Insulin is a hormone that is needed to convert sugar, starches and other food into energy needed for daily life. The cause of diabetes continues to be a mystery, although both genetics and environmental factors such as obesity and lack of exercise appear to play roles
Fasting Blood Sugar:70 - 100 mg/dl
(8-10 hrs in empty Stomach)
Post Prandial Blood Sugar : 100 - 140 mg/dl
(1 ½ hrs after breakfast / lunch)


1552 BC Egyptian Papyrus
Oldest preserved medical document
20.23 m length X 30 cm height 110 pages scroll contains 700 magical formulas and folk remedies
Hieratic script (similar to hieroglyphics) Mentions polyuria
George Ebers discovered this Papyrus in 1872

Prameha: Miha­ Sechane: watering, Pra: excess
Prameha is of three types: Madhumeha - 'Madhu' or 'honey‘- diabetes
Ikshumeha & Sheeta Meha - non-diabetic polyuria
Classifications of madhumeha:
     Sahaja : Genetic Apathyannimitaja: Acquired due to unhelathy diet and activity
Two types of Madhumeha
Krisha: Lean Diabetic (Type 1 diabetes)
Sthula: Obese Diabetic (Type 2 diabetes
Genetic: Prameha running in families
Symptoms: Daha: Thirst, Shweta madhura
mutrata sada: honey like urine, Sheena: Fatigue
Obese: physical exercise and liberal quantities of vegetables
Lean: must be dealt very cautiously, strict supervision must be done. If Ayurvedic drugs are started, should be given a nourishing diet
Starvation is to be avoided. Rigorous physical activity is advocated for Prameha patients

Diet and Health

Keeping a diet that meets the strict nutritional requirements of diabetes can be difficult and time-consuming, but it is a critical part of maintaining a healthy lifestyle. You need meals that you can prepare quickly with little fuss and even less guesswork. A 7 day meal plan with recipes is provided for you. (Diabetic Meal Planning and Diabetes Menu)

Herpes Simplex Virus (HSV)

HSV is a member of the family of viruses responsible for chicken pox, shingles, and infectious mononucleosis. The strain HSV-1 of this common virus is also responsible for cold sores, canker sores, and fever blisters that appear on the mouth. HSV-1 may be responsible for the genital sores we think of in relation to herpes, but more often the strain HSV-2 is the cause of sores and blisters below the waist. Like other viruses, there is no cure for HSV, but there are drugs to help manage most infections.

The virus which causes herpes lives in nerve cells at the bottom of the spine, and “creeps” to the surface once in a while to cause sores and blisters. In fact, herpes is named after the Greek word for “creeping”. Recent studies have shown that most people with a herpes infection — probably as many as three-quarters — don't even know they have the disease because they have no symptoms: they never have any sores or blisters to alert them to the infection.

People who are unaware that they are infectious can unwittingly spread the disease. But even people who are aware of their infection can unknowingly spread it because viral particles are “shed,” meaning they are present on the skin of the genitals, even when no sore or blister is apparent. This “asymptomatic” shedding happens prior to reappearance of the sore.

Because of its ease of transmission, the virus has become extremely common. HSV is not a reportable disease, but an estimated 30 million Americans or more are thought to have it. More than 200,000 new cases are expected each year.

• Risk factors: You are more likely to get herpes if you or your partner have multiple or casual sexual partners. Rates are high among all racial groups. Approximately one in every five 30-year-old white females has HSV.

• Signs and symptoms: Many people with HSV have no signs or symptoms. If and when trademark sores appear, they can be on the vulva, in or around the vagina, in the anus, or on the cervix. Many women notice itching or a tingling sensation in the genital area before the sores appear. These are known as “prodromal symptoms.”

The first “outbreak” of a herpes infection is always the most severe, often lasting for three weeks or longer. The average length of time for a first episode is 12 days. Fever, headaches, swollen lymph glands, and sore muscles (especially in the legs) are common, in addition to the painful blisters. Some people will have one blister during an outbreak, while others will have many. Blisters deep in the vagina or cervix may not cause any pain. Recurrent episodes, during which the virus is reactivated, are milder and usually last about five days. For many people, the recurrences will occur less frequently over time.

• Cause: HSV is spread by skin to skin contact, especially during vaginal, anal, or oral intercourse. HSV-1 and HSV-2 are almost identical, so someone with a cold sore performing oral sex can give his or her partner genital herpes. It is thought that 20 percent of genital herpes is transmitted during oral sex.

Once the virus enters the genital area, it quickly camps out in clumps of nerves at the base of the spine. It can lie dormant there for the rest of one's life, as it does in about 10 percent of all cases, or it can reappear sporadically. Many things can trigger recurrence of symptoms: surgery, illness, stress, fatigue, skin irritation (such as sunburn), dietary imbalance, menstruation, hormonal imbalance, or vigorous sexual intercourse.

• Incubation period: Symptoms usually start appearing within a week after infection if they are going to appear at all (remember, as many as 75 percent of people with HSV may be asymptomatic.) However, symptoms have been known to start one day to 26 days after exposure to the virus.

• Possible health affects: One complication from HSV is very rare and easily avoided: accidentally spreading the infection to the eyes. This can occur if you should happen to rub your eyes or put in contact lenses after touching an HSV sore. The herpes virus is easily killed with soap and water, though, so an eye infection can be avoided through stringent hygiene during outbreaks.

Having trouble paying for acyclovir treatment? Burroughs Wellcome Co., the makers of Zovirax, offers a patient assistance program for hardship cases. Request an application by calling 1-800-722-9294.

Although an association between herpes and cervical cancer has not been established, women with the virus should have regular Pap tests because of their increased risk of other infections such as HPV.

• Diagnosis: It is important to see your doctor while symptoms are still present, because diagnosis is made by viewing sores and by taking a sample from the sore to look at under a microscope. Blood tests that detect antibodies to HSV are also reliable. You can request a specific culture for HSV, but it is fairly expensive and takes about a week to give results.

• Treatments: Although nothing is available to rid the body of a virus, acyclovir (Zovirax) can alter the herpes virus' ability to cause damage once it comes out of its hiding place in the nerve ganglia.

Zovirax is the most frequently prescribed drug for an initial herpes outbreak. Duration of symptoms can be reduced from nine days to about five; healing time is reduced from about three weeks to about two weeks; and viral shedding can be cut down from 10 days to about two.

The topical cream form of Zovirax can be effective for the initial outbreak, but rarely works well for recurrences. Taking oral Zovirax for recurrent outbreaks, while it can still be effective, has a less significant impact for some people.

The recommended regimen for an initial herpes outbreak is 200 milligrams orally five times a day for seven to 10 days or until symptoms disappear. If you are aware enough of your body and can know when a herpes attack is about to strike, taking Zovirax within two days of onset can help lessen the severity of recurrences. Usually the initial warning symptoms — muscle aches, genital itching and tingling — will alert you. For recurrent outbreaks, you will probably take Zovirax for five days, at a dose of either 200 milligrams five times a day, 400 milligrams three times a day, or 800 milligrams twice a day. This conservative therapeutic approach can reduce shedding time by almost half, from nearly four days to slightly over two days.

Taking Zovirax only at the onset of an outbreak is referred to as “episodic” therapy. If you suffer from many outbreaks a year — once every month or two — or if having herpes is causing you great psychological distress, you might consider “suppressive” therapy. Taking the drug suppressively (400 milligrams twice a day, every day), reduces outbreaks by at least 75 percent among patients with frequent outbreaks. It has not, however, been shown to cut down on viral shedding, so you could still pass the disease to a partner, and the outbreak will resume when therapy stops.

There is varying opinion on how long a person should stay on suppressive therapy. The U.S. Food and Drug Administration currently recommends only one year, although studies have shown that patients do well with three or even seven years. Additionally, suppressive therapy's expensive, costing between $2 and $4 a day. Talk with your doctor to decide what is best for you.

Drug companies are working hard to come up with new drugs to fight herpes outbreaks. Zovirax was a breakthrough that helped many people, but it has its flaws. Only 15 percent of the drug is actually absorbed into your body for use against the virus. For this reason, it is important to understand that if your bowels are moving more quickly than normal (as with gastrointestinal problems), you may not be getting a high enough level of the drug.

A new drug called valacyclovir is being studied, and researchers believe it will have an absorption rate of about 80 percent. Neither valacyclovir, or another drug, famcyclovir, will be available until clinical studies are completed and the drugs have received FDA approval.

• Follow-up: If an initial outbreak warns that you have herpes, tell all sex partners from the prior three weeks. If you find out some other way, from a blood test for example, you may not know when you were infected. It is up to you and your doctor to decide which partners to tell. It is also up to you to decide when and if to tell a new partner about your infection.

• Prevention: People with herpes are most likely to shed the virus asymptomatically for up to three months after the initial outbreak. It is not known exactly how often asymptomatic shedding occurs, though researchers believe it is a major cause of the high numbers of herpes cases. However, in long-standing marriages where one partner is infected and the other is not, the uninfected partner often stays herpes-free. Use of condoms and spermicides (which kill the herpes virus) is an important part of any prevention strategy.

HSV-1 and HSV-2 can easily migrate through the body, so oral sex should be avoided when there is an active sore on the mouth or genitals.

• Pregnancy: The most serious known complication of herpes threatens infants born to HSV-infected mothers. An HSV-infected baby is at risk for blindness, brain damage, and even death. Fortunately, the risk of transmitting the infection to a newborn at birth is low, even for women who have long-standing, recurrent outbreaks. If the baby does get infected (a less than 3 percent chance for women with recurrent infections), Zovirax will probably be used as treatment. HSV also increases the risk of miscarriage or premature labor and delivery.

The group at highest risk are women who acquire HSV late in their pregnancy, particularly those who have no immune defense to the virus (developed from having had diseases like chickenpox, or cold sores, etc.). Women with immune defense, which can be measured by antibodies to HSV in the blood, pass immunity to the baby through the placenta during the third trimester of pregnancy. Infants born to HSV-infected and antibody-carrying mothers are thus protected from the disease should they come into contact with it as they pass through the birth canal. Most HSV-infected women can have normal, vaginal deliveries. Having an active sore at the time of delivery will warrant a cesarean delivery.

If you are pregnant and either have HSV or have sex with an infected partner during your pregnancy, or if you or your partner have sex with more than one partner during your pregnancy, be sure to tell your doctor. He or she will then test to see if you are shedding the virus when it comes time to deliver the baby.

Zovirax has not been thoroughly studied for use by pregnant women, so your doctor will probably advise stopping suppressive or episodic therapy during pregnancy.

Human Papilloma Virus (HPV)

HPV refers to a group of more than 60 viruses. They are responsible for warts anywhere on the body, but only certain types are sexually transmitted. These are called condylomata acuminatum, better known as genital warts or venereal warts. Like other warts, they can not be cured but they can be treated.

Warts are the “clinical” version of this infection; that is, they can easily be seen and diagnosed. However, there is a much more common version, referred to as “subclinical,” in which the virus resides under the skin and cannot be seen. Some experts believe that HPV causes warts in about 30 percent of infected people and subclinical infections in the other 70 percent. The subclinical varieties have been linked to cancer, so it is important for women to have yearly checkups including Pap smears to detect precancerous cervical changes.

HPV is coming close to being considered an epidemic in the United States, with a 1,000 percent increase in the number of HPV patients since 1987. Since it is a nonreportable disease, accurate figures aren't available, but it is believed that 48 million to 50 million Americans currently live with this virus. Almost one million Americans are newly infected with the HPV virus every year.

• Risk factors: You are more likely to get genital warts if you are between the ages or 20 and 24, if you and your partner have multiple or casual sexual partners, and if you have another STD, such as chlamydia or herpes simplex virus (HSV). If you are pregnant, using oral contraceptives, or have a condition that suppresses the immune system such as Hodgkin's disease or leukemia, you are also at higher risk for viruses such as HPV. Researchers have also found that white people have higher rates of HPV than do others. People who smoke put themselves at higher risk as well.


Although these warts signal the presence of the human papilloma virus (HPV), they show up in as few as 30 percent of infections. The cases in which the wart doesn't appear are actually more dangerous, since this type of HPV has been linked to the development of cervical cancer. The danger of cancer resulting from undiscovered infection makes the need for regular checkups all the more urgent. When discovered early enough, cervical cancer can usually be cured.

• Signs and symptoms: Many people with HPV have no signs or symptoms. If and when warts appear, they can be on the vulva, in or around the vagina or anus, on the cervix, or anywhere on the groin or thighs. They may also be found in the mouth. Warts on men usually show up on the penis or scrotum. The warts can appear as raised or flat, small or large, and single or clumped in a group that sometimes looks like cauliflower. Normally, the warts are flesh-colored and painless. They can also appear as slightly pink or grey. Rarely, they cause itching, pain, or bleeding.

• Cause: HPV is spread by skin to skin contact, especially during vaginal, anal, or oral intercourse. It is thought that the virus enters the body through tiny breaks in the skin, which could be caused by the friction of sex or even by using tampons incorrectly. Once it is in the skin, the virus makes its way into the lower layers of skin. It can stay there for months or years, and may never come back up to the surface at all. For this reason, it is important to understand that if you are diagnosed with HPV, you could have gotten it at any time in your past sexual life.

• Incubation period: Viral infections are harder to get than bacterial ones. It can take from four to six weeks to infect a partner with HPV. In two-thirds of infected people, it can be up to nine months before any warts appear.

• Possible health affects: Although the reason is unclear, women with HPV are at increased risk for cancer of the vulva and cervix. However, only a few strains have been linked to cancer (types 16, 18, 31, 33, and 35) , and the potential for malignancy is low. These strains usually cause subclinical infections. The strains that cause growths (types 6 and 11) do not lead to cancer. Annual pap smears, are particularly important for women with malignant strains, and for women at high risk for exposure to any type of STD. In addition, women with HPV should periodically have an examination of the cervix, vagina, and vulva.

• Diagnosis: HPV remains a mystery because it can not be grown in the lab and there is no blood test for it. For the 30 percent of people with the clinical or outward expression of the virus — the warts — diagnosis is made just by looking at them. Some warts are very hard to see because they are flat and look like normal skin, so your doctor will look at them through a magnifying lens called a colposcope. Also, your doctor or nurse will probably put a vinegar-like substance called acetic acid on your cervix and on the skin of your vagina. If the area then turns white, it is possible you have HPV. If the diagnosis is still unclear, several more sophisticated tests are available.

• Treatments: Treatment of HPV should be considered cosmetic rather than curative. Like other viruses, no therapy has been shown to cure HPV. Many treatment regimens are available and the choice is based on factors, such as the size and number of warts, as well as the expense, convenience, and potential adverse effects of the treatment.

Regardless of treatment, one in four HPV-infected people will have a recurrence within three months. Many studies have shown that small warts and warts that have been present for less than one year are the ones most amenable to treatment. In any case, never use an over-the-counter wart remedy for genital warts.


The hallmark of a herpes infection, these tiny blisters may break out for up to three weeks, then disappear on their own—only to return at unpredictable moments later on. Treatment with the drug Zovirax can ease the severity of an outbreak, but won't eradicate the infection. Because the herpes virus can be passed along even when there are no blisters in evidence, chances of contracting it are comparatively high: 200,000 new cases are reported each year.

Here is a list of available treatments, along with their best use and potential side effects:

Nothing. Letting the warts go away by themselves is actually a common treatment. Within three months, 20 to 30 percent of patients' noncervical warts will have cleared up on their own.

Cryotherapy. The warts are frozen with liquid nitrogen. This relatively inexpensive treatment is best used for small, single warts. There may be pain at the site where the liquid is applied.

Podofilox (Condylox ). This prescription drug is applied at home with a cotton swab, twice daily for three days, followed by four days of no treatment. You can repeat this cycle up to four times. This safe and relatively inexpensive drug is for external warts only, not those that might be in the vagina or on the cervix. You will probably feel burning and experience some irritation. Do not use this drug if you are pregnant.

Podophyllin (Pododerm, Podocon-25). This chemical, applied by a doctor or nurse, is best used on small, external warts. It too is safe and relatively inexpensive, but causes mild to moderate pain and discomfort at the site. It should not be used on large vulvar surfaces. Podophyllin needs to be washed off after one to four hours and you will need to be treated weekly for up to six weeks. Very large amounts can cause harmful side effects, including nerve damage. Do not use this treatment if you are pregnant.

Trichloroacetic acid (TCA). TCA is absorbed by the wart and causes it to slough off. You will feel some burning at the site of application. Application is repeated weekly for up to six weeks. It is also best used for external warts.

Electrocautery. Warts are destroyed with an electric current. Local anesthesia is required, and discomfort is moderate.

Laser vaporization. Intense light is used to destroy the wart. This procedure is useful for extensive warts on the genitals or vocal cords and should be tried only after other regimens have failed. Local anesthesia is required, scarring and infection are possible, and you will probably need analgesic for the pain for about three weeks. Laser treatment is also expensive.

Interferon therapy. Injected into the wart itself, this antiviral drug is not generally recommended because it is expensive, time-consuming, produces adverse effects in many people, and has not proven to be any more effective than other treatments.

• Follow-up: If either you or your partner are being treated with medication, it is advisable to abstain from sex, due to the possibility of reinfection and because the friction caused by sex could impede healing. Once the warts are gone, you do not need to return to your clinic. If your partner does not have obvious warts, there is no need for him to be treated.

• Prevention: Most experts believe that recurrences of warts are caused by the virus being reactivated rather than by reinfection. Condoms do offer some protection from reinfection, though. Obviously, areas not covered by the condom, like the vulva and scrotum, are vulnerable to repeat infection. Spermicides have not proven to be effective against HPV.

You can help protect yourself from HPV by trying to prevent the tiny skin abrasions through which the virus can enter the body. For example, the tender lining of the vagina can tear easily when it is dry. Since sexual intercourse can cause lacerations of the vagina, use a lubricant if dryness is a problem. Also, don't use tampons at the beginning or end of your period when the vagina is dry; use a sanitary pad instead, until your period is well underway and again towards the end.

• Pregnancy: Pregnant women should not use podophyllin and podofilox. Other treatments should be discussed with your doctor. Infants born to HPV-infected mothers can be born with warts in and around their larynx (voice box) although this is very rare. Cesarean deliveries are not necessary unless warts are so extensive that they block the birth canal.


Infertility is NOT an inconvenience; it is a disease of the reproductive system that impairs the body's ability to perform the basic function of reproduction.
Infertility affects about 5.3 million people in the U.S. -- about nine percent of the reproductive age population.
Infertility affects men and women equally.
Most infertility cases -- 85% to 90% -- are treated with conventional medical therapies such as medication or surgery.
While vital for some patients, in vitro fertilization and similar treatments account for less than 5% of infertility services, and only three hundredths of one percent (.003%) of U.S. health care costs.
Overcoming Infertility (From the PDR Family Guide to Women's Health Chapter 18 )
Types of Infertility
Hypofertile couples have trouble conceiving quickly. Their fertility may be less than ideal or they may be having problems with timing, but they can eventually conceive without special treatment. For example, the man might have a low sperm count, or the woman might have endometriosis—roadblocks, but not brick walls.

Sterile couples won't be able to conceive without medical or surgical treatment. For example, the man might not create enough sperm to fertilize an egg, or the woman might have blocked fallopian tubes. [more]

Infertility's Many Causes

A poorly functioning male reproductive system is the problem for 30 to 40 percent of couples seeking help for infertility. Another 30 to 40 percent of fertility problems are caused by a malfunction in the female system.... [more]

Improving Your Chances

Ovulation—prime time for fertilization—occurs in mid­ to late morning.
The best time to have intercourse is on the day or evening before ovulation.
You should lie still for about 10 minutes after intercourse to give the sperm that have entered the vagina enough time to proceed through the cervix.
Having intercourse at least 3 times during the week you expect to ovulate raises the odds that sperm will be present in the fallopian tubes when ovulation occurs.
.... [more]

MENOPAUSE: Holding Back Osteoporosis

P eople tend to think of their bones as an unshakable foundation -- a strong and solid support system for the muscles and inner organs. However, our skeletal structure isn't solid at all, but composed of living, growing cells. Our bones depend on a dynamic balance of available minerals (such as calcium) and the hormones that control mineral absorption, to stay strong and healthy well into old age.

Osteoporosis, the condition that turns so many elderly women into smaller, shrunken, weakened versions of their former selves, is not inevitable. It is possible to grow older and still stand tall, walk confidently, retain strong bones, and enjoy a great deal of physical strength. Today, women can benefit from increasing medical knowledge about how to ward off this disease that weakens bone.

In fact, osteoporosis, the "silent thief" that robs us of bone strength, can often be prevented, or at least minimized, by simple improvements in nutrition and exercise before bone loss begins, generally around age 35. And even those already affected by severe bone loss, can take preventive measures to minimize the risk of disabilities.

Though 25 million Americans, mostly women, are affected by osteoporosis, surveys show that most (3 out of 4) women from ages 45 to 75 have never spoken to their doctor about the disease. This is a missed opportunity, because there is much you can do during and after menopause to protect yourself from this disease. This chapter outlines steps you can take to strengthen your bones and contribute to your better overall health and well-being as you get older.

When the life-long process called bone remodeling slows, calcium leaches out faster than bone cells can restore it. The result is an increasingly porous skeletal structure given to tiny fractures you may never notice. As the disease progresses and bone density declines, major fractures of the hip, spine, or wrist become ever more likely.

The Framework: Understanding Bones

Bone cells, which store 99 percent of the calcium in our bodies, are continuously breaking down and building up, in a process called remodeling. The cells, which are interlaced with nerves and blood vessels, both collect calcium molecules from the bloodstream and release calcium back into circulation. The retained calcium adds to bone mass and keeps the skeleton strong.

As we age, the balance of retained versus lost calcium tends to tip in the wrong direction, with more calcium leaching out of our cells than is taken in. Losing a certain amount of bone mass is therefore a natural result of the aging process. However, after menopause, lower estrogen levels cause an accelerated rate of bone loss in most women, making them vulnerable to osteoporosis.

In osteoporosis, the bones become progressively more porous, making them more likely to break. Imagine osteoporatic bone as a honeycomb or Swiss cheese, and you can understand how the slightest trauma can cause debilitating bone fractures -- typically occurring in the hip, spine, and wrist.

Since the loss of crucial bone mass usually occurs without symptoms or pain, osteoporosis can go undetected for years -- until a fracture occurs. In young people, a broken bone usually heals itself in a month or two, but in old age, the process is slower and some fractures never fully heal.

A woman's lifetime risk of developing a hip fracture is equal to her combined risk of developing breast, uterine, and ovarian cancer. Hip fractures leave many women permanently disabled; and within 6 months following the injury, between 15 and 20 percent of patients will die because of a hip fracture and its complications. One in 3 women over 50 suffer vertebral fractures, which can lead to height loss and a stooped posture.

Hormones and Bone Strength

Our body balances the two processes of building new bone and removing old bone through the actions of a variety of hormones, including estrogen. Estrogen plays a dual role in bone metabolism: It facilitates the absorption of calcium from the blood into the bone and inhibits the loss of calcium from the bone. Bone density peaks in women about age 35. After this time, and especially when estrogen levels drop after menopause, bone loss exceeds new bone formation.

Normal estrogen levels help to ensure an adequate level of calcium in the blood, which, in turn, influences muscle and nervous-system functions. As estrogen levels decline, calcium blood levels can drop excessively, stimulating the production of another hormone called PTH. This hormone, which is secreted by the parathyroid gland, then triggers the leaching of calcium from the reservoir in the bones to correct the deficit in the blood, at the expense of bone health.

Bone loss accelerates after menopause, but varies considerably among individuals, for there is a wide variation in blood hormone levels among postmenopausal women. A woman can lose from one-half to 6 percent of her bone mass per year. This percentage may be even higher for women who experience surgical or chemically-induced menopause, in which the estrogen supply is abruptly cut down. By the time a woman is 80, she can easily have lost 40 percent of her bone mass. Once bone is lost it cannot be restored with tissue of equal strength or, as yet, be replaced.

Are You At Risk?

The risk of developing osteoporosis varies according to a number of factors, including sex, race, weight, and family history. People who enter midlife with light, thin bones have a smaller margin of bone mass that they can safely lose, and are therefore more vulnerable to bone disease.

Risk Factors You Cannot Control

Gender. Women generally have lighter, thinner bones than men. At age 35, men have 30 percent more bone mass than women, and they lose bone more slowly as they age. Because of the decrease in estrogen production that occurs during menopause, just being a woman puts you in the high-risk group for developing osteoporosis.

Race. Caucasian and Asian women have lower bone density than blacks by as much as 5 to 10 percent. Until recently it was thought that Caucasian women were at greatest risk for osteoporosis, but a recent large-scale study has found that Hispanic, Asian, and Native American women are at least as likely to have low bone mass as Caucasians. And one-third of African American women are also at risk.

Build. Having a delicate frame or weaker bones predisposes you to a higher fracture risk. Overall muscle tone also plays a role in the likelihood of sustaining an injury.

Onset of Menopause. Undergoing early menopause, naturally or surgically, increases your risk, because you will have reduced levels of estrogen for a longer period of time than you would with normal menopause. Because of the abrupt cessation of estrogen production that accompanies surgical menopause, women whose ovaries are removed (69 percent in one study) tend to show signs of osteoporosis within 2 years after surgery if no hormone replacement therapy is instituted. When medically possible, doctors recommend keeping your ovaries intact in order to maintain estrogen production, even if a hysterectomy (removal of the uterus) is necessary.

Heredity. Having a mother, grandmother, or sister with a diagnosis of osteoporosis or its symptoms ("dowager's hump" or multiple fractures) increases your risk. Body type, as well as a possible genetic predisposition to osteoporosis, can be passed from one generation to the next.

Controllable Factors

Exercise. The amount of exercise you get has a major impact on bone strength and growth. Bones tend to lose mass from inactivity; on the other hand, the mechanical stress of exercise -- especially weight-bearing exercise -- such as jogging, walking, and tennis -- has been shown to stimulate bone growth and improve strength.

Weight. Heavier women are at a smaller risk for osteoporosis since bone mass is positively affected by a slight excess of fat. Fat tissue converts other hormones to estrogen, even after menopause, and estrogen, as we know, aids with the absorption of calcium.

Childlessness. Never having children puts you at higher risk of bone loss because you won't experience the temporary surges of estrogen that accompany each pregnancy. These surges help to protect against osteoporosis later in life.

Calcium. Calcium is critical for building bones. You may have less bone mass than you should if you haven't been getting the recommended daily allowance of 1,200 milligrams per day throughout your life. Studies have shown that over 75 percent of American women get less than 800 milligrams of calcium a day; one out of four ingests less than 300 milligrams a day. For postmenopausal women, a high daily intake of 1,000 to 1,500 milligrams is recommended.

Smoking. Women who smoke generally experience menopause up to a year and a half earlier than nonsmokers, and thus face a longer period of estrogen deficiency and accompanying bone loss. Smoking also hampers efficient processing of calcium. Smokers have a higher rate of vertebral fractures than nonsmokers.

Alcohol. Consuming more than two alcoholic drinks daily can decrease calcium absorption. It also interferes with the vitamin D synthesis that helps the bones absorb calcium.

Deep within the bones, an army of cells constantly tears down aging bone mass and builds it anew. Since estrogen fosters new growth, the reduced levels found in menopause can quickly lead to a reduction in bone density. Adequate supplies of calcium throughout life can alleviate the problem. After menopause, hormone replacement therapy can boost the bones' calcium absorption, preventing osteoporosis in three-quarters of the women at risk.

Medical Factors

Lactose Intolerance. This problem is caused by the deficiency of the enzyme, lactase, which aids in the digestion of milk products. Less milk means less calcium. Sixty percent of women with osteoporosis (but only 15 percent of the general population) are lactose intolerant.

Medications. Commonly prescribed steroids like cortisone and prednisone, thyroid for hypothyroidism, and phenobarbital or phenytoin (Dilantin) for seizures all interfere with the body's ability to absorb calcium from food or calcium supplements.

Medical Conditions. Women with anorexia, Celiac disease, (an intolerance of certain grain products), diabetes, chronic diarrhea, kidney, or liver disease are all more likely to develop osteoporosis.

A persistent low backache, or sudden localized pain, could be a warning sign of compression fractures in the vertebrae of the spine. But for many, these breaks cause little pain, and may go undetected for years. For some, the only tip-off is a noticeable loss of height, which can reach as much as 8 inches.

Warning Signs of Osteoporosis

Loss of bone mass produces minimal symptoms, while it quietly eats away skeletal strength, making bones more susceptible to fracture. For some women, a fracture may therefore be the first outward sign of osteoporosis. A broken bone as the result of a minor jolt, such as a wrist fracture following a simple fall, is a good reason to suspect the development of osteoporosis. An x-ray of the fracture can confirm the extent to which the break was caused by deterioration of the bone. Fortunately, for many women there are other, less dramatic signs to watch for.


Because the vertebrae are the most common site of fracture in osteoporotic women, an early symptom of the disease is a persistent backache in the lower part of the spine. Sudden muscle spasms or pain in the back can occur while you are resting or doing routine daily tasks. This sudden pain is often caused by the spontaneous collapse of small sections of the spine that have been severely thinned or weakened over time. Unlike back pain due to other causes, this pain is localized and seldom spreads. Seeking treatment from an orthopedic specialist or gynecologist is important. Those who develop osteoporosis often begin to notice more severe backaches about 9 and a half years after their last menstrual period or 13 years after surgical menopause.

Height Loss

Spinal osteoporosis is rarely diagnosed until spinal bones have broken. These breaks occur at the weakest points of the spinal column -- places where the spine naturally curves. Women are often unaware that they have these compression fractures because they don't always cause prolonged or severe pain, or disability. However, one unmistakable warning sign is a loss of height, which is directly related to spinal crush fractures. This loss of 2-and-a-half up to as much as 8 inches occurs in the upper half of the body. You can and should watch for development of spinal osteoporosis by routinely measuring and recording your height.

"Dowager's Hump"

With a loss of height due to vertebral fractures comes distortion of the spine's normal curves. This can lead to the development of a "dowager's hump" -- a protrusion in the upper back and a shortening of the chest area, that leaves the ribs practically sitting on the pelvic region. One consequence is more difficulty in digesting food. Another is the impact on your appearance and self-esteem. This hunchback-like appearance is not a natural part of growing older or the result of poor posture; it is a clear indication of osteoporosis.

This unbecoming distortion of the spine is a direct result of osteoporosis and the spinal fractures that accompany it. Take measures to prevent osteoporosis now and you'll avoid this development in your later years.

Tooth Loss

Tooth loss during midlife and the thinning of bones supporting the teeth is another indication of osteoporosis. The loss of tooth-bearing bone, called periodontal disease, is common among osteoporotic women. This bone thinning may be detected early by dental x-rays. To prevent periodontal disease, menopausal women should take extra care with their dental hygiene. This includes regular checkups and cleanings, brushing, and daily cleaning with dental floss or a Water Pik to retrieve food particles below the gum line.

Detecting Osteoporosis: Bone Density Screening

If you are at high risk for developing osteoporosis, or if you have already seen the early warning signs, discuss an evaluation of your skeletal health with your doctor. Ordinary x-rays do not detect osteoporosis until at least 30 percent of the bone is already lost and the disease has progressed much further than is healthy. But sophisticated technology is now available for earlier detection of bone loss, when it can still be stopped or perhaps reversed.

Several different methods of bone screening exist, all of which are painless, involve low-dose x-ray procedures, and range in cost from $75 to $250. Make sure you use a facil-ity that does bone density testing on a regular basis. Most large hospitals have the necessary equipment, and some even have special osteoporosis centers.

The current gold standard in bone density testing is dual x-ray absorptiometry (DXA), which can measure the spine, hip, or total body. It uses a minimal amount of radiation--about 10 percent of what you'd receive in a chest x-ray. The p-DEXA, a cheaper alternative found at many health fairs and malls, takes just 10 minutes. However, it measures bone density only at the wrist, not at the spine and hip, where fractures are most serious, and isn't particularly helpful in predicting such fractures. Be sure to discuss your test results with a qualified medical professional.

Routine screening for changes in bone density is still considered controversial. However, most experts agree that it's justified for women over 65 and others clearly at risk. It's also recommended if you've already been diagnosed with osteoporosis, so the doctor can monitor the effects of treatment. New biochemical tests, which measure bone breakdown products in blood and urine, can also be helpful in gauging your response to therapy. Such tests are not, however, reliable enough to provide a diagnosis.

Preventing Osteoporosis

While the effects of osteoporosis are most often seen in later life, your risk is determined by your level of bone mass at age 35. For this reason, it is important to build bone to its peak density prior to menopause. It is essential for young women to be aware of risk factors and to take steps to slow bone loss and improve bone remodeling. However, women in their 50s and 60s can also benefit by taking immediate anti-osteoporosis action. These steps focus on diet and exercise.


Calcium, the primary component of bone tissue, is the key factor in maintaining bone strength. But if you diet, fast, or habitually eat little, your daily calcium requirements are probably not being met. In addition, excess consumption of protein, sodium, sugar, alcohol, and caffeine has been shown to decrease absorption of calcium from your diet. And a certain amount of calcium is lost naturally each day through excretion. Since your body needs calcium to function, it tries to compensate for all of these deficits by taking calcium from your bones.

This situation is further complicated as a woman reaches menopause. Since estrogen increases the absorption of calcium into your system, lower estrogen levels generally mean you need to take in more calcium. Your body will absorb calcium without estrogen -- but only at a lower rate.

Calcium (mg.)

Cream of Wheat, Instant
1 cup, cooked


1 ounce

1 cup

1 ounce


1 cup

Whole, fat 3.5%
1 cup

Yogurt from skim milk
1 cup


3 ounces

Sardines, canned
8 medium

Scallops, cooked
3-1/2 ounces


1 medium

Figs, dried
5 medium


Broccoli, raw
1 stalk

Broccoli, cooked
2/3 cup

Collards, cooked
1/2 cup

Parsley, raw
3-1/2 ounces

Watercress, raw
3-1/2 ounces

Calcium needs vary according to unique requirements, but the bottom line is: To build bone mass, you need calcium. Studies have shown that women consume less than half of the calcium they need, pre-, peri-, and postmenopause. For a woman in her twenties, 650 milligrams of calcium may be adequate. But by menopause, most women need to ingest about 1,000 milligrams of calcium a day in order to prevent a loss of bone mass. Women in their 40s should consume 1,000 to 1,500 milligrams of calcium every day. After menopause, 1,500 milligrams daily is suggested for women who are not on hormone replacement therapy. Because your body can absorb only about 600 milligrams of calcium at a time, it is advisable to consume calcium-rich foods at separate sittings.

Ideally, calcium should come from a natural diet. Devising a plan to promote adequate calcium levels includes making calcium-rich foods -- such as dairy products, nuts, leafy greens, broccoli, rhubarb, salmon, sardines -- a regular part of your diet. Skim milk is just as valuable to your bones as high-fat whole milk.

Women who are lactose intolerant should consider using LactAid, which supplies the enzyme needed for proper digestion of milk products. Calcium-rich yogurt is another alternative because it is easier to digest than other dairy products.

Analyze your diet to learn how much calcium you are actually getting each day. Using the nearby chart can help you become more aware of calcium content in food, and aid you in shifting slowly to a new nutritional program.

Calcium supplements are recommended if you or your doctor feel your calcium needs are not being met through your diet. The recommended amounts are the same for dietary calcium: 1,000 to 1,500 milligrams of elemental calcium daily for women in their 40s, and 1,500 milligrams for postmenopausal women not on hormone replacement therapy. Don't overdo it. Excessive calcium can create other problems in the body, such as promoting kidney stones and hardening of the arteries.

The most important point about supplements is absorption. To be properly absorbed calcium supplements must dissolve quickly in the stomach. Yet in recent studies about half of the pills on the market failed to dissolve fast enough. You can test your brand of choice at home. Drop a tablet into a container with 2 to 4 ounces of vinegar, stirring twice. After 30 minutes the pill should have completely dissolved or disintegrated into fine particles. If not, change brands.

Calcium citrate is the preferred formulation of many doctors because it is easily absorbed (especially by older women who make less gastric hydrochloric acid), and does not need to be taken with meals. To ensure best absorption, calcium should be taken in two daily doses, preferably at breakfast and dinner. Also, for some women calcium needs to be accompanied by daily doses of vitamin D (see below) or it is likely to go unabsorbed.

Antacids have become a newly touted source of calcium. However, with alternatives like calcium-rich food and pure calcium supplements, there's reason to wonder why anyone would choose antacid tablets as a major source of calcium. Though antacids may be less expensive than supplements, many contain aluminum, which can actually cause your body to lose calcium. (Two popular brands, Tums and Titralac, are aluminum-free, however.)

If you need to take an antacid for its intended purpose, there's nothing wrong with taking one that contains calcium. However, taking antacids solely for their calcium content is not recommended. Taken five to six times a week, they may be harmless; but in excessive amounts they can cause constipation and may lead to the formation of kidney stones and other urinary problems. In addition, certain pre-existing medical conditions can be aggravated by antacids, including colitis, stomach or intestinal bleeding, irregular heartbeat, and kidney disease.

Other Vitamins and Minerals

Vitamin D is essential to ensure adequate supplies of calcium in your body because it not only helps the body absorb calcium but also promotes its uptake into the bone. But very few foods in our diet are rich in vitamin D so you may be at risk of a deficiency. It's important to monitor your intake of this crucial vitamin, or the efforts you make to get adequate supplies of calcium may be futile.

The recommended daily dose of Vitamin D is 400 international units (IU). If you do opt to get your daily dose from supplements, be aware that amounts over 1,000 IU a day can interfere with calcium absorption. Also, because vitamin D is stored in the body for long periods of time, megadoses can be toxic. Most women need supplements of no more than 400 IU daily -- and only during winter in cloudy regions at that. For women over 65 years of age, supplements of 800 IU per day are usually the most that's recommended.

Vitamin D is present in such foods as egg yolk, certain fish, fish liver, and butter. Fortunately, it is also added to milk, bread, cereals, and other foods. An 8 ounce glass of milk contains 100 IU of vitamin D. Exposure to sunshine for about 15 minutes a day can also trigger the body's formation of needed vitamin D.

Magnesium is an important mineral for strong teeth and bones because it helps your body utilize calcium and vitamin D. Physicians agree that your daily magnesium dosage should be at least half the amount of calcium you consume on a daily basis -- for example, 600 milligrams of magnesium to 1,200 milligrams of calcium. Provided you eat a balanced diet, however, your chances of having a magnesium deficiency are very low.

Phosphorus is a mineral necessary to metabolize calcium, and should be consumed in amounts equal to your calcium intake. However, most Americans get too much phosphorus by eating excessive quantities of red meat, white bread, processed cheese, and soft drinks. Excess phosphorus, like excess vitamin D, actually accelerates bone demineralization and increases urinary calcium levels. To keep your phosphorous level in line, avoid consuming large quantities of foods labeled as containing sodium phosphate, potassium phosphate, phosphoric acid, pyrophosphate, or polyphosphate.

Exercise and Posture

Physical activity affects bone strength because bone mass increases or decreases in response to the demands placed on it. Developing and maintaining good exercise habits can significantly reduce your risk of age-related bone fracture. Women who work out regularly have a bone density that is often 10 percent higher than that of women who do not. Research also shows that just 3 hours a week of weight-bearing exercise can decrease bone loss by as much as 75 percent. In addition, exercise increases muscle tone and mass, which serves to cushion and support bones and makes falls due to unsteadiness less likely.

Weight bearing exercises, which work the muscles against gravity, are the key to creating positive stress on your bones. These exercises includes jogging, aerobics, dancing, and tennis. Walking is also an excellent way to strengthen the back, legs, and stomach muscles. Though swimming and biking provide less positive bone stress, these exercises do help to increase muscle tone. Strength training exercises with free weights or machines offer almost no beneficial effect on the bones, but are still well worth pursuing. By increasing steadiness and strength, they can help prevent the falls that often result in fractures.

Just as exercise has profound effects on the strength of bone, the way you sit and stand everyday affects the way your bones shape themselves. If you slouch, your bones will grow to conform to that curvature. If you sit and stand with an erect posture, your bones will have a tendency to grow straight.

Hormone Replacement Therapy

Long term hormone replacement therapy (HRT) after the onset of menopause improves calcium absorption and has been shown to prevent osteoporosis in 75 to 80 percent of women. It is especially effective in women with chemically or surgically induced menopause. Employing products such as Premarin, Premphase, or Prempro, HRT is usually continued for 8 to 10 years or more after menopause, the time when women experience bone loss at an accelerated rate. Evista, the new drug with estrogen-like effects on the bones, provides an additional option. In order for the medications to be fully effective, a woman's calcium, vitamin D, and magnesium intake should be at recommended levels.

The medical community is still debating the best dosage and length of time for HRT. To make an informed decision about whether you should consider this therapy, see the next chapter.

Bone-Building Medications

One alternative to hormone replacement therapy is the bone-strengthening drug alendronate (Fosamax), now approved for the prevention and treatment of osteoporosis in postmenopausal women. This once-a-day pill has been shown to increase bone mass density in the spine and the hip, thus decreasing fracture risk. To maximize absorption of the pill -- and minimize the risk of irritation to the throat and upper digestive tract -- alendronate must be taken with a full glass of water on an empty stomach upon rising in the morning. It's necessary to wait 30 minutes after taking the pill before eating breakfast.

Another alternative, calcitonin (Calcimar, Miacalcin), is a naturally occurring hormone involved in bone metabolism. It slows bone loss and increases spinal bone density, and may relieve the pain associated with fractures. It is available as an injection or a nasal spray.

Coping with Osteoporosis

Once osteoporosis has been diagnosed, treatment usually consists of vitamin D, adequate calcium intake, and perhaps estrogen supplements or a bone-building medication.

If you already have osteoporosis, your doctor is also likely to advise appropriate exercise regimens that strengthen, but do not fracture, the bones. Exercise will not cure osteoporosis, but it can help you preserve the bone mass you do have, strengthen your back and hips, maintain flexibility, and steady your gait. Within only 6 months, a regular exercise program can reduce your risk of bone fractures. The best program is one you can continue on a regular basis.

In addition to specific treatment programs, you may need to make other adjustments in your daily life to reduce your risk of sustaining an injury. The following recommendations are made by the National Osteoporosis Foundation:

Wear sturdy, low-heeled, soft-soled shoes; avoid floppy slippers and sandals.
Ask your doctor whether any medications you are taking can cause dizziness, light-headedness, or loss of balance. If so, is there anything you can do to minimize these side effects.
Minimize clutter throughout the house.
Secure all rugs; avoid using small throw rugs that can slip and slide.
Remove all loose wires and electrical cords that can cause tripping.
Make sure treads and handrails are installed on staircases and remain secure.
Keep halls, stairs and entries well lighted.
Use nightlights in the bedroom and bath.
In the bathroom, use grab bars and nonskid tape in the shower or tub.
In the kitchen, use nonskid rubber mats near the sink and stove.
Avoid using slippery waxes; watch out for wet floors; clean up spills immediately.
When driving, wear seat belts and adjust seat properly.

Ovarian Cysts: Treatments

Treatment depends on many factors, including the type of cyst, its size, its precise location, the type of material it contains, and your age.

Functional Ovarian Cysts: “Watch and Wait”
If you have a small functional ovarian cyst that is not causing any problems, your doctor may recommend a “watch and wait” approach. That is, you may need to return for a follow­up examination or ultrasound after one or two menstrual cycles, when there is a good chance that the cyst will have dissolved. Your doctor may suggest you avoid intercourse during this time, since it can cause a cyst to rupture. If the cyst grows, especially if it becomes larger than about 2 inches, it may need to be removed surgically.

While small functional ovarian cysts generally disappear over time, they also tend to recur with subsequent menstrual cycles. In most cases, functional cysts can be controlled with the use of birth control pills, which reduce the hormones that promote growth of cysts and prevent formation of large, mature follicles that can turn into cysts. If you are already taking birth control pills for contraception, and think you may have an ovarian cyst, see your doctor because it is unlikely to be a functional cyst.

It may take a few months of using birth control pills before your cysts clear up. Your doctor can determine if the pills have been successful by repeating the pelvic exam, the ultrasound, or both. Your cysts may or may not return once you stop taking birth control pills. You can decide with your doctor how long you wish to stay on the pills.

Polycystic Ovaries: No More Surgery
Treatment for polycystic ovaries is more varied. If you have polycystic ovaries and are having problems conceiving, your doctor may recommend that you take clomiphene citrate (Clomid) to stimulate ovulation.

If you are not trying to get pregnant, and you have infrequent periods or no periods due to polycystic ovaries, the treatment is different. Your doctor may start you on the synthetic hormone called medroxyprogesterone acetate (Provera), which is similar to the natural progesterone your body would produce if you were ovulating. Provera fills in for the progesterone that would ordinarily appear after ovulation, allowing you to menstruate. This is important because even if you are not ovulating, your ovaries are still producing the estrogen that causes the uterine lining to grow. Without sufficient progesterone, the lining won't be shed during the menstrual period, and can grow too much. Although you probably feel fine and may not be eager for your periods to return, if your body is exposed only to estrogen without progesterone for long periods of time, the overgrowth of the uterine lining may increase the danger of cancer developing in the uterus.

There are several different schedules used for taking Provera tablets. Most experts agree that one good option is to take one 10­milligram tablet of Provera for 10 days each month. Taking the tablets on the first 10 days of the month makes it easy to remember. You should expect some menstrual bleeding approximately 3 to 5 days after you stop taking the tablets. Don't forget that even though you have polycystic ovaries, you may ovulate occasionally, and it is possible to become pregnant. Provera is not a contraceptive pill. In fact, it is not recommended for use during pregnancy. If you need contraception, you should continue to use your preferred method during your treatment with Provera.


During laparoscopy, the doctor inserts a narrow tube with a fiberoptic light at one end into the lower abdomen through a small incision just below the navel. This minor surgical procedure is used to diagnose many gynecological problems that may not be identifiable with less invasive methods, such as ultrasound or x­ray. For example, laparoscopy can help identify particular types of ovarian cysts, or determine the cause of pelvic pain or fertility problems.

Laparoscopy can also be used to treat your cyst. If it's small enough, the surgeon may be able to either drain the fluid from it or remove it through the laparoscope. Use of the laparoscope has eliminated the need for much major abdominal surgery.

Though laparoscopy is generally an outpatient procedure, it is usually performed under general anesthesia. This means that you will be required not to eat or drink for at least 8 hours prior to your surgery. You will also have a physical exam and routine blood and urine tests to be certain that you have no underlying illness or infection.

Often, using a vaginal speculum, the surgeon will attach a small instrument to the cervix that will allow movement of the uterus as needed during the procedure. The surgeon will then make a one-inch incision just below the navel and insert a small needle to deliver harmless carbon dioxide gas into the abdomen. The gas serves to lift the abdominal wall away from the internal organs and create a space so that the surgeon can see them. The needle is then replaced with the illuminated laparoscope. When the operation is finished, usually after 30 to 60 minutes, the gas is removed through a thin tube placed in the same incision. A few stitches close the incision which will probably be covered with a Band­Aid® type of dressing.

After your laparoscopy you will stay in the recovery room until you are feeling awake and alert and until your vital signs (temperature, pulse, blood pressure) are normal. Before you are sent home (usually within 2 hours after your surgery), you will receive instructions on follow­up care from your doctor and nurse. Postoperative pain should be minimal, but your doctor will probably give you a prescription for a mild painkiller.

It is not unusual to have some abdominal cramping or shoulder discomfort due to the carbon dioxide gas that filled your abdomen but this should gradually subside over a few days. You will probably be able to bathe and shower as usual, but you may need to avoid strenuous physical activity as well as sexual intercourse for a day or two.

Postoperative complications are rare, but be sure to call your doctor if you have bleeding from your incision, severe abdominal cramping or pain, or a fever over 100 degrees. Your doctor will probably want to see you a week or two later to check how you are doing, and to remove any stitches that are not the absorbable type.

Though laparoscopic incisions are truly Band-Aid sized, the operation frequently requires more than one puncture. Shown here, the surgeon views an ovary through one incision while manipulating it through another.

Some doctors treat the symptoms of polycystic ovaries with low­dose birth control pills. When you take birth control pills your normal periods will resume, and you'll be protected against pregnancy if that is a concern. Another advantage of birth control pills over Provera is that they decrease the production of the male hormone androgen. Not only does this help control excess hair growth, sometimes a symptom of polycystic ovaries, but it also may reduce the risk of heart disease in women with polycystic ovaries.

The original cure for polycystic ovaries was a surgical procedure called ovarian wedge resection. This involved removing at least one­third to one­half of each ovary in order to return it to normal size. In most women, this operation resulted in resumption of normal periods and normal fertility. The wedge resection is rarely done anymore thanks to the availability of drugs that induce ovulation and restore normal periods.

When Surgery Is Needed
Sometimes, however, surgical removal of a cyst is the only option. Doctors take several factors into account when deciding whether surgery is advisable. One of the most important considerations is the size of the cyst. Because there is a very slight risk of a large ovarian cyst becoming cancerous, the larger your cyst, the more likely the surgery. Although gynecologists differ on the precise “cut­off point,” in most cases if a cyst is at least 2 to 2.5 inches in diameter (about the size of a tennis ball), it will be surgically removed. If your cyst is less than 2 inches, your doctor may want to track it with ultrasound examinations over a period of a few months to see whether it grows to a size that requires surgery.

Another factor doctors consider is your age. Because ovarian cysts are less likely to become cancerous in a woman in her 20s than one in her 40s, or in a woman who has passed menopause, your chance of needing surgical removal of an ovarian cyst increases with age.

The type of cyst is also an important consideration. A “simple cyst,” containing only liquid material, is less likely to require surgery than a “complex cyst,” containing a mixture of materials. However, if a “simple” functional cyst grows quite large or bleeds, surgery may be necessary. Once your doctor has determined the size and type of cyst you have, he or she will discuss with you the advisability of surgery. The common types of cysts that almost routinely demand surgical removal are endometriomas, cystadenomas, and dermoid cysts.

Endometriomas. Because endometrial cysts are caused by endometriosis, you may wonder whether the drugs used to control endometriosis could also be effective in treating endometrial cysts. (See the chapter on “Keeping Endometriosis at Bay” for more on these drugs.) And indeed, these medications may help control the growth of cysts. However, because endometrial cysts can grow quite large and are prone to rupture, perhaps causing internal bleeding, these cysts are often treated surgically.

Cystadenomas. Since cystadenomas are almost always benign, it would seem reasonable to leave them alone unless they are large or cause complications. The problem is that cystadenomas often do become enormous, causing complications simply due to their size. An additional concern is that cystadenomas are “neoplasms,” or new growths of abnormal tissue, and evaluation of neoplasms can be tricky. It is difficult to determine whether a neoplasm is benign or malignant simply by looking at it. Instead, tissue from most types of neoplasms needs to be analyzed under a microscope, and the only way to get a tissue sample is through surgery.

Dermoid Cysts. Dermoid cysts are also neoplasms, and therefore candidates for surgical removal. You may know before surgery that your cyst is a dermoid because if it contains teeth as one­third to one­half of them do, your doctor may have seen them on an x­ray.

What to Expect
When the Doctor Operates
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Once surgery is decided upon, you'll have a meeting with your surgeon to discuss the operation and have a physical exam.

Before Surgery
Your surgeon will review the reason for your operation, the possible risks, no matter how small, and any possible aftereffects. You may find it helpful to bring a written list of questions to the meeting. Feel free to ask your surgeon to explain the operation by drawing a simple diagram of what will be removed.

Although at this point you will probably feel there are no lab tests you have not already undergone, a few basic studies may be ordered to establish that you are healthy enough for surgery:

A complete blood count (CBC), to make sure that you have no underlying infection and that your body can tolerate loss of a small amount of blood during surgery
A urinalysis to screen for infection and diseases such as diabetes or kidney problems
A blood sample to check your blood type, in the unlikely event that you need a transfusion
A recent chest x­ray or recent electrocardiogram (ECG) if you are over 40 years old
In Surgery
If you have a large cyst, your surgeon will probably remove it through an incision in your lower abdomen. The general term for any operation through the abdomen is laparotomy. If the cyst is small enough, your doctor may be able to remove it with a laparoscope, which requires only a small incision.

The type of operation you will have will depend on the size and nature of your cyst. The goal is to remove only the cyst, leaving the ovary intact. When the cyst alone is removed, the operation is called an ovarian cystectomy. If a portion of the ovary is also removed, the operation is a partial oophorectomy. Occasionally, the large size of the cyst or complications such as bleeding, twisting, or rupture, may require removal of the fallopian tube with the ovary. This operation is called salpingo­oophorectomy. Surgeons make every attempt to preserve the reproductive organs, especially if you have not yet reached menopause since it's still possible to have children when only a small portion of one ovary remains. Removal of the uterus, fallopian tubes, and ovaries ( total abdominal hysterectomy with bilateral salpingo­ oophorectomy or TAHBSO) is very rarely used to treat the types of ovarian cysts described in this chapter, unless there is a reasonable chance that your cyst is cancerous.

After Surgery
If you have a laparatomy, you will probably be in the hospital for a few days after the surgery. During the early recovery and postoperative period, you will receive fluids and medication through your intravenous (IV) line, but you should be eating solid foods fairly quickly. You will receive medication for pain, and you can expect to be walking around the day after surgery. Your wound should heal quickly, and if your incision was closed with staples, the staples and bandage will probably be removed before you leave the hospital. If you have non­absorbable stitches, they will probably be removed 5 to 7 days after your operation.

Before you leave the hospital, you will receive a summary of the type of operation that was performed and the type of cyst that you had. You may wish to ask for a copy of the surgery report for your records. You should also receive complete instructions from your doctor or nurse regarding what to expect in the postoperative period.

You should expect to have some abdominal discomfort for a few days after you return home. You may be given a prescription for a mild pain reliever. You should call your doctor if the medication doesn't help, or if the pain does not improve after a week. You should also contact your doctor if you develop a fever of over 100 degrees, or if vaginal bleeding is heavier than a normal period.

You should expect your incision to look quite red and feel uncomfortable for a few weeks. It is normal to notice some dried blood around the incision, but call your doctor if you see pus oozing from the wound. It's fine to bathe and shower; don't worry about getting the incision wet as long as it's not oozing. The red color of the incision will gradually fade, and eventually the scar will barely be visible.

You may be able to start some non­strenuous physical activity after a week or two. Be sure not to resume intercourse or to use tampons or anything else in the vagina until you have had your postoperative checkup (usually about 2 weeks after surgery). You will probably be able to resume all your normal activities and return to work about 6 weeks after surgery.

Unless you have had both of your ovaries removed, your periods will return to normal, usually by about 4 to 8 weeks after surgery. Remember that if even a portion of one ovary remains, you can still become pregnant if you're of childbearing age. That's one of the many reasons it's important to discuss the specifics of your surgery with your doctor.

Chances are that once the ovarian cyst has been removed, it will not recur. However, the operation does not always guarantee that you'll be cyst­free in the future. As long as you have ovaries, you can have ovarian cysts. It's a good idea to continue any medical treatments your doctor has prescribed to control the cysts and, of course, to have regular gynecological exams.

Pain During Intercourse

This problem is so emotional and sensitive that many woman find it difficult to consult a physician. But it's important to seek treatment, and in many cases the cause is a physical illness that can be treated.

Painful intercourse, which a doctor may call dyspareunia, is a burning, tearing, ripping, or aching sensation associated with penetration. The pain can be at the vaginal opening, deep in the pelvis, or anywhere in between. It also may be felt throughout the entire pelvic area and the sexual organs, and may occur only with deep thrusting.

The most common explanation is irritation of the vagina caused by having intercourse without sufficient arousal and lubrication. This experience can create a vicious circle, leading a woman to fear intercourse which in turn makes it more difficult to become aroused. Women who have had a hysterectomy or mastectomy may have problems with arousal because of feelings of incompleteness. Stress or problems in your relationship with a partner can also block arousal. Counseling can help address these psychological issues, and over-the-counter lubricants (consult your doctor or pharmacist) can increase lubrication and reduce discomfort.

Another frequent explanation for painful intercourse is thinning and drying of the vaginal tissue as menopause begins. This happens because the body is producing less and less of the estrogen that is needed to maintain moist vaginal tissue. As the vagina's ability to make its own mucus declines, it becomes dry, itchy, and painful, leading to discomfort during intercourse. Estrogen creams and lubricating gels can help restore moisture, as can estrogen replacement therapy taken in pills or through a patch on the body.

Unintentional muscle spasms of the thighs, pelvis, and vagina can make penetration impossible. This condition, called vaginismus, can develop along with any of the other causes of painful intercourse described here or can result from psychological factors. A traumatic sexual experience, rape, or an irrational fear of genital injury can lead to vaginismus. Counseling can be helpful.

Other causes of painful intercourse include:

Infection—vaginal, pelvic, herpes, infected cysts or boils
Scars, tumors, or anything that narrows the vagina
Endometriosis (uterine tissue growing outside the uterus with bleeding, pain and scarring)
Intact hymen (in virginal young women)
Complications of surgery
Diseases that interfere with the physical process of arousal or orgasm (such as diabetes and multiple sclerosis)

Pelvic Inflammatory Disease: PID

nsidious and often dangerous, Pelvic Inflammatory Disease (PID) is a major health problem in the United States. More than 1 million women experience an episode of PID every year, which translates into an annual price tag of more than $4 billion. If present trends continue, by the turn of the century PID will cost Americans more than $10 billion annually in lost work time and medical bills.

For every four women who have PID, one will develop complications such as infertility or an ectopic pregnancy in one of the fallopian tubes between the ovaries and uterus—a potentially fatal condition.

Pelvic inflammatory disease is not really a single illness. It's actually an umbrella term for a variety of infections of the inner reproductive organs, including the ovaries, the fallopian tubes, the endometrial lining of the uterus, the uterine wall, the ligaments that support the uterus, and even the lining of the abdomen.

Silence Versus Symptoms

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Unfortunately, PID isn't always accompanied by obvious symptoms such as fever, abdominal pain, or a vaginal discharge. Sometimes the disease is “silent” and has mild symptoms or none at all, especially in women whose PID is caused by a germ called Chlamydia trachomatis, the most common cause of sexually transmitted disease. In women who have been rendered infertile by an infection in their fallopian tubes (the medical term is salpingitis), roughly half don't remember having any symptoms at all!

For those who do have symptoms, the most common is a dull, constant pain in the lower abdomen. This pain may be aggravated by movement or sexual activity. The hallmark of the condition is pain or tenderness as the doctor probes during a physical examination.

Since PID is often associated with a coexisting infection of the cervix, or birth canal, some women may notice a vaginal discharge. In fact, this is often one of the first symptoms of the disease. Only about 1 in 3 women who are diagnosed with PID has a fever. Nausea and vomiting may also signal PID, but they usually occur when the disease has progressed to peritonitis, in which the infection spreads to the lining of the abdomen.


If your doctor suspects the infection may be due to an adnexal abscess—a pus-filled pocket of fluid and bacteria around the ovary or fallopian tube—you may have to undergo an ultrasound examination, in which sound waves beamed into the body are used to build an image of internal organs on a computer screen.

The only completely conclusive way to diagnose PID is a surgical procedure called laparoscopy in which a special kind of viewing instrument called a laparoscope is inserted through a small incision below the navel. This type of surgery usually involves general anesthesia that puts you to sleep, but it can often be performed on an out-patient basis and does not usually require overnight hospitalization. By examining the affected organs with the laparoscope, your doctor can make a definite diagnosis. You'll usually be given antibiotics to protect you from further infection by the operation itself. The procedure generally takes less than 45 minutes and most patients can return home after resting from 2 to 6 hours.

Although laparoscopy is necessary for a definitive diagnosis of dangerous conditions such as adnexal abscess or ectopic pregnancy, most cases of PID do not call for it; and most doctors will start treatment for PID immediately if they even suspect the problem. If you have gonorrhea or chlamydia, delaying even a few days can greatly increase your chances of complications such as ectopic pregnancy or infertility. The risk of taking some unnecessary antibiotics is far less than the risk of letting PID go unchecked.

The Leading Culprits
PID is usually caused by more than one kind of bacteria. The bugs most commonly involved are Neisseria gonorrhoeae and Chlamydia trachomatis, both transmitted by sexual intercourse. However, other kinds of bacteria generally accompany them. The infection usually starts in the vagina, then moves up the reproductive system through the cervix, into the uterus, up the fallopian tubes, and finally into the ovaries.

Generally, gonorrhea-associated infections start quickly with more severe symptoms than the ones caused by chlamydia. When chlamydia is the major culprit, symptoms tend to be milder and fewer, developing slowly over a period of months or years. In either case, abdominal pain frequently begins during or shortly after a menstrual period.

Risk Factors
Because its two most common causes are both sexually transmitted, sexual activity is by the far the greatest single risk factor for PID. Youth also increases the odds; roughly 75 percent of all cases of PID occur in sexually active women under 25 years of age. For reasons not yet understood, younger women are more susceptible to chlamydial and gonorrhea-associated infection than older women are. Also, the disease rarely occurs in nonmenstruating women such as girls who have not yet reached sexual maturity as well as pregnant and postmenopausal women.

Clearly, there is a direct relationship between the number of sexual partners a woman has and the risk of PID—the more partners, the greater the risk. A woman who has only one partner does not have an increased risk. If he has had a vasectomy, the risk of PID is actually lowered.


If a pelvic infection takes hold in the critical corridor between the ovary and the uterus, the resulting inflammation and swelling (see tube on right) can totally block the passage, while pus building up outside the tube can cement it to other organs and spread the infection elsewhere in the abdomen.

Contraceptive Choices and the Risk of PID
It used to be thought that use of an intrauterine device (IUD) increased the risk of pelvic inflammatory disease. However, having a variety of sexual partners appears to be the real culprit. Women who use an IUD with a single partner are at no increased risk of the disease.

For those with multiple partners, certain other kinds of contraceptive devices—condoms, diaphragms, and spermicides—provide greater protection against the bacteria that cause PID than does an IUD. Barriers such as condoms or diaphragms physically prevent the bacteria from moving up the reproductive tract just as they prevent the passage of sperm. Spermicides used with these barrier methods, especially one called nonoxynol 9, can kill the bacteria that cause PID infections. On the other hand, frequent douching after sex can increase the risk of PID by pushing bacteria further up into the reproductive system.

Oral contraceptives don't block the passage of bacteria, but they do hinder them, lowering the risk of contracting PID and often keeping the infection milder. They accomplish this by increasing the thickness of cervical mucus which makes it more difficult for bacteria to move up the reproductive system. They also decrease menstrual flow, which presumably limits the opportunity for bacteria to grow in the upper reproductive tract.


Compare the normal fallopian tube on the left with the victim of PID on the right. Even after the disease has cleared up, it's impossible for an egg to make its way through the scarred, unnaturally narrow channel the infection leaves behind. If PID effectively closes both fallopian tubes, the result is sterility.

Why Pid Is Dangerous
If PID were merely an annoying infection that could be cleared up by antibiotics with no lingering or long-term effects, it wouldn't deserve a chapter in this book. But PID is much more than an annoyance. If the infection moves up the reproductive tract to the fallopian tubes, it can cause permanent damage to these critical reproductive organs, resulting in infertility.

Gonorrhea causes an inflammation that can permanently scar the delicate fallopian tubes, decreasing their width, and making them unfit to transport eggs to the uterus. While chlamydia produces a milder form of infection than does gonorrhea, it can linger in the tubes for months prompting a violent immune response that can damage the tubes just as thoroughly as a sudden bacterial onslaught. Whether it is due to a direct gonoccocal attack on the tubes or the more insidious chlamydial assault, the end result is the same—infertility.

In addition to destroying reproductive capacity, just one episode of PID can greatly increase your chances of having an ectopic pregnancy in which an egg begins to grow in the fallopian tube rather than in the uterus where it belongs. Ectopic pregnancies can be a life-threatening emergency requiring hospitalization and surgery. Experts estimate that the risk of death due to ectopic pregnancy is 10 times greater than it is in childbirth and 50 times greater than it is in properly performed surgery.

A bout of PID also quadruples your chances of suffering chronic (long-term) pelvic pain. If you develop this problem, surgical exploration is necessary to determine the cause and extent of the disease.

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How PID Is Diagnosed
Since PID can range from the “silent” variety (no symptoms) to a full-blown infection complete with pain, fever, and abnormal blood tests, there is no “standard” diagnostic procedure. If your doctor suspects that you may have PID, he or she must be able to distinguish between the disease and emergency conditions such as an ectopic pregnancy and appendicitis. For every 100 women suspected of having PID, about three or four will actually have an ectopic pregnancy and another three or four will turn out to have appendicitis.

Most women who develop PID have abdominal pain, pelvic tenderness, and some symptoms of a lower genital tract infection such as cervicitis. To help confirm the presence of infection, your doctor will probably do a couple of blood tests. There may also be a test for human chorionic gonadotropin, a hormone that rises during pregnancy and can signal that the pain is due not to PID but to an ectopic pregnancy. You will also probably be checked for gonorrhea and chlamydia. Samples swabbed from your cervix, or birth canal, will be taken with a cotton swab and sent to a lab for examination.


With its exit to the uterus blocked by scarring in the fallopian tube, a
fertilized egg may become implanted and develop within the tube
instead. Such an ectopic (outside the uterus) pregnancy can be fatal if left uncorrected. Cramps and spotting shortly after the first missed period are the major warning signs. Surgery is invariably needed.

Treatment Options

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Since PID infection is almost always caused by more than one kind of bacteria, your doctor will most likely prescribe a combination of antibiotics. Only one woman in four is hospitalized for PID; so unless your infection is severe enough to need hospitalization, you will not receive intravenous (IV) medication.

The Centers for Disease Control and Prevention recommend the following antibiotic treatments for PID outpatients:

An injection of cefoxitin (Mefoxin) plus
Probenecid (Benemid) tablets or
An injection of ceftriaxone (Rocephin) plus
Doxycline (Vibramycin or Doryx) orally for 14 days or tetracycline (Achromycin V or Sumycin) orally for 14 days
Ofloxacin tablets (Floxin) plus
Clindamycin (Cleocin HCl) orally for 14 days or metronidazole (Flagyl) orally for 14 days
Whichever regimen your doctor chooses, you should be checked two or three days after the antibiotics have been started to ensure that they are working. If the antibiotics don't seem to be working, your doctor may suggest hospitalization. If you are hospitalized, you can receive IV antibiotics that can work more quickly and more powerfully than ones you can take on an out-patient basis.

Since the great majority of PID cases are the result of sexually transmitted disease, it's not enough to be cured yourself. You need to make sure your partner also gets treatment. Otherwise, he'll reinfect you as soon as you resume having sex.

Preventing Recurrence

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As is the case with so many illnesses, “an ounce of prevention is worth a pound of cure,” because once you've had PID, it can recur, especially if you're a younger woman. In fact, roughly one of every four women with PID will suffer future episodes, and women who are hospitalized for PID have an even greater chance of entering the hospital again with PID or some related condition.

Perhaps even more alarming, recent studies suggest that silent or symptomless PID may be even more common than the classic kind in which acute abdominal pain warns you that something is wrong. However, there is also good news of sorts. Experts believe that symptomless PID is sexually transmitted, probably through germs such as chlamydia and others called trichomonas and mycoplasma. This means that you can avoid PID by sticking with a single partner, using protection, or refraining from sex.

Premenstrual Syndrome (PMS): Guide to Women's Health

No Explanation Yet
The term premenstrual syndrome was coined in 1931, when researchers first suggested that the condition was due to a hormonal imbalance related to the menstrual cycle. More recent studies have documented that PMS does, in fact, occur only during the childbearing years between puberty and menopause and subsides during pregnancy. PMS can also affect women who have had their uterus removed leading researchers to conclude that the uterus is not part of the problem.

Despite these clues and the recognition of PMS as a legitimate medical concern, researchers have been unable to find a cause. Even today, no one knows for certain what triggers PMS, though a number of theories have been advanced.

Much of the research has focused on the hormones estrogen and progesterone, which are produced by the ovaries and are known to interact with certain brain chemicals. At about day 5 of the menstrual cycle, estrogen signals the lining of the uterus to grow and thicken, in preparation for receipt of a fertilized egg. Once an egg is released from one of the ovaries at mid-cycle, about day 14 of a 28-day cycle, progesterone production begins, causing the release of nutrients and the swelling of blood vessels to prepare for pregnancy. If the egg is not fertilized, the uterine lining and the egg are shed in menstruation.

Thus, estrogen, which interacts with important brain chemicals affecting your mood and energy, dominates the first half of the menstrual cycle, while progesterone, which tends to suppress the actions of these brain chemicals, is more prevalent during the second half.


PMS coincides with the final enrichment of the uterine lining in preparation for arrival of a fertilized egg (see “A” at left). Not coincidentally, this phase of the lining's growth depends on increased levels of the hormone progesterone, which begins to appear as soon as an ovary releases its egg.

In addition to its effect on the uterus, the extra progesterone is thought to have a damping effect on certain chemicals in the brain, possibly accounting for the agitation and mood swings that often accompany PMS. But the connection—if there is one—is still far from clear. Many doctors find that additional progestrone, taken as a daily shot or suppository, helps to reduce symptoms of PMS.

Whatever the truth of the matter, this much is certain: If conception fails to occur, progestrone levels decline precipitously, and the hormone-starved uterine lining sloughs off in the monthly menstrual flow. During the following 2 weeks, when progesterone levels are low and the lining is relatively lean (see “B” at left), PMS symptoms generally abate.

Despite this, levels of the hormones themselves appear to be normal in women with PMS. To confound the issue further, one major study found that women with PMS continued to show symptoms even after their menstrual cycles were artificially “reset” with medication. Researchers are studying the possibility that some unknown outside factor disrupts the normal interaction of estrogen and progesterone with chemicals made in the brain to cause some PMS symptoms.

One theory links fluctuations in the levels of serotonin with PMS. Serotonin (a byproduct of L-tryptophan, an essential amino acid found in many foods) plays several important roles in the body: it helps regulate sleep and menstrual cycles as well as the appetite. Some researchers speculate that low levels of serotonin may underlie PMS, throwing off the delicate timing of ovulation and prompting the restlessness and food cravings so often experienced by women with PMS.

Other theories proposed by researchers include: a deficiency of endorphins, the chemicals in the brain that create a “natural high”; defects in the metabolism of glucose or vitamin B 6; low concentrations of zinc in the blood; fluctuations in prostaglandins, a family of hormone-like compounds found in most body tissue; low magnesium levels; an imbalance in the body's level of acidity; and chronic candidiasis, a vaginal yeast infection.

As of yet, there is no conclusive evidence to support any of these theories, making a definitive cure difficult, if not impossible. But research has shown that PMS responds well to a variety of treatments and that most women can minimize its effects by understanding and carefully managing their symptoms.

Deciding Whether You Have It

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The first step toward effective treatment is to confirm that your symptoms actually are caused by PMS. This is usually done by process of elimination, as there are no reliable tests to diagnose the condition.

Your doctor may first recommend some simple laboratory tests, such as blood tests or urinalysis, to rule out other conditions with similar symptoms, particularly diabetes or thyroid problems. If you regularly experience pelvic pain, your doctor may check for the presence of sexually transmitted diseases such as gonorrhea or chlamydia. You should also receive a thorough physical examination, including breast and pelvic exams, to rule out other undiagnosed medical conditions.

Mark your calendar on the day your period starts as Day 1. Number each subsequent day and use a letter code such as “A” for anger, “B” for breast tenderness, “C” for cravings, or “F” for fatigue to record any symptoms on the days they occur. You can use capital letters if the symptoms are severe and small letters if they're moderate, or use letters in combination with a rating scale of 1 to 10 to indicate mild to severe. Additional details to record include your daily weight and, to pinpoint when ovulation occurs, your basal temperature, taken after you wake up but before you get out of bed. Your local pharmacy should stock a basal thermometer.
Alternatively, design a simple chart that lists all of your symptoms down one side of a page and the days of your menstrual period across the top. Fill in the boxes that correspond with a given symptom and the day of your cycle in which it occurs. On days that you experience only mild symptoms, color in half the box.

The next step in establishing a diagnosis is to record your symptoms over a period of time to verify their appearance, severity, and duration. In fact, the only way PMS can be accurately diagnosed is by keeping a careful record of when each symptom appears each month. Simple record-keeping can be done with an ordinary calendar. See the nearby box on “Collecting the Evidence” for two methods.

It also helps to keep a diary that describes not only your symptoms but also their effect on your daily activities. Feelings of social withdrawal, outbursts at family members or co-workers, or difficulties in coping can be more thoroughly described in such a journal.

It's important to maintain your records for at least three menstrual cycles. Record your entries every day, while the symptoms and their effects are fresh in your mind. You and your doctor can then review the charts and journal to help determine whether you have PMS and the extent to which it affects your life.

Simple Steps
You Can Take Yourself

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After you've been able to document the cyclical nature of your symptoms and their severity, you and your doctor can develop a treatment plan. Your doctor may first recommend simple lifestyle changes, since PMS often responds remarkably well to modifications in eating habits, stress management, and increased amounts of sleep or exercise.

Caffeine is a major culprit of PMS symptoms. Found in a variety of substances—coffee, tea, soft drinks, chocolate and some over-the-counter medications—caffeine is a stimulant that is often consumed precisely for the “lift” it provides. Nevertheless, caffeine can exaggerate PMS-related problems such as anxiety, insomnia, nervousness, and irritability, and it can interfere with carbohydrate metabolism by depleting your body of vitamin B. Reducing your caffeine intake is a smart move to counteract PMS symptoms and can provide almost instant relief. In fact, some doctors routinely advise eliminating caffeine from the diet before every menstrual period as a first step in coping with PMS.

Many women with PMS gain several pounds during the two weeks preceding their period, much of this in fluid weight. Avoiding salty foods can dramatically reduce bloating and water buildup, resulting in less breast and abdominal tenderness and less swelling in the hands and feet. Since brain cells also have a tendency to retain fluid, you may find that a salt-free diet eliminates or curbs headaches and allows you to concentrate better.

Sugar can also play havoc on your body, especially in the days preceding your period. Eating sugary foods often initiates a vicious cycle of additional sugar cravings, as an increase in your body's need for B-complex vitamins prompts even more craving for sugar-laden simple carbohydrates. Although a link between PMS and difficulties in metabolizing sugar has not been proven, consuming sweets can put your body on a roller coaster between feeling weak and feeling high strung and jittery—your body's response to low sugar levels at one extreme, and elevated sugar levels at the other.

PMS has been linked to serious psychological problems in a small group of women. In Great Britain, women have been acquitted of various crimes on the grounds that the PMS from which they were suffering at the time of their action caused a temporary psychiatric disturbance. Though PMS is not recognized as a valid legal defense in the United States, the American Psychiatric Association (APA) recently recognized the possible psychiatric implications of PMS when it classified the related Premenstrual Dysphoric Disorder (PMDD) as a “depressive disorder not otherwise specified,” and included it in the appendix of the APA's Diagnostic and Statistical Manual of Mental Disorders, or DSM-IV.
PMDD, which is thought to affect fewer than 5 percent of menstruating women, is described by the APA as a pattern of severe, recurrent symptoms of depression and other negative moods that occur during the last week of the menstrual cycle and markedly interfere with daily living. While PMDD is not an official diagnostic category, the APA hopes its inclusion in DSM-IV will encourage further psychiatric research into the condition. (See “Spelling out PMDD.”)

Nicotine, a brain stimulant, can magnify PMS symptoms much like caffeine, so reducing or eliminating smoking should be part of any treatment program. Alcohol can also intensify symptoms because it depletes the body of vitamin B, disrupts the metabolism of carbohydrates, and affects the liver's ability to process hormones.

Some foods may genuinely relieve PMS symptoms. Complex carbohydrates such as whole grains, beans, fresh fruits, and vegetables help to maintain your body's essential vitamins and minerals. Eating a low-fat diet based on grains and vegetables while reducing your intake of red meat—especially during the two weeks prior to the beginning of your period—may help to control your PMS symptoms. And at least one study has suggested that a modest increase in calcium, to 1,300 milligrams per day, may reduce irritability and physical symptoms such as backaches.

Many women also find that exercise produces positive benefits in moderating PMS symptoms, while improving their general health. Consider a monthly workout plan that rotates activities designed to strengthen your muscles, reduce fat, and relieve tension. Vigorous exercise—running, biking, swimming, aerobics, racquet sports and the like—has been shown to elevate your mood and improve alertness, while calisthenics and body-building tone muscles and improve strength. Contrary to popular belief, exercise helps to control—not increase—your appetite.

With your doctor's approval, try a program that mixes more vigorous cardiovascular exercises during the early days of your menstrual cycle with stretching, flexibility exercises, and less vigorous cardiovascular work such as walking on the days when you're most prone to PMS symptoms. This regimen can increase your heart-lung capacity and improve your overall physical condition while reducing the strain on your breasts, thighs, and abdomen during the latter phase of your cycle.

PMS is also associated with disruptions in a woman's normal sleep patterns. Women with moderate to severe PMS symptoms are more likely to complain of insomnia and are known to spend less time in deep sleep than those who are symptom-free. Reducing caffeine intake can help. You may also benefit from short naps on certain days. In any event, try to get at least eight hours of uninterrupted sleep each night, especially during the latter half of your cycle.

You may also benefit from some stress management techniques. Unlike diet, exercise, and sleep, outside stress is the one factor of daily life that no one can control. How you approach and handle stress, however, can have a tremendous impact on your behavior and mood.

The causes of stress can be physical, such as chronic or episodic illness or injury; psychological, such as fears, anxieties, or frustrations; and social, such as crying children, rush-hour traffic, and even holiday preparations. These everyday aggravations are particularly annoying during the days you're experiencing PMS symptoms.

A stress management class can help you channel the tension caused by stress so you are less likely to lose control, a common complaint of women with PMS. Whether they emphasize breathing exercises, visualization, biofeedback, or other stress management techniques, a common theme is to help you maintain a positive attitude and develop realistic expectations.

How much improvement you can expect from these remedies—and how quickly—depends largely on your commitment to them and your willingness to change your habits. You may notice dramatic improvements almost immediately, or gradual improvement over several menstrual cycles. As you continue to record your symptoms, you may observe that more sleep or a brisk walk helps during certain premenstrual days, while modifying your diet helps during others. The bottom line is to focus on continual improvement rather than dwell on the symptoms.

Even though you can make many of these lifestyle and dietary changes without seeing a physician, it's better to enlist your doctor's expertise in developing a program tailored to your particular PMS symptoms and other health factors. Since no single treatment is uniformly effective for PMS, you can benefit from your physician's experience with other women who are successfully managing their condition.

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