Menopause and Menopausal Testing

First Mammogram

Women used to start mammographic screening years before menopause. Today the recommended age is 50, which will generally mean that the start of menopause will be the start of mammogrphic screening. Mammography is an x-ray, and total life x-ray dosages are important to think about. But the amount of radiation is low, and mammography remains a safe, appropriate screening tool for many women, and has saved many lives. When to get a mammogram is an important decision for each woman. Individualized evaluation and assessment of your risk of breast cancer should occur on an annual basis. Factors that we should consider will include, among others: your personal history, your family history, hormone and medication history, nipple discharge, breast pain, cysts or masses, and prior breast surgery.

The U.S. Preventive Services Task Force has begun recommending new guidelines calling for fewer mammograms and mammograms beginning later in life. These guidelines are in conflict with some of the recommendations I have given most of my patients over the past few years. As a Board Certified Obstetrician and Gynecologist, the organization I belong is to called the American Congress of Obstetrics and Gynecology (ACOG). They are studying the new guidelines, but they have not yet had time to complete their review or revise their own guidelines.

Insurance coverage for medical exams is based both on medical necessity and on recommendations of organizations such as these. Insurance coverage you may have had in the past may be affected by these changes. Remember, your individual physician can help you with preauthorizing medical tests, but it's important that you specifically ask before any medical exam if the insurance issues have been clarified and resolved, or there may be unplanned costs that cannot be undone.

Heart Health

Basic recommendations are to normalize weight, improve exercise, and get tested to figure out your risk status. The American Heart Association and the American College of Cardiology are good sources of more detailed information on ways to control heart heath risk.

Vitamin D, Calcium and Nutrition for Your Bones

Osteoporosis is a disorder of the bone which causes deficient bone strength. Much of our bone health advice is aimed at avoiding this disease, which can start as early as your thirties or forties if you don’t take care of your nutrition. No matter what your age, you need calcium and vitamin D for bone health. Osteoporosis affects an estimated 8 million American women and 2 million American men. Another 34 million Americans have poor amounts of calcium, so essentially thinner bones or low bone mass, placing them at increased risk for the actual medical disease of osteoporosis as they age. 4/10 white women aged 50 or older will suffer a hip, spine or wrist fracture sometime during the remainder of their lives. Consuming adequate calcium and vitamin D over your lifetime can prevent bone weakness and fractures as you age.

Should You Get a Calcium Blood Test?

Calcium consumption in your diet can help maintain bone density by preventing the body from stealing the calcium it needs from the bones. If you think you have a reasonable diet but just aren’t sure if it is enough, both calcium and vitamin D can be measured in the blood. Whether you should have a blood test is another issue, and the answer may very well be yes. As many as 40% of women in menopause may have low vitamin D.

Medicines and Bone Health

Some medications can harm bone health. As October is Breast Cancer Awareness Month, it is another fact that bones of breast cancer patients tend to age prematurely as a result of chemotherapy and aromatase inhibitor therapy, according to research reported at the American Society for Bone and Mineral Research in 2009. In 2010 the FDA began to warn about increased fracture risk in women on PPIs, or proton pump inhibitors, over-the-counter medicines to reduce stomach acid.

Do You Need a Bone Density Test?

The most important tool we use for determining the need for treatment is bone density testing with a Densitometry machine (DXA). DXA scans are painless, they have minimal x-ray exposure and reveal a lot of important information. They are for all women over 65, all men over 70, and anyone with risk factors. Many need this test younger than these ages. You should consult your gyno about what is best for you.

We really want to know not just about the thickness, but also the strength of your bones. Bone strength is greatly determined by the density of the bone. This is what we measure with the Bone Densitometry test, or the “DXA” test, that gives a T score and and a Z score. Thickness has to do with how thick the bones started. A teenage girl will accumulate about 90% of her bone mass by age 20, and she will accumulate the amount from age 13 to 15 that is about equal to what she’ll lose in the last 4 decades of life! The genes you were born with will affect your overall bone strength, but diet can dramatically alter what you were given. Poor bone health from ages 13 to 15 for a girl has significant potential consequences. Call your granddaughters now and make sure they swig down a calcium chew mid-day (not with pop) and boost those bones! And if you still have questions, get them to call me, as it’s a topic I’m very interested in.

How Strong are Your Bones?

Having strong bones is important. Stronger bones means fewer fractures. Osteoporosis is a disorder of compromised bone strength that predisposes bones to fractures. All strategies for diagnosis and treatment have to do with fracture assessment and prevention. Knowing how strong your bones are can help tailor exercise, diet, therapies and monitoring. Establishing how likely you are to fall is actually part of prevention of fractures as well. But how do we determine an accurate representation of bone strength, especially in the doctors office? This turns out to be an interesting question. Several components are important, and in truth, your physician may not know exactly how strong your bones are. Looking at you across the doctor’s desk will not usually give you the answer. Probing intently really answers the question.

In the most simplistic terms, bone strength is the sum of the thickness of the bone and its internal structure, or the “quality” of that bone. Quality has to do with the actual architecture, the damage accumulation, the turnover rate of bone (as our bones grow and develop our whole lives), and how the calcium is deposited on the underlying bone structure. For instance, some people are born with a structural abnormality: for example, very bowed shins. That bone has a different inherent quality than a very straight leg. Bones that are most susceptible to osteoportic fractures (the hip, the spine, the end of the wrist) have a chain link fence-like structure called trabecular structure. In high quality bone the trabeculae are greater in number, thicker, more plate-like and better connected. The pace of bone turnover is very important too. Slow bone turnover can be less optimal, but very fast turnover is not ideal either.

Signs of Poor Bone Heath

Many times poor bone health is not symptomatic, although poor tooth health may be a clue! Acute or chronic back pain might be an osteoporotic fracture, which is most common at the spine vertebral bodies labeled T12 or L1. These are located approximately in your mid back.

Vertebral Fractures and How You Can Test

As I said earlier, gynos care about your real balance, not just how good you are on kittens or stilettos! Balance, as we get older, determines whether we fall, and falling on weak bones will lead to fractures. Here is one simple balance test: sit down on the floor and then stand up without using your hands, then stand on one foot, and then on the other. Bad balance can mean muscular weaknesses, postural deformities, or pre-existing fractures. Your gyno will only make a firm diagnosis with x-rays and tests, assess your risk, and determine whether you should have a bone densitometry test, known as a DXA scan (see above). This will give you a T-score and a measurement of bone strength. There is actually no specific number that is known to be completely “safe” from fracture, but the denser your bones on this test the less likely it is that you will get a fracture. Here's an odd fact: half of all osteoporotic fractures occur in individuals without a diagnosis of osteoporosis. Yes, sometimes you just haven't gotten the right diagnosis, and other times the strength of the bone is compromised, but not the thickness. In one study of men with osteoporotic fractures, their bone thickness measured by the actual BMD (the number you get when you do a DXA test) was not different from the group that did not have fractures! And not all fractures are preventable with strong bones. If you slip too hard on that fru-fru rug in the foyer, you might just get a fracture anyway!

Sunshine for Vitamin D and Bone Health

At my gyno office we recommend the most complete sun protection you can get. There are medical grade sunscreen products to help you do this. No sooner after I had begun offering our #1 best selling sunscreen at my spa, ColoreScienc, did I hear of three new offices and the local breast center taking up sales of the same product line, so I did set a bit of a mini trend! However, The Surgeon General’s report of 2004 recommends that patients adopt several interventions to decrease the risk of developing osteoporosis, especially increasing their vitamin D. Former guidelines were 400 IU of vitamin D daily for adults, and for women past menopause and men over 65, 800 IU. Newer studies show even greater amounts are important: up to 2000 IU daily for many people can help protect bones while giving other positive health benefits. Poor vitamin D intake leads to muscle aches, incoordination and loss of balance (that factor we just discussed as so critical). It's not only sunscreen that leads to vitamin D deficiency. As we age the skin's precursor substances start to wane, so the skin is unable to produce as much vitamin D as it did in youth. If you are unsure of your vitamin D intake, ask for a vitamin D blood test. Here’s another interesting fact: low vitamin D is a major cause of chronic fatigue.

Back Pain and Bone Health

Low back pain is one of the most common complaints in every gyno office. Many patients self treat with glucosamine, stating that they have seen dramatic improvement in their doggies or their friends with the treatment. Unfortunately, scientific studies say something is wrong with that doggie study, and that there is no evidence that it relieves pain at the 6 or 12 month time period as studied in NCT00404079.

And for more bone health and osteoporosis news, look at other posts on

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