, severe vulvar itching, heavy menstrual periods, and breast tenderness.  As far as she was concerned, sex was expendable and its elimination altogether would not have troubled her a bit.  She was also tired of catching everything that came along (colds, sore throats, etc.).  She brought a large bag full of  $300 worth of vaginal creams and prescription drugs to our consultation.  When I asked about her dietary and exercise history, I soon learned that she fit the classic profile of most North American women — one which I consider a health disaster waiting to happen.  I sat her down and introduced her to The Program.

Get With The Program!             

Nora’s diet consisted of red meat, chicken, no coldwater fish, some vegetables, soda pop, and little to no exercise, despite the fact that she belonged to a health club.  I introduced her to “The Program.”  In a nutshell The Program involves a change in eating habits and the addition of  exercise. I also informed her about the “Dynamic Duo” (genistein and natural progesterone cream) to treat her heavy periods, PMS, etc. To top it all off, I told her to get on transfer factor for her immune system (which was obviously failing to function properly).  We concluded the 45 minute discussion with the vulvar and vaginal programs.

When she came back in a month, her only complaint was some fatigue. She hadn’t been sick for the entire month and her family had all been sick with colds.  I smiled and asked her why she hadn’t shared her transfer factor with them.  She said that she had tried, but they just didn’t believe her.  Let me stress that she had dramatically changed her diet but was having a hard time convincing her husband and two teenagers to tame their love of red meat. She was also exercising and was finally able to get her overweight husband to go the gym. Her vaginal discharge and vulvar problems were gone. She was on her way.

When Nora left after her first return visit, I suggested that she add a potent mix of vitamins, minerals, antioxidants, etc. to her daily regimen.  Nora represents the pharmaceutical industry’s icon — she ate a lousy diet, did not exercise and took no dietary supplements.   The drug industry would have us believe that we eat anything we want, sit on the couch all day, and then take their medicines to make us all better. Nora chose to participate in her health destiny and in so doing reduced her risk of cancer, heart disease and Alzheimer’s. I have no doubt that her family will eventually come around.

To most of you this approach may sound too easy but it really is. On the other hand there are some conditions of the vulvar that are a bit more challenging.

Lichen Sclerosis;

This is a condition that affects hundreds of women. Its most common symptom is vulvar itching. The cause of vulvar dystrophy is unknown and there is no male counterpart disease. Symptoms are primarily itching of the vulva that can be severe, even keeping women up all night.

First the diagnosis can only be made by a biopsy of the tissue. However, physicians with considerable experience treating this disease can diagnosis it with tissue sample. Once the diagnosis has been made, the tissue must be carefully examined with colposcopy. This is necessary to rule out cancer and a precancerous condition.

Treatment consists of vulvar hygiene accompanied by a powerful cream to control the condition. Recent studies have shown that Clebetasol is the cream of choice. Then the tissue must be given at least a two week rest before retreatment is resumed for another two week period. When Clebetasol is not being used a mild steroid can be applied. Unfortunately this condition is a lifelong problem. However, we have recently found that natural progesterone cream applied at least once a day will help keep the condition under control once Clebetasol has reached maximum benefit. If ulcers develop in this condition then a biopsy of the ulcer is mandatory to rule out cancer. Women with improperly or untreated vulvar dystrophy have an increased chance of cancer of the vulva.

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Menopause & Natural Alternatives to HRT

Baby boomer women are coming of age — menopausal age. More women than ever before are experiencing that infamous marker of life that signals the end of menstruation and childbearing. For decades, many doctors knew less about menopause than their patients. Fortunately, over the last few years physicians have educated themselves about the important physiological chapter referred to as “the change”.  A well-informed doctor will focus on improving the quality of a woman’s life after 50, rather than merely working to extend that life.  Women now have a life expectancy of more than 80 years. What this means is that they can expect to live 30 to 40 years after menopause. Today menopause marks a new beginning rather than an ending.  Menopause is not a single event that happens out of the blue.  A period of time called peri-menopause usually begins several years before the last menstrual cycle.  It typically starts around the age of 40 when changes in the menstrual flow and length of the cycle occur. While estrogen levels may be starting to decline,  women still experience estrogen surges or dominance.  Many patients who enter into the peri-menopause find that their periods become more irregular with the gradual development of PMS which can worsen until menopause

Eventually, as estrogen levels continue to dip, periods will occur more sporadically and then stop altogether. The true beginning of menopause is marked by a dramatic drop in estrogen levels.  This decline triggers the primary signal of menopause, hot flashes, which can last from a few months to years. Menopause means that the ovaries no longer produce estrogen and progesterone. The ovaries will, however, continue to produce tiny amounts of testosterone which can be converted to estrogen in adipose tissue (fat stores).  Regardless, the amount of circulating estrogen will be very small and progesterone production be reduced to zero   

Hormone Replacement Therapy             

Most women take traditional HRT on the advice of their doctors because advertising campaigns made them believe that they have no other viable choices.  These women have been led to believe that if they don’t take HRT, they are putting their bones and heart at risk.

For almost half a century, the FDA has approved scores of estrogen and estrogen/progestin drugs. These drugs contain estradiol, estrone, and estriol and sometimes a pinch of testosterone is added to enhance a woman’s libido.  HRT comes in pills, patches, creams and pellets.  .

The July Bombshell

In July 2002  the news broke  — one of the most extensive and largest federal studies of hormone replacement therapy that combined estrogen and progestin was halted because women taking the hormones after menopause were found to have a greater risk of breast cancer, heart disease, stroke, and phlebitis. When the announcement that HRT probably does more harm than good hit the airways, the repercussions were enormous and have yet to die down, but this really wasn’t new.  Any doctor that had done his/her homework knew that the data had been there for years.

Ironically, the hope and the hype of the drug companies was that testing an estrogen/progestin drug would yield results confirming that it was safer than estrogen alone.  The health effects of estrogen alone are still being studied by researchers at the NHLBI.(National Heart, Lung and Blood Institute).

The trial in question involved over 16,000 women,  ages 50 to 79  who still had their uterus. It was to be an eight year trial, but after five years, researchers pulled the plug. The data was alarming — the drug combo of Premarin and Provera (a manufactured progestin) increased the risk of breast cancer, heart attack, stroke and blood clots by almost 35% compared to women who took a placebo. Another separate study in Europe just reported that HRT increased a women’s risk of developing breast cancer by 50%.

Senile dementia

The hidden problems for HRT just never seem to end. A recent study in the JAMA pointed out that women over 65 who used HRT for 5 or more years had a fourfold increase in senile dementia.

HRT: The Last Word

A woman and her health care provider need to decide for or against using traditional HRT based on what is right for her alone.  As for myself, estrogens alone or estrogens combined with progestins [HRT} are just too dangerous.  I urge menopausal women to eat right, exercise and stay as close to nature as possible (even if they choose to go on a synthetic drug). When a woman uses hormonal therapies, ie estrogen, I recommend the lowest possible dose and ALWAYS combine it with phytoestrogens (genistein) and natural progesterone cream.

In the past, estrogen prescriptions were routinely given at 1.25 mg to 2.5 mg per day.  Common doses today are .625 or.5 mg.  Lower doses are now being recommended in hopes of reducing the risks of these hormones. However, it is extremely easy to significantly lower their risks with isoflavones and natural progesterone.

If estrogen are used, choices are oral preparations, or patches and estrogen creams that are placed directly on the skin. Some drugs are taken daily while others on specific days of the month only. However, I find that most women do just great on the “dynamic duo’ (genistein and natural progesterone cream) alone.  It is possible to take low dose estrogen with isoflavones and natural progesterone with little risk. I call this the best of both worlds. And for women with severe hot flashes, osteoporosis risk, etc. this may be the best option. 

Plant isoflavones alone naturally protect breast and uterine tissue and lower cholesterol (not to mention other health benefits). Natural progesterone may further lower risk of breast and uterine cancer, may put on bone, reduce fibrocystic disease of the breast, and help prevent or even reverse wrinkling.

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Natural Alternatives to HRT    

Slowly but surely, more and more physicians are phasing out estrogens and progestins and suggesting more natural ways to replace lost hormones. As is always the case, if you can extract compounds from nature that mimic female hormones, you forgo many of the side effects associated with artificial chemical imposters.   Over 75% of woman do absolutely nothing after menopause and they need to become aware of the potential of natural products. It is possible to get progesterone and estrogen cream by prescription from compounding pharmacies. However there are no natural estrogens in current drug therapies. They are all manufactured except Premarin, which is obtained from the urine of pregnant mares. However, some estrogens cream such as Bi-est and Tri-est are one step away from being natural.

Isoflavones:  Phytoestrogen Powerhouses

Among the isoflavones found in nature, Genistein rules. Numerous clinical studies (over 2000) clearly indicate that Genistein acts as a desirable weak estrogen in the body. Genistein has the unique ability to bind to receptor sites in breast and other tissue that would normally link up with estrogens made by the female body.  Consequently, they provide significant protection to vulnerable tissue. In other words, genistein fools the body into thinking that its own estrogen has already been there. In this way, it acts as an anti-estrogen.  Conversely, genistein can also boost estrogenic effects by stimulating safe estrogenic activity in postmenopausal women.

Genistein is also an antioxidant, blocking certain enzyme pathways that may lead to cancer (prostate) and making blood vessels more elastic.  Clinical studies indicate that isoflavones protect against osteoporosis.

Isoflavones like genistein are metabolized by intestinal bacteria in the gut, absorbed from the intestinal tract and then transported to the liver.  One reason soy-eating patients do so well is that continually consuming small amounts of soy protein can maintain steady  phytoestrogen levels in the blood.  Eating soy-foods that supply 50 mg/day of total isoflavones (close to what Japanese women eat) are able to maintain these levels.  Is this a practical suggestion?  Yes, It is possible to add a variety of soy-based foods to ones diet (soy nuts, spreads, soy milk, tofu etc.), however, many will or won’t, simply because they don’t like soy.  If this is the case, an isoflavone supplement containing genistein may be a better way to go. Unquestionably, eating more phytoestrogenic foods during postmenopausal years is a good thing.  If a woman is on any form of HRT, by all means they should eat soy or take genistein supplements as well as well as natural progesterone.

NOTE: For women who have had their ovaries removed and are experiencing premature menopause, low dose estrogen in combination with dietary soy supplementation and progesterone cream is advised. Black Cohash when added to Genistein and natural progesterone also provides excellent relief from hot flashes.

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Menopause: A Progesterone Deficiency Disease?

In the great estrogen shuffle of menopause, the role of progesterone, not progestins, has been sorely neglected. First of all, be aware that progestin and progesterone are not the same thing. While estrogen production drops to around 40 percent during menopause, progesterone stops altogether. So even though there is a lot less estrogen, what is present is no longer balanced by progesterone — hence, even in menopause, estrogen can still dominate.

Without the mitigating effects of progesterone, vulnerable tissue (breast and uterine) is still at risk for cancer. To make things worse, giving a woman synthetic estrogen when progesterone is totally missing from her body, is even more risky. In fact, some studies have found that women low in progesterone had a tenfold increased chance of dying from cancer compared with women who have normal levels of progesterone.  Replenishing progesterone may be a key to creating the best possible post-menopausal health scenario for women.

Why Don’t More Doctors Use Natural Progesterone Cream?

The lack of medical interest in progesterone stems from simple ignorance. Moreover, because only drugs can be patented, pharmaceutical companies have no way of collecting the huge profits they’ve become accustomed to from natural compounds. Unlike patented drugs, products like natural progesterone can be marketed by various companies.

Natural Progesterone for Menopause

As mentioned earlier, menopause means zero progesterone production and that’s not a good thing. Combining a good natural progesterone cream with soy isoflavones can go a long way to promote post-menopausal female health. I don’t hesitate to require the cream as an integral part of a program designed to address the risks of osteoporosis, heart disease, breast cancer, uterine cancer, hot flashes, vaginal dryness, etc.  One needs to ask , “What was the body supplied with when it was in hormonal balance?”  First of all, women were continually producing estrogen which was at its highest level during the first two weeks of the cycle. Progesterone was also present and rose dramatically just after ovulation when the estrogen levels dropped. Now, doesn’t it make sense to provide the body with both estrogen and progesterone once the ovaries stop making it?  It never fails to amaze me that women who have had a hysterectomy are not told to replenish their bodies with progesterone as well as estrogen. Remember, I’m talking about natural progesterone not progestins (which do nothing but impair the natural chemical reactions that occur in a woman’s body).

While most studies are still in the anecdotal stage, the case for progesterone supplementation is a strong one.  For instance, one double-blind study showed that using a topical preparation of natural progesterone cream led to a reduction in hot flashes in 83% of women, compared with improvement in only 19% of those given placebo.

Personally, I have found that combining progesterone cream with a genistein supplement gives even better relief. It seems that where one slacks off, the other picks up.  

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Micronized Progesterone

In the past, the only effective delivery system for natural progesterone was topically or through the skin. Currently oral, micronized progesterone is available by prescription.  It is a form of progesterone that partially survives the digestive process and may offer another alternative to cream products. It appears to have merit for hot flashes, anxiety, depression, sleep problems, and sexual functioning, but is relatively new and more data is needed. Moreover, in order to get the desired effects from micronized progesterone, the required dosage may result in undesired intestinal side effects.

Diet, Diet, Diet

While I’m all for using soy isoflavones, natural progesterone cream and low dose estrogen to combat the foibles of menopause, nothing is as important as what is consumed.   

Clearly, a diet of red meat and lots of sugar and white flour foods, is a total disaster and soon patients are  taking drugs to control  cholesterol, depression, hypertension and diabetes. Over 60% of the population is overweight, a real boon for the pharmaceutical industry. Like it or not, the human body thrives on certain foods. To our great misfortune, we usually avoid the very foods we need and consume those that shorten our lives  

Smart Eats for Menopause

As far as eating for menopause goes, it’s the same plan as eating for optimal health and longevity. A special diet is not needed  for individual disorders or diseases. What works for one, usually works for all.  The studies on reducing heart disease, cancer and Alzheimer’s always start with an identical diet. Avoid the trans fatty acids, saturated fats, reduce omega 6 fatty acids and increase  omega 3 fatty acids. 

Eat more alkaline-producing foods like raw fruits and vegetables, legumes, raw nuts, and whole grains help prevent osteoporosis.  Avoid fast foods, processed foods, processed sugar, hard fats and soft drinks. Eat soy foods and decrease or eliminate red meats (unless grass feed or free range, the same for chicken) and most dairy products (unless fat free).  Try tofu, soy milk, tempeh, roasted soy nuts, and other soy-based sources of phytoestrogens. 

Supplements containing isoflavones extracted from soy are commercially available. Freshly ground Flaxseed (as opposed to flaxseed oil) is also a good source of phytoestrogens and Omega 3 fatty acids. Phytoestrogens are also found in red clover and kudzu.

Move Your Muscles

It’s not surprising to learn that sedentary women are more likely to have moderate or severe hot flashes and other menopausal symptoms than women who exercise. Many women note that their menopausal symptoms immediately ease up after an aerobic workout.  Exercise also raises Human Growth Hormone and endorphin levels (the happy hormone), keeping weight down  not only prevents bone loss but actually makes  bones stronger. What more could one ask for?  I’ll put it this way — exercise is not optional.   The case for diet, exercise and the natural way is clear. By modifying one’s diet, exercising and taking a few supplements, the cost of health care can be dramatically reduced

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Osteoporosis

Women with osteoporosis develop brittle bones, which increases their risk of bone fracture, particularly in the hip, spine, and wrist.  While genetic factors play into your risk, when estrogen production takes a dive, your bone loss inevitably accelerates.  People tend to think of osteoporosis as a disease that only targets women. It is, however,  not an exclusively female condition. In one series, an estimated 40% of individuals affected with osteoporosis were men.  Osteoporosis-related fractures are estimated to account for $13.8 billion in hospital and nursing home costs each year, and those costs are going up. Keep in mind that more than 25% of Americans will be age 50 or older by 2011 so we are only beginning to see the tip of the osteoporosis iceberg.
           

If you are a woman approaching menopause, you need to know that nearly half of all menopausal women either have the disease or are beginning to show the signs of bone loss (osteopenia). While your race, age, and gender will impact your risk, the incidence of osteoporosis varies widely. Of even more significance is the fact that this disease is preventable.

When Does Bone Loss Start?           

You don’t have to be menopausal to start losing bone density. In fact, by the time you get to menopause, you may have already lost considerable bone mass.  Most young women fail to consume the amounts of calcium they need to maintain good bone density.  That coupled with a diet heavy on animal protein, sugar and soft drinks can set the stage for the development of brittle bones. In addition, a young woman who does not ovulate can be at a higher risk for osteoporosis.            

Risk Factors That Raise Your Risk of Osteoporosis

Ovarian Failure:

Young women who repeatedly miss their periods and are not pregnant may develop premature ovarian failure which means that their hormonal output will not be adequate. When the ovaries stop producing hormones prior to age 35 or 40, periods cease and increased bone loss can commence.  According to the National Institutes of Health, roughly 1% of American women experience ovarian failure by age 40.  I know what many of you are thinking — what woman would complain about missing her period?  Let me stress here that skipping periods at a non-menopausal age is medically significant and should be addressed by your doctor. Your ovaries produce the hormones that keep your bones flexible. A simple blood test for FSH, (follicular stimulating hormone) that is typically elevated above 20 can test you for ovarian failure.

Breast Cancer and Osteoporosis:  A Hormonal Quandary

Women who have breast cancer have less osteoporosis and those who have osteoporosis have less breast cancer. Why?  Because a woman with higher circulating levels of estrogen puts vulnerable tissue in estrogen’s path, thereby risking cellular changes that can turn into tumors. When it comes to bone health, however, higher estrogen levels mean that more calcium will get into the bone matrix helping to preserve bone density. It’s a catch twenty-two. By using estrogen blockers and natural progesterone however, a woman can have cancer AND bone protection. It’s like having your cake and eating it too.

Birth Control Pills: Good or Bad For Your Bones?

Interestingly,  some studies also tell us that women who are taking birth control pills have lower bone mineral density (BMD) than women who have never used oral contraceptives. Remember that the hormones in a birth control pill suppress ovulation with doses of estrogen.  Data from the a 2001 issue of the Canadian Medical Association Journal reveals that bone mineral density was 2.3% to 3.7% lower in women who had used birth control pills than those who had not.  In addition, the bone loss appeared to target the spine and the upper part of the thigh bone more than other areas.  Keep in mind that some experts have been telling woman that using oral contraceptive may actually protect them against osteoporosis because estrogen levels are artificially elevated.  As is the case with so many studies on the effects of synthetic hormones, conflicting data is common.  My view is that you should know all of the facts before going on an oral contraceptive for a long period of time.

Salt and Caffeine           

Hide your salt shaker. Short-term increases in dietary salt consumption resulted in increased urinary calcium loss, which could cause bone loss over time.  Granted, a concrete link between salt intake and osteoporosis has not yet been established, but regardless, cutting down on salt is wise, especially if you have high blood pressure or tend to retain water. Another culprit called caffeine also increases urinary loss of calcium and has been linked to the increased risk of hip fractures and overall lower bone mass especially in women who did not consume adequate amounts of calcium.  Too many women rely on caffeine-containing soft drinks to boost their energy levels. Caffeine may temporarily spike your energy curve, but it comes with a high price tag. You can become dependent on its effect and when it wears off, feel like an old dish rag. Eating right and exercising are the only way to get through the day.   Interestingly, caffeine-containing tea seems to prevent bone loss which would suggest that its high phenol (antioxidant) content may exert a bone-protective effect.

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Carbonated Drinks

Get rid of your big gulp. People who regularly consume soft drinks have an increased incidence of bone fractures.   Phosphoric acid found in many soft drinks can significantly lower your blood calcium levels. In one trial, children consuming at least six glasses of soft drinks containing phosphoric acid had more than five times the risk of developing low blood levels of calcium compared with other children. Soft drinks often contain sodium as well, which may also negatively impact bone density.  When the phosphoric acid found in most soda pop is absorbed, your blood can become more acidic. When this happens, certain built-in alarms go off and the body neutralizes the acid with alkaline materials like calcium and magnesium. Where does the calcium and magnesium come from?  Bone.

Dairy Products — Good or Bad?

Countries that have the highest rates of osteoporosis are England, Australia, and the U.S.  Is it just a coincidence that citizens of these countries eat the most dairy products and red meat?    I know what you’re thinking — don’t milk and cheese, etc. provide much needed calcium for bone strength?  Perhaps not. There are several theories suggesting that our pasteurized and artificially treated milk, cheese, etc., is not digested the way it should be, therefore its calcium content may not be adequately absorbed.  Moreover, when you add meat to your plate, it may cause calcium to be leached from your bones and teeth. So having a burger with a big glass of milk is not good for your bones. There is substantial evidence that eating a diet heavy on protein is not bone-friendly. If you’re going to consume dairy products, choose non-fat milk, which has a lower protein and salt content while sporting higher calcium content. Cottage cheese on the other hand, is actually higher in protein and salt and lower in calcium. Many hard cheeses are also high in fat and salt and are not preferable sources of dietary calcium. Low fat yogurt offers another good source of dietary calcium if they contain “active” lactobacteria cultures.

Smoking and Drugs

Here’s another reason to quit smoking. Smoking leads to increased bone loss.  There is plenty of evidence out there that smoking causes a significant increase in the risk of bone loss and osteoporosis.  For instance, one study showed that women who smoked one pack of cigarettes a day experienced a loss of bone density equaling five to ten percent more than nonsmokers by the time they reach menopause.  Smoking reduces the blood supply to bones and nicotine inhibits the production of bone-forming cells (osteoblasts) and also compromises the absorption of calcium.  When your bone mineral content goes down, the fragility of your bones goes up.   Smoking also appears to impair the actions of estrogen, which naturally protects bone mass. We also know that smoking increases your risk of a hip fracture as you get older. Older women who smoke have a 41 percent increase in the rate of hip fracture. Bone density scanning is recommended for all women after the age of 40 but is absolutely crucial if you smoke.

Drugs That Hurt Bones

There are several drugs that can cause secondary osteoporosis and if you are on any of them, talk to your doctor about preserving the health of your bones. If you can’t get off of any of these drugs, then, for heaven’s sake, take the necessary steps to protect your bones from this additional hazard. For example, taking a compound called ipriflavone may help to mitigate some of the bad effects of these drugs.

Corticosteroid Drugs:

Cortisone, prednisone, and dexamethasone are commonly prescribed corticosteroid drugs and if used over a long period of time, pose a significant bone risk.  The amount of bone loss that you will experience while on these drugs can vary. For instance, your bone loss may be greater if you take corticosteroids orally as opposed to injections, inhalers, or in topical creams, etc. The stronger your dosage and the longer you take a corticosteroid drug, the higher your chances are for developing osteoporosis.

Thyroid Hormone Drugs:

Most people who take this class of drug have an underactive thyroid.  Because artificially manipulating this hormone can be difficult, an excess amount can decrease bone mass when used over time. If you’re on this drug, make sure to have your blood tested every six months to check on your thyroid hormone levels and be diligent about taking calcium/magnesium supplements and exercising regularly.

Antacids:

While some antacid tablets contain calcium and are advertised as being good for your bones, those that contain aluminum are not if you have kidney problems, or repeatedly take them in high doses.  Check your antacid for aluminum and don’t rely on antacids as your only source of supplemental calcium. If you are on prescription antacid drugs, talk to your doctor about potential bone loss.

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Other Medications That Can Cause Bone Loss

Phenytoin (Dilantin)

Barbiturates that are used to prevent seizures

Methotrexate (Rheumatrex, Immunex, Folex PFS)

 Cyclosporine (Sandimmune, Neoral)

 Luteinizing hormone-releasing hormone agonists (Lupron, Zoladex),

 Heparin (Calciparine, Liquaemin)

Cholestyramine (Questran) and colestipol (Colestid)

The Weight Loss Link to Bones           

Someone told one of my heavier patients that because she carried extra fat stores that product estrogen, her risk of osteoporosis was less. Technically, this is correct but while being overweight may seem like an advantage, the extra weight exerted on your bones and muscles may not be. Moreover, obese women are at higher risk for breast cancer, heart disease, etc. You do need to know, however that women who lose weight have greater bone loss than those who don’t.  While this info may sound like a mixed bag, the important thing is to be careful if you lose weight by keeping your bone mass in optimal condition through nutritious eating, supplementation and exercise.

Drugs for Osteoporosis

Conventional treatment options for osteoporosis include prescription drugs that suppress the breakdown of bone (e.g., alendronate [Foamex®], calcitonin [Calcimir®, Miacalcin®], raloxifene [Evista®]), and those that provide hormone replacement therapy (e.g., estradiol [Estrace®, Estraderm®, Fempatch®], conjugated estrogens [Premarin®], and conjugated estrogens with medroxyprogesterone acetate [Premphase®, Prempro®, Provera®]) for postmenopausal women.  Many of these drugs come with unpleasant side effects which should be discussed thoroughly with your doctor.  Unless your situation is extreme, I like to turn to Mother Nature has provided some viable alternatives to protect your bones.

Does HRT to Prevent Osteoporosis?

Why don’t women that live in third world countries and eat very little dairy or meat get the kind of osteoporosis American women do?  Of equal relevance, if estrogen replacement is the way to prevent bone loss after menopause, what are these women doing?  It’s certain that they aren’t wearing Depo patches or popping Provera. Obviously, there are more factors at play here.            

Like the heart connection, the data on HRT and bone loss conflicts.  There is abundant research that shows that synthetic hormones do NOT  prevent bone loss. In fact, one of these studies concluded that the risk of hip fractures for women over 75 is the same whether or not she took synthetic estrogen.  On the other hand, there are scores of studies that advocate the bone-protective properties of HRT, but does it justify any potential risks?             

At the risk of sounding redundant, I believe that the most important aspect of osteoporosis management is prevention of the disease. Remember that the higher your bone mass before menopause, the less your risk of osteoporosis.  Good bone health depends on exercise and diet (surprise, surprise).           

So, while the ability of estrogen to prevent osteoporosis is still engendering debate, we do know this — synthetic estrogen cannot increase bone mass. Granted, it may delay or slow bone loss but it can never replace bone.

Bone Density and Soy Isoflavones

Recently,  researchers at the University of Illinois in Urbana found that soy isoflavones can help to strengthen the bones of the lumbar spine and help to prevent the dowager's hump often seen in postmenopausal women with osteoporosis. The bone density of one group of women who took 92 mg of soy isoflavones daily increased by 2.2 percent over a period of six months.  It's important to realize that most women lose 2 to 3 percent of bone density in the initial two to three years following menopause, suggesting that the sooner isoflavone consumption is increased, the better.            

Eating soy foods such as tofu, soy milk, roasted soy beans, and soy protein powders is a good way to get these much-needed isoflavones.  In another double-blind trial, postmenopausal women who supplemented with 40 grams of soy protein powder (containing 90 mg of isoflavones) per day were protected against bone mineral loss in the spine, although lower amounts were not protective. While the use of soy in the prevention of osteoporosis looks hopeful, no long-term human studies have examined the effects of soy or soy-derived isoflavones on bone density or fracture risk.

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Ipriflavone: Potentiated Isoflavone Compound for Bone Health

Ipriflavone is an isoflavone synthesized from daidzein (which is naturally found in soy). It appears to have a great deal of potential in the prevention and treatment of osteoporosis and other bone diseases.  Studies to date have found that it enhances bone formation and mineral absorption, thereby increasing bone density.  It works by boosting the effect of estrogen, although it has no estrogenic activity in and of itself.  For this reason, if osteoporosis runs in your family and you want an HRT alternative, ipriflavone may be a good choice for you.  Preliminary studies also reveal that taking this compound may help to protect your bones from steroid use, immobility, and if you have had your ovaries removed.            

Ipriflavone has the distinct ability to increase the activity of bone-building cells called osteoblasts while inhibiting the action of osteoclasts, which actually break down bone material. One study conducted in 1998 found that ipriflavone was able to dramatically boost new bone formation and repair.  A group of 56 post-menopausal women with low bone density all received 1,000 mg of calcium and random subjects were given an additional 600 mg of ipriflavone.  The women who only took the calcium actually experienced increased bone loss after two years. By contrast, bone loss was totally halted in those who took the ipriflavone. The study concluded that, "Ipriflavone prevents the rapid bone loss following early menopause." The recommended dosage of ipriflavone is 600 mg daily.

Natural Progesterone Lays On Bone

I don’t believe that soy alone offers a strong enough defense against bone loss. Complementing soy with natural progesterone cream is wise. Preliminary evidence suggests that progesterone reduces the risk of osteoporosis. Dr. John Lee talks about his encounter with scores of women who suffered from osteoporosis. Many of them were continually losing bone density regardless of the fact that they were on estrogen therapy. At best, he believes that all supplemental estrogen therapy did was to slow their bone loss, not stop it and certainly not reverse it. He mentions that even when these women took calcium, vitamin D and C, and even quit smoking, their bone loss continued.           

He relates that over a 3 year time interval, the typical woman who was not taking any hormonal therapy would lose four and a half percent of her bone mass. He emphasizes that adding estrogen therapy can help maintain bone mass for several years, but that it will gradually go down.   Here’s the clincher — by adding natural progesterone treatments, he saw a 15 percent increase in bone mass over a period of three years with no negative side effects. 

Tips On How To Prevent and Even Reverse Bone Loss

Eat More Vegetables

A recent study reported in the Journal of Clinical Nutrition conducted by the Department of Endocrinology at the University of California Medical School in San Francisco, emphasized the importance of maintaining a proper balance between the consumption of animal protein and vegetable protein. Menopausal women whose protein consumption was 3:1 (favoring animal protein over vegetable protein) had a much risk of osteoporosis and hip fractures. When that ratio dropped to 1:1 the risk dramatically dropped. Once again the devastating effects of the typical diet of most North American women is underscored. 

All Protein is Not Created Equal

Why does the type of protein source you choose to eat make such a difference to your health?  For one thing, animal protein leaves a type of  “ash” when it is burned because it contains high levels of sulfur amino acid contents (methionine and cystine).  As a result, acid levels increase and need to be neutralized.  Innate chemical mechanisms turn to calcium and magnesium to do the job.  Where do we store the most calcium and magnesium?  You know! 

On the other hand, a diet rich in vegetables helps to keep your blood more alkaline which can prevent mineral depletion from the bones.  Moreover, many vegetables are rich in vitamin K which works to maintain calcium deep within your bones.           

While you may find opposing arguments by other experts, I believe that obtaining your protein from soy, and other legumes (beans, raw nuts, etc.) is not only bone protective, but is much better for your entire body.  As opposed to red meat and dairy products, when was the last time you saw red beans or almonds linked to heart disease or cancer?  And I must add that my vegetarian patients have excellent bone mass and flexibility. In virtually every health category, they far surpass my meat and potato patients.

Take The Right Calcium Supplement

Close to three fourths of all women DON’T get enough daily calcium and over 50 percent don’t even get half the recommended amount. Unfortunately, you may not find out you’re calcium depleted until your teeth and bones start falling apart. Moreover, if you're calorie or cholesterol-conscious, or if you're allergic to milk, or are lactose intolerant, getting enough calcium from your diet will be virtually impossible.            

Calcium supplements are a good way to ensure that you get enough calcium and they are relatively inexpensive. The confusion lies in what type to pick. Be aware that it isn’t the amount of calcium listed on that label that counts, but rather how much of it your body will absorb.           

There are three commonly available forms of this mineral – calcium carbonate, calcium lactate, and calcium citrate.  According to the latest research available, calcium citrate wins over its competitors.   A study found in the November, 1999 issue of The Journal of Clinical Pharmacology reveals that the human body absorbs 2-1/2 times more calcium citrate than calcium carbonate.  So while calcium carbonate supplements may contain more elemental calcium than calcium citrate, less of it actually finds its way to your bones. You may find that a calcium supplement contains a variety of calcium types. Make sure that calcium citrate is the major calcium player on that label. Avoid calcium supplements derived from bone meal, oyster shell or dolomite. These supplements may be contaminated with lead.

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Maximizing the Action of a Calcium Supplement

1. Make sure that you add Vitamin D and magnesium to your calcium supplement to enhance its absorption.  The calcium-magnesium ratio in the supplement you choose should be 2-1 (for example, 500 mg. calcium to 250 mg. magnesium).

2.  If possible, spread your calcium doses throughout the day, limiting each dose to no more than 500 mg. This helps to increase absorption and decrease any possible side effects, which can include constipation and bloating.

3. Take your supplement with a large glass of water to ensure that it breaks down properly.  The last thing you need is a bunch of undissolved calcium tablets residing in your colon. Chewable forms of calcium are also recommended. Don’t take calcium supplements with meals because fiber can tie up the calcium and prevent its absorption.

Note: Check with your doctor before taking any calcium supplement. If you have kidney disease, kidney stones or an overactive parathyroid gland, you should not take calcium supplements.

Minimum Calcium Requirements

Pre-menopausal women age 25-50:  1000 mg daily

Pregnant/nursing women:  1200 - 1500 mg daily

Post-menopausal women under 65 on estrogen replacement therapy(ERT): 1000 mg daily

Post-menopausal women not on ERT: 1500 mg daily

All women over 65:  1500

NOTE: Calcium intake up to about 2,000 mg/day appears to be safe in most individuals.

My Recommendation           

I don’t recommend crunching on Tums to get your calcium. Tums are nothing more than calcium carbonate, which is a source of calcium, but is not the most absorbable kind.  I like calcium citrate and suggest taking 1,200 to 1,500 milligrams prior to retiring.

Preferred Calcium-Rich Foods

Non-fat milk, active culture low-fat yogurt, leafy green vegetables, canned sardines and salmon with edible bones, calcium-fortified orange juice and cereal, tofu, raw almonds.

Start Young

Encourage your teenage daughters to take start taking calcium supplements since the best time to build strong bones is during the second decade of life.  Research has found that 12 year old girls who took calcium supplements had better bone building than those who did not. The more bone mass you can build when you’re young, the less your risk of osteoporosis later.

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Magnify Your Magnesium

If you have osteoporosis, you may also have trouble absorbing magnesium. Low blood and bone levels of this mineral can be low in women suffering from osteoporosis. Magnesium supplementation at 250 mg to 750 mg per day actually stopped bone loss or increased bone mass in 87% of people with osteoporosis in a two-year, controlled trial. You need to take a minimum of 350 mg of magnesium with your calcium daily.

Vitamin D for Density

Good old Vitamin D boosts calcium absorption. How much of you have in your blood is directly related to the strength of your bones.  A deficiency of vitamin D is common in the elderly and accelerates of age-related loss of bone mass and an increased risk of fracture. Many studies show that vitamin D supplementation reduces bone loss in women who don’t get enough of it in their diets.

Choose Your Oils Wisely

Elderly women with osteoporosis who were given 4 grams of fish oil per day for four months had improved calcium absorption and even showed evidence of new bone formation. Combining fish oil with evening primrose oil (EPO) may be even better. In another controlled study, women who took 6 grams of a combination of EPO and fish oil plus 600 mg of calcium per day for three years experienced no spinal bone loss in the first 18 months and showed a dramatic 3.1% increase in spinal bone mineral density during the last 18 months.

Vitamin K is For Keeps

Women who have osteoporosis are also frequently low in vitamin K. One study found that post-menopausal women can actually decrease a loss of calcium in the urine by taking 1 mg of vitamin K per day. And those who already have the disease who took supplemental vitamin K showed an increase in bone density and overall decreased bone loss after six months.

Trace Minerals Too

Trace minerals like zinc and copper are also critical for proper bone mass and should be included in your multiple vitamin and mineral supplement in chelated forms. You should be getting 10 mg of zinc and 2 to 3 mg of copper daily. 

Weight Bearing Exercise

Engaging in weight bearing exercises is an absolute must for sustained bone health. These exercises require your muscles to work and can include aerobic exercises like walking, water aerobics (also known as aqua aerobics) and step aerobics. Women who exercise at least three times a week consistently show a higher bone mineral content than those who don’t. Mild weight lifting can be helpful but you should avoid exercises that put an abnormal amount of stress on your bones and joints.  Simply stated, regular exercise protects against bone loss and the more weight-bearing exercise you do, the better your bone mass will be.




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The above comments are excerpts from Dr. Townsend's new book "A Maverick of Medicine Speaks to Women" by Duane Townsend, M.D. and Rita Elkins, M.H. These excerpts may not reprinted in whole or part without permission of the author. All rights reserved. Copyright ® 2003 Duane Townsend, M.D.