Best Home Treatments to Cure Osteoporosis

The Osteoporosis Reversing Breakthrough

eres just a few things youll learn about how to get back into health. and conquer Osteoporosis. Those not-so innocent yet everyday substances that are currently attacking your body, perpetuating and aggravating your Osteoporosis. What to do and what Not to do to overcome your Osteoporosis effectively and permanently. How to create the energy you need to be able to work full time and feel confident you will be able to take care of your loved ones. How the pharmaceutical and food industry are conspiring to poison you and make you sick (Hint: American medical system is now the leading cause of death in the US). Which food industries use advertising to encourage doctors to tell you that their food is good for you just like those cigarette ads in the 1950s! The single most effective fruits and vegetables in cleaning up excess acidic waste and how to cleanse your inner terrain completely from systemic acidosis. Why, what your Doctor has told you is wrong, and why many medications actually increase the side effects and complications of Osteoporosis (primarily by depleting vital vitamins, minerals and nutrients from your body). Which supplements every patient must take to stop the symptoms and boost your body's ability to reverse Osteoporosis. How to naturally reduce your cravings for toxic foods. Lifestyle and food choices to reverse your Osteoporosis fast, naturally, and for good. Why treating the symptoms of disease is like using an umbrella inside your house instead of fixing the roof. The most powerful creator of health (Hint: its not a food or vitamin!) The best way to simplify the task of making a health-conscious lifestyle adjustment. A miraculous scientific discovery that jump-starts your body to do its natural work, which is to heal itself and restore your Health. More here...

The Osteoporosis Reversing Breakthrough Overview

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Measurement of bone mineral density and rate of bone loss

Bone mineral density is measured noninvasively by dual energy X-ray absorptiometry (DXA) performed on the forearm, lumbar spine and proximal femur. Rates of bone loss can be predicted by measuring serum or urinary biochemical markers of remodelling. Serum markers of bone formation include osteocalcin and bone specific alkaline phosphatase (BSAP). Urinary markers of bone resorption are based on the pyridinoline cross-links of collagen, specifically the amino terminal telopeptide and lysyl and hydroxyly-syl pyridinoline (Kleerekoper, 1996).

Type I osteoporosis

This syndrome manifests in women typically between 50 to 75 years of age, and results from an acceleration of cancellous bone loss after the menopause. About one in five postmenopausal women will develop type I osteoporosis unless treated. Within the first 1 to 5 years after the onset of menopause, the rate of cancellous bone loss is two to six times the pre-menopausal rate of about 1 per year, but it gradually returns to the pre-menopausal rate about the 10th year after onset of menopause (Krall & Dawson-Hughes, 1999). There is only a slight corresponding increase in cortical bone loss. Fractures occur most commonly in the distal radius (forearm) and the spinal vertebrae. The Osteoporosis in post-menopausal women is due to the dramatic decrease in oestrogen production that accompanies menopause this is evident by the well-established efficacy of hormone replacement therapy (Lindsay, 1993). The accelerated phase of bone loss is associated with increased osteoclastic resorption and...

Type II osteoporosis

Type II osteoporosis is a purely age-related syndrome, which affects men and women over 70 and is twice as common in women as in men. Bone loss increases gradually with aging, unlike the accelerated loss seen in type I osteoporosis. In both sexes, cancellous bone loss begins at about age 40 and continues into old age. Cortical bone loss commences five to ten years later but slows or ceases later in life (Riggs & Melton, 1986). In elderly women, type I and type II osteoporosis A number of age-related factors are implicated in the aetiology of type II osteoporosis (Kassem et al., 1996). Two important factors are (1) impaired bone formation at the cellular level, where osteoblasts fail to refill the resorption pits created by osteoclasts during bone remodelling, and (2) secondary hyperpara-thyroidism, which leads to increased bone turnover. Impaired bone formation may be due to a decreased production of osteoblasts or to their decreased responsiveness to regulatory factors. Secondary...

Osteoporosis

With respect to osteoporosis, the effect of specific nutrients on bone metabolism and in disease incidence has been previously published. Thus, in this chapter, only the studies on diet patterns, food groups that characterize these diet patterns, and their effect on the incidence of osteoporosis, risk of osteoporotic fractures, or bone mineral density (BMD) will be summarized and discussed. There are no large epidemiological studies that were designed with the primary objective of determining the incidence of osteoporosis and related To date, about a dozen studies have been published studying the bone health of vegetarians (Table 6.2). These are cross-sectional studies with small sample sizes compared with what is typically seen in large cohort studies. The first study, published in the early 1970s,21 compared a group of British lacto-ovo vegetarians (LOV) to non-vegetarians from the same geographical area. BMD of the third metacarpal was higher and age-related decline slower among...

Diet as therapy Menopausal symptom control

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

Diet and medical problems Diabetes

Because diabetes maybe a state ofincreased oxidative stress, vitamins maybe of benefit. Placebo-controlled trials of antioxidants have failed to show a benefit and, in some cases, have raised concern about adverse effects. B-complex vitamins have been considered in the treatment of diabetic neuropathy, but benefit has not been established. Deficiencies of certain minerals (potassium, magnesium, zinc, chromium) may worsen carbohydrate intolerance. Benefit from chromium supplementation has been reported, but conclusions are limited by methodological issues in the studies. In all, there is no clear evidence of benefit from vitamin or mineral supplementation for women with diabetes, with the exception of calcium for osteoporosis prevention. Routine use of antioxidant supplements is not advised because of questions regarding long-term safety and efficacy (evidence level B).

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.

The Disease Should Be an Important Health Problem

As the most common male cancer in Europe and the United States, and second only to lung cancer in terms of male cancer deaths, there is little doubt that prostate cancer represents a significant public health burden in Western countries 2 . In the U.S. alone, an estimated 220,900 new prostate cancer cases were diagnosed in 2003, with 28,900 deaths attributable to the disease 3 .Although a dramatic increase has been observed in the number of men diagnosed with localized disease as a consequence of PSA testing, those with advanced prostate cancer continue to present a significant burden to the community, developing metastatic disease at a rate of 8 per year, and reaching 40 at 5 years. These metastases predominately affect the skeleton, causing high levels of morbidity and hospitalization, and necessitating expensive palliation. In addition, the use of hormone manipulation in the form of androgen suppression to treat advanced disease causes iatrogenic morbidity by reducing bone density...

Oral Contraceptive Side Effects

Imaging DEXA osteopenia in thoracolumbar vertebral bodies. Treatment Symptomatic control of minor side effects (as in this patient) if estrogen supplementation is contraindicated or complicated by severe refractory side effects, consider alternative medications for osteoporosis prophylaxis (e.g., calcitonin). 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,...

The Side Effects of Hormonal Therapy

As time has progressed, the GnRH agonists have also been shown to have side effects. These include memory loss, parkin-sonism, anemia, and osteoporosis, in addition to the hot flushes and impotence that were obvious from their first use. The most important of the side effects physiologically is osteoporosis, with a loss of bone mass of nearly 10 per annum. Although bispho-sphonates have been shown to be of little effect in prostate cancer in terms of limiting pain and tumor progression, which are the main benefits of their use in breast cancer and myeloma, this group of agents is of significant use in limiting osteoporosis in prostate cancer 11 .

Combined Radiotherapy and Hormone Therapy

The potential benefits of androgen deprivation have to be balanced against toxicity. Most patients experience hot flushes, fatigue, and impotence of varying degrees, which can impact significantly on quality of life. Other toxicities include loss of libido, weight gain, muscle wasting, and changes in texture of hair and skin. Longer-term concerns include the development of osteoporosis and the possibility that low testosterone levels may predispose to cardiovascular disease. There is no evidence yet that long-term hormone therapy increases non-prostate cancer mortality, but this is being investigated in the meantime, it is sensible to restrict the use of long-term hormone therapy to patient groups in which it has been shown to have an overall survival benefit.

Immediate or Deferred Treatment The Swinging Pendulum

There are potential advantages to deferring treatment, with any side effects resulting from treatment occurring for a shorter period of time and the possibility that many patients might not need treatment, as they would die first from an unrelated cause. However, a number of potential harmful effects could arise from delaying treatment 13 (Table 6.1), but these in turn must be balanced against the long-term toxicity of chronic androgen deprivation, which has been recognized, with particular concern about osteoporosis 14 .

Is the Case for Immediate Treatment Proved

On the other hand, are there problems with immediate treatment The immediate side effects of impotence, hot flushes, and so on have been long recognized. However, just as studies have started to show that clear benefits may result from immediate treatment, so has the possibility emerged that serious harmful effects may result from androgen treatment. Some of these are specific to particular therapies, such as cardiovascular complications of estrogens, and liver toxicity of antiandrogens. However, testosterone deficiency, including androgen deprivation from orchiectomy or LHRH analogues, long considered safe options, is now recognized to cause weight increase, loss of muscle mass, and loss of energy 26 . Anemia may be a particular problem in patients treated with combined androgen blockade 27 . Osteoporosis has been

Immediate or Deferred Treatment in 2005

We still have a dilemma with hormone treatment. Not treating cancer is a difficult concept for patients and many doctors. Treatment has possible benefits, benefits that recent trial data have made firmer. Yet treatment is also a source of side effects and potential toxicity. Hormone treatment is only temporarily beneficial hormone refractory relapse is inevitable. Future clinical research must address a number of issues quality of life, specific monitoring of potential toxicity, osteoporosis, and treatment-related death. Meanwhile, in the laboratory, the mechanism of hormone refractory relapse and treatment-related toxicity must be addressed. Prevention of androgen insensitivity would change hormone therapy from a palliative to a curative treatment. Hormone treatments with the benefits and without the toxicity would further shift the balance immediate treatment might then hold undisputed sway.

Renal Tubular Acidosis

XR widening of growth plates osteopenia of cranial and long bones irregularity and cupping of distal ends of long bones pseudofractures in metaphysis ( looser's lines). Excess amount of uncalcified bone at junction of cartilage bone stretched and pulled out of shape by gravity increased osteoid seams osteopenia frontal bossing of skull pigeon breast deformity.

Doxorubicin Cardiotoxicity

Discussion Heparin complexes with antithrombin III to form a potent inac-tivator of factor Xa and inhibitor of the conversion of prothrombin to thrombin. This complex also inactivates factors IXa, XIa, and Xlla. Its major adverse effect is bleeding, which occurs with a higher incidence in women over age 60. Other adverse effects include hypersensitivity, hyperlipidemia, hyperkalemia, osteoporosis, and, in up to 30 of patients, thrombocytopenia. The severity of thrombocytopenia appears to be dose related and is due to the direct effect of heparin on platelets or to an immunoglobulin that aggregates platelets.

Meat And The Pathology Of Human Disease

Osteoporosis, Fractures roidectomy.62,63 These data have been used to support the presence of another causal pathway whereby the increased dietary phosphorus-to-calcium ratio of meats contributes to secondary hyperparathyroidism a condition that could potentially contribute to loss of bone mass. Specifically, when the homeostatic balance of serum calcium and phosphorus is altered in favor of increased phosphorus, there is a compensatory release of parathyroid hormone that activates increased calcium resorption from the bone. This mechanism suggests that the high serum phosphorus levels among meat-eaters should produce chronically increased calcium resorption from bone that could decrease skeletal mass and increase risk of osteoporosis and bone fractures. Recent data from clinical studies have shown that even short-term (1-4 weeks) maintenance of high-phosphorus, low-calcium diets among women and men can produce mild hyperparathyroidism.64,65 In a cross-sectional study, Metz reported a...

Prevention of chronic disease

Over the past few decades, HT has been touted widely to provide both primary and secondary prevention for several major chronic conditions. More than 30 case-control and prospective observational studies have suggested that HT provided primary prevention against coronary heart disease (CHD), secondary prevention for women with prior myocardial infarction (MI), and both primary and secondary prevention against fractures from osteoporosis.

The choice to use hormoneestrogen therapy

Is used solely to prevent osteoporosis since there are equally efficacious and possibly safer strategies that deserve careful consideration. For women at high risk of osteoporosis, combined HT should be considered only when other treatments are not tolerated, when the woman is at low cardiovascular, thrombotic, and cancer disease risk, and when the woman is fully informed of the risks and alternatives. soy on CHD and osteoporosis For women interested in chronic disease prevention, safer, equally efficacious options exist. Women who desire treatment or prevention strategies for osteoporosis may benefit from calcium and vitamin D supplementation, weight-bearing exercise, strength training, SERMs, biphosphonates, and calcitonin, alone or in combination. A new product, Forteo , was approved by the US FDA in 2002 (see Chapter 14). Women may obtain maximal protection from HT after three years of use, equal to that obtained by women using HT for more than three years. Limiting use to three...

Discontinuing hormone therapy

ACOG recommends that women should be counseled regarding alternatives that might reduce their risks when they discontinue HT. Women at risk for CHD should be informed regarding lifestyle modifications and the risks and benefits of statin drugs and aspirin. Women at risk for osteoporosis should explore alternative therapies, such as calcium, weight-bearing exercise, and biphosphonates. Once HT is stopped, clinicians may want to monitor women for signs of reversal of its beneficial effects. For instance, a woman who has been on HT may have had beneficial effects on her bone mineral density regardless of whether its intent was to prevent osteoporosis. She may benefit from osteoporosis screening a year or two following cessation to determine whether osteoporosis is developing, even if prior bone mineral density (on estrogen) was within acceptable limits. This is particularly true because rapid bone loss may occur in the first year following discontinuation of estrogen, and, if identified,...

Glycogen storage diseases

Other biochemical defects affect different organs, especially the brain, heart and liver. There may be hepatomegaly, hypoglycaemia, hyperlipidaemia, hyperuricaemia, lactic acidosis, impaired growth, cyclical neutropenia and bacterial infection. If dietary compliance is poor, chronic renal disease, inflammatory bowel disease, hepatic adenoma, amyloid, gout or osteoporosis may result.

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...

Lipid Differences Between Omnivores And Vegetarian Or Vegans

Cholesterol and triacylglycerol production as previously discussed. Exogenous plant dietary fat supplies a dominance of unsaturated to saturated fatty acids to minimize not only the atherosclerotic diseases, but also several of the rheumatoid states, the mineral problems of osteoporosis, and possibly several types of cancer by the inclusion of polyunsaturated fatty acids (PUFA).3,40,41 This protective diet combined with adequate exercise inhibits the initiation of these diseases before they reach the lipid deposition stages by decreasing the initial free radical attack with antiox-idants. For example, in coronary artery disease (CAD), the vegetarian or vegan diet supplies the antioxidant vitamins and minerals from a high

Additional Pu1 Target Genes

It will be interesting to perform such studies in other cell types. For example, recent studies have also indicated that PU.1 is critical for development of the monocyte-related osteoclast, and that PU.1_ _ mice develop osteoporosis (Tondravi et al., 1997). It is anticipated that there may be an entire novel set of PU.1 targets in this lineage.

Nutritional Complications

In those who are lactose intolerant, lactose ferments in the colon and creates cramping and more diarrhea. A dairy-free diet may be prescribed, which may in turn lead to more nutritional deficiency if calcium is lacking. Calcium deficiency over time can lead to loss of bone density, a condition known as osteoporosis. This can be especially dangerous to those being treated with corticosteriods such as prednisone. Prednisone use over time can lead to osteoporosis, even when the individual is consuming and absorbing calcium.

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

Believed the drugs caused a slightly elevated risk of breast cancer after long-term use, but conferred protection against cardiovascular disease (heart attacks, strokes, thromboses) and prevented osteoporosis, the thinning of bones that lead to fractures. HRT was known to prevent uncomfortable symptoms of menopause such as hot flashes, night sweats, mood swings, and vaginal dryness. cases of osteoporosis. The increased breast cancer risk did not develop for four years. The increased incidence of pulmonary embolisms occurred in the first two years, and the decrease in col-orectal cancer occurred after three years. The increased risks observed applied to an entire population of women, not any individual woman, and did not distinguish between other risk factors a woman might have for breast cancer or other diseases. No distinction was made for ethnic background or the presence of mutations in BRCA1 or BRCA2. ACOG recommends that the decision to stay on hormones or to withdraw be a...

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

Bone mineralization depends on adequate nutritional status in childhood and adolescence. Therefore, measures to prevent osteoporosis should begin with improving the nutritional status of adolescents to increase bone mineralization, including increasing milk intake.6 Because other nutrients Table 14.1 Risk factors for osteoporosis besides calcium are essential for bone health, adolescents must maintain a balance between the intake of calcium, protein, phosphorus, and other calorie sources. Substituting phosphorus-laden soft drinks for calcium-rich dairy products and juices compromises calcium uptake by bone and thereby promotes decreased bone mass. A summary of risk factors for osteoporosis is shown in Table 14.1. Sedentary lifestyle and or immobility (those confined to bed or wheelchair), low body weight, cigarette smoking, and excessive alcohol consumption all influence bone mass negatively. Eating disorders affect BMD because the inability to maintain normal body mass promotes bone...

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...

Differential diagnosis and screening

The greatest challenge for clinicians is to know which asymptomatic patients would benefit from screening for osteoporosis, rather than determining a treatment regimen for those with known disease. All women and girls should be counseled regarding appropriate calcium intake and physical activity. Assessment of osteoporosis risk is also important when following a patient for a chronic disease known to cause secondary osteoporosis. Preventive measures are always the first step in therapy. Recognizing the variety of conditions conferring risk of osteoporosis, the National Osteoporosis Foundation makes the following recommendations to physicians Counsel all women on the risk factors for osteoporosis. Osteoporosis is a silent risk factor for fracture, just as hypertension is for stroke one out of two white women will experience an osteoporotic fracture at some point in her lifetime. Perform evaluation for osteoporosis on all postmenopausal women who present with fractures, using BMD...

Items 738 through 741

A 52-year-old woman presents to your office for her annual gynecological examination. She stopped menstruating about 6 mo ago and is getting some hot flashes. Her history reveals that she drinks one glass of wine per day and smokes about 10 cigarettes per day. She does not exercise much and is overweight. Her most important risk factor for developing osteoporosis is

Calcium and vitamin D

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.

Selective estrogen receptor modulators

Pre-existing fractures was 4.5 times greater than in the group with osteoporosis but no pre-existing fracture (21 versus 4.5 ). Thus, it is important to identify and treat patients at higher risk. Studies of women at higher risk for breast cancer are currently under way.

Complementary and alternative therapies

A topical form of natural progesterone derived from diosgenin, which occurs in soybeans and Mexican wild yams, has been promoted as a treatment for osteoporosis, hot flushes, and premenstrual syndrome, and as a prophylactic against breast cancer. However, eating or applying wild yam extract or diosgenin does not produce increased progesterone levels in humans because humans cannot convert diosgenin into progesterone.45

Type 1 diabetes and menopause

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.

The Glucocorticoids Hydrocortisone Cortisol And Others

Hypersecretlon of Glucocorticoids. An increase in the production of glucocorticoids can produce a number of serious effects. One such effect is osteoporosis, a thinning and weakening of bone. A second effect is the moon face and the buffalo hump, a condition characterized by atypical disposition of fat in the shoulder areas (buffalo hump) and in the face (moon face). A third effect is increased susceptibility to infection due to the anti-inflammatory action of the glucocorticoids.

Medications to Increase Outlet Resistance

Estrogen therapy for SUI has, as with other pharmacologic agents, been noted to have mixed results (108-118). It is hypothesized that estrogens may work by changing the autonomic innervation, the receptor content, the function of the smooth muscle, the estrogen binding sites, the supporting tissues, or the mucosal seal mechanism (119-123). There have been others that endorsed the use of estrogens in combination with alpha agonists (111,112,116,124,125). Estrogens, however, can increase the risk of endometrial cancer if they are used unopposed in those with an intact uterus. Progestins exert a protective affect in these situations. There is also an association between breast cancer and estrogen replacement in those receiving such therapy for more than 15 years. The beneficial effects of estrogen include osteoporosis prevention and decreased cardiovascular disease. Estrogen therapy can be administered orally, transdermally, subcutaneously implanted, and topically. Furthermore, the...

Prophylactic Management And Monitoring For Nutritional Deficiencies

Monitoring of nutritional status should begin preoperatively. Table 3 displays a list of routine laboratory and micronutrient tests and procedures. Although no formal guidelines are available, it is reasonable to obtain all the micronutrient tests listed (except DEXA scan) preoperatively and at 6-mo intervals for the first 2 yr, followed by yearly assessments thereafter. Assessment of bone mineral density and screening for osteoporosis by DEXA should be considered for all patients because of the higher risk for development of metabolic bone disease. The timing and frequency of the DEXA test should be based on several factors, including gender, age and presence of other risk factors. Table 4 provides a summary of the assessment and treatment of micronutrient deficiencies. Once detected, deficiencies should be treated and monitored carefully. Patients at particularly high risk, such as women with menorrhagia or patients receiving corticos-teroids, will likely require additional...

Primary Amenorrheatesticular Feminization

Treatment Advise patient to either gain enough weight to restore menses or take oral contraceptives to prevent osteoporosis. pregnancy. Women who are involved in vigorous physical exercise and who lose weight may present with a functional gonadotropin deficit. When body weight falls > 15 of ideal weight, GnRH secretion from the hypothalamus is decreased, producing a secondary amenorrhea. The inhibitory effect of estrogens on bone resorption is also lost, predisposing patients to an increased risk for osteoporosis.

Protein Differences Between Omnivores And Vegetarians Or Vegans

A varied diet based on plant proteins is adequate, yielding growth and body maintenance results equivalent to a diet based on meat protein.39 The lower incidence of obesity, constipation, lung cancer, hypertension, coronary artery disease, type 2 diabetes, gallstones, reduced risk of breast cancer, diverticular disease, colon cancer, calcium kidney stones, and osteoporosis appear to be obvious advantages particularly of the well balanced vegan diet for the elderly.3,39,40 Key et al.,40 (Table 11.1) show the protective effect of daily fresh fruit intake in ischemic heart disease, cerebrovascular disease, and lung cancer, and daily raw salad protection for ischemic heart disease. They also presented a higher incidence of breast cancer in the vegetarian women, but the confidence interval was broad. The smokers in their study population demonstrated a higher rate of ischemic heart disease, cerebrovascular disease, and, of course, lung cancer, to emphasize the disease problems associated...

Pseudohypoparathyroidism

XR widening of growth plates osteopenia of cranial and long bones irregularity and cupping of distal ends of long bones pseudofractures in metaphysis (looser s lines). Excess amount of uncalcified bone at junction of cartilage bone stretched and pulled out of shape by gravity increased osteoid seams osteopenia frontal bossing of skull pigeon breast deformity.

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...

Endocrine Causes of Obesity

Many patients are concerned that they have a metabolic or glandular cause for their obesity. This may be a reflection of the frustration that some of these individuals feel over the difficulties that they have had in battling a weight problem over many years. They may be looking for a medical explanation of why they have not succeeded in their goal of losing weight. Endocrine causes of serious obesity are not common. The three most commonly cited are hypothyroidism, Cushing's syndrome, and hypothalamic obesity. To evaluate the patient for hypothyroidism, questions can be asked about cold intolerance, constipation, irregular menses, fatigue, or depression. The presence of easy bruisability, proximal muscle weakness (difficulty getting out of a chair, trouble getting things out of a high cupboard), a change in appearance, or osteoporosis may be signs of hypercortisolism. The patient can be examined for signs of hypothyroidism including bradycardia, cool dry skin, a firm palpable...

Resistance training

Although resistance training has been proven to alter positively some of the modifiable risk factors for disease (obesity, hypertension, lowbone mass, etc.), fewer than 16 of the US population between the ages of 18 and 64 years participate regularly in a resistance-training program.16 Women who participate in a resistance-training program increase muscle strength and power, alter muscle ultrastructure (type II fiber area), increase or preserve bone mineral density, and improve cardiovascular risk factors for disease.17,18 Regular participation in a resistance-training program has profound effects on muscle ultrastructure. Resistance training attenuates the loss in muscle cross-sectional area, type II fiber area, strength, and bone mineral density commonly associated with aging.5,22,23 Significant increases in maximum torque, electromyography, maximal strength, and type II mean fiber area have been observed in middle-aged women after participating in an explosive-strength training...

Endurance training

In addition to improvements in the cardiovascular system, endurance exercise also improves a woman's psychological outlook and the skeletal system. Women who exercise regularly are less neurotic, have greater self-esteem, and are more satisfied with life compared with their sedentary counterparts.34 Weight-bearing activities such as walking increase or preserve bone mineral density by approximately 5 .35 However, as with resistance training, the positive effects of exercise are negated when exercise is discontinued or reduced (fewer than three days per week). Regular exercise has a significant impact on the human body.

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.

Systemic

Systemic corticosteroids are effective in controlling active OCP 23 . The high doses required for such control, and the inevitable recurrence of inflammation upon cessation of steroids, restricts their use and essentially makes them less efficacious than immunomod-ulatory agents 20, 22 . Long-term steroid therapy is associated with inescapable side effects (e.g. avascular necrosis of femoral head, osteoporosis, hypertension, glucose intolerance with development of steroid-induced diabetes melli-tus). The high potential for complications mandates that corticosteroids should be reserved for short-term therapy in conjunction with long-term immunomodulatory therapy (IMT) in severely inflamed eyes. If corticosteroids are integrated into the treatment program, they should be used for no longer than 3 months, inclusive of tapering.

Remodelling

Communication network between osteoblasts and osteoclasts. An imbalance in bone remodelling leads to a progressive decrease in bone density (osteopenia) and a breakdown of bone architecture which, in combination, results ultimately in osteoporosis. Remodelling imbalance may be due to increased osteoclastic activity, creating resorption pits which are too deep for normal osteoblasts to fill alternatively, or in addition, osteoclastic activity may be normal but the ability of osteoblasts to fill the resorption pits is impaired.

Further reading

L. (1998) The role of receptor kinases and arrestins in G protein-coupled receptor regulation. Annual Review of Pharmacology and Toxicology, 38, 289-319. Manolagas S. C. (2000) Birth and death of bone cells basic regulatory mechanisms and implications for the pathogenesis and treatment of osteoporosis. Endocrine Reviews, 21, 115-37.

Introduction

Epidemiological data as well as clinical experience clearly suggest that relatively unrefined vegetarian diets can provide remarkable health protection for chronic disease prevention.1 Vegetarian diets typically contain higher amounts of whole grains, legumes, vegetables, fruits, nuts and seeds2-4 with concomitantly decreased levels or elimination of refined foods and animal products (Table 6.1). Thus, in contrast to the omnivorous diet, the nutritional composition of the vegetarian diet is high in dietary fiber and low in saturated fat.5 Industrialized countries face the problem of excess dietary energy and saturated fat consumption, leading to an increased incidence of chronic degenerative diseases. Not much conclusive data is available on the protective role of vegetarian diets in the prevention of osteoporosis, diabetes, and neurological disorders. However, this review summarizes the brief literature on the possible role of vegetarian dietary practice in the incidence of these...

Kathy Andolsek

Case a 51-year-old healthy woman presents to the office. She has two children, 24 and 21 years of age, both delivered by cesarean section for fetal distress. Following the second delivery, she had a bilateral tubal ligation for contraception. She has had no other medical conditions. She reports that her menses have changed over the past year, becoming shorter and lighter. She occasionally skips a period altogether. She reports hot flushes, palpitations, and some sleep disruption. She believes that the sleep disruption has led to fatigue and some mild cognitive changes, which are beginning to interfere with her work performance. She has no personal or family history of breast cancer, coronary artery disease, or thromboembolic disease. She does have a family history of osteoporosis. She is a non-smoker, drinks two beers weekly, and exercises inconsistently. Her best friend had been on hormone therapy but stopped with the recent news concerning adverse effects. She wants to know whether...

Weight Reduction

At least for the first 6 months of a high-fat, low-carbohydrate diet, there seem to be no adverse effects on risk factors for atherosclerosis, although carotid intimal thickening can occur if high-saturated fat alternatives to carbohydrates are chosen. Ketosis can cause bad breath and prolonged ketosis may increase the risk of osteoporosis caused by calcium loss from bone. The long-term safety of this diet remains to be demonstrated.

Tibolone

Tibolone is a steroid compound with estrogenic, progestogenic, and androgenic properties.66 It is effective for reducing the frequency and severity of hot flushes and improving vaginal dryness and libido. Tibolone has been shown to increase bone mineral density, with little effect on the breast or endometrium. It should not be used in women with a history of coronary artery disease, stroke, or liver disorders. Caution is also advisable in women with kidney disease, epilepsy, migraine, diabetes, and high cholesterol. Tibolone may interact with some drugs, including anticoagulants. Its androgenic properties may cause oily skin and extra hair growth. Breast symptoms are rare. It is not available in the USA.

The future

Postmenopausal women at increased risk for breast cancer can compare safety and efficacy of chemoprophylaxis (tamoxifen and raloxifene) in reducing the risk of the disease. Risk assessment tool at www.cancer.gov bcrisktool Duke University site for women www.thewomenshealthsite.org National Osteoporosis Foundation www.nof.org 78 US Preventive Services Task Force. Screening for osteoporosis in postmenopausal women recommendations and rationale. Am. Fam. Physician 2002 66 1430-32. 79 US Preventive Services Task Force. Screening for osteoporosis in postmenopausal women recommendations and rationale. Am. Intern. Med. 2002 137 526-8.

Imaging

A key new tool in the validation of analytical models is high-resolution imaging coupled with computer analyses to calculate the material stresses, strains, and stimuli within cancellous bone. The average thickness of a trabecula is 100-150 m, undetectable with conventional computed tomography resolution of 100-200 m. Microcomputed tomography can image bone at 17 m resolution, and the images can be converted directly into large-scale finite element models (Figure 7.7). These models can determine bone stiffness and strength without the need for a traditional mechanical test. These 'virtual bone biopsies' have the potential to revolutionise the clinical assessment of bone health, an increasingly important clinical objective in an aging population susceptible to osteoporosis. Although these tomography-based models simulate the architecture precisely, the magnitude and variation of tissue-level material properties still need to be determined.

Vitamin D

Vitamin D is essential for calcium absorption and optimal bone health. The current U.S. DRIs for vitamin D are 5 to 15 mcg. (200 to 600 IU) depending on age. Those under 50 years. of age require 5 mcg, those 51-70 require 10 mcg, and those over 70 require 15 mcg. Most individuals Geographical latitude was a significant factor in the 15-country population study on bone fractures.108 Countries with the lowest fracture rates typically occurred in regions of high sunlight exposure while the three countries with the highest fracture rates were all Scandinavian. While Finland has lower fracture rates than its neighboring countries, the Finnish do fortify foods with vitamin D, as well as having higher calcium intakes than their Scandinavian neighbors. Countries with similar protein intakes may have hip fracture rates that vary two- to threefold, depending largely on latitude, suggesting that obtaining adequate vitamin D is important for bone health. Results from a meta-analysis suggest a...

Symptoms and signs

The history and physical examination are important in screening for secondary forms of osteoporosis and directing the evaluation, although they are neither sensitive enough nor sufficient for diagnosing primary osteoporosis. A medical history provides valuable clues to the presence of chronic conditions, behaviors, physical fitness, and or the use of long-term medications that could influence bone density. Patients already affected by complications of osteoporosis may complain of upper or mid-thoracic back pain associated with activity, aggravated by long periods of sitting or standing, and easily relieved by rest in the recumbent position. Low bone density, a propensity to fall, greater height, and presence of previous fractures confer increased fracture risk. Asymptomatic hyperparathyroidism, where osteoporosis would suggest parathyroidectomy Monitoring therapeutic response in woman undergoing treatment for osteoporosis if the result of the test would affect the clinical decision

Laboratory findings

Basic chemical analysis of serum is indicated when history suggests other clinical conditions influencing the bone density. These tests provide clues to serious illnesses that may otherwise have gone undetected and that, if treated, could result in resolution or modification of the bone loss. Specific biochemical markers, such as human osteocalcin, bone alkaline phosphatase, immunoas-says for pyridinoline cross-links, and type 1 collagen-related peptides in urine, which reflect the overall rate of bone formation and bone resorption, are now available. However, these markers are primarily of research interest and are not recommended as part of the basic work-up for osteoporosis.16 They suffer from a high degree of biologic variability and diurnal variation and do not differentiate between causes of altered bone metabolism.16-18

Imaging tests

Plain radiographs are not sensitive enough to diagnose osteoporosis until total bone density has decreased by 50 , but bone densitometry is useful for measuring bone density and monitoring the course of therapy (Table 14.2).19 Single-photon absorptiometry (SPA) and dual-photon absorptiometry (DPA) have been used in the past, but these provide poorer resolution, less accurate analysis, and more radiation exposure than X-ray absorptiometry. The most widely used techniques of assessingbone mineral density are dual-energy X-ray

Special tests

Bone densitometry reports provide a T-score (the number of standard deviations above or below the mean BMD for sex and race matched to young controls) or Z- score (comparing the patient with a population adjusted for age, sex, and race). The BMD result allows the classification of patients into three categories normal, osteopenic and osteoporotic (Table 14.3). Osteoporosis is a T-score of more than 2.5 standard deviations below the sex-adjusted mean for normal young adults at peak bone mass.21 Z-scores are of little value to the practicing clinician.

Conclusions

In Western countries, there is a heightened interest to provide adequate calcium to support the attainment of optimal bone mineral density. Lacto-ovo-vegetarian diets are not likely to be deficient in calcium when low-fat dairy foods are regularly eaten. Vegan diets need to be appropriately planned to contain adequate calcium. Some vegans, particularly Caucasian and Asian females, may need to consume calcium-fortified foods or supplemental calcium to ensure nutritional adequacy.

Calcitonin

Calcitonin, a hormone directly inhibiting osteoclastic bone resorption, is an alternative for patients with established osteoporosis and in whom estrogen Treatment should be continued until pain is controlled, followed by tapering of medication over four to six weeks. Calcitonin decreases further bone loss at vertebral and femoral sites in patients with documented osteoporosis, but it has a questionable effect on fracture frequency.31 Calcitonin prevents trabecular bone loss during the first few years of menopause, but it is unclear whether it has any impact on cortical bone.29 The Prevent Recurrence of Osteoporotic Fractures (PROOF) study - a five-year double-blind study that randomized 1255 postmenopausal women with osteoporosis to receive placebo or one of three dosages of intranasal calcitonin (100, 140, or 400 IU day) - demonstrated a 36 reduction in the relative risk of new vertebral fractures compared with placebo.32 There was no effect with 100 IU day and no significant change...

Bisphosphonates

In clinical trials, alendronate was generally tolerated well and no significant clinical or biological adverse experiences were observed. Alendronate is effective at doses of 5 mg daily in preventing osteoporosis induced by long-term glucocorticoid therapy. In placebo-controlled studies ofmen and women (aged 17-83) who were receiving glucocorticoid therapy, femoral neck bone density and the bone density of the trochanter and total body increased significantly in patients treated with alendronate.36 Risedronate is a pyridinyl bisphosphonate approved as treatment for several metabolic bone diseases. In doses of 5 mg daily, risedronate reduces the incidence of vertebral fractures in women with two or more fractures by rapidly increasing BMD at sites of cortical and trabecular bone.37 Arandomized trial of more than 1400 postmenopausal women with diagnosed osteoporosis showed a 40 reduction in risk of new vertebral fractures and reduction in incidence of non-vertebral fractures.38...

Items 388390

A 51-year-old G3P3 presents to your office with a 6-month history of amenorrhea. She complains of debilitating hot flashes that awaken her at night she wakes up the next day feeling exhausted and irritable. She tells you she has tried herbal supplements for her hot flashes, but nothing has worked. She is interested in beginning hormone replacement therapy, but is hesitant to do so because of its possible risks and side effects. The patient is very healthy. She denies any medical problems and is not taking any medication except calcium supplements. She has a family history of osteoporosis. Her height is 5 ft, 5 in. and her weight is 115 lb.

Legumes

Intense research over the past decade has shown that soybean has health-promoting properties and may be useful in lowering the risk of heart disease, cancer, osteoporosis, menopausal symptoms, and other problems. Soy is now available in many different kinds of foods such as tofu, soy The isoflavones are well known for their estrogenic activity, which varies substantially from one compound to another. These nonsteroidal phytoestrogens have an array of potent biological activities, of both a hormonal and non-hormonal nature, which influence the development of chronic diseases. The isoflavones can undergo enterohepatic recycling and reach circulating levels that exceed, by several orders of magnitude, the amounts of natural endogenous estrogens.82 The major tissues targeted by the phytoestrogens are the reproductive tissues (uterus, breast, and prostate), the cardiovascular tissues (arteries and blood lipids) and the skeletal tissues.83 About 30-60 mg of isoflavones, per day appear to be...

Erbs Palsy

HPI She suffers from diabetes, hypertension, and osteoporosis. XR-Plain intertrochanteric fracture of femur osteoporosis. N A N A Discussion Frequently seen in elderly postmenopausal women with osteoporosis. The mechanism of fracture is often a trivial force, causing subcapital fractures, impacted or not, as well as pretrochanteric, intertrochanteric, or extracapsular fractures. Patients with hip fractures are at high risk for developing deep venous thrombosis postoperatively thus, proper prophylactic measures (e.g., sequential compression stockings, anticoagulation) must be taken.

Items 408411

A 90-year-old G5P5 with multiple medical problems is brought into your gynecology clinic accompanied by her granddaughter. The patient has hypertension, chronic anemia, coronary artery disease, and osteoporosis. She is mentally alert and oriented and lives in an assisted living facility. She takes numerous medications, but is very functional at the current time. She is a widow and not sexually active. Her chief complaint is a sensation of heaviness and pressure in the vagina. She denies any significant urinary or bowel problems. On performance of a physical exam, you note that the cervix is at the level of the introitus.

Items 128130

A 78-year-old female nonsmoker with a history of osteoporosis is seen with the chief complaint of increased exertional dyspnea. Physical examination pulse 110 bpm temperature normal respirations 24 min blood pressure 110 60 mm Hg. The patient is frail-looking, with decreased respiratory excursion on chest exam. Heart exam reveals normal sinus rhythm with grade 2 6 systolic murmur and loud P2 sound. Laboratory data Hb 14.2 g dL Hct 42 WBCs 9.0 L. ABGs on room air pH 7.38 PCO2 45 mm Hg PO2 56 mm Hg. Chest radiographs are shown below in Fig. 71.

Hip Fracture

Discussion Femoral neck fracture is frequently seen in elderly postmenopausal women with osteoporosis. The mechanism of fracture is often a trivial force, causing subcapital fractures, impacted or not, as well as pretrochanteric, intertrochanteric, or extracapsular fractures. Patients with hip fractures are at high risk for developing deep venous thrombosis postoperatively thus, proper prophylactic measures (e.g., sequential compression stockings, anticoagulation) must be taken.

Items 485487

A 60-year-old white female presents for an office visit. Her mother recently broke her hip, and the patient is concerned about her own risk for osteoporosis. She weighs 165 lb and is 5 ft, 6 in. tall. She has a 50-pack-year history of tobacco use. Medications include a multivitamin and levothyroxine 50 M-g d. Her exercise regimen includes mowing the lawn and taking care of the garden. She took hormone replacement therapy for 6 years after menopause, which occurred at age 49. 485. Which test related to osteoporosis, if any, is appropriate for this patient 486. In counseling this patient about osteoporosis, you should advise her that she might benefit from 487. Which of the following contributes to the development of osteoporosis a. Family history of osteoporosis

Estrogen

Not have the same risk as estrogen for breast or uterine cancer 183 . They are currently being promoted as an alternative to estrogen for the treatment of post-menopausal symptoms and possibly to reduce the risk of fracture from osteoporosis, but their use is not standard 184, 185 . Some examples are raloxifene, tamoxifen, droloxifene and tiboline. No published studies have yet examined the role of these agents in the prevention or treatment of AD.

Osteoblast

The osteoclast, the bone-resorbing cell, is of monocyte macrophage origin. Absence of osteoclast function leads to osteopetrosis, while increased activity causes osteoporosis. Osteoclast differentiation comprises the recruitment of new osteoclast precursors from the haematopoietic system, their development to mature osteoclasts, and finally their activation (Fig. 3). Osteoclast differentiation is generally controlled by osteoblasts.

Cell Function

The differentiation of osteoclasts and osteoblasts is tightly connected during bone formation. This observation, and the fact that under normal circumstances bone mass is constant, led to the assumption that osteoblast and osteoclast activity is also linked during bone remodeling. This implies that a reduction in osteoblast function would automatically lead to a decreased osteoclast activity. Corall and colleagues (126) generated a mouse model to specifically address this question. The transgenic mouse contains an inducible construct to ablate osteoblasts. Although bone formation ceased, the level of osteoclast activity did not change, resulting in controllable osteoporosis. The results indicate that bone resorption is not controlled by bone function. Thus, the requirement for interaction between cells of the two lineages is limited to differentiation. This is further confirmed by the fact that in the absence of bone resorption, as occurs in the c-fos, OPG, and Src-knockout mice, bone...

Medical bi

This is the classic presentation of a fracture of the neck of the femur. This type of fracture typically occurs in postmenopausal women with significant bone resorption due to osteoporosis. Dislocation of the head of the femur can produce a similar effect. The change in the position of the leg is due to the action of the gluteal muscles, particularly the gluteus maximus.

Osteopetrosis

Labs Serum calcium, phosphates and alkaline phosphatase and PTH within normal limits densitometry used to quantify osteoporosis. Discussion Osteoporosis is characterized by a reduction of total skeletal mass due to increased bone resorption (bone formation is normal) there is greater loss of trabecular than compact bone it results in a predisposition to pathologic fracture, p. 242

Rickets

Advise patient to either gain enough weight to restore menses or take oral contraceptives to prevent osteoporosis. The most common cause of secondary amenorrhea is pregnancy. Women who are involved in vigorous physical exercise and who lose weight may present with a functional gonadotropin dcficit. When body weight falls > 15 of ideal weight, GnRH secretion from the hypothalamus is decreased, producing a secondary amenorrhea. The inhibitory effect of estrogens on bone resorption is also lost, predisposing patients to an increased risk for osteoporosis.

Items 322323

A 5 2-year-old woman presents to your office for her annual gynecological examination. She stopped menstruating about 6 months ago and is getting some hot flashes. Her history reveals that she drinks one glass of wine per day and smokes about 10 cigarettes per day. She does not exercise much and is overweight. Her most important risk factor for developing osteoporosis is

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