Osteoporosis and Calcium

It is a common belief that taking calcium and excercising is all that is needed to prevent osteoporosis (softening of the bones) in the menopause. Taking calcium is important but all the more important in prevention is ensuring that  calcium intake is adequate from as young as the teenage years. Studies have shown however that overdosing with calcium does not prevent osteoporosis. Those who have low calcium intake should go with about 600-700mg/day to avoid deficiency. Taking more is not better. Osteoporosis in menopause  is due in part to a lack of the female hormone oestrogen. Without oestrogen the calcium has difficulty in being absorbed into the matrix of the bone and is simply excreted in the urine. Thus, prevention would involve ensuring an adequate calcium intake from diet and supplements, excercise and adequate oestrogen in the body.

Oestrogen levels start decreasing from the early 40's and if combined with an inadequate calcium rich diet and lack of excercise, could lead to the onset of osteoporosis even better full menopause has been reached.
It is therefore important to start calcium supplements early as possible, excercise and see your gynaecologist who will check your hormone levels.
http://www.latimes.com/health/boostershots/la-heb-calcium-20110526,0,408286.story?track=rss

Pelvic Infection

Why are intrauterine devices (IUD) and contracting a sexually transmitted disorder (STD)  dangerous in those who haven't had children? The risk of pelvic infection and infertility due to damage to the fallopian tubes is high. The incidence of  STD's has been steadily rising with the incidence of chlamydia infection as high as 1:10 women in some countries. The trouble is chlamydial and gonococcal infections can have relatively few symptoms and in some none at all. The bacteria however has a propensity to climb up the genital tract to the fallopian tubes causing an inflammatory reaction and subesquent blockage.

I recently had to operate on a lady with vaque abdominal discomfort and little else, but with large masses on pelvic ultrasound scan. At operation the masses as suspected were tubo-ovarian abscesses with structural inflammation, swelling and adhesions to surrounding organs. The damage was too great to save the fallopian tubes, and the condition could well have been life threatening if not for early intervention. The same infection could well have been caused by common bacterial infection resulting from inserting an IUD. Which is why an IUD, although a convenient form of contraception, should never be inserted in a women who has never had children or are planning for more.

Avoidance would be the best, but if not, early detection through vigilance and early treatment with antibiotics would greatly reduce the need for surgical intervention and the possibility of long term damage and perhaps heartache.

Newer HPV test

It is common knowledge that cervical cancer is related to HPV (human papilloma virus ) infection. There are many strains of HPV but 98% cervical cancer is due to HPV strains 16, 18 . HPV-DNA testing has been available in Singapore in the last 2 years and forms part of the testing that is done during the annual PAP smear. Although not always offered, it is a test which is advisable as it gives an indication of whether you are at high risk of cervical cancer even though your PAP smear may have been normal.

It is now possible to detect whether infection is due to the two main strains ie 16 and 18. A positive test means a 4x higher risk of cervical cancer. A positive test with a normal PAP smear should then be investigated with a colposcope (microscopic examination). Colposcopic examination and perhaps a biopsy may be necessary. A normal PAP with HPV positive of other strains need not be examined with colposcopy but observed. The HPV may in time be removed from the body by the bodies immune system and revert to HPV negative.

Ovarian Cancer screening

Even though ovarian cancer is the second most common gynaecological cancer it is often forgotten or overlooked. Screening is not often done and a routine yearly PAP smear doesn't pick up ovarian cancer unless and ultrasound scan of the pelvis is done at the same time. Ovarian cancer is the most dangerous of all the female cancers as it does not present with any symptoms until the cancer is in the advanced stage. The good thing is that if discovered early ie stage I, the cure rate is extremely high.

The best way to pick up an ovarian cancer is to have a pelvic scan at the time of your regular PAP smear. An ovarian cyst with or without features of ovarian cancer will be seen. The next step is to determine whether it is likely that this ovarian cyst is cancerous by doing a blood test called the oviplex screen. Previously, a single cancer marker, CA 125 was used but this has shown to have an accuracy rate of only 60+%. The oviplex screen is recently available and this combines the CA 125 with other blood markers giving an accuracy of over 90%.

Urgency incontinence ( overactive bladder )

This is a common problem in women and should be distinguished from stress incontinence. The need to go several times a day, and the feeling of having to go again almost immediately after emptying the bladder, getting up at night to go, or being incontinent if not able to get to the toilet in time, indicates urge incontinence . The cause is often due to a hyperactivity of the nerves on the back of the bladder which are responsible for the sensation of fullness of the bladder. Whereas stress incontinence is a condition when increased pelvic pressure such as coughing, sneezing, excercising brings about a leakage of urine.

Once your gyne has excluded a urinary tract infection, he could then diagnose the condition through urodynamic studies or alternatively give you a trial dose of a drug for the treatment of urge incintinence and see if there is improvement. Initially, 'bladder training' may help. Getting you to delay voiding urine and gradually increasing the interval of time between voiding over a period of time will stretch the bladder and enable you to hold more urine. The drug of choice is detrustol ( tolterodine tartrate ) given as a single long acting dose.

Recently studies have been shown that botox injected into the bladder wall appears to help with this condition. The use of botox however is still experimental and at this point of time should be used only in cases of intractable urge incontinence. The effect of botox is also temporary and lasts for a few months.
http://www.obgmanagement.com/article_pages.asp?AID=4668

Are oral contraceptives safe?

In Singapore fewer women use oral contraceptives than in western countries. They are usually concerned about putting on weight and acne changes. Although the newer oral contraceptives (OC) seems to address this problem, new studies  show that the older generation of OCs may be safer than the newer generation ones in terms of more serious side effects!. The older generation OCs would be microgynon 30 which contains levonorgestrol while the newer third generation OCs such as mercilon and yasmin contain desogestrol and drospienone respectively as the progesterone component of the OCs. Recent studies show that the risk of non fatal thromboembolism ( blood clots in the legs..sometimes known as the 'economy class syndrome' ) is double that of the older generation OCs! The overall risk of thromboembolism however is very low.

In the light of these studies, it may be prudent to take the older generation OCs as first line if this is the choice of contraception.
http://www.bmj.com/content/342/bmj.d2151

http://www.bmj.com/content/342/bmj.d2139

Heavy periods

Heavy periods ( menorrhagia ) is a common problem which many women tolerate until they either become anaemic or so anxious as it becomes a social problem. I remember a patient who very often when she attended  functions or events would have to excuse herself because she  had to go to the toilet until one day she collapsed in a cinema toilet and had to be helped to hospital.

Because of the adverse publicity of hormones in its treatment, many women either simply take iron tablets and hope for the best. Your gynaecologist may have suggested surgical options such as stripping the uterine lining or a hysterectomy, and this may be the best option eventually for intractable menorrhagia. However there is a drug that is not often used by gynaecologists but does have good results in controlling menorrhagia from a recent double blind study. Tranexamic acid ( Cyklokapron ) given during periods dramatically reduces the heavy flow. Menorrhagia may be due to an excess of plasminogen in the body which prevents clotting. Tranexamic acid prevents the effects of plasminogen on the clotting mechanism. Of course your gynaecologist will first have to rule out other causes for the menorrhagia such as fibroids, endometriosis and cancer which will require surgery. So this drug would be a useful alternative to those who do not want hormonal or surgical treatment where the menorrhagia is not due to any pathological growth.

Polycystic Ovaries ( PCO )

You may have been trying to get pregnant without success, and noticed that your periods are often delayed, you are putting on weight, or you have persistent acne. This may be due to a condition called polycystic ovary syndrome ( PCO ). Or your gynaecologist may have told you that you have PCO. Do you really have PCO?. The diagnosis is made on the finding of multiple small cysts on the outer portion of both ovaries on ultrasound scan (>8 cysts) and a hormone profile which shows an imbalance in two hormones (LH:FSH of >2:1). There may also be a raised male hormone, testosterone.

Nobody knows why this condition comes about but it is extremely common. It can occur from a young age or later years, it may be temporary or longstanding. If temporary, weight gain is usually not an issue and the irregular periods spontaneously resolve. If longstanding, the condition may be mild or become more severe with increasing weight gain, excessive hair growth, periods even just once or twice a year. There is also a tendency for these women to develop diabetes in later life.

Treatment will depend on the severity of the symptoms and whether pregnancy is desired. If wanting to get pregnant, the options include fertility tabs, injections, or surgery which involves drilling and clearing the cysts from the ovaries.There is a feedback mechanism to the part of the brain which controls the hormones and it appears that this procedure causes the a 'shake-up' resulting in a re-regulation of the hormones. The procedure is done through key-holes as a day procedure.  Medical treatment to lower the male hormone, and a drug known as metformin appears to help. Losing weight also appears to have a great effect in treating this condition. Unfortunately, it is difficult to lose weight with this condition!

 The miscarriage rate is much higher if pregnancy is achieved with PCO. Nobody knows the reason but is thought to be related to the high hormone levels. The risks are even higher if conception with metformin is achieved.

                                                 Ultrasound scan showing cysts in ovary