What is osteoporosis? Osteoporosis is a condition. How can you prevent osteoporosis?

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1 Preventing Osteoporosis Half of all women over the age of 50 will fracture their hip, wrist, spine, or other bone due to osteoporosis. What is osteoporosis? Osteoporosis is a condition that causes your bones to weaken and to break or fracture easily. As many as 1 in 2 women and 1 in 4 men will suffer from a fracture in their lifetime. However, you can reduce your risk of bone loss and fractures by taking some simple steps now. How can you prevent osteoporosis? Take calcium and vitamin D every day to prevent osteoporosis Most adults over the age of 50 need 1,200 mg of calcium and 1,000 to 2,000 IU of vitamin D (preferably vitamin D3) every day in order to keep bones strong and healthy. Since most diets do not provide enough calcium and vitamin D, it is best to take at least a 500 to 600 mg daily calcium supplement and a 1,000 IU daily vitamin D supplement. Low-fat dairy foods (milk, cheese, and yogurt) are good natural sources of calcium. Green vegetables, almonds, and tofu also have very small amounts of calcium. Foods fortified with vitamin D include milk, orange juice, and some breakfast cereals. Check the amounts on the label carefully when you buy calcium and vitamin D fortified foods or drinks and supplements. Your body also makes vitamin D when your skin is exposed to the sun. However, the amount of vitamin D your body can make is limited by several things such as sunscreen use, your skin-color, where you live, and the amount of time you spend outdoors. Make activity and exercise a part of each day. Daily activity helps keep your bones strong and makes them less likely to break if you fall. Weight-bearing exercise (walking, jogging, dancing, or lifting weights) is the best way to build strong bones and muscles. Stop smoking. Smoking reduces bone strength and is a major risk factor for heart disease and cancer. Ask your physician or other health care professional for help to quit. Cut down on caffeine, salt/sodium, and alcohol. Caffeine, sodium, and alcohol can reduce bone strength. Protect your bones by using less caffeine and sodium in your diet. Research shows that people who drink too much alcohol have more bone loss and fractures. Limiting how much alcohol you drink will help protect your bones. Keep it to one drink a day for women; two drinks or fewer a day for men. Get a bone mineral density (BMD) test if you are a woman over age 65 or a man over age 70. We all lose some bone mass as we age. Bones naturally become thinner (called osteopenia) as you grow older because existing bone is broken down faster than new bone is made. As this occurs, our bones lose calcium and other minerals. Bones become lighter, less dense, and more porous. This increases the chance that they might break or fracture. The BMD test estimates the strength of your bones by measuring the density of minerals in your bones. The results help determine how much bone mass you ve lost. HEALTH EDUCATION

2 Preventing Osteoporosis What are the risk factors for osteoporosis? It s important to know if you are at risk. Risk factors include: Having a fracture after age 50 due to brittle bones. Smoking. Weighing less than 127 pounds or having a body mass index (BMI) less than 21. Having a parent, sister, or brother who has had a hip fracture. Having a history of falls in the past 12 months. When should you get a bone mineral density test? A bone mineral density test is recommended for all women at age 65 and for all men starting at age 70. For women at high risk of osteoporosis, bone mineral density testing may be recommended before age 65. If you are uncertain, talk with your doctor or other health care professional about whether you need a test. How can you prevent falls? As you age, simple steps can prevent fractures. Stay active to maintain balance, strength, and coordination. Wear low-heeled shoes with non-slip soles. Use a cane if your walk is unsteady. Get your vision checked regularly and wear glasses or contacts if needed. Tell your doctor if you feel dizzy or lightheaded. This may be caused by medications you are taking. Keep your house well lit to avoid falling or bumping into things. Avoid throw rugs and use rugs with non-slip backing. Keep floors and hallways clear of boxes, papers, clothing, and electrical cords. Install handrails and non-slip mats in your bathtub or shower and beside your toilet. Make sure you can easily reach all items in your kitchen. Avoid standing on chairs, stepstools, or ladders. Additional resources Visit our Web site at kp.org. Read Menopause... A Kaiser Permanente Guidebook for Women. Contact your local Kaiser Permanente Health Education Center or Department. Contact the National Osteoporosis Foundation: (202) or Being hit, hurt, or threatened can seriously affect your health. There is help. Call the National Domestic Violence Hotline at or connect to ndvh.org. This information is not intended to diagnose health problems or to take the place of medical advice or care you receive from your physician or other health care professional. If you have persistent health problems, or if you have additional questions, please consult with your doctor. If you have questions or need more information about your medication, please speak to your pharmacist. Kaiser Permanente does not endorse the medications or products mentioned. Any trade names listed are for easy identification only. 2006, The Permanente Medical Group, Inc. All rights reserved. Regional Health Education (Revised 4-11) RL 8.7

3 healthy living Facts on Perimenopause, Menopause, and Hormones Who should read this? Women who are... in perimenopause (the years before the time of menopause) already in menopause past menopause and concerned about bone loss (osteoporosis) and heart disease T he end of a woman s menstrual periods is called Menopause. It marks the transition between a woman s childbearing and non-child-bearing years. It usually occurs between the ages of 47 and 55 when women stop producing female hormones (estrogen and progesterone). But hormone levels can begin to decrease as early as age 35, starting perimenopause, which may cause irregular bleeding, hot flashes, insomnia, and mental confusion. Some women experience more troubling problems, like occasional loss of bladder control (incontinence), dryness of the vagina, and pain during sex. Lower estrogen levels also increase the risk of heart disease and osteoporosis (thinning bones). How to stay healthy before, during, and after menopause Follow a healthy balanced diet. Eat less fat and cholesterol-rich foods. Eat less animal protein. Eat more fiber, such as whole grains, beans, fruits, vegetables, and soy. Make physical activity and exercise part of your routine. Daily physical activity reduces your risk of heart disease and helps keep bones strong. Exercise can also lower your risk of breast cancer and may lessen the hot flashes and insomnia which can happen during this time in a woman s life. We recommend that you try to get 30 to 60 minutes of exercise (like walking or gardening) on most days of the week. If you smoke, quit now. Smoking increases your risk of developing heart disease and reduces bone strength. If you smoke, ask your doctor, nurse, or health educator to help you quit. Use alcohol in moderation. Alcohol can also reduce bone strength and has been associated with a higher risk of breast cancer. Experts recommend that women drink no more than one serving of alcohol each day. Ask for our information sheet about alcohol. Take adequate amounts of calcium and vitamin D. Women need 1,000 mg of calcium before menopause and 1,500 mg after menopause as well as 800 I.U. of vitamin D every day. Most take less than half of this amount. Dairy foods like milk, cheese, and yogurt are the best natural sources of calcium. As a general rule, you need to eat about four servings of dairy foods every day, or take a calcium supplement. Reduce stress by taking time for yourself. Women tend to take care of everyone else, but don t make time for themselves. Treat yourself to relaxation periods throughout your busy schedule to renew your energy and to help create a positive attitude. Schedule and take these three important screening tests 1. Pap test to screen for cervical cancer if under 30, every one to two years if over 30 and Pap is still normal, Pap/HPV test every three years until age 65 (after, decide along with doctor or other medical professional) 2. Mammogram to screen for breast cancer every one to two years beginning at age Flexible sigmoidoscopy to screen for colorectal cancer every 10 years after age 50 REGIONAL HEALTH EDUCATION

4 healthy living Facts on Perimenopause, Menopause, and Hormones If you have special health needs or risks, you may need to test more often. Ask your doctor or nurse for additional information. 4. Stool Hemoccult Blood testing every 2 years between ages 60 and 79. Take this simple home test in addition to the flexible sigmoidoscopy every 10 years. What about hormone therapy? Hormone therapy pills and skin patches increase levels of estrogen and progesterone in your body, helping to reduce most of the unpleasant symptoms of menopause, such as hot flashes and vaginal dryness. Estrogen is combined with progesterone to eliminate your risk of uterine cancer. If you have had a hysterectomy, you will be prescribed estrogen alone. If your symptoms are very bothersome, you may want to consider hormone therapy for a short time (one to three years) to help manage those symptoms. According to the recent results of a large study, longer use of hormone therapy has been connected to a small increase in your risk for breast cancer. There is also a small risk of stroke and blood clots in the lung and leg at any time while taking hormones, and an increase in heart disease in women who start hormones at age 59 or older. Although these risks are small, they are significant. We recommend that you consider natural ways to manage your symptoms before trying hormones. If you are unsure what to do, we recommend that you attend a menopause class or group appointment or talk to your physician or other medical professional at your next appointment. How do I decide what to do? Carefully review your medical history and re-examine your personal values and beliefs. You will then be better able to determine your goals and how best to achieve them. For example, some women choose only lifestyle changes, like diet, exercise, and relaxation. Others favor herbal remedies and acupuncture. And still others prefer to use medication. The choice is up to you. How can I prevent osteoporosis? It is important that all women take calcium ( mg) before and after menopause and vitamin D (800 I.U.) to prevent osteoporosis, particularly at the time of menopause. Women who are at high risk for osteoporosis (over age 65, or with 2 of the following risk factors: smoking, slender, immediate family history of hip fracture or a history of a fracture yourself when over the age of 45) should talk with their physician or medical professional about other possible treatments. There are other drugs (including raloxifene and alendronate) that can prevent osteoporosis while avoiding some of the other health risks. These newer drugs do not relieve symptoms of menopause, such as hot flashes. Alternatives to hormone therapy Some women find that certain botanical, herbal, vitamin, and nutritional supplements help reduce menopause symptoms. Herbs and supplements are sold over-the-counter. Kaiser Permanente carries only herb categories for which some evidence exists to show that the herbs may be effective to treat certain medical conditions. For more information about supplements and their effects, call or visit your local Kaiser Permanente Health Education Center. Additional resources See the Menopause section of your Kaiser Permanente Healthwise Handbook. Visit the Kaiser Permanente Health Education Center nearest you. Visit our Web site at kp.org. Request a copy of Menopause: A Kaiser Permanente Guidebook for Women from your physician or other medical professional. This information is not intended to diagnose health problems or to take the place of medical advice or care you receive from your physician or other medical professional. If you have persistent health problems, or if you have additional questions, please consult your doctor. If you have questions or need additional information about your medication, please speak to your pharmacist. Kaiser Permanente does not endorse any brand names; any similar products may be used. 2002, The Permanente Medical Group, Inc. All rights reserved. Regional Health Education (Revised 8-07) RL 7.8

5 Complementary and Alternative Approaches to Help You with Menopause Symptoms Whether or not you decide to take hormone therapy, you can take steps to help lessen discomfort and improve your health during menopause. Although scientists are just beginning to document the benefits of mind-body and herbal approaches, there are some methods you can try to see if they help relieve your menopause symptoms and improve your sense of well-being. How can you relieve symptoms of menopause naturally? Hot flashes Keep track of what triggers your hot flashes. Some women s hot flashes are related to strong emotions, caffeine, alcohol, spicy food, certain clothing, or heat. Once you know what your triggers are, try to avoid them. Sleep in a cool room. Use fans to improve air circulation. Practice deep breathing for 15 minutes in the morning and 15 minutes in the evening. Breathe slowly and deeply, bringing air into your lungs and belly. Drink cool beverages. Wear layers of cotton clothing. Some women find that foods containing soy (such as tofu, tempeh, soymilk, or soybeans) help with hot flashes. Talk to friends or find a support group. Take a stress management or mindbody class. Menopausal sleeplessness Keep your bedroom cool. Exercise daily for at least 30 minutes. You can exercise all at once or in three separate 10-minute sessions, but not within two hours of your bedtime. Wear light clothing made of natural fabrics. Avoid relying on sleeping pills. Don t have caffeine or alcohol in the the evenings. Take a warm bath or shower at bedtime. Drink warm milk. Attend an Insomnia or Sleep Better class at your local Kaiser Permanente facility. Mood swings and anxiety Use relaxation techniques, such as deep, slow breathing. Talk to friends or join a support group. Exercise daily for 30 minutes. Decrease the amount of caffeine and alcohol you drink. Find a creative activity you enjoy. Set aside 15 minutes every day just for worrying. Use this time to think about the things that cause your anxiety. Try not to think of your worries the rest of the day. Important points to consider before using herbs and dietary supplements Women who are concerned about side effects or the increased risks for some medical conditions associated with hormone use may try herbs and dietary supplements for symptom relief. Please review the following important points before using herbs and dietary supplements: The Food and Drug Administration (FDA) does not regulate herbs and dietary supplements, so it s hard to tell what you re getting. The amounts of the active ingredients in similar herbal products may be different, or they may not even be present in some of these products. Herbs sometimes don t work well together with other herbs, medications, and over-the-counter drugs. Make sure to talk to your physician, pharmacist, or other health care professional if you are taking medications and wish to start herbs, or vice versa. Please use caution when taking herbs and dietary supplements. Be aware that some of these products may contain contaminants that are introduced during production. Regional Health Education

6 Complementary and Alternative Approaches to Help You with Menopause Symptoms Herbs and dietary substances Soy products Soy has some positive effects on health. Soybeans and soy products contain a beneficial substance called isoflavone (also found in red clover) that has been shown to lower the risk of heart disease by lowering cholesterol. But research results about whether soy can decrease hot flashes are mixed. Some show a modest decrease only in women who take soy protein supplements not isoflavones alone in pill form. Research does support eating a daily serving of soy (25 grams of soy protein) as part of a low-fat, well-balanced diet. Progestin cream Studies have shown that creams containing progestin may reduce hot flashes. Progestin creams should never be used in place of prescription progestin. Black cohosh Black cohosh is the most widely studied herb in menopause treatment. Some short, limited studies of a brand named Remifemin show that it may help relieve hot flashes, but other research does not support this. More importantly, there have been recent reports of serious liver problems developing in women taking black cohosh. Dong quai The first study on the use of dong quai for hot flashes was carried out at Kaiser Permanente. It showed that dong quai was no more helpful for hot flashes than a placebo (sugar pill). There are also concerns about the safety of dong quai. For these reasons, dong quai is not recommended. DHEA DHEA is a hormone that may change into male hormones when it enters the body. DHEA can cause acne, voice deepening, liver problems, and may decrease HDL (good) cholesterol. Women with high levels of DHEA seem to have more heart attacks. There is no evidence that DHEA is effective in improving health and the effects of long-term use is unknown. DHEA may be dangerous and is not recommended. Bioidentical or alternative estrogens The term bioidentical refers to hormones that are the same as hormones we have naturally in our bodies. They can be extracted from soy and yams and put into pills, patches, or creams. No studies prove that one hormone is safer than another. Concerns about the risks of breast cancer, stroke, and heart disease apply to all forms and types of hormones. The hormones estradiol and progesterone are available in FDA-approved products (including estrogen pills and patches and progesterone capsules). These products have been tested for effectiveness, purity, and consistency and are on the Kaiser Permanente formulary. Prescription estrogens and progesterone can also be purchased from compounding pharmacies. In addition to estradiol, there are compounds called Tri-est or Bi-est that combine different types of estrogen with emphasis on a weak estrogen called estriol. There are no studies in humans comparing the effects of these estrogens to the standard prescription estrogens. In addition, these estrogens are much more This information is not intended to diagnose health problems or to take the place of medical advice or care you receive from your physician or other health care professional. If you have persistent health problems, or if you have additional questions, please consult with your doctor. If you have questions or need more information about your medication, please speak to your pharmacist. Kaiser Permanente does not endorse the medications or products mentioned. Any trade names listed are for easy identification only. expensive, are not FDA-controlled, and are no more natural than most of the prescription estrogens. Evening primrose oil There is no scientific evidence that evening primrose oil can reduce menopausal hot flashes. St. John s wort Studies have shown that St. John s wort may relieve symptoms of mild depression. St. John s wort is not effective in treating major depression and is not usually recommended beyond two years. Side effects may include stomach upset, fatigue, and increased sensitivity to sunlight. This herb (also called hypericum) should not be used with anticlotting drugs or with prescription antidepressants. How to purchase herbs and supplements safely Herbs and supplements are sold overthe-counter. Kaiser Permanente carries only herbs and supplements backed by research to show that they are effective in treating certain medical conditions. Additional resources Connect to our Web site at kp.org to access health and drug encyclopedias, interactive programs, health classes, and more. Check your Kaiser Permanente Healthwise Handbook. Contact your Kaiser Permanente Health Education Center or Department for health information, programs, and other resources , The Permanente Medical Group, Inc. All rights reserved. Regional Health Education (Revised 11-07) RL 8.7