Natural Menopause Relief Secrets

Natural Female Hormone Balance Program

Joan Atman with the help and inspiration from Dr Stephanie put down this book. Dr Stephanie is the mastermind behind this helpful guide. He is a nutritionist and a medical practitioner who has been very active in this case. Joan Atman is an international Life coach and Energy medicine specialist. The Natural Female Hormone Balance program is a 28 day Hormone reset Detox program for female. It is a very easy and gentle program that is designed by the author to support the female body detox and eventually regain the normal hormonal balance. All the tips and the dietary changes discussed in the program will kick start the body's natural ability to balance hormones. This eventually helps your body look and feel incredible. The full program contains 6 modules designed to lead you step by step through the Hormone reset Detox program. This program is available in PDF formats. The author has also included some video and audio tutorials. You can download the program and print or just download the PDF file, the Videos and the Audio. More here...

Natural Female Hormone Balance Program Summary


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Perimenopause and menopause

Loss of ovarian follicular activity may lead to the common minor mood changes of the perimenopausal period. Minor cognitive and depressive symptoms and vasomotor instability respond well to hormone replacement therapy. Menopause is associated with an increased risk of recurrence of depressive disorders but is not a high-risk time for the new onset of depressive disorders.18 Women who are vulnerable to depression during periods of hormonal fluctuations are likely to experience recurrent depressive episodes during perimenopause and menopause. If such a woman has a depressive episode, then hormone therapy alone is ineffective and a course of antidepressants and or psychotherapy is required.

Hormonal changes at menopause

Estrogen levels in postmenopausal women are one-tenth of those in premenopausal women. Postmenopausal estrogens are produced by the adrenal glands and fat cells rather than the ovary, the primary source of premenopausal estrogen. Estrone, produced by fat, replaces estradiol as the main source of estrogen. HT approximately doubles the estrogen level of a postmenopausal woman. After menopause, progesterone is essentially absent. Another hormone that declines around the time of menopause is testosterone, produced in men as well as in women. In women, the ovaries and the adrenal glands are the major producers of testosterone. The adrenal glands produce dihydroepiandrosterone (DHEA), which is converted to testosterone in peripheral tissues. Testosterone affects the brain, bone, muscle, skin, blood vessels, and vagina and contributes to bone density, strength, energy, hair growth, and libido in women. Levels peak when women are in their twenties and decrease to about half that level when...

The Menopausal Transition

Menopause signals the end of child-bearing capacity, and is also associated with changes in susceptibility to various chronic diseases, including breast cancer, heart disease, and osteoporosis.66 Differences in age at menopause between vegetarian and omnivorous women, should they exist, could be associated with differences in chronic disease patterns between these groups. Furthermore, some women experience unpleasant symptoms during menopause (vasomotor symptoms such as night sweats and hot flushes, mood swings, insomnia, weight gain, headaches, and fatigue),67 and these symptoms have been observed to differ among women in different cultures.67,68 Whether dietary variables contribute to these differences in symptom experiences has not been clearly established, but there is speculation that they could.68-70 Some of these dietary differences may also exist between vegetarian and omnivorous women. Accordingly, after defining and describing the menopausal transition, available research on...

Postmenopausal Bleeding

A patient is considered to be in menopause after 12 continuous months of cessation of menses and elevated gonadotropins. Menopause usually occurs at approximately 52 years of age. Postmenopausal bleeding is anv bleeding that occurs after menopause. Differential Diagnosis. The differential diagnosis of postmenopausal bleeding includes endometrial carcinoma, vaginal or endometrial atrophy, and postmenopausal hormonal replacement therapy. Although the most common cause of postmenopausal bleeding is vaginal or endometrial atrophy, the most important diagnosis to rule out is endometrial carcinoma. Risk Factors. These include obesity, hypertension, and diabetes mellitus. Other risk factors include nulliparity, late menopause, and chronic anovulation conditions, such as polycystic ovarian (PCO) disease. Endometrial sampling. Patients with postmenopausal bleeding must be evaluated with an endometrial sampling, which can be done in an office setting. Sometimes in postmenopausal...

Hormone replacement therapy a preventive therapy that has fallen from favor

Physicians have had to rethink the use of hormone replacement therapy (HRT) for primary and secondary prevention of CHD, given the results of recent studies. The first surprise came with the results of the Hormone Replacement Study (HERS) in postmenopausal women with established vascular disease. This large, randomized clinical trial of combined estrogen and progesterone versus placebo showed that at 6.8 years of follow-up, combined HRT did not reduce the risk of subsequent cardiovascular events in women who already had CHD.58 The HERS trial did not have an estrogen-only arm.

Type 1 diabetes and menopause

The relationship between type 1 diabetes and menopause is even more complex, as menopause in patients with type 1 diabetes may occur at a younger age.24' Genetic factors, including haplotypes found in association with the DR4 haplotype (more common in type 1 diabetes), may increase the risk of early menopause two-fold. The long-term effects of premature menopause, in addition to a shorter time for childbearing, include a higher risk of cardiovascular disease, abnormal lipid profile, and increased risk of osteoporosis. Earlymenopause may occur in women with type 1 diabetes from autoimmune premature ovarian failure (similar to the autoimmune thyroiditis seen more commonly in patients with type 1 diabetes), from peripheral hyperinsuline-mia and hyperandrogenemia seen in polycystic ovary syndrome, and from hypothalamic dysfunction from poorly controlled diabetes. A good menstrual history will help with the early detection of premature menopause in these women.

Psychological aspects of menopause Menopause as a transition

Menopause is a transition encompassing a developmental stage in the lifecycle, during which women gradually adapt to biologic, social, psychological, and spiritual changes that accompany recognized physiologic changes. While women throughout the world experience menopause, diagnosis is often difficult because it canbe made only in retrospect. Along withbiologic changes, significant psychological events occur during mid life, including changing relationships with children, marital instability, widowhood, and the illness or loss of parents. Menopause is a time of transition from childbearing and child-rearing to a time of growth, concentration on marital relationships, and sometimes freedom to travel. It is also a transition to old age, increased risk of illness, disability, and grandparenting. Contrary to medical models of menopause that characterize it as an en-docrinopathy in need ofhormonal treatment, women tend to viewmenopause as a developmental life event, or a rite of passage....

Postmenopausal Adnexal Mass

A pelvic mass that is identified after menopause. Ovaries in the postmenopausal age group should be atrophic, and anytime they are enlarged, the suspicion of ovarian cancer arises. Epithelial tumors 80 . The most common type of histologic ovarian carcinoma is epithelial cancer, which predominantly occurs in postmenopausal women. These include serous, mucinous, Brenner, endometrioid, and clear cell tumors. The most common malignant epithelial cell type is serous.

Spiritual aspects of menopause

Spiritual aspects of menopause deal with challenges to a woman's view of herself, her world, and, often, her god. Women's religious and spiritual beliefs play an important role in their views of life and medical illness. In this chapter, spirituality will be defined as beliefs that give meaning to one's life and provide connection to the trascendant.4 Religion will refer to a formal set of sacred beliefs, rituals, and practices. Many clinicians fail to consider the important role that spiritual and religious views play in providing women a context for interpreting life changes and illness. Failure to address spiritual and religious beliefs can frustrate the shared medical decision-making process because of lack of communication about fundamental issues. Physicians should not allow themselves to attempt to influence spiritual or religious views of their patients, but neither should they ignore patients' beliefs used to interpret the world around them.5 Physicians must inquire about...

Menopause and diabetes Type 2 diabetes and menopause

Menopause is defined as the cessation of menses for one year. Erratic menses that may occur before that time is known as perimenopause. As the population ages, estimates suggest that by 2015,45 of all women will be 45 years or older, an age often associated with changes in the menstrual cycle.13 The decrease in endogenous estrogen associated with the onset of menopause can be associated with All of these physiologic changes can affect glycemic control in the menopausal woman with diabetes. Evidence regarding the effects on glycemic control of hormone replacement therapy (HRT) used for the management of menopausal symptoms is inconclusive and conflicting. In the Postmenopausal Estrogen Progestin Intervention (PEPI) trial, combination treatment with estrogen plus medroxyprogesterone increased two-hour postprandial glucose levels.16' Other studies have shown that estrogen alone may improve diabetes control in post-menopausal women by decreasing relative androgen levels, since androgens...

Diet as therapy Menopausal symptom control

With fewer women taking hormone replacement therapy due to recent evidence, more women are looking for alternatives to control menopausal symptoms, particularly hot flushes. Several possibilities have been promoted for this, with a variety of depth of evidence. Soy products contain estrogen-like compounds called isoflavones. These are converted in the liver to substances similar to selective estrogen receptor modulators (SERMs) and have both agonist and antagonist activity at estrogen receptors. Intake of soy protein may therefore be helpful in the short-term (two years or less) treatment of hot flushes associated with menopause (evidence level C). Soy intake in the longer term may reduce serum cholesterol and protect against osteoporosis (evidence level C). Dietary soy intake may differ in biological activity from isoflavones in supplements (Table 3.2).2,3 Redclover contains isoflavones similar to those found in soy products. There is conflicting evidence as to whether red clover has...


Women usually stop menstruating at about the age of 45. This is known as the menopause. At this time, nearly all the primary follicles in the ovaries have been released or have become involuted (returned to normal size). Since the primary follicles supply most of the body's estrogen, the cyclic increase and decrease of estrogens cannot occur. Thus, the menstrual cycle is ended. Some women experience various effects (for example, hot flashes, fatigue, anxiety, and irritability) because of the metabolic changes the body is undergoing because of the decreased production of estrogen. The physician may prescribe estrogen therapy to the woman during this time.

Contemporary Endocrinology

Thorner, 2000 Hormones and the Heart in Health and Disease, edited by Leonard Share, 1999 Menopause Endocrinology and Management, edited by David B. Seifer and Elizabeth A. Kennard, 1999 Emile Baulieu, Michael Schumacher, and Paul Robel, 1999 Autoimmune Endocrinopathies, edited by Robert Volp , 1999 Hormone Resistance Syndromes, edited by J. Larry Jameson, 1999 Hormone Replacement Therapy, edited by A. Wayne Meikle, 1999 Insulin Resistance The Metabolic Syndrome X, edited by Gerald M. ReavenandAmi Laws, 1999 Endocrinology of Breast Cancer, edited by Andrea Manni, 1999 Molecular and Cellular Pediatric Endocrinology, edited by Stuart Handwerger, 1999 Gastrointestinal Endocrinology, edited by George H. Greeley, Jr., 1999 The Endocrinology of Pregnancy, edited by Fuller W. Bazer, 1998 Clinical Management of Diabetic Neuropathy, edited by Aristidis Veves, 1998 G Proteins, Receptors, and Disease, edited by Allen M. Spiegel, 1998 Natriuretic Peptides in Health and Disease, edited...

Regular physical activity

Moderate levels of physical activity have significant effects on a woman's health. Burning approximately 150 kilocalories per day or 1000 kilocalories per week leads to a reduction in the risk of coronary heart disease by 50 and of hypertension, diabetes, and colon cancer by 30 .2 After adjusting for covariates such as age, smoking, alcohol use, history of hypertension, and history of high cholesterol, women who are regularly physically active are 50 less likely to develop type II diabetes (relative risk 0.54) than women who are not regularly active.8 Vasomotor and psychosomatic symptoms associated with menopause are also reduced with moderate amounts of activity.6,9 Examples of moderate levels of physical activity are depicted in Table 2.2.

The Rising Incidence of Breast Cancer

Breast cancer is a serious, potentially lethal disease. Its incidence has been rising steadily since 1950, most significantly in postmenopausal women. Approximately 183,000 new cases are diagnosed in the United States each year, comprising 31 percent of all cancers. Of these cases, over 40,000 will die. In fact, breast cancer is the leading cause of death in women forty to fifty-nine years old. An American woman today has a one in eight (12.5 percent) cumulative risk of developing breast cancer in her lifetime1 (table 1.1).

The Roles of Age Sex and Ethnicity

Although breast cancer can strike women in their twenties, it is primarily a disease of older age (table 1.2). At least 78 percent of patients are age fifty or older, and the incidence rate is increasing most rapidly in post-menopausal women. However, the incidence of breast cancer in women under age forty is also increasing. This is significant because the hormonal status of the female patient seems to play a role in the behavior of the disease. In younger women the tumors tend to be more aggressive, and the patients may have a less favorable prognosis.

Developmental issues for the midlife woman

Women in the USA are presented with two predominantly negative scripts of the mid-life experience. One script is of a medicalized focus on menopause as a time of transition from a healthy, estrogen-rich time of life to the stage of inevitable health decline, with an attendant increased risk of heart disease and osteoporosis. The other readily available scenarios are social descriptions of an empty nest, abandonment for the woman, or that of a useless, used-up fertility has-been.1 Both of these views are in contrast with the repeated observations that women feel better about menopause, and themselves, after having traversed it.2,3 Considerable sociocultural variation in attitude toward the experience of menopause exists.4,5 Yet, overall, women have positive associations with mid life as a time to take stock and renew. Primary care providers have the opportunity to explore these beliefs with their patients and educate them about what is actually known about wellbeing during mid life.

Implications for work with midlife women

The medical orientation of training has been to approach life stages that are marked by biological events, such as birth and menopause, as pathological 2 Dennerstein, L., Smith, A. and Morse, C. Psychological well-being, mid-life and the menopause. Maturitas 1994 20 1-11. 3 Avis, N. E. and McKinlay, S. M. A longitudinal analysis of women's attitudes toward the menopause results from the Massachusetts Women's Health Study. Maturitus 1991 13 65-79. 4 Sampselle, C. M., Harris, V., Harlow, S. D. and Sovers, M. Midlife development and menopause in African American amd Caucasian women. Health Care Women Int. 2002 23 351-63. 5 Adler, S. R., Fosket, J. R., Kagawa-Singer, M., et al. Conceptualizing menopause and midlife Chinese American and Chinese women in the US. Maturitas 2000 35 11-23. 7 Hunter, M. S. and O'Dea, I. Perception of future health risks in mid-aged women estimates with and without behavioral changes and hormone replacement therapy. Maturitas 1999 33 37-43.

Studies in Seventh Day Adventists

Breast cancer was not strongly associated with intake of animal products in the mortality study. After taking into account age at menarche, age at first pregnancy, age at menopause, relative weight, and education, increasing consumption of meat, milk, cheese, and eggs was unrelated to fatal breast cancer risk.23

Hormonal fluctuations

Women have more erratic fluctuations in their hormonal status compared with men. Estrogens and progesterone rise to high levels during pregnancy, only to drop abruptly postpartum as prolactin levels elevate. Perimenopause is now recognized as a unique physiological entity, with dropping levels of estrogen and an even greater loss of progesterone as ovulationbecomes inconsistent. The perimenopausal state can last years before menopause. Based on the results of small studies, the perimenopausal state appears to have unique, albeit perhaps transient, effects on sexual health and functioning. An interview survey of 124 perimenopausal women found that the age group centering around 49 years did not have sexual difficulties in desire, response, or satisfaction in their sexual life, whereas a subset of women with very low estradiol levels tended to have reduced coital activity.19 In a study of 43 perimenopausal women who kept daily records of menstrual cycles and sexual activity, a negative...

New Adventist Health Study

**Adjusted for age at menarche, age at first pregnancy, age at menopause, weight, education, and for several foods. **Adjusted for age at menarche, age at first pregnancy, age at menopause, weight, education, and for several foods. *Adjusted for age at entry, age at first pregnancy, age at menarche, menopausal status, history of benign breast disease, maternal history of breast cancer, education and weight.

Soy Isoflavones and Breast or Prostate Cancer Risk

Several case-control studies and one cohort study have reported on the relationship between soy intake (or indirect measures of intake) and breast cancer risk. These studies are summarized in Table 4.4. In a study in Singapore involving 200 breast cancer cases, breast cancer risk was reduced approximately 60 among women in the highest quintile of soy consumption, compared with those in the lowest quintile of soy consump-tion.39 However, this relationship was observed only in premenopausal women. In a larger hospital-based study in Japan, those women consuming soy three or more times per week had approximately 20 lower risk of Premenopausal women only Hospital-based study premenopausal only Includes both pre- and postmenopausal Includes both pre- and postmenopausal Soy intake estimated by metabolite excretion. Both pre- and postmenopausal Postmenopausal breast cancer than those women who consumed soy less frequently. Again, the findings of a protective relationship were restricted to...

Initiation Of Folliculogenesis And Preantral Follicle Growth

Apoptotic cell death occurs in oocytes and granulosa cells of both primordial follicles and growing follicles. Members of the Bcl2-related protein family play either positive or negative roles in regulating apoptosis (45,46) (see Chapter 6). Bcl2 and BclxL protect against apoptosis, while Bax, which can heterodimerize with Bcl2 and BclxL, counters their protective effect and promotes cell death when overexpressed. Bax is expressed in granulosa cells and oocytes, and plays a critical role in regulating ovarian-cell death 6-wk old Bax-deficient mice have three times more primordial follicles than controls and one-half the number of atretic primordial follicles. This difference in the rate of follicu-lar-pool depletion results in the presence of growing, functional follicles at 640 d of age. Despite the presence of growing follicles, no corpora lutea or pregnancies have been seen in these very old mice. Ovulation could be induced by injection of exogenous gonadotropins, indicating that...

Environmental factors

Problem drinking in mid-life women is associated with marital disruption, children leaving home, and not having employment outside the home. Other risk factors are a failure to adapt to aging, heavy spousal drinking, drinking alone at home, and abuse of prescribed psychoactive drugs.29 Perimenopause is a time of increased psychological and physical vulnerability for some individuals, which may be related to concurrent changes in the reactivity of the hormonal stress system.

The Nature of Breast Abnormalities Benign and Malignant Lesions

Breast lumps and irregularities are extremely common. Many women have lumpy breasts and are often told they have a condition known as fibrocystic change in which benign, fluid-filled cysts or excessive growth of fibrous, connective tissue occur.3 These lumps tend to grow and shrink with the menstrual cycle, and may be associated with cyclical breast tenderness and even nipple discharge. Younger women often develop a solid but benign tumor known as a fibroadenoma, which consists of glandular and fibrous tissue. These, too, are benign. However, some abnormal breast conditions and lumps have a higher probability of progressing to malignancy. A condition called atypical hyperplasia is correlated with increased cancer risk. In this condition, there is an overgrowth of the ductal epithelium, and the cells are not quite normal in microscopic appearance. It is therefore important that a physician check out palpable, persistent lumps. In pre-menopausal women, approximately 8 percent of breast...

Medical consequences of longterm alcoholism Harmful effects

Many studies report that moderate to heavy alcohol consumption increases the risk for breast cancer.35 A meta-analysis involving more than 150 000 women with and without breast cancer showed an increased relative risk of breast cancer of 1.32 (95 CI 1.19-1.45) for an intake of 35-44 g of alcohol per day. The relative risk increased by 7.1 for each additional 10 g day alcohol-intake.36 The investigators concluded that if the observed relationship is causal, then about 4 of the breast cancers in developed countries are alcohol-related. A prospective cohort study of approximately 45 000 postmenopausal women has shown that the relative risk is doubled when alcohol consumption is combined with hormone replacement therapy.37 In contrast, smoking has little or no independent effect on the risk of developing breast cancer.36

The Role of Sex Age Hormonal Status and Ethnicity on the Biology of Breast Cancer

Age is the greatest risk factor for developing breast cancer, but tumors in post-menopausal women are sometimes less aggressive than in those who are pre-menopausal. A role for female sex hormones in breast cancer has long been suspected because women are far more susceptible than men. Early menarche and late menopause, which lengthen the period of exposure to sex hormones, increase the risk for breast cancer. The age at which a woman has her first child, the number of pregnancies, and whether she breast feeds may also be risk factors and are related to hormonal status. The amount of breast tissue available may be a factor, but small-breasted women are at similar risk to those with large breasts.

Etiology of gender differences

In a predisposed individual, life events can trigger depression. Women are more likely than men to report a stressful life event in the six months prior to a major depression and may be more vulnerable to developing depression after stressors.5 Many mid-life women face a cluster of potential triggers, such as divorce, relationship issues, loss or illness of parents, retirement employment issues, concerns over adolescent and adult children, financial stress, domestic violence, and health concerns, including menopause.6

Clinical presentation

Overt symptoms during a routine physical exam, and may disclose depressive symptoms only if she feels safe and confident that the physician can provide effective help. Physicians are five times more likely to recognize depression if psychiatric symptoms are mentioned early in the interview and if no physical illness is detected.8 Awareness of gender differences in depression can facilitate diagnosis (Table 7.1). Women may present at certain times, such as premenstrually, during perimenopause, and during exogenous hormone therapy, because of hormonal triggers of depression. Women tend to have a more chronic pattern of depressive illness than men and to express more symptoms of appetite weight changes, sleep disturbances, psychomotor retardation, guilt, panic, anxiety, and somatization (especially pain syndromes).9

Dualenergy Xray Absorptiometry

For example, in obese premenopausal women, although DEXA consistently overestimated fat mass (10 ) and underestimated fat-free mass ( ) before and after a 14 diet-induced weight loss intervention, it did report comparable mean decreases in fat (11.5 vs 10.9 kg) and fat-free mass (1.6 vs 2.0 kg) as compared with the four-compartment model (64). The authors concluded that DEXA provides unbiased estimates of fat loss in response to caloric restriction however, those estimates were also no better than those derived using a simple equation with BMI (mean difference vs four-compartment model 0.6 2.1 vs -0.3 2.1, DEXA vs BMI, respectively). Similarly, a study by Tylavsky et al. (81) reported that in response to a 7 weight loss in women, changes in the thigh fat mass and lean mass as measured by CT were correlated with changes as measured by fan-beam (fat r 0.67, lean mass r 0.55) and pencil-beam (fat r 0.66, lean mass r 0.60) DEXA (81). However, again both...

Physical and laboratory assessment

Physical examination and laboratory investigations serve primarily to identify comorbid conditions that could have precipitated the episode of MDD and or are likely to complicate its management. Investigations are targeted to the needs of the individual patient. They may include complete blood count, thyroid studies, assessment of electrolyte (sodium, potassium, calcium) and glucose levels, and evaluation of hepatic and renal function. Menopausal status maybe confirmed by increased levels of follicle-stimulating hormone (FSH) (greater than 20 IU dl) and decreased estradiol (less than 60 pg ml) on day two or three of the menstrual cycle. Physical examination and laboratory findings are normal in many women with depression.

Computed Tomography Quantification of Tissue Size

Or more commonly, in Hounsfield units (HU), which is a linear scale relative to air and water (-1000 and 0 HU, respectively). Cross-sectional CT images are composed of picture elements or pixels, each of which has a CT number or HU value on a gray scale that reflects the molecular composition of the tissue. Although CT is more assessable than MRI, exposure to radiation precludes its use for multiple-image whole-body tissue quantification, and limits applicability in children and premenopausal women.

Gender and Antidepressant Response

In our recent collaborative study of patients with either chronic major depression or so-called ''double depression,'' we observed a significant effect of gender on acute antidepressant response to treatment with imipramine or sertraline 2 . In this large study of 635 cases, patients were initially treated for 12 weeks with imipramine or sertraline under double-blind conditions 3 . Maximum doses were 300mg day and 200mg day for imipramine and sertraline respectively. Men responded significantly better to treatment with imipramine than they did to sertraline. In contrast, women responded significantly better to sertraline than to imipramine. Moreover, the preferential response in women to the SSRI was primarily found in premenopausal women. Postmenopausal women responded equally to both drugs that is imipramine was relatively more effective in older than in younger women 2 . These data do indeed suggest a possible interaction between hormonal status and SSRI response. Many previous...

Determination of Tissue Volume and Mass

Differences in abdominal muscle at L4-L5 and thigh muscle in two obese premenopausal women with high and low levels of whole-body skeletal muscle mass as measured by magnetic resonance imaging.The skeletal muscle is outlined by the white dotted line. Fig. 9. Differences in abdominal muscle at L4-L5 and thigh muscle in two obese premenopausal women with high and low levels of whole-body skeletal muscle mass as measured by magnetic resonance imaging.The skeletal muscle is outlined by the white dotted line.

How The Sleep Of Women Differs

Even greater attention has been paid to conditions distinctive in women, notably changes in their reproductive hormones and related developmental status. Menarche, the menstrual cycle, pregnancy, and menopause all have been found to have effects on sleep quality and quantity. (Much of this research has been done by Kathryn Lee, PhD, a nurse with the Department of Family Health Care Nursing, School of Nursing, University of California, San Francisco, and her associates Lee, McEnany, & Zaffke, 2000 Lee, Zaffke, & McEnany, 2000 Baratte-Beebe & Lee, 1999.) The end of the reproductive years in a woman is marked by menopause when the production of progesterone and estrogen begin to fall and eventually remain low. One of the consequences, hot flashes during sleep, is reported by over a third of women. They contribute to an increase of brief arousals during sleep. In extreme cases, severe hot flashes can result in hundreds of awakenings per night. Even a moderate level can result in...

Diabetes And Minerals Vitamins And Dietary Supplements

This study evaluated the intake of various antioxidant vitamins found in foods and supplements to their relationship to coronary artery disease and overall mortality. This study evaluated close to 35,000 postmenopausal women (aged 55-69 years) with no history of cardiovascular disease for 7 years. Intake of vitamins A, E, and C were estimated by questionnaires and then correlated with

Risks of hormone therapy

Any discussion of HT risks must include the baseline risks of women not using HT or ET (Figure 10.2). Table 10.4 outlines the probability that a menopausal woman will develop chronic disease Another useful perspective maybe gained by comparing these risks with risks from some common everyday activities (Table 10.5). One out of 100 women who use HT for one year will experience a net additional adverse outcome compared with non-users. Safer preventive strategies for most chronic conditions are available. Table 10.6 lists the additional adverse outcomes of 10 000 women EPT users for each year of use. There were 19 excess events in the women using EPT, or a 1 five-year risk. Of 200 women who use HT for five years, one woman will not have an osteoporotic fracture or colorectal cancer. Four will develop invasive breast cancer, CHD, stroke, or venous thromboembolism.13 * 7-8 of individuals 75-84 years of age have dementia postmenopausal women have a 1.4-3.0 higher risk of Alzheimer's disease...

The choice to use hormoneestrogen therapy

At the present time, excess adverse effects appear to outweigh benefits from the use of combination HT to prevent chronic disease.48 HT is not protective against cardiovascular disease and may increase its risk. The American Heart Association,49 the American College of Obstetricians and Gynecologists (ACOG),50 and the North American Menopause Society (NAMS)51 recommend against the use of HT for primary or secondary prevention of cardiovascular disease. Both ACOG and NAMS recommend caution if HT The principle indication for EPT and ET is the management of menopausal symptoms in women without established CHD, breast (or other hormonal-dependent) cancer, thrombosis, or riskfactors for these conditions, especially if the menopausal symptoms have not responded to alternative strategies. NAMS recommends that the primary indication for EPT or ET is the treatment of menopausal symptoms.53 ET markedly improves menopause-related symptoms, such as hot flushes, hot disordered sleep, and vaginal...

Discontinuing hormone therapy

There are no evidence-based recommendations to guide discontinuation of HT. Women who did not have menopausal symptoms prior to starting HT appear to have few if any symptoms when it is discontinued. Similarly, there are no data on whether or how to taper use, although many clinicians will reduce a dose and maintain the woman at that dose for one to two months before decreasing again. Alternatively, some clinicians change to a different formulation of estrogen (i.e. from oral to transdermal) as part of the process.

Types of estrogenprogestin therapy and estrogenalone therapy

All forms of estrogen are equivalent in treating menopausal symptoms such as hot flushes and vaginal dryness. Oral estrogens generally improve lipid panels favorably, particularly by increasing the high-density lipoprotein (HDL) cholesterol. In some women, however, oral estrogens may raise serum triglyceride levels.

The Reproductive Years

The time between menarche and menopause, during which reproduction is possible, spans a period of almost 40 years in women. Although the presence of menstrual bleeding is often equated with the ability to conceive, establishing a pregnancy actually depends on the presence of a normal ovarian cycle (i.e., a normal ovulatory menstrual cycle). If vegetarianism affected women's reproduction, it would necessarily affect the characteristics of the ovarian cycle. To provide background information for an examination of this issue, the normal ovarian cycle will be described, as will subclinical and clinical disturbances of the cycle and their potential impact on reproduction. This will be followed by a discussion of the effects of various dietary and non-dietary factors on cycle characteristics, and finally, by a review of the available literature assessing whether differences exist between vegetarians and non-vegetarians. The normal ovulatory cycle described above does not invariably occur...

In vitro fertilization

IVF begins with hormone-induced superovulation followed by egg aspiration. Superovulation employs numerous therapies utilizing one or more medications, including clomiphene citrate, human menopausal gonadotropins (hMG), FSH, and luteinizing hormone releasing hormone (LHRH). Egg aspiration requires direct laparoscopy or ultrasound-guided percutaneous technique, the latter being performed easily as an outpatient or same-day procedure. The process proceeds with fertilization with capacitated sperm, followed by culture of fertilized eggs and fertilized egg replacement into the uterus.

Implications for Current Breast Cancer Investigations

Clinical and epidemiological studies have revealed a close association between breast-cancer risk and the cyclical exposure of the mammary gland to ovarian sex steroids that occurs during the premenopausal years (reviewed in 151). This correlation is further substantiated by the fact that inhibition or reduction of such steroidal exposure, (e.g., after oophorectomy, and in late menarche and early menopause), has been demonstrated to markedly reduce breast-cancer risk (152-155). The increase in breast cancer observed with advancing age (Fig. 10) is currently hypothesized to arise from ovarian sex-steroid-induced proliferation of the mammary epithelial cell, which allows for the occurrence and aggregation of genetic changes throughout the reproductive years that result in breast cancer in later life (156). With a primary correlate of breast-cancer risk linked with the cyclical exposure of the mammary epithelial cell to ovarian sex steroids, breast-cancer prevention treatments based on...

Effect of Expression of Hormone Receptors on Breast Cancer Cells

Express estrogen receptors, whereas only 50 percent of ductal carcinoma in situ (DCIS) cells and 30 percent of invasive carcinoma cells express them. In post-menopausal women, 75 percent of tumors are likely to be estrogen receptor-positive compared to fewer than 50 percent in younger women, and are often less aggressive.


The ovary is the preferential source of testosterone it is estimated that 75 of circulating testosterone originates from the ovary (mainly through peripheral conversion of prohormones by liver, fat, and skin, but also through direct ovarian secretion). Androstene-dione, of both adrenal (50 ) and ovarian (50 ) origin, is the only circulating androgen that is higher in premenopausal women than in men, yet its androgenic potency is only 10 that of testosterone. However, it is often elevated in PCOS patients. Dihydrotestosterone (DHT) is the most potent androgen, although it circulates in negligible quantities, and results primarily from the intracellular 5a-reduction of testosterone.

Pharmacological Management Estrogens

The ability of sex hormones to induce physiological changes of the lower urinary tract during the menstrual cycle, pregnancy, and menopause is the rational for using these agents pharmacologically to Since the majority of women with stress incontinence are perimeno-pausal or postmenopausal, restoring the tissue integrity of the urethral, bladder neck, and vaginal epithelium with the use of estrogen therapy serves as a fundamental adjuvant to the other management options available for urinary incontinence. Clinical studies have revealed its subjective usefulness especially in conjunction with behavioral interventions and pharmacologic agents (22). By promoting upregulation of neurotransmitter receptor function, estrogen therapy may augment the effect of anticholinergics and alpha-adrenergic agonist (23). Therefore, it is recommended as baseline therapy for all forms of urinary incontinence and is usually initiated as a first-line intervention following the detection of estrogen...

Special Concerns For Athletes On Vegetarian Diets

High fiber, low fat vegetarian diets have been associated with reduced blood estrogen levels and increased menstrual irregularity.72-75 Large volumes of exercise have also been related to menstrual irregularity.1,76-78 Approximately 5-20 of women who exercise regularly and vigorously, and up to 50-65 of competitive athletes may develop oligo-amenor-rhea.76,77 The causes are hotly debated, but may include the effect of exercise itself on the hypothalamic-pituitary-ovarian axis, low energy intake, and depleted fat stores in the female athlete.1,76-78 Amenorrheic athletes typically display reduced levels of estradiol and progesterone and have hormonal profiles more similar to those of postmenopausal women. The reduced levels of endogenous estrogen associated with athletic amen-orrhea may prevent the formation of adequate bone density.1,76,77 The syndrome of amenorrhea, disordered eating (and often excessive exercise), and osteoporosis is called the female athlete triad.76

Modification of Genetic Risk Caused by Environmental Factors

Before age twelve, does not have children or has her first child after age thirty, does not breastfeed her children, or undergoes menopause after age fifty-five. The correlation appears to be with the number of ovulatory cycles the woman undergoes in her lifetime. The period between menarche and first pregnancy, during which time the breast tissue is developing, appears to be most sensitive to environmental insults, possibly because rapidly dividing cells have the highest probability of incorporating mutations. It is thought that events initiating breast cancer may occur during this time, but that the promotional events necessary for the disease to be expressed occur over years. There have been many questions concerning the use of synthetic estrogens as birth control pills or for post-menopausal hormone replacement. It is thought that the estrogens in these preparations increase the risk of breast cancer slightly, but only as consequences of long-term use (i.e., more than ten years)....

Role of Diet in Preventing Breast Cancer

Many physicians take a guarded view of the benefits of dietary supplements. Since the FDA does not regulate the industry adequately, there are concerns as to the purity of these products, the true concentrations of active ingredients (if they are active), their side effects, and potentially dangerous contaminants. There are also concerns that their actions, if any, may be due to a placebo effect. Specific effects cannot legally be put on labels. Some of these products have potentially dangerous interactions with conventional medicines. Some, however, may be beneficial. For example, most physicians recommend dietary supplements of calcium for peri-menopausal and post-menopausal women to help prevent osteoporosis. Soy byproducts known as isoflavones act as phytoestrogens (phyto plant) and may eliminate some of the discomforts of menopause while not stimulating proliferation of breast tissue.

Nutritional prevention

Excessive alcohol use Long-term use of certain drugs Postmenopausal status Low body weight Impaired calcium absorption Regular physical exercise can reduce the risk of osteoporosis and delay the physiological decrease of BMD.9 Exercise training (walking, jogging, stair-climbing) in healthy, sedentary, postmenopausal women results in improved bone mineral content.10 Weight-bearing exercise results in increased bone mineral content, but the bone mass reverts to baseline levels when weight-bearing exercise is discontinued.11-13 In the elderly, progressive strength training is a safe and effective form of exercise that reduces risk factors for falling and may enhance BMD.14

Can Breast Cancer Be Prevented

Although researchers and clinicians are continuing to learn more about the nature of genetic defects and environmental interactions that may lead to development of breast cancer, no magic bullet is currently available for prevention of the disease. In chapter 6 I discuss some of the state-of-the-art research relating to prevention and therapy for the disease. For example, studies have shown that women at high risk can benefit from prophylactic tamoxifen therapy, but there is increased risk of endometrial cancer and potentially fatal blood clots. For now, it will suffice to say that for women of average risk, there are probably no specific options for prevention other than leading an active, healthy lifestyle including exercise and a healthy, well-balanced diet. Some risk factors can be avoided, but involve conscious lifestyle choices. For example, a menopausal woman should carefully weigh the potential risks of classic HRT (breast cancer and cardiovascular disease) versus the benefits...

Ruptured Ectopic Pregnancy

Usually a result of stretching of pelvic supporting structures during delivery, coupled with years of gravitational weight and menopausal loss of muscle tone. Pelvic floor support is given by the levator ani muscle and its fascia, which continues with the urogenital diaphragm, endopelvic fascia, and cardinal and uterosacral ligaments.

Calcium and vitamin D

Calcium supplementation produces small beneficial effects on bone mass throughout postmenopausal life and may reduce fracture rates by more than the change in BMD would predict -possibly as much as 50 .27 Postmenopausal women receiving supplemental calcium over a three-year period in a placebo-controlled, randomized clinical trial had stable total body calcium and bone density in the lumbar spine, femoral neck, and trochanter compared with the placebo group.28 Dietary calcium augmentation should be recommended to maintain lifetime calcium levels and to help to prevent early postmenopausal bone loss (Table 14.5). Adults should ingest 1000 mg of elemental calcium per day for optimal bone health.21,30 Teenagers, pregnant lactating women, women over 50 years of age and taking ERT, and all people over 65 years of age should ingest 1500 mg of elemental calcium per day for optimal bone health. If this cannot be achieved by diet alone, then calcium supplementation is recommended.

Urinary Incontinence

A 58-year-old patient presents to the gynecologist's office complaining of urinary leakage after exertion. The patient complains of loss of urine after coughing, sneezing, and playing golf. She has been in the menopausal state for 5 years and is not on estrogen replacement therapy. On examination there is evidence of urethral detachment with a positive Q-tip test.

Addressing glucocorticoidinduced osteoporosis

Recent evaluations of the effects of inhaled glucocorticoids on bone density in premenopausal women demonstrated a dose-related decline in bone density at both the total hip and the trochanter.47 Women asthmatics were enrolled who were using no inhaled steroids, using four to eight puffs per day, or using more than eight puffs per day at 100 g puff. No dose-related effect was noted at the femoral neck or the spine. Serum and urinary markers of bone turnover and adrenal function did not predict the degree of bone loss. To achieve the best Modified from Gueldner, S. H. Managing Osteoporosis - Part 3 Prevention and Treatment of Postmenopausal Osteoporosis. Chicago AMA 2002. Gonadal hormones in all postmenopausal women, premenopausal women with low levels of estradiol, and men who have low levels of testosterone (unless contraindicated)

Randomized Trial of UAE

Both to improve generalizability, and to speed enrollment, this RCT should involve multiple sites throughout the country. Data elements to be collected should encompass all those factors which panelists unanimously agreed were key to advancing knowledge in this field. Power calculations for these outcomes are shown in Table 6. Panel members agreed that data should be collected for a three to five year period following enrollment to ensure adequate information on premature menopause experienced by women enrolled in the trial.

Diabetes complications

Cardiovascular disease remains the major cause of morbidity and mortality for all patients with diabetes. Women with diabetes are five times more likely to develop coronary artery disease than women without diabetes.33 The protective effect of female gender against cardiovascular disease before menopause is not true for any woman with diabetes. Presentation of heart disease may be atypical in the woman with diabetes. Fatigue, decreased exercise tolerance, or dyspepsia may be anginal equivalent symptoms in the woman with diabetes.34 Routine evaluation with exercise stress testing may have up to a 54 false-positive rate in women, so other cardiac evaluations, such as a stress nuclear perfusion study or stress echo, may be necessary. Small-vessel disease is common in diabetes therefore, revascularization procedures may be more difficult in women with diabetes. Risk-factor modification, including smoking cessation, aspirin use, blood pressure control (with consideration of an...

Summary And Conclusions

Reports of UAE in the lay press have generated considerable enthusiasm, suggesting that demand for a non-surgical (albeit still invasive) treatment of myomata would be high (Gilbert,1999). The prevalence of symptomatic fibroids, the apparent high demand for a new treatment, and the rough equivalence of outcomes among UAE, hysterectomy, and myomectomy suggest that controlled trials of these treatments would be feasible, ethical, and desirable. The expert panel concluded that beginning a properly designed randomized, controlled trial would be crucial in establishing the comparative risks and benefits of UAE, hysterectomy, and myomectomy. The panel further believed that the validity of such a trial would be enhanced by careful measurement of several short and long term outcomes. Key short term outcomes which the panel agreed should be included were death, reoperation (e.g. hysterectomy for infection following UAE), and operative injury. Long term outcomes similarly identified included...

When Women Stop Having Periods

The menopause or climacteric is the time in a woman's life when the menstrual periods stop coming. After menopause, she can no longer bear children. In general, this 'change of life' happens between the ages of 40 and 50. The periods often become irregular for several months before they stop completely. There is no reason to stop having sex during or after the menopause. But a woman can still become pregnant during this time. If she does not want to have more children, she should continue to use birth control for 12 months after her periods stop. When menopause begins, a woman may think she is pregnant. And when she bleeds again after 3 or 4 months, she may think she is having a miscarriage. If a woman of 40 or 50 starts bleeding again after some months without, explain to her that it may be menopause. During menopause, it is normal to feel many discomforts anxiety, distress, 'hot flashes' (suddenly feeling uncomfortably hot), pains that travel all over the body, sadness, etc. After...

Evaluation of abnormal Pap test

Atypical cells of undetermine sequence (ASCUS) may be the reading that causes much of the difficulty. One wants to neither overinvestigate with invasive procedures nor miss a cervical cancer before cure is possible. Use of HPV testing, often done routinely by the laboratory if ASCUS is detected, may determine a group of women with high-risk HPV infection who need closer and more frequent evaluation. Women with readings of ASCUS - favor low-grade squamous intraepithelial lesion (LGSIL) or high-grade squamous intraepithelial lesion (HGSIL) are found to be more likely to be infected with high-risk HPV.12 Follow-up evaluation for ASCUS can include repeat Pap testing in three months, HPV testing, and or colposcopy, especially if the woman is infected with high-risk HPV or has had previous abnormal Pap tests, or a more definite diagnosis is wanted immediately by patient or physician.13 Because postmenopausal women have a much lower rate of HPV infection and cervical cancer, ASCUS can be...

Risk factors and etiology

The risk factors linked with cervical cancer include infection with certain subtypes of HPV, multiple sexual partners, sexually transmitted diseases, low socioeconomic status, and smoking.20 Estrogen use, including hormone replacement therapy, is not a risk factor for cervical cancer and in fact may be protective.21

Differentiated Vulvar Intraepithelial Neoplasia

Differentiated VIN, a lesion unrelated to HPV, is much less common than the usual HPV-related VIN (Fig. 30A and B). It occurs in postmenopausal women, significantly older than women in whom usual VIN is seen, and is thought to pose a more significant risk of progressing to invasive squamous cell carcinoma (55). It is associated with, and may be seen adjacent to, the non-HPV-related squamous cell carcinomas of the vulva that arise in older women. Clinically, the lesions of differentiated VIN are more subtle than usual VIN lesions. They may be unifocal or multifocal and tend to be pale white or gray plaque-like or nodular areas. They may appear simply as thickened areas. Differentiated VIN is often seen in a background of lichen sclerosus or squamous hyperplasia (56,57) The lesion may also be quite subtle histologically, and may be misdiagnosed as squamous cell hyperplasia because of the parakeratosis and acanthosis. Atypia is minimal, and confined to the basal layers, with large...

The Need for Emotional Support

Physicians and others who care for breast cancer patients are becoming more sensitive to quality-of-life issues. An important part of breast cancer therapy is emotional support both for the patient and for the family. Many women feel a deep sense of loss following mastectomy and even lumpectomy, and need the support that can be provided by professional counselors. Chemotherapy often causes hair loss, induces premature menopause, and may cause serious mood swings that affect not only the patient but also her loved ones. Many medical centers now provide integrated services including physicians, surgeons, nutritionists, and social workers as part of a team. Patients often have supportive family members and friends, or may be part of a religious group or other organization that provides support sessions and religious healing services. A diagnosis of cancer is a life-altering event even if the prognosis for long-term survival is excellent.

Hereditary nonpolyposis colon cancer

The spectrum of malignancies associated with HNPCC includes colon, endometrial, renal-cell, ovarian, breast, stomach, pancreas, and brain malignancies. Endometrial carcinoma associated with HNPCC may be seen at an earlier age and in the premenopausal years. HNPCC has been associated with

Routine use of endometrial biopsy

Mass sampling for endometrial cancer has been conducted in Japan since 1987. Patients judged at risk for endometrial cancer and who are undergoing cervical cancer screening are offered screening by endometrial smears. The procedure is offered to women with abnormal genital bleeding in the previous six months and who are also older than 50 years of age, postmenopausal, or nulligravidas with irregular menstrual cycles. Positive or suspicious smears are followed by fractional curettage. In this group of women, with an incidence of endometrial cancer of 7.3 per 100 000, patients participating in screening were diagnosed at an earlier stage and had a significantly improved five-year survival rate. The hazard ratio of dying of endometrial cancer in screened women was reduced by more than half.35 However, this may be more clearly considered to be case-finding, since, by definition, all women who were screened were symptomatic (i.e. had abnormal uterine bleeding). Studies of routine...

Technique and normal values

An observational study of asymptomatic postmenopausal women determined a mean endometrial thickness of 2.3 + - 1.8 mm (range 1-10 mm). Women with a higher BMI and higher circulating levels of estrone and estradiol had an endometrium thicker than 5 mm.41 Women with no endometrial hypertension had a thickness of less than 5 mm. Besides endometrial thickness measurements, endometrial morphology should demonstrate no irregularity of echo pattern, focal increase or diffuse increase in echogenicity, or irregularity of the endometrial border. An appearance of an endoluminal mass is clearly abnormal and warrants investigation.

Transvaginal ultrasound for diagnosis in symptomatic women

Large studies of postmenopausal women evaluated with transvaginal ultrasound because of postmenopausal bleeding demonstrate very low rates of endometrial carcinoma (0.6-3.9 ) in women with an endometrial thickness of 5 mm or less.50,51 Accuracy of transvaginal ultrasound is improved by combining endometrial thickness cut-off values of 5 mm with endometrial morphology and the assessment of the regularity of the endometrial border,52,53 producing a sensitivity of 97 , specificities of 61-65 , and a positive predictive value of 72-80 . In women with postmenopausal bleeding and with an endometrial thickness of less than 5 mm on ultrasound, both those randomized to expectant management and those managed initially with dilation and curettage experienced a recurrent episode of bleeding approximately 20-33 of the time. An isolated incident of recurrent uterine bleeding was not associated with US consensus statements on assessment of uterine bleeding recommend either transvaginal ultrasound or...

Risk factors for ovarian cancer

The risk of ovarian cancer has been linked to overall number of lifetime ovulations, with increasing risk among women of low parity and late menopause and decreasing risk in women using oral contraceptives and in women of high parity. The overall lifetime risk in the general population is 1.6 . These risk factors are unlikely to be of help to the clinician for purposes of screening. However, historical information can be of benefit in delineating women at higher risk for ovarian cancer.

History and pelvic examination

Retrospectively, symptoms have been reported by 78 of patients with early tumor diagnosis, including abdominal pelvic pain (35 ), bloating (32 ), and vaginal bleeding (19 ).26 Clinicians providing primary care to women will recognize that abdominal and pelvic complaints are common. Diagnostic investigations in the setting of the above symptoms may be more properly considered case-finding than screening, and the yield of an ovarian cancer diagnosis may be low compared with other diagnoses. The finding of a symptomatic or asymptomatic pelvic mass on routine examination always bears further investigation, but confounding factors that may make detection of masses difficult include obesity and coexisting uterine fibroids. In general, ovaries should not be readily palpable in the menopausal woman, and any ovarian enlargement should be considered suspicious until proven otherwise.

Routine use of transvaginal ultrasound in the general population

Transvaginal ultrasound is relatively expensive as a screening procedure applied to a general population of women and requires specialized training, but it would be considered minimally invasive. It is not uncomfortable, causing approximately the same or less sensation of pelvic pressure as performance of a speculum exam. General observational studies of transvaginal ultrasound to exclude disease of the pelvis report negative predictive values greater than 90 , but these studies include both pre- and postmenopausal women who were evaluated for a wide range of pelvic complaints.27 There are no data at the time of writing that indicate transvaginal ultrasound to be an effective screening modality in the general population.

Prophylactic oophorectomy at the time of hysterectomy

Experience onset of menopausal symptoms within one to two years.41 A significant portion of these women also experience decreased bone density.42 This consideration makes oophorectomy more attractive in women aged 40 years or older and seeking hysterectomy for other conditions.

Malignant Lesions Of The Urethra Urethral Carcinoma

Primary urethral carcinomas are rare in women, but are more common than in men in most series (Fig. 46A and B) (89,90). They tend to occur in postmenopausal women (90). While potentially curable if of low stage, the vagueness of early symptomatology may lead to late diagnosis and poor outcome (91). Distal urethral neoplasms are more likely to be diagnosed at an earlier stage than proximal ones. Histology is variable, and carcinomas may be squamous cell, adenocarcinoma, ade-nosquamous carcinoma, transitional cell, or undifferentiated carcinoma, reflecting the variability of the lining cells in the female urethra. Carcinoma can arise in a urethral diverticulum (92), and these may be clear cell adenocarcinomas (90). Distal carcinomas tend to be squamous cell carcinomas, while proximal lesions are more likely either transitional or adenocarcinoma (90). Rare adenocarcinomas with enteric differentiation have also been described (Table 46) (93).

Management options in BRCA12

Reduction of anxiety has been associated strongly with an interest in prophylactic oophorectomy in genetic counseling programs, independent of actual risk classification.62 Conflicting information is available regarding the psychological impact of prophylactic oophorectomy. A prospective study of women in a familial cancer clinic compared women who did and did not undergo prophylactic oophorectomy it found significant reduction in ovarian cancer anxiety and a high degree of satisfaction with the decision to undergo the prophylactic procedure.63 Another small study compared utilized responses to the Short-Form (SF)-36 Health Status Questionnaire and the General Health Questionnaire (GHQ) women undergoing oophorectomy for prevention scored poorer functioning on the role-emotional and social functioning subscales, with a trend to report more menopausal symptoms, and reported higher scores on the GHQ. There were no significant differences in the groups with respect to cancer worry or...

Node Positive Early Breast Cancer

A large number of prospective randomized trials, as well as recent overviews and meta-analysis of adjuvant systemic therapy, have determined that both chemotherapy and tamoxifen therapy reduce the odds of recurrence in breast cancer patients. A few randomized clinical trials and the overview of meta-analysis of randomized clinical trials have suggested that the combination of chemotherapy and tamoxifen is superior to chemotherapy alone or tamoxifen alone in postmenopausal patients with node-positive breast cancer. Women with estrogen receptor-negative breast cancer appear to have no improvement in recurrence or survival from tamoxifen use. Premenopausal, ER- or PR-positive Premenopausal, ER- and PR-negative Postmenopausal, ER- or PR-positive(> ) Postmenopausal, ER- and PR-negative

Indications of upper tract disease and need for hospitalization

S., Grad, D., Ouslander, J. G., etal. Prevalence of urinary incontinence and associated risk factors in postmenopausal women. Obstet. Gynecol. 1999 94 66-70. 31 Fantl, J. A., Cordozo, L. K., Ekberg, J., et al. Estrogen therapy in the management of urinary incontinence in postmenopausal women a meta analysis. Obstet. Gyencol. 1994 83 12-18. 51 Melekos, M. D., Asbach, H.W., Gerharz, E., et al. Post intercourse versus daily ciprofloxin prophylaxis for recurrent urinary tract infections in premenopausal women. J. Urol. 1997 157 935-9. 52 Eriksen, B. A randomized open, parallel-group study on the preventive effect of an estradiol releasing vaginal ring (Estring) on recurrent urinary tract infections in postmenopausal women. Am. J. Obstet. Gynecol. 1999 180 1072-9.

Treatment of Infertility

Offers a high rate on monofollicular development ( 50 or greater) with a significantly lower risk of OHSS (20-25 ) leading to cycle cancellation or more serious sequelae (146-150). A Cochrane review reports a reduction in the incidence of OHSS with FSH compared with human menopausal gonadotropin (hMG) in stimulation cycles without the concomitant use of a GnRH-a (OR 0.20 95 CI 0.08-0.46) and a higher overstimulation rate when a GnRH-a is added to gonadotropins (OR 3.15 95 CI 1.486.70) (151). Despite theoretical advantages, urinary-derived FSH preparations did not improve pregnancy rates when compared to traditional and cheaper hMG preparations their only demonstrable benefit was a reduced risk of OHSS in cycles when administered without the concomitant use of a GnRH-a. A meta-analysis found no studies of adequate power to confirm the benefit of pulsatile GnRH-a to induce ovulation in PCOS (152).

Protein Differences Between Omnivores And Vegetarians Or Vegans

Animal protein contains considerably more sulfur as methionine and cysteine. These amino acids cause a higher acid load with the omnivore diet, which appears to be partially retained as a major component of the pathogenesis of bone disease and muscle wasting in aging.16 This helps to explain the improved mineral balance and skeletal metabolism in postmenopausal women treated orally with potassium-bicarbonate.16 Also, lipid peroxidation is enhanced with decreasing extracellular pH. Acidic pH releases iron from safe binding sites where this free iron then enhances free radical activity.17 Thus, the lower sulfur and phosphorus intake on an all-plant diet appears to provide a significant longevity advantage for elderly subjects.

Obstetrics and Gynecology

The answer is b. (Seidel, 4 e, pp 508-512.) Women between the ages of 30 and 55 may develop benign cyst formation of the breasts or fibrocystic breast disease. Patients typically state that the symptoms worsen premenstrually or as they approach menopause (decreased progesterone). Physical examination often reveals bilateral lumpy and tender breasts. Mammography shows dense breast tissue. Mastitis is most com- mon in lactating breasts and is usually secondary to Staphylococcus aureus infection. The breast is warm, tender, swollen, and erythematous. Mammary duct ectasia is a nonmalignant condition that affects menopausal women. The subareolar ducts become blocked with debris, causing pain, inflammation, nipple discharge, and retraction of the nipple. 459. The answer is b. (Fauci, 14 e, p 2102.) The patient is presenting with symptoms of normal menopause, which may include hot flashes, urinary frequency, dysuria, urinary incontinence, vaginal dryness, vaginal itchiness, and...

Xylocaine Infiltration For Marsupialization

Marsupialization For Pulmonary

A postmenopausal woman presents with pruritic white lesions on the vulva. Punch biopsy of a representative area is obtained. Which of the following histologic findings is consistent with the diagnosis of lichen scle-rosus 318. A 55-year-old postmenopausal female presents to her gynecologist for a routine exam. She denies any use of hormone replacement therapy and does not report any menopausal symptoms. She denies the occurrence of any abnormal vaginal bleeding. She has no history of any abnormal Pap smears and has been married for 30 years to the same partner. She is currently sexually active with her husband on a regular basis. Two weeks after her exam, her Pap smear comes back as atypical glandular cells of undetermined significance (AGUS). What is the next most appropriate step in the management of this patient

Plant Based Mixed Diet Diet

Jacobs, D.R., Meyer, K.A., Kushi, L.H., and Folsom, A.R. Whole-grain intake may reduce the risk of ischemic heart disease death in postmenopausal women the Iowa Women's Health Study. Am. J. Clin. Nutr, 68 248-257, 1998. 74. Barbosa, J.C., Shultz, T.D., Filley, S.J., and Nieman, D.C. The relationship among adiposity, diet, and hormone concentrations in vegetarian and non-vegetarian postmenopausal women. Am. J. Clin. Nutr, 51 798, 1990.

Overflow Incontinence After Lefort Surgery

The answer is d. (Scott, 8 e, pp 767-768.) As patients age, the incidence of vesicle instability or unstable bladder increases dramatically. Although estrogen has been reported to decrease urgency, frequency, and nocturia in menopausal women, its effect on correction of stress urinary incontinence or vesicle instability is unclear. In the elderly population there are also many transient causes of incontinence that the physician should consider. These include dementia, medications (especially a-adrenergic blockers), decreased patient mobility, endocrine abnormalities (hypercalcemia, hypothyroidism), stool impaction, and urinary tract infections. 412-414. The answers are 412-d, 413-a, 414-b. (Droegemueller, 3 e, pp 569, 590-591. Beckmann, 4 e, p 389.) This patient's presentation is most consistent with urge incontinence. Urge incontinence is the involuntary loss of urine associated with a strong desire to void. Most urge incontinence is caused by detrusor or bladder dyssynergia in...

Decreased arousal andor plateau

As with increasing erectile difficulties with age alone, there are age-related changes in vaginal lubrication for women. Sildenafil is beneficial to women experiencing arousal difficulties during perimenopause and should be considered a treatment option.33 Additionally, nitric oxide - required for cGMP and subsequent vasocongestion - is believed to be androgen-sensitive, heightening the possible benefits of androgen supplementation to enhance arousal.

Atrophic Vaginitis And Serosanguineous Discharge

The answer is c. (Hoskins, 2 e, p 987.) Benign cystic teratomas (der-moids) are the most common germ cell tumors and account for about 20 to 25 of all ovarian neoplasms. They occur primarily during the reproductive years, but may also occur in postmenopausal women and in children. Dermoids are usually unilateral, but 10 to 15 are bilateral. Usually the tumors are asymptomatic, but they can cause severe pain if there is torsion or if the sebaceous material perforates, spills, and creates a reactive peritonitis. both adrenal tumors and Sertoli-Leydig tumors produce androgens. The androgen production can result in seborrhea, acne, menstrual irregularity, hirsutism, breast atrophy, alopecia, deepening of the voice, and cli-toromegaly. Recurrences of Sertoli-Leydig cell tumors, which seem to have a low malignant potential, usually appear within 3 years of the original diagnosis. Granulosa and theca cell tumors are often associated with excessive estrogen production, which may cause...

Is Livergen Suitable For Three Months Pregnancies

The answer is b. (Braunwald, 15 e, pp 2230-2236.) The World Health Organization and the National Osteoporosis Foundation agree that all postmenopausal patients who are estrogen-deficient should have a central bone densitometry A nuclear medicine scan has no role in the diagnosis of osteoporosis. Certainly this patient with estrogen deficiency, low calcium intake, family history, and previous tobacco use has a high pretest probability of osteoporosis therefore a peripheral bone densitometry, 486. The answer is b. (Braunwald, 15 e, pp 2194, 2232-2234.) Post-menopausal women not on estrogen replacement should achieve a daily intake of calcium at 1200 mg of elemental calcium. The average woman in the United States receives 600 to 700 mg from diet alone. The current recommendation is that women consume 1200 mg oral calcium supplement in two or three divided doses. Although fluoride is an osteoclast inhibitor, early studies revealed an increased fracture rate with fluoride...

Alternatives to hormone therapy including complementary treatments

Although over 85 of women experience hot flushes, most women find that their symptoms resolve or improve over two to five years. More than 30 of women use complementary and alternative measures, such as acupuncture, natural estrogen, herbal supplements, and plant estrogens to control symptoms. Most studies of menopausal interventions demonstrate a 20-30 improvement in the symptoms of the placebo groups regardless of whatever method is chosen for the intervention.63 This high rate of resolution of symptoms makes it imperative that methods that purport benefit be subjected to careful scrutiny. Menopausal symptom relief Adapted from National Institutes of Health. Facts about postmenopausal hormone therapy, and Duke Heart Center, Management of HRT in the wake of HERS II and WHI article.php id.2115 Table 10.12 Ineffective therapies for menopausal symptoms Table 10.12 Ineffective therapies for menopausal symptoms postmenopausal bleeding one case of reduction in INR in...

Uterine Leiomyomata Definition and Symptoms

Uterine leiomyosarcoma is a rare tumor with a poor prognosis that does not appear to be related to uterine leiomyomata. That is, women with leiomyomata are not at increased risk for sarcoma. However, because of its rarity and lack of clear symptoms, leiomyosarcoma is often discovered at the time of surgery for what are believed to be leiomyomata. This occurs in approximately 0.1 - 0.3 of such surgeries in reproductive age women, and in as high as 1 of such procedures in postmenopausal women (ACOG, 1994).

Fruits And Vegetables A Population Studies

The protective effect of vegetables has also been observed for hormone-related cancers, such as breast cancer. A recently published case control study found a strong inverse association between total vegetable intake and breast cancer risk in premenopausal women.8 A risk reduction of 54 was seen in women with the highest intake of vegetables compared with those with the lowest intake. The protective effect appeared to be due to the synergistic effect of a variety of substances in the vegetables. A Greek study also noted that vegetable and fruit consumption was independently associated with significant reductions in the incidence of breast cancer.9 Women consuming four to five servings of vegetables per day had a 46 lower risk of breast cancer, compared with women consuming less than two servings a day. Furthermore, women consuming six servings of fruit a day had a 35 lower risk of breast cancer than women consuming less than two servings a day.

Vertical Mammaplasty The Era of Maturity

Development of our knowledge in areas other than surgical techniques deserves interest, for example, vascular anatomy in relation to surgery breast content, which varies with menstrual cycle, parity, age, weight, and heredity capacity for lactation, which combines hereditary and hormonal factors variable fat degeneration after menopause and so on. Let us hope that the interest will increase with time, just as it did for vertical mammaplasty.

Subsyndromal Depressive Symptoms SSD

Depression and Menopause The prevalence of depressive disorders does not seem to increase during menopause 74 . However, further investigation may be needed 75 . Negative beliefs about menopause and experiencing a longer than usual menopause are associated with an increased risk of developing a depressive disorder.

Hyperaldosteronism Primary

ID CC A 55-year-old menopausal female comes to see her internist because of progressive constipation and excessive urination over the past 2 months she also complains of palpitations both at rest and during exercise. HPI She has read all about osteoporosis during menopause and is afraid of developing it, so she has been taking abundant calcium supplements and vitamin D injections.

Oral Contraceptive Side Effects

ID CC A 55-year-old, postmenopausal white female complains of nausea, headaches, weight gain, and breast tenderness. Discussion Hormone replacement therapy is an effective prophylaxis against primary and secondary osteoporosis (due to hypogonadism, glucocorticoid excess, immobilization, hyperthyroidism, diabetes mellitus, or primary hyperparathyroidism). Estrogen supplementation is the first choice for prevention and treatment of osteoporosis in women who are postmenopausal. The mechanism of action is thought to be decreasing bone resorption by inhibiting the synthesis of interleukins such as IL-6 as well as retarding the bone-resorbing effects of PTH. Estrogen is contraindicated in pregnancy, breast cancer, or active hepatitis. Side effects include breast tenderness, migraines, and vaginal bleeding spotting. Long-term adverse effects include gallstones, breast cancer, and thrombophlebitis. Estrogen alone also increases the risk of endometrial cancer, and progesterone is often added...

The Identification of Diagnostic Subtypes of Depressive Disorders

The clinical core of the modern diagnosis of depressive disorders (DD) is the ''depressive episode'' (DE) or ''major depression'' (MD), which can occur as a single episode or be recurrent. DE is presented descriptively in ICD-10, whereas MD is defined by operational criteria in DSM-IV. These diagnostic categories are comparable, and include depression with or without psychotic symptoms, with or without catatonic features, and with or without somatic (melancholic) symptoms. Other subtypes of depression include subsyn-dromal symptomatic depression 1 and specific conditions limited mostly by temporal frameworks recurrent brief depression, dysthymia, cyclothymia, seasonal depression, premenstrual dysphoric disorders, postpartum and menopausal depressions, and so on.

Treatment of Breast Cancer

Surgery is usually followed by an additional (adjuvant) therapy. A lumpectomy is usually followed by a course of radiation to destroy undetected cancer cells that may have been left behind in the breast, chest wall, or lymph nodes and that have the potential to metastasize. Some lumpectomy and most mastectomy patients also receive chemotherapy in which toxic drugs are given orally or by IV to block DNA synthesis or division of cancer cells (table 5.3). Although the drugs target tumor cells, they are not specific and affect all rapidly dividing cells such as those in hair follicles, intestinal lining, and bone marrow. That is why chemotherapy causes such unpleasant side effects as hair loss, vomiting, and low blood cell counts. Chemotherapy may also cause premature menopause and infertility. Chemotherapy is usually given in cycles, with each period of treatment followed by a period of recovery. The total course of treatment can span three to six months. Side effects usually vary with...

Prevention of chronic disease

In one of the largest of these studies, the Nurses' Health Study, 70 533 postmenopausal women were followed for 20 years. HT users had a decreased risk of CHD compared with women who had never used HT.8 Table 10.2 Signs and symptoms from hormonal changes at menopause Figure 10.1 Disease rates for women on hormone replacement therapy (HRT) of estrogen plus progestin or placebo. Annual cases per 10 000 women. (From the Writing Group for the Women's Health Initiative investigators.) Although it is a large, well-conducted clinical trial, the WHI does not answer all clinically pertinent questions. Not all WHI participants began EPT or ET during the perimenopausal or early menopausal period, the usual time for women to initiate these drugs. Many study participants began these hormones in their seventh and eighth decades, when they had established (if unrecognized) heart disease. In addition, only one type of estrogen and one type of progestin were studied, and only one regimen (daily fixed...

Prevention of recurrent infections

Other methods include dietary, hormonal, and mechanical treatments. Ingestion of more water, Lactobacillus juice, and cranberry or other juices has been suggested for the prevention of recurrent UTIs. One RCT of 150 women found that 50 ml of cranberry-ligonberry concentrate reduced recurrences by approximately 50 while ingestion of Lactobacillus GG juice had no effect.30 In menopausal women, supposed urethral and periurethral tissue laxity has been treated with topical and oral estrogens. These hormones are supposed to increase the strength and tone of the urethral tissues, promoting more effective bladder emptying. Estrogen vaginal cream has been used two to three times a week. A small RCT found that women with recurrent UTIs who used the Estring, the vaginal estrogen-embedded ring with no systemic absorption, prolonged the time until the next occurrence and more than doubled the number of women who had no further UTIs when used for 36 weeks.52

Jo Ann Rosenfeld

Despite the fact that there are more women than men at every age, this time of change is poorly studied and understood for women (Figure 1.1). Many large population studies have not included women, have included only a few women, or have not reported data by gender. Few studies have examined this age group. The change to adolescence, adulthood, and elder has been well examined and researched. Each of these ages has their own specialists (obstetrician gynecologist or geriatrician). However, the middle ages are often neglected. Menopause is not a disease, a definite time, or a curse. Its needs, challenges, and effects on women's health are not understood well. Familial and social stresses may be challenging or overpowering, as the woman has to redefine herself within society, employment, and her family. These women must not be viewed either as finished or unimportant simply because they are finished with childbearing and or approaching menopause, nor must they be considered pre-elderly....

Resistance training

Cross-sectional and longitudinal exercise data support the efficacy of resistance training as an effective modality for the prevention and treatment of osteoporosis.24 A recent meta-analysis demonstrated that resistance training can increase or preserve bone mineral density in pre- and postmenopausal women. With the cessation of exercise, bone mineral density will return to pre-exercise levels at a rate similar to that in age-matched controls.25 Thus, the continued participation in a resistance-training program is essential for bone health.

The History

Risk factors that can lead to the progress of vascular disease such as smoking, diabetes, hypertension, and hyperlipidemia are ascertained in the history. Additionally, an adequate exercise history should be elicited. One question that elucidates the rate-limiting organ system is how far patients can walk, and what stops them (leg pain, shortness of breath, chest pain, etc.). It is also important to know if the patient is taking hormonal medications such as oral contraceptives or hormone replacement therapy. These medications can predispose to venous and occasionally arterial thrombosis. It is during the history taking that a physician can begin to address many of these risk factors. By recruiting antismoking clinics or eliciting the help of diabetes and cardiac specialist physicians, a surgeon can improve a patient's overall health both pre-and postoperatively.

Adequate calcium

Menopausal women are at increased risk for osteoporosis, especially if they are Caucasian and or thin. Cigarette-smoking and a positive family history increase the risk. While taking adequate calcium during the bone-building years (before age 30) is essential, calcium intake in later years is still important to slow the bone mineral loss that inevitably happens after menopause.

Hormone Therapy

Hormone replacement therapies (HRT) based exclusively on oestrogens increase the risk of endometrial cancer, to the extent that there is a tendency to prescribe oestrogen and progesterone HRT except in hysterectomized women. There are reports indicating a two- to fourfold increased risk of DVT in women on HRT 9, 15 this should be taken into account when evaluating menopausal women. It should also be kept in mind that a large number of epidemiological studies conclude that Asian women, because of their diet rich in soy, reach the menopause in better condition than Occidental women and have a lower incidence of undesirable effects. Moreover, and despite the large number of published reports focusing on isoflavones (a Medline search of the term iso-flavones yields over 7500 citations), there is no mention in the literature of an increased risk of thrombosis linked to the uptake of these components of soy.

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Natural Cures For Menopause

Are Menopause Symptoms Playing Havoc With Your Health and Relationships? Are you tired of the mood swings, dryness, hair loss and wrinkles that come with the change of life? Do you want to do something about it but are wary of taking the estrogen or antidepressants usually prescribed for menopause symptoms?

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