Osteoporosis

Posted on May 2, 2013 by mcminnclinic

Osteoporosis (thinning bones) is one of the most dreaded diseases of women, and with just cause. Like a silent killer it sneaks up on its victim without symptoms, until finally it becomes a potentially fatal disease. About 30 million Americans suffer from osteoporosis, 80% of whom are women. In fact, in the United States nearly 50 percent of all women between the ages of forty-five and seventy suffer from some degree of osteoporosis. About a quarter of these will eventually go on to have a hip fracture later in life, many of whom will die of complications related to the fracture. In fact, the lifetime risk of death from a broken hip for a 55 year old woman rivals the death risk from breast cancer. The ravages of osteoporosis are not confined to broken hips however. Thinning bones also result in other fractures, as well as collapsed vertebrae, disfigurement, disability, and chronic pain. Overall osteoporosis results in an $18 billion price tag for the American health care system.

So why is this becoming such an epidemic? As with many other common diseases, the modern American diet, sedentary lifestyle, and stress have a lot to do with it. In some less developed cultures, osteoporosis is actually quite rare. Our high sugar, processed food, fast food diets often don’t have the vitamins and minerals needed to build new bone. Also, we don’t get out in the sun as much as we used to. This creates a lack of vitamin D, which is necessary for building healthy bones. Weight bearing exercise also stimulates bone strengthening, but more and more, we have become a sedentary society. Finally, our body reacts to this stressed out culture we live in by raising levels of the hormone cortisol, which then results in thinning of the bones.

What actually happens in osteoporosis? Childhood, adolescence, and early adulthood are the prime opportunities for building strong bones. Our skeletal system reaches its greatest density at about the age of thirty. After that we start a long steady decline. With the onset of menopause, women begin an accelerated period of bone loss. In fact white women in America tend to loose 30-40% of their bone mass between the ages of 55-70.

So who’s at risk? Women are at greater risk than men, and caucasian women are at greater risk than African-American women. Asian women fall somewhere in the middle. In general you’re at greater risk if you’re fair skinned and blue eyed, if you’re thin or small framed, if you smoke, if you’re sedentary, if you rarely get out doors, if you drink too much alcohol or coffee, or if you went through long term depression. You’re also at increased risk if you went through late puberty or early menopause, if you have a poor diet, if you have a history of chronic liver or kidney disease, if you took steroid drugs for an extended period of time, if you had a hysterectomy with ovariectomy, if you have a history of anorexia or bulimia, if you’ve had a prolonged absence of menstrual periods, or if you don’t get enough calcium in your diet. Stress and a poor immune system may also contribute to bone loss. Osteoporosis tends to run in families, so if your mom has it, you’re more likely to get it. Some drugs such as those in the Prilosec or Nexium family put the patient at significant increased risk of osteoporosis.

The key is to get tested. Ideally one should get tested with a bone density screening either before or during perimenopause. Although the fractures don’t show up until later, it helps to get a baseline test in order to establish a trend later on.

Hormones play an important role in bone health. In fact, the primary cause of osteoporosis is hormonal imbalances that interfere with the bone-forming cells. Estrogen prevents bone loss. Progesterone, and to a lesser degreee, testosterone, actually help to build new bone. Together, progesterone and estrogen offer a powerful one-two punch against thinning bone disease. DHEA, melatonin, growth hormone, and calcitonin also support sturdy bones. On the other hand excessive levels of cortisol (the stress hormone), and too much thyroid can lead to bone loss. When it comes to using hormones for bone health, I prefer to use bio-identical hormones. Artificial progestins have actually been found to cause bone thinning.

Here is a game plan to help you to keep your bones strong:

*Healthy diet

*Regular exercise (especially weight bearing)

*Stress reduction

*Targeted nutritional supplementation

*Bio-identical hormone Optimization.

The optimal bone- building diet should include foods that are rich in the building blocks of bones such as nuts, seeds, flax, soy, fish, yogurt, broccoli, and green leafy vegetables. At the same time we should avoid excessive caffeine and alcohol, sugar, and refined grain. Eliminate soda from your diet and reduce red meat. Keep a lid on the added salt and avoid processed foods. Supplements should contain calcium, magnesium, vitamin D, boron, silicon, vitamin C, strontium, and vitamin K.

Take care of your bones and they’ll carry you through into your happy, healthy, vibrant golden years.

Grumpy Ol’ Man Syndrome

Posted on December 12, 2012 by mcminnclinic

On a given day if you asked my wife, she might claim that they named the above medical syndrome after her own beloved husband. I must admit that I have my good days and bad days on the home front. However, I take some comfort in knowing that I’m in good company. In fact, if my women patients are right, “grumpy ol’ man syndrome” has reached epidemic proportions.

The usual scenario is that the wives drag their husbands in, kicking and screaming the whole way. Of course, the men are in complete denial and are busily hoping that Scotty will beam them up at any moment and rescue them from any event in which “feelings” are discussed. Guys need to have just the right pretense for talking about such things. It’s OK to ask “how’s the marriage” when you’re riding around in a golf cart with a good ol’ buddy, or out in the middle of a lake on a fishing boat. It’s like foreplay; the only acceptable ways to engage in such conversation is if the foreplay is centered around football, golf, beer, fishing, hunting, or NASCAR. Just to cold turkey and purposely sit down and have a talk about sensitive issues such as feelings can seem extremely unmanly and may be down right uncomfortable, even with the doctor.

Fortunately the wives are on the case big time, and they usually have the common sense to come with their strong silent types to the initial doctor’s appointment. Although I know going into it, who is going to be the communicator, I at least show the guy enough respect to address the question directly to him. “How’s it going” I say. “Fine,” or some other one worder is usually about all I get. Then the truth spews forth like an Icelandic volcano from the fairer half. “He’s grumpy, sullen, irritable, moody, depressed, and he has no sex drive. He comes home after work and just crashes into his Lazyboy. He doesn’t have any energy, and he doesn’t want to do anything. He has no interests, no get up and go, no joy in life. He’s totally disconnected. And he’s getting fat and lazy.”

On the face of it such phrases may sound like fighting words. Instead, more often than not, he agrees with her, or through his silence and lack of argument one can assume that she is not too far from the truth. Now we’re starting to get somewhere. Just like when you look up at the summer night sky and see the big dipper, it all comes into focus. He has “Grumpy ol’ Man Syndrome.” Another name for this dreaded and all too common condition is “Andropause.” At that moment, I know that I can help him.

Just like women go through menopause, men go through a similar process wherein their levels of hormones (in this case testosterone) fall to well below the acceptable range. Also just as a woman’s menopause may have dramatic affects on her health, her mood, and her behavior, so too andropause may insidiously choke the life out of even the most macho of men. They often become a shell of their former selves. The men, their wives, family, friends, and co-workers all suffer the dreaded consequences of the decline in testosterone and its accompanying symptoms.

At the risk of seeming to be biased toward men, after all I personally fall into that category, I have to stand up for the guys just a bit and let them off the hook. In many instances they can’t help it. The behavior, as I described above, is not of their choosing, but instead it is often hormonally driven. If only they had a robust and balanced hormone profile they most likely would be their usual lovable and manly selves.

True story: I had a patient in the office just recently who fit this description to a tee. His wife drug him in back about 6 months ago with the classic symptoms of “grumpy ol’ man syndrome.” He was clinically depressed, grumpy, frail, had no libido and was starting to suffer from ED (erectile dysfunction). We did all the appropriate lab testing and found that his testosterone was quite low. I put him on a program of hormone repletion, nutritional supplementation, and life style changes. WOW! He came back in for his follow-up visit and announced that he was feeling fantastic. As he put it, his energy was “through the roof.” He could hardly believe what a difference the program had made for him. The depression was gone. Energy was better. He was exercising again. He was interested once again in sex, and interested in life in general. His ED had magically disappeared, and he was thinking much more clearly. He and his wife were both ecstatic. She had her beloved husband back. He had his life back, and they had their marriage back. There is no antidepressant or any other “drug” in this world which could have achieved this outcome for this patient.

Furthermore, low testosterone and andropause can have even more dire consequences. A study published in the Archives of Internal Medicine describes an 88% increase in mortality in male veterans with low testosterone. Other published studies form reputable medical journals have linked low testosterone with poor cognitive function, Parkinson’s disease, Alzheimer’s disease, osteoporosis, hardening of the arteries, heart failure, insulin resistance, diabetes, and metabolic syndrome. Testosterone decline may also contribute to abdominal obesity, decreasing muscle mass, joint pains, loss of self confidence, fatigue, disturbed sleep, anxiety, and excessive worry. Low testosterone is not just about muscles and libido. It is about optimal health, and even mortality.

Testosterone must be respected. Like all medications it must be used properly and must not be abused or used in excess. Testosterone replacement should never be done if it is not medically indicated. Furthermore, the replacement program must be conducted properly with adequate monitoring to attain optimal levels, while paying attention to possible side effects. If done properly, it is safe and may be profoundly effective. Testosterone replacement therapy is not for everybody. However, in the presence of “grumpy ol’ man syndrome” like with my patient described above, it can make a remarkable difference in the life of the patient and his partner.

Bottom line, if you suffer from “grumpy ol’ man syndrome,” get your T checked, and get it optimized. If your loved one shows signs of this dreaded disease, drag him in and get him checked for “low T.” You’ll be glad you did.

Feeling Fat, Fatigued, and Depressed; Think Low Thyroid

Posted on November 26, 2012 by mcminnclinic

Many experts now agree that millions of Americans are falling through the cracks when it comes to the diagnosis and management of low-thyroid conditions (hypothyroidism). Unfortunately, the lack of proper attention to this issue often results in the patient living a life of fatigue, low mood, struggles with obesity, and many other problems.

Although the thyroid gland is small, it has powerful effects on the body. Thyroid hormone regulates the metabolic rate of every single cell. If thyroid function is underactive (hypothyroid) a person can have a multitude of symptoms, sometimes subtle and sometimes profound. These symptoms may include, but are not limited to: fatigue, weight gain, cold extremities, low libido, dry skin, aches and pains, fibromyalgia, constipation, hair loss, brittle nails, poor memory, low stamina, headaches, puffy face, and low body temperature. Perhaps the most common and important of the symptom being varying degrees of fatigue.

Diagnosis of low thyroid conditions, like most medical conditions, starts with listening to and examining the patient. Symptoms, as mentioned above, family history, and physical signs often point to the diagnosis of hypothyroidism. If thyroid disease is suspected, a thorough lab evaluation should also be performed to assist in the diagnosis. However, the goal is to treat the whole patient, and not just to treat the labs.

If hypothyroid disease is confirmed, then proper treatment may include thyroid medications. There are several medications on the market, which may be quite helpful in relieving low thyroid symptoms. These include Synthroid, Armour thyroid, Cytomel, compounded thyroid, and others. One patient may respond well to a particular medicine, while another patient may find that a different medication works best to alleviate his or her thyroid related symptoms. Although Synthroid is often the drug of choice for many physicians, I have found Armour thyroid to be particularly effective in many of my low-thyroid patients. For others, Cytomel may be the key to alleviating their symptoms.

In summary, thyroid dysfunction is a condition that may have a profoundly negative impact on many patients. Yet according to various experts, millions of Americans suffer from inadequate diagnosis and treatment of hypothyroidism. Proper evaluation and treatment of these patients may help tremendously in improving their symptoms, and their quality of life.

To Menopause or not to Menopause? That is the Question

Posted on May 25, 2011 by mcminnclinic

Imagine that you are traveling through the journey of life and you come to a fork in the road. As you stand at the fork, looking left, then right, you can clearly see down each path. Obviously, others have traveled this path before because the terrain is well-worn. You discover that your decision as to which path to travel has been aided by a road sign.

The sign pointing to the left reads as follows: “Travel here for hot flashes, night sweats, brain fog, insomnia, weight gain, low libido, mood swings, anxiety, irritability, rapid heart beat, dry thin skin, headaches, vaginal dryness, painful intercourse, urinary incontinence, hair loss, and osteoporosis.”

The sign pointing to the right reads: “Vibrant living ahead.”

Which path will you choose? To menopause or not to menopause? That is the question.

For most of our history as humans on this earth, women did not have such a choice. For most of our existance, the life expectancy of a woman did not allow most women to reach the age of menopause. They died before they got there. For those rare and lucky women who reached the ripe old age which lead to menopause, they suffered in silence as the sweat of the hot flashes poured off their chins, and they soaked their own beds night after night. Then along came hormone replacement therapy (HRT). Suddenly everything changed. Finally, women had the right to “opt-in” and go through menopause, or “opt-out” and say “no thank you” to the misery.

For many years the only “opt-out” options were synthetic drugs such as Premarin, Provera, and PremPro. Now at this point, I have a confession to make. When I was a young doctor (many years ago), just about every woman who came through our clinic was placed on PremPro. This is an artificial patented drug, that is not a true human hormone, but has hormone like activity. The mantra we all learned was that the women who received PremPro were going to live longer and better. This notion had been drilled into our heads since we were medical students. We bought it hook, line, and sinker. Everything was hunky-dory until the drug companies made the mistake of doing a major study attempting to show what a great drug they had, and how smart we all were for prescribing it. Unfortunately for us all, the studies didn’t show what they thought they would. In fact, they had to halt the studies half way through because so many women were being affected by heart attacks, strokes, breast cancer, and blood clots. Many women were taken off these drugs without being offered any alternative. Others were left on the drugs only to take their chances with the consequences.

Meanwhile in Europe, for the last fifty years women have been offered another option called bioidentical hormones. These are compounds which are made to be 100% exactly the same as the natural human hormones they are intended to supplement. The body cannot tell the difference between its own hormones and bioidential hormones, because there is no difference.

For example, if your body is low on potassium, do you eat a banana, or do you take some patented drug that your body has never seen before which has been synthesized to have potassium like activity, but lots of negative side effects. It seems clear to me that most people would wisely choose to eat the banana. Likewise, it seems only reasonable to chose the bioidentical hormones which are just exactly like the body’s own natural hormones.

At this point as one is standing at the fork in the road, it seems to boil down to risk and benefit. In the big picture the evidence seems to support that bioidentical hormone therapy, if used properly, can help a woman live longer and better. Here are a few examples:

*A study publishes in the journal “Obstetrics and Gynecology” showed that women who took estrogen lived longer than women who did not take estrogen.

*A study in the medical journal Lancet showed that women who took transdermal estrogen had less blood clots than women who took Placebo.

*A huge study in the International Journal of Cancer showed that women who took a combination of bio-identical estrogen and progesterone had less breast cancer than women who took placebo.

*A study in JAMA showed that the incidence of Alzheimer’s disease was significantly reduced in women on hormone replacement therapy.

*Numerous quality studies have shown heart protective benefits of women who start hormone replacement early in menopause.

*Another study in JAMA showed a significant improvement in cognitive function (memory and thinking skills) in women who took hormone replacement therapy.

*Studies have shown that hormone replacement therapy can help to reduce hip fractures in osteoporotic women.

*Major studies have also shown that hormone replacement therapy (HRT) can reduce the incidence of colon cancer.

*A study in the International Journal of Dermatology showed that hormones can significantly reduce skin wrinkle depth, and improves thickness and elasticity of skin.

*Numerous studies have proven that HRT can help to boost a sagging libido.

*Studies have clearly shown that HRT is effective in treating vaginal dryness, vaginal atrophy, and pain with intercourse.

*HRT can be a miracle cure for those awful hot flashes, night sweats, as well as the associated insomnia.

HRT is not for everybody. However as you approach the crossroads of menopause, it’s important to know that you have a choice. Carefully consider your options. The right choice for one woman may not work for another. For many women, the right choice is a carefully designed, evidence based, closely monitored, customized plan of bioidentical hormone replacement therapy, which will help her live a longer and more vibrant life.

Women’s Health

Posted on January 31, 2011 by mcminnclinic

Throughout my career in medicine, when studying the care of
children, I have often heard the phrase “ Children are not just small
versions of adults” . They have their own unique characteristics
that make them special, and which require a different approach
when providing medical care. I have found the same is true when
it comes to women’ s health care, i.e. women are not just different
versions of men. Certainly, men and women have their similarities.
At the root of our existence, bodies of both men and women have
the fundamental missions of surviving and reproducing, albeit
the way men and women go about both of these is very different.
Fundamentally women are biologically, chemically, hormonally,
genetically, mentally, and spiritually, and sexually different
than men. As a result, there are a whole host of conditions and
diseases that disproportionately affect women, such as depression,
anxiety, obesity, thyroid problems, and many autoimmune diseases
including lupus, rheumatoid arthritis and multiple sclerosis.
Now let’ s begin to take a look as some of the differences which
contribute to these discrepancies.

The most profound difference between women and men is the fact
that women have babies and men don’ t. This basic fact propels us
into a whole host of other characteristics that distinguish women
from men. In addition to the obvious anatomical differences
there are many other unique characteristics of women. Women
go through puberty earlier, mature quicker, but have fewer fertile
years than men. In order to produce healthy offspring, women
must have a higher percent of body fat, and a higher waist to hip
ratio. They have different mating, sexual, and orgasmic tendencies
than males. Men are taller, with more body hair and have thicker
skin. Women tend to tolerate pain better and live longer. Sugar
metabolism in the brain is different in women and men. This may
help to explain why women are more likely to suffer depression
and act impulsively, while men are more likely to be aggressive
and hyperactive.

Women generally have smaller organs, including liver and
bladder. I can personally vouch for the bladder issue after taking
many long road trips with my daughters and having to stop every
thirty minutes for the potty. The smaller liver is associated with
an increase in sensitivity to toxins. This fact may help to explain
why women are much more likely to suffer from multiple chemical
sensitivity than men. Also associated with the liver is the fact
that alcohol is metabolized more quickly by women, therefore
the effects of alcohol come on quicker and are more pronounced.
Compounding this fact is the tendency of women to be more likely
to be binge drinkers. Women also have a higher fat to water ratio
which makes it more difficult for them to dilute toxins.

Breast cancer is much more common in women than in men and
it has reached epidemic proportions. This contributes to breast
cancer being the most feared disease of women. However, it
is vitally important to understand that heart disease kills about
six times more women than breast cancer. Hearts are smaller in
women. They beat faster and are less prone to atherosclerotic
disease while being more prone to spasm of the heart arteries.

Differences in men and women are seen even at the genetic level.
In many situations, men and women may have many of the same
genes, but the expression of the genes often has a significant
gender based component.

Hormonally men and women are quite different. Women have the
cyclic production of estrogen and progesterone associated with
ovulation, while men have about 10 times as much testosterone as
women. This has a profound effect on women at every level.

The implications of these differences are profound for women. In
my many years as an ER doctor, we applied a male model of heart
disease to women for many years. In order for a women to be
considered for a cardiac diagnosis we thought that she had to have

the same symptoms that men had, i.e. chest pain, nausea, left arm
pain, and shortness of breath. Recently we have begun to realize
that almost half of women with a heart attack have no chest pain.
As a result women often don’ t get the help they need until it is too
late. Women are less likely than men to survive their initial heart
attack, less likely to get out of the hospital alive, and more likely to
die within a year of their heart attack.

As evidenced by the above differences, women and men are
each unique unto their own. Yet most of the medical literature
is based on studies of men. Historically we have just assumed
that what is good for men is also good for women. The American
medical community was so negligent in this arena that the federal
government finally had to step in and in 1993 pass a law that
required that women be included in medical studies. Medicine still
has some catching up to do as far as appreciating the uniqueness of
women. We need to develop a more gender specific approach to
diagnosis, treatment and prevention in order to improve women’ s
outcomes. Indeed, women are not just different versions of men.
There are fundamental differences at every level, which have a
profound effect on wellness.

James E. McMinn, M.D.