Older women with complaints of vague symptoms such as abdominal bloating and discomfort, low-back pain, pelvic pain, urinary frequency, and constipation (e.g., frequently
blamed on benign conditions). By the time it is diagnosed, the cancer has already metastasized. If metastases, symptoms depend on area affected. Symptoms may be bone pain, abdominal pain, headache, blurred vision, others. Ovarian cancer is rarely diagnosed during the early stage of the disease (before metastasis). It is the fifth most common cancer among women in the United States.
Traditional oral contraceptive pills have 21 days of "active" pills and 7 days of placebo pills.
■ The last 7 days are the "hormone-free" days. The menstrual period usually starts within 2 to 3 days after the last active pill was taken (from very low levels of
■ Some brands of birth control pills (e.g., Loestrin FE) contain iron during the last 7 days of the pill cycle (instead of a placebo pill). The last 7 days (hormone-free) of the
pill cycle are there to reinforce the habit of daily pill-taking.
■ For the first pill cycle, advise patient to use "back-up" (an alternative form of birth control).
■ All the COCs, the patch, and the NuvaRing contain both estrogen and progesterone
(i.e., levonorgestrel, norethindrone, desogestrel, others).
■ The preferred birth control pill for breastfeeding women is the progestin-only pills or the "mini pill" (e.g., Microno, Nor-QD). Side effects includes spotting and
■ Yaz or Yasmin contains estrogen and drospirenone. Has a higher risk of blood clots, stroke, heart attacks, and hyperkalemia.
■ The contraceptive patch (i.e., Ortho Evra) results in higher levels of estrogen exposure compared to COCs (higher risk of blood clots, DVT).
■ The estrogen in COCs can elevate blood pressure. Check patient's BP before and 2 to 4 weeks afterward.
■ Educate patient that she may have spotting/light bleeding during the first few weeks after starting birth control pills.
■ Discourage patient from switching to another pill brand during the first 3 months because of spotting. Advise patient that most cases resolve within 3 months.
Missed 1 Day
■ Take two pills now and continue with same pill pack ("doubling up"). Missed 2 Consecutive Days
■ Take two pills the next 2 days to catch up and fi nish the birth control pill pack (use condoms for the current pill cycle).
A gradual loss of bone density secondary to estrogen defi ciency and other metabolic disorders.
Most common in older women (White or Asian descent) who are thin and with small body frames, especially if positive family history. Treat postmenopausal women
(or men aged 50 years or older) who have osteoporosis (T-score -2.5 or less) or history of hip or vertebral fracture.
Other risk groups include:
■ Patients on chronic steroids (severe asthma, autoimmune disorders, etc.) are at high risk for glucocorticoid-induced osteoporosis.
■ Rule out osteoporosis in older men on chronic steroids, especially if accompanied by other risk factors (lower testosterone, small frame, thin, White or Asian).
■ Androgen defi ciency, hypogonadism (low testosterone levels).
■ Anorexia nervosa and bulimia.
■ Gastric bypass, celiac disease, hyperthyroidism, ankylosing spondylitis, rheumatoid arthritis (RA), and others.
Lifestyle Risk Factors
Low calcium intake, vitamin D deficiency, inadequate physical activity.
■ Alcoholic (three or more/day), high caffeine intake.
■ Smoking (active or passive).
■ Weight-bearing exercises most days of the week.
- Swimming is not considered a weight-bearing exercise (but good for severe arthritis).
- Weight-bearing exercises are walking, jogging, biking, aerobic dance classes, most sports.
- Isometric exercises are not considered as weight-bearing type of exercise.
■ Calcium with vitamin D 1,200 mg /day and vitamin D3 (800 mg to 1,000 IU/day).
■ First-line drug for treating postmenopausal osteoporosis, osteoporosis in men, andglucocorticoid-induced osteoporosis (men and women).
■ Potent esophageal irritant (advise patients to report sore throat, dysphagia, midsternalpain). May cause esophagitis, esophageal perforation, gastric ulcers,reactivation/bleeding peptic ulcer disease (PUD).
■ Increases BMD and inhibits bone resorption.
■ Fosamax (alendronate) 5 mg to 10 mg/day or 70 mg weekly.
■ Actonel (risedronate) 5 mg/day or 35 mg weekly (or 150 mg tablet once a month).
- Take immediately upon awakening in a.m. with full glass (6-8 ounces) of plain water (do not use mineral water).
- Take tablets sitting or standing and wait at least 30 minutes before laying down.
- Do not crush, split, or chew tablets. Swallow the tablets whole.
- Never take these drugs with other medications, juice, coffee, antacids, vitamins.
- Will cause severe esophagitis or esophageal perforation if lodged in the esophagus.
■ Contraindications: Inability to sit upright, esophageal motility disorders, history of PUD or history of gastrointestinal (GI) bleeding.
■ Osteonecrosis of the jaw (mandible or maxilla) more likely if on chronic high doses of IM bisphosphonates. Complains of jaw heaviness, pain, swelling, and loose teeth.
Treatment about 4 years
Then consider Reclast.