Posts tagged ‘menopause’
Stanford University photo of Dr Aaron Hsueh, professor of obstetrics and gynecology at Stanford University, who developed a technique that has induced the ovaries of two infertile women into producing eggs that has resulted in live births (AFP/STANFORD UNIVERSITY/ROBERT VON DER GROEBEN)
Women who enter menopause at a young age could still give birth through a new technique successfully experimented on two women
A new technique that coaxes an infertile woman’s ovaries into producing eggs again has resulted in the birth of a baby in Japan.
A second woman has become pregnant using the same method, according to the study in the Proceedings of the National Academy of Sciences, a US journal.
Researchers caution that the technique is still in its early stages, but could offer hope for young women whose ovaries are no longer producing eggs.
This condition, known as primary ovarian insufficiency, affects about one percent of women and causes the ovaries to stop working before age 40.
Since these women enter menopause at a young age, egg donation as the only option if they want to attempt to carry a pregnancy.
The research involved 27 women with primary ovarian insufficiency. Their average age was 37.
All had stopped menstruating nearly seven years earlier on average, and all agreed to have both ovaries removed as part of the experiment.
Of this group, 13 women were found to still have residual follicles, which typically contain one immature egg.
Human females are born with about 800,000 of these follicles. Most will remain dormant, but normally one follicle develops to maturity each month and releases an egg.
“Our treatment was able to awaken some of the remaining primordial follicles and cause them to release eggs,” said senior author Aaron Hsueh, professor of obstetrics and gynecology at Stanford University.
The ovaries were dissected and treated with stimulant drugs to block a certain growth pathway, called PTEN, that causes the follicles to stay dormant.
Small pieces of the ovaries were then transplanted back into the women near their fallopian tubes.
Eight of the 13 women showed signs of follicle growth, and were treated with hormones to stimulate ovulation.
From that group, five developed mature eggs, which the researchers harvested for in vitro fertilization using the sperm of the women’s partners.
One woman received two embryos and carried a single pregnancy to term, with the birth done by C-section since the fetus was in a breech position at 37 weeks.
Lead author Kazuhiro Kawamura, associate professor of obstetrics and gynecology at the St. Marianna University School of Medicine, did the C-section himself.
“Although I believed, based on our previous research, that this in vitro activation (IVA) approach would work, I monitored the pregnancy closely and, when the baby was in a breech presentation, I performed the Caesarean section myself,” said Kawamura in a statement.
“I could not sleep the night before the operation, but when I saw the healthy baby, my anxiety turned to delight,” he said.
“The couple and I hugged each other in tears. I hope that IVA will be able to help patients with primary ovarian insufficiency throughout the world.”
Of the other four women in the experiment, one is pregnant, two are preparing for embryo transfer or are undergoing additional egg collection, and one woman was implanted with an embryo but failed to become pregnant, the researchers said.
Alan Copperman, director of the division of reproductive endocrinology at Mt. Sinai Medical Center in New York, said he applauded the US-Japanese team’s “novel approach to an age-old problem.”
“That being said, it is extremely premature to comment on the widespread potential for this procedure to help women with ovarian failure to achieve reproductive success,” said Copperman, who was not involved in the study.
“It may be years before we see clinical benefit in our patients who suffer from ovarian failure.”
The researchers said they hope to investigate next whether the technique could help counteract other causes of infertility, such as cancer treatment.
The excessive bone loss that can occur in menopause compromises bone strength, resulting in an increased risk of fracture.
BONE is made up of calcium and protein. There are two types of bone: compact and spongy. All the bones in the body contain some of each type.
Compact bone appears hard and solid, and is found on the outside of bones. Spongy bone is found on the inside of bones and is filled with holes.
Bone is constantly undergoing change, with old bone broken down and new bone formed daily.
More bone is formed than is broken down when young, especially in childhood. Our bones stop growing between 16 and 18 years of age, with peak bone mass density attained by 30 years of age.
After that, more bone is broken down than is formed. This gradual and small amount of bone loss continues for the rest of your life.
A little bit of bone loss does not usually cause problems. However, excessive bone loss results in osteoporosis, which is characterised by compromised bone strength, resulting in an increased risk of fracture.
Although the bones are still of the same size, the outer walls of compact bone become thinner and the holes in spongy bone become larger, thereby weakening the bone considerably.
Osteoporotic fractures are increasingly common in Asians. The impact of these fractures is tremendous. It affects the physical, psychosocial and financial aspects of a patient’s life and family, as well as the community. The mortality risk is about 25% in the first year. The quality of life is also substantially affected.
About 10% will be bedridden and 25% wheelchair bound. In addition, chronic disabling pain affects the patient emotionally and mentally.
Women have a higher risk of developing osteoporosis than men as their bones are smaller and lighter. The condition of a woman’s skeleton depends on two factors: the amount of bone attained before menopause and the rate of bone loss thereafter.
Bone loss increases after menopause when the ovaries stop producing oestrogen, which is essential for bone health as it protects against bone loss. Hence, menopause is the biggest culprit in the process of bone loss.
Osteoporosis is more common in Asian and Caucasian women, and those of slender build.
Women’s risks of osteoporosis are increased further if they have an early menopause, ie before 45 years of age and when their uteri are removed (hysterectomy) before 45 years of age, especially when the ovaries are removed at the same time or if they do not have periods for more than six months due to exercise or excessive dieting.
The risk of osteoporosis is also increased in hormone-related conditions, for example, overactive thyroid gland (hyperthyroidism), overactive parathyroid glands (hyperparathyroidism), reduced oestrogen, adrenal gland conditions like Cushing’s syndrome, and conditions affecting the pituitary gland.
The risk is also increased if there is a family history of osteoporosis; a parent had a hip fracture; heavy smoking and alcohol consumption; lack of exercise; rheumatoid arthritis; eating disorders like anorexia nervosa and bulimia; prolonged use of high doses of steroids, eg in treating asthma and arthritis; and by medicines like diuretics, anticonvulsants and some medicines used in the treatment of breast cancer.
The clinical features of osteoporosis do not appear until a lot of bone is lost, thus explaining why it is called a silent disease. There are no warning symptoms or signs in most instances until a bone fractures following a minor fall or sudden impact.
The most common fracture sites are found in bones that have a lot of spongy bone – spine, hip and wrist.
The features include backache, decrease in height and slight back curvature.
There is usually no pain with osteoporosis. However, when there is a fracture, there will be pain, tenderness and even deformity. An obvious sign of osteoporosis is the characteristic bending forward (stooping) of the spine. This occurs because the fractured bones in the spine cannot support the body weight.
Diagnosing bone loss
The diagnosis of osteoporosis is often made after a fracture has occurred.
Individuals who are at increased risk of osteoporosis will be referred by their doctors for a dual energy X-ray absorptiometry (DEXA) scan. The procedure is painless and takes about 15 minutes to be done.
The DEXA scan measures the bone density and compares it with the bone mineral density (BMD) of a healthy young adult. The difference between the BMD measured and that of a healthy young adult is calculated as a standard deviation (SD), which is a measure of the variability based on an average or expected value.
The SD, which is called a T score, is classified as follows:
·Normal (T -1)
·Osteopenia, in which BMD is less than normal but not sufficient to be classified as osteoporosis (T -1 to T -2.5)
·Osteoporosis (T -2.5)
Another term used in bone density measurement is the Z score, which is the individual’s bone density expressed in standard deviation units compared to an age-matched population.
A diagnosis of osteopenia or osteoporosis does not mean that the risk of fracture is increased. The doctor will consider other factors like age, other medical conditions, use of medicines and previous injuries, before providing the appropriate advice.
The World Health Organization has developed a fracture prediction tool (FRAX). FRAX uses the clinical risk factors and BMD at the hip to provide a 10-year probability of hip fracture and the 10-year probability of a major osteoporotic fracture of the spine, forearm, hip or shoulder.
Preventing bone loss
There are several lifestyle measures that influence bone health.
The benefits of exercise are well documented, with beneficial effects on bone, heart and lung health. There are three types of exercises: aerobic, weight-bearing, and flexibility. An example of a moderate aerobic exercise of at least 30 minutes each day is a two-mile walk.
Weight-bearing exercise, ie those in which the legs and feet support the body’s weight, can delay or prevent bone loss. They include aerobics, dancing, walking, running, skipping and jumping on the spot, all of which also strengthens the muscles, ligaments and joints.
It is essential to wear footwear that supports the ankles and feet. Flexibility exercises, like yoga and stretching, help maintain muscle function and joint flexibility, and may also improve balance, which can decrease the risk of fractures due to falls.
Each exercise session should start with a 10 minute warm-up, and at the end, a cool-down session for five to 10 minutes.
In a good workout, a person will need to exercise towards the target heart rate for at least 30 minutes three times a week. A doctor will be able to provide advice on the target heart rate, which is dependent on a person’s age.
If a person has been diagnosed with osteoporosis or is not used to strenuous activity, it would be prudent to check with the doctor before commencing an exercise programme, especially if you’re above 40 years old or overweight.
A healthy diet is vital as it prevents cardiovascular disease, osteoporosis, diabetes and some cancers.
A balanced diet is high in grains, fruits and vegetables, with adequate water, vitamins and minerals, but low in fat.
The intake of sweets and fatty food should be limited. Fat intake should be less than 30% of daily calories.
Calcium is essential to maintain strong bones. The recommended daily consumption of elemental calcium in premenopausal and postmenopausal women is 1,000mg and 1,500mg respectively.
This can come from leafy green vegetables, calcium-rich dairy products (low fat or non-fat), and calcium-fortified foods and juices.
If this is not sufficient, calcium supplements may be used.
The body’s absorption of calcium is increased by vitamin D, which can be attained with about 15 minutes of daily exposure to the sun without any sunscreen, eating certain foods like milk, eggs, oily fish and liver, or vitamin D supplements.
It is advisable to eat plenty of fresh fruits and vegetables, nuts and seeds, legumes, complex carbohydrates like oats, wholegrain bread, brown rice, and essential fatty acids (good fats) from oily fish, like sardines and pilchards.
You should limit or reduce the intake of salt, saturated fat, stimulants like alcohol, coffee and tea, sugary food and junk food.
Supplemental vitamins and minerals may or may not be required, depending on whether the diet is balanced or otherwise. A discussion with the doctor or nutritionist would be helpful.
Other lifestyle factors that can help prevent osteoporosis include:
·Limiting alcohol consumption – the recommended daily limit is three to four units of alcohol for men and two to three units for women. Avoidance of binge drinking is essential.
It is important to eliminate environmental factors that can result in falls, thereby reducing the risk of fractures.
Some measures to avoid falls indoors include keeping rooms free of clutter, keeping floors smooth but not slippery, installing grab bars and using a rubber bath mat in the tub or shower, avoiding obstacles that you might trip over, and switching on the lights if getting up at night.
Some measures to avoid falls outdoors include wearing rubber-soled shoes, avoid walking on slippery surfaces, and using a cane if it is needed for added stability.
Perimenopause is the time during which the ovaries start to fail, and ends 12 months after the last menstrual period, when menopause commences.
THERE are numerous stories and even myths about midlife.
For many, it is the prime of life. For others, there may be some dismay that the best life has to offer is over.
Nothing is further from the truth. What is true is that midlife is usually a busy time.
The children are older and some may be living on their own, giving a woman more time than she has ever had for years. Some women may have embarked on new activities.
The body also changes during midlife.
There are hormonal changes in the perimenopause, which is the period of time when the ovaries start to fail until the end of menstruation, and it ends 12 months after the last menstrual period, hailing the onset of menopause.
As these hormone changes usually occur gradually, it may not be obvious at first to the woman.
The perimenopause and menopause are natural events. Although the basic changes occur in all women, each woman feels and copes differently. No two women experience these changes in exactly the same way.
During the reproductive years, every woman usually has a distinctive menstrual pattern.
At the perimenopause, some women may just have one last period. However, most women experience changes or irregular periods over a period of time during the perimenopause.
This is due to the reduced frequency of the release of eggs (ovulation), leading to consequent irregular secretion of the ovarian hormones.
The initial changes may not be noticeable.
The menstrual cycle usually shortens, with periods occurring more frequently.
The duration of bleeding may vary, and the amount of blood flow may be light, heavy, or just spotting.
As the menopause approaches, it is not uncommon for there to be missed periods.
Some women may have no periods for several months, and then menstruate regularly again.
Sometimes, the bleeding may occur unexpectedly, even to the extent that it may lead to embarrassment.
Any pattern is possible, but the menstrual changes are recognisable.
Although irregular periods are normal and common during the perimenopause, it cannot be assumed that all changes are due to the body’s hormonal changes.
Other conditions may cause abnormal uterine bleeding (AUB).
A doctor should be consulted if the periods last more than seven days, or two or more days than usual; the interval between the start of one period to the start of the next period is less than 21 days; there are heavy periods, clots or the flow is similar to that from an open water tap; there is bleeding, whether it is spotting or heavier flow, between periods; or there is bleeding after sexual intercourse.
The causes of AUB include hormone imbalance; miscarriage; contraceptive pills, depot contraceptives or intra-uterine contraceptive devices; fibroids; non-cancerous (benign) uterine polyps; cancers of the cervix, uterus or vagina; and conditions that affect blood clotting.
The doctor may perform one or more of the following procedures to establish the cause of any abnormal uterine bleeding:
> Ultrasound, which uses sound waves to create a picture of the pelvic organs.
> Endometrial biopsy, in which a small tissue sample of the uterine cavity is removed.
> Dilatation and curettage, in which the cervix is dilated and the uterine lining gently scraped to remove a small tissue sample of the uterine cavity.
> Hysteroscopy, in which a thin telescope-like instrument is inserted into the uterine cavity to look inside and remove a tissue sample.
Ultrasound and endometrial biopsy can be done in the clinic, whilst dilatation and curettage and hysteroscopy is done under sedation, whether local or general anaesthetic, as a day case. The tissue samples removed are sent to a pathologist who will carry out a microscopic examination.
The treatment of AUB depends on the cause. It includes operative hysteroscopy to remove polyps or fibroids in the uterine cavity; endometrial ablation, in which the lining of the uterine cavity is destroyed by heat or freezing (it cannot be used to treat fibroids unless the fibroids are also removed at the same time); laparoscopy, where growths like ovarian cysts and fibroids may be removed; myomectomy, in which fibroids are removed through an abdominal incision (laparotomy) several centimetres long or laparoscopically; or hysterectomy, in which the uterus is removed through a laparotomy or laparoscopically.
The ovaries may or may not be removed at the same time.
It is advisable to consult a doctor immediately should any bleeding occur 12 months after the last menstrual period.
Some women who are taking hormone therapy (HT) may have bleeding. Unless the bleeding is the typical pattern caused by hormone treatment, all post-menopausal bleeding requires investigation to rule out cancer of the genital tract.
The management of postmenopausal bleeding is similar to that of AUB.
Some women experience hot flushes (also known as hot flashes). This is the most common symptom of the perimenopausal years. It is more common in Caucasians than Asians, and is believed to be due to sudden changes in the body’s temperature regulation.
The brain, which mistakenly senses that one is too warm, initiates events to cool down. The blood vessels near the skin surface increase their diameter and blood flow, which produces the sudden feeling of heat.
It may or may not be accompanied by a red blushed appearance of the face and upper body. The woman may also start to sweat.
A hot flush occurs suddenly and may last a few seconds to several minutes or more. A few women may experience a cold chill after the flush.
Hot flushes usually have a consistent pattern. However, there is individual variation of the pattern. The flushes can occur several times a day, or a few times a month.
Some women will get hot flushes for a few months. Others have it for a few years. Some may escape it altogether. There is no way of knowing when they will stop.
Hot flushes can occur at any time. It may occur with increased sweating during sleep. The night sweats and hot flushes may interfere with sleep, although it may not wake the affected woman up.
Some hot flushes are tolerable while others are a nuisance, embarrassing or even debilitating to the extent that it interferes with daily life.
However, it must be remembered that hot flushes are not harmful.
Most women can identify certain factors that initiate their hot flushes – hot or spicy food, caffeine, alcohol, stress, cigarette smoke, tight clothes or external heat. Certain medicines, like tamoxifen for cancer chemotherapy and raloxifene for prevention and treatment of osteoporosis, can also trigger hot flushes.
Several measures can be taken to deal with the hot flushes and improve one’s comfort, which can sometimes even eliminate them altogether. They include:
> Identifying the factor(s) that trigger the hot flush and avoid it if possible.
> Wearing thin layers of clothing made from natural fibres like cotton, and removing some pieces at the first sign of a hot flush to feel cooler.
> Keeping the office and/or home cool by using a fan or air conditioner.
> Sleeping in a cool room.
> Exercising regularly to reduce stress and promote better sleep. Some research indicates that women who exercise have fewer and less intense hot flushes.
> Reducing stress by a leisurely bath, meditation, massage or yoga.
> Taking slow and deep, abdominal breaths of about six to eight breaths a minute at the start of a hot flush may be helpful.
> Consulting a doctor and discussing the benefits and risks of prescription medicines like HT, oral contraceptives, progestogens, antihypertensives like methyldopa and clonidine, and antidepressants. Non-prescription treatments include vitamins B and E.
A woman’s fertility declines from the late 30s due to ageing of the eggs in the ovaries. The risk of spontaneous miscarriage is also increased, so much so that by the age of 45, the rate is about 50%.
At the same time, the risk of congenital abnormality in the foetus increases with increasing maternal age.
Some perimenopausal women may still want to get pregnant. Although assisted reproduction technologies (ART) are available, they are expensive, and have some risks and low success rates. There is also an increased risk of pregnancy complications like maternal hypertension and diabetes, Caesarean section and stillbirth.
Despite reduced fertility, a woman is not free from an unplanned pregnancy until a year after the last menstrual period (when it can then be definite that menopause has been reached).
Even if there are other signs of the perimenopause like hot flushes, it does not mean that one cannot get pregnant. About 75% of pregnancies in women over the age of 40 are not planned.
If pregnancy is not desired, it is important that an appropriate, effective and safe contraceptive method be used. A pregnancy in the 40s will impact not only on the individual’s health, but also on family and social life.
Too late: An X-ray is not the best way to detect osteoporosis because by the time it shows up on X-ray (as very thin and lighter bones), at least 30% of bone has been lost.
Osteoporosis leads to brittle bones that are more prone to fractures.
MY aunt went for a routine medical check-up. She had some X-rays and the doctor told her that she has osteoporosis. What is osteoporosis?
Osteoporosis is a condition that is caused by decreased density in your bones. This causes your bone to be abnormal and porous, and thus much weaker and more fragile.
When your bones are weak, they fracture a lot more easily, especially with small injuries that would not otherwise break normal bone.
Osteoporosis is very, very common. In fact, every one out of two white women will experience a fracture due to osteoporosis in her lifetime.
After age 35, we start to lose 0.3 to 0.5% of our bone density every year as we age. If you are a woman, as long as you have your periods, you are protected by oestrogen.
But as soon as you hit menopause, this loss of bone density increases exponentially, as much as 2 to 4% loss per year.
But my aunt never knew she had osteoporosis before this. She certainly didn’t have any pain in her bones.
Unfortunately or fortunately, osteoporosis can be there for a long, long time without causing any symptoms, and you don’t know you have it until you have the first fracture.
Worse still, osteoporotic fractures can be present for years without any symptoms either.
Osteoporosis can cause fractures in your hips and spine, two places that can cause severe discomfort and disability. Hip fractures usually occur after a fall. A fracture of your spine can cause severe pain that radiates from your back to the sides of your body, causing chronic back pain.
For some people, osteoporosis can cause repeated spinal fractures, resulting in them losing their height. Their spines can also start to curve, giving a “dowager hump” hunchback appearance in their upper back. This is more commonly seen in older people.
And because your bones are so weak, even your feet can develop stress fractures during walking or stepping off a sidewalk.
Other than causing fractures, osteoporosis is not dangerous, is it? I mean, it’s not like heart disease.
Well, think again. Once you have a fracture, you lose mobility. If you are elderly, you can develop pneumonia and blood clots in your leg veins a lot more easily.
Pneumonia can kill you, especially if you are older. And these blood clots that develop in your leg veins can travel up to your lungs and get stuck there. This is called pulmonary embolism.
Studies have shown that osteoporosis is linked with an increased risk of death. In fact, 20% of women who have a hip fracture will die within the year as an indirect result of the fracture.
Scary, but true.
Is every woman at risk of osteoporosis, then?
Yes. As long as you are female, you are at risk. Other risk factors include:
> Being Asian
> Being thin and having a small body frame
> Having a family history of osteoporosis, such as if your mother and grandmother had osteoporosis
> If you have had a fracture as an adult
> If you smoke
> If you consume alcohol excessively
> If you don’t exercise
> If you don’t eat much calcium-containing foods, such as milk and other dairy products
> If you have vitamin D deficiency
> If you have malabsorption in your gut
> If you don’t have periods in your young age, such as if you exercise severely
> If you have been immobile because of disease, such as a stroke
> If you have diseases like chronic rheumatoid arthritis, hyperthyrodism
> If you take certain long-term medications like steroids and heparin
Is X-ray the only way to diagnose osteoporosis?
No. An X-ray is not even the best way to detect osteoporosis because by the time it shows up on X-ray (as very thin and lighter bones), at least 30% of bone has been lost.
A DEXA scan or dual-energy X-ray absorptionmetry scan is the best test to perform. This test gives you your T score. If you have a T score of -2.5 and below, you have osteoporosis.
There’s a condition called osteopenia that is somewhere between normal and osteoporosis. This has a T score of -1 and -2.5
Is there anything I can do to combat osteoporosis?
You can take calcium supplements, but they are often not enough. You also need vitamin D. When you have menopause, you can take hormone replacement therapy.
And there are plenty of drugs such as the bisphosphonates that can prevent osteoporosis. Be careful though. Once you take a bisphosphonate, you must stay upright for at least 30 minutes or they can cause serious gastro-esophageal side effects.