Menopause and Osteoporosis Update 2009

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Journal of Obstetrics and Gynaecology Canada
The of?cial voice of reproductive health care in Canada
Le porte-parole of?ciel des soins génésiques au Canada
Journal d’obstétrique et gynécologie du Canada
Volume 31, Number 1 • volume 31, numéro 1
January • janvier 2009 Supplement 1 • supplément 1
Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S1
Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S4
Chapter 1: Towards A Healthier Lifestyle . . S5
Chapter 2: Vasomotor Symptoms . . . . . S9
Chapter 3: Cardiovascular Disease . . . S11
Chapter 4: Hormone Therapy
and Breast Cancer
. . . . . . . . . . . . . . . . . . . . S19
Chapter 5: Urogenital Health . . . . . . . . . S27
Chapter 6: Mood, Memory,
and Cognition
. . . . . . . . . . . . . . . . . . . . . . . . S31
Chapter 7: Bone Health . . . . . . . . . . . . . . S34
Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S42
Menopause and
Acknowledgements / Disclosures . . . . . S46
U p d a t e 2 0 0 9
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CPL Editor / Rédactrice PPP
Vyta Senikas
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Adjointe à la rédaction
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ISSN 1701-2163

Menopause and Osteoporosis Update 2009
Values: The quality of the evidence was rated with use of the criteria
described by the Canadian Task Force on Preventive Health Care.
This guideline was reviewed and approved by the Executive and
Recommendations for practice were ranked according to the
Council of the Society of Obstetricians and Gynaecologists of
method described by the Task Force. See Table.
Sponsor: The Society of Obstetricians and Gynaecologists of
Robert L. Reid, MD, FRCSC, Kingston ON
Jennifer Blake, MD, FRCSC, Toronto ON
Summary Statements and Recommendations
Beth Abramson, MD, FRCPC, Toronto ON
Aliya Khan, MD, FRCPC, Hamilton ON
Chapter 1: Towards a Healthier Lifestyle
No recommendations.
Vyta Senikas, MD, FRCSC, Ottawa ON
Michel Fortier, MD, FRCSC, Quebec QC
Chapter 2: Vasomotor Symptoms
1. Lifestyle modifications, including reducing core body temperature,
regular exercise, weight management, smoking cessation, and
avoidance of known triggers such as hot drinks and alcohol may
be recommended to reduce mild vasomotor symptoms. (IC)
Objective: To provide updated guidelines for health care providers
on the management of menopause in asymptomatic healthy
2. Health care providers should offer HT (estrogen alone or EPT) as
women as well as in women presenting with vasomotor symptoms
the most effective therapy for the medical management of
or with urogenital, mood, or memory concerns, and on
menopausal symptoms. (IA)
considerations related to cardiovascular disease, breast cancer,
3. Progestins alone or low-dose oral contraceptives can be offered as
and bone health, including the diagnosis and clinical management
alternatives for the relief of menopausal symptoms during the
of postmenopausal osteoporosis.
menopausal transition. (IA)
Outcomes: Lifestyle interventions, prescription medications, and
4. Nonhormonal prescription therapies, including treatment with
complementary and alternative therapies are presented according
certain antidepressant agents, gabapentin, clonidine, and
to their efficacy in the treatment of menopausal symptoms.
bellergal, may afford some relief from hot flashes but have their
Strategies for identifying and evaluating women at high risk of
own side effects. These alternatives can be considered when HT is
osteoporosis, along with options for the prevention and treatment
contraindicated or not desired. (IB)
of osteoporosis, are presented.
5. There is limited evidence of benefit for most complementary and
Evidence: MEDLINE was searched up to October 1, 2008, and the
alternative approaches to the management of hot flashes. Without
Cochrane databases up to issue 1 of 2008 with the use of a
good evidence for effectiveness, and in the face of minimal data
controlled vocabulary and appropriate key words.
on safety, these approaches should be advised with caution.
Research-design filters for systematic reviews, randomized and
Women should be advised that, until January 2004, most natural
controlled clinical trials, and observational studies were applied to
health products were introduced into Canada as “food products”
all PubMed searches. Results were limited to publication years
and did not fall under the regulatory requirements for
2002 to 2008; there were no language restrictions. Additional
pharmaceutical products. As such, most have not been rigorously
information was sought in BMJ Clinical Evidence, in guidelines
tested for the treatment of moderate to severe hot flashes, and
collections, and from the Web sites of major obstetric and
many lack evidence of efficacy and safety. (IB)
gynaecologic associations world wide. The authors critically
reviewed the evidence and developed the recommendations
6. Any unexpected vaginal bleeding that occurs after 12 months of
according to the methodology and consensus development
amenorrhea is considered postmenopausal bleeding and should
process of the Journal of Obstetrics and Gynaecology Canada.
be investigated. (IA)
7. HT should be offered to women with premature ovarian failure or
early menopause (IA), and it can be recommended until the age of
Key Words: Menopause, estrogen, vasomotor symptoms,
natural menopause (IIIC).
urogenital symptoms, mood, memory, cardiovascular disease,
breast cancer, osteoporosis, fragility fractures, bone mineral
8. Estrogen therapy can be offered to women who have undergone
density, lifestyle, nutrition, exercise, estrogen therapy,
surgical menopause for the treatment of endometriosis. (IA)
complementary therapies, bisphosphonates, calcitonin, selective
estrogen receptor modulators, antiresorptive agents
This document reflects emerging clinical and scientific advances on the date issued and is subject to change. The information
should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate
amendments to these opinions. They should be well documented if modified at the local level. None of these contents may be
reproduced in any form without prior written permission of the SOGC

Menopause and Osteoporosis Update 2009
Key to evidence statements and grading of recommendations, using the ranking of the Canadian Task Force
on Preventive Health Care*

Quality of evidence assessmentH
Classification of recommendationsI
Evidence obtained from at least one properly randomized
A. There is good evidence to recommend the clinical preventive
controlled trial
II-1: Evidence from well-designed controlled trials without
B. There is fair evidence to recommend the clinical preventive
II-2: Evidence from well-designed cohort (prospective or
C. The existing evidence is conflicting and does not allow to
retrospective) or case-control studies, preferably from more
make a recommendation for or against use of the clinical
than one centre or research group
preventive action; however, other factors may influence
II-3: Evidence obtained from comparisons between times or
places with or without the intervention. Dramatic results in
D. There is fair evidence to recommend against the clinical
uncontrolled experiments (such as the results of treatment
preventive action
with penicillin in the 1940s) could also be included in this
E. There is good evidence to recommend against the clinical
preventive action
III: Opinions of respected authorities, based on clinical
L. There is insufficient evidence (in quantity or quality) to make
experience, descriptive studies, or reports of expert
a recommendation; however, other factors may influence
*Woolf SH, Battista RN, Angerson GM, Logan AG, Eel W. Canadian Task Force on Preventive Health Care. New grades for recommendations from the
Canadian Task Force on Preventive Health Care. Can Med Assoc J 2003;169(3):207-8.
HThe quality of evidence reported in these guidelines has been adapted from the Evaluation of Evidence criteria described in the Canadian Task Force
on Preventive Health Care.*
IRecommendations included in these guidelines have been adapted from the Classification of Recommendations criteria described in the Canadian
Task Force on Preventive Health Care.*
Chapter 3: Cardiovascular Disease (CVD)
Chapter 5: Urogenital Health
Urogenital concerns

1. Health care providers should not initiate or continue HT for the sole
purpose of preventing CVD (coronary artery disease and
1. Conjugated estrogen cream, an intravaginal sustained-release
stroke). (IA)
estradiol ring, or estradiol vaginal tablets are recommended as
effective treatment for vaginal atrophy. (IA)
2. Health care providers should abstain from prescribing HT in
2. Routine progestin cotherapy is not required for endometrial
women at high risk for venous thromboembolic disease. (IA)
protection in women receiving vaginal estrogen therapy in
appropriate dose. (IIIC)
3. Health care providers should initiate other evidence-based
therapies and interventions to effectively reduce the risk of CVD
3. Vaginal lubricants may be recommended for subjective symptom
events in women with or without vascular disease. (IA)
improvement of dyspareunia. (IIIC)
4. Health care providers can offer polycarbophil gel (a vaginal
4. Risk factors for stroke (obesity, hypertension, and cigarette
moisturizer) as an effective treatment for symptoms of vaginal
smoking) should be addressed in all postmenopausal women. (IA)
atrophy, including dryness and dyspareunia. (IA)
5. As part of the management of stress incontinence, women should
5. If prescribing HT to older postmenopausal women, health care
be encouraged to try nonsurgical options, such as weight loss (in
providers should address cardiovascular risk factors; low- or
obese women), pelvic floor physiotherapy, with or without
ultralow-dose estrogen therapy is preferred. (IB)
biofeedback, weighted vaginal cones, functional electrical
stimulation, and/or intravaginal pessaries. (II-1B)
6. Health care providers may prescribe HT to diabetic women for the
relief of menopausal symptoms. (IA)
6. Lifestyle modification, bladder drill (II-1B), and antimuscarinic
therapy (IA) are recommended for the treatment of urge urinary
Chapter 4: Hormone Therapy and Breast Cancer
7. Estrogen therapy should not be recommended for the treatment of
postmenopausal urge or stress urinary incontinence but may be
1. Health care providers should periodically review the risks and
recommended before corrective surgery. (IA)
benefits of prescribing HT to a menopausal woman in light of the
association between duration of use and breast cancer risk. (IA)
8. Vaginal estrogen therapy can be recommended for the prevention
of recurrent urinary tract infections in postmenopausal women. (IA)
2. Health care providers may prescribe HT for menopausal symptoms
9. Following treatment of adenocarcinoma of the endometrium
in women at increased risk of breast cancer with appropriate
(stage 1) estrogen therapy may be offered to women distressed by
counselling and surveillance. (IA)
moderate to severe menopausal symptoms. (IB)
Sexual concerns
3. Health care providers should clearly discuss the uncertainty of
risks associated with HT after a diagnosis of breast cancer in
10. A biopsychosexual assessment of preferably both partners (when
women seeking treatment for distressing symptoms. (IB)
appropriate), identifying intrapersonal, contextual, interpersonal,

Menopause and Osteoporosis Update 2009
and biological factors, is recommended prior to treatment of
future fracture and confirms the diagnosis of osteoporosis
women’s sexual problems. (IIIA)
irrespective of the results of the bone density assessment. (1A)
11. Routine evaluation of sex hormone levels in postmenopausal
5. Treatment should be initiated according to the results of the
women with sexual problems is not recommended. Available
10-year absolute fracture risk assessment. (1B)
androgen assays neither reflect total androgen activity, nor
correlate with sexual function. (IIIA)
Calcium and vitamin D
12. Testosterone therapy when included in the management of
6. Adequate calcium and vitamin D supplementation is key to
selected women with acquired sexual desire disorder should only
ensuring prevention of progressive bone loss. For postmenopausal
be initiated by clinicians experienced in women’s sexual
women a total intake of 1500 mg of elemental calcium from dietary
dysfunction and with informed consent from the woman. The lack
and supplemental sources and supplementation with 800 IU/d of
of long-term safety data and the need for concomitant estrogen
vitamin D are recommended. Calcium and vitamin D
therapy mandate careful follow-up. (IC)
supplementation alone is insufficient to prevent fracture in those
with osteoporosis; however, it is an important adjunct to
pharmacologic intervention with antiresorptive and anabolic drugs. (1B)
Chapter 6: Mood, Memory, and Cognition
1. Estrogen alone may be offered as an effective treatment for
Hormone therapy
depressive disorders in perimenopausal women and may augment
7. Usual-dosage HT should be prescribed for symptomatic
the clinical response to antidepressant treatment, specifically with
postmenopausal women as the most effective therapy for
SSRIs (IB). The use of antidepressant medication, however, is
menopausal symptom relief (1A) and a reasonable choice for the
supported by most research evidence (IA).
prevention of bone loss and fracture. (1A)
2. Estrogen can be prescribed to enhance mood in women with
8. Physicians may recommend low- and ultralow-dosage estrogen
depressive symptoms. The effect appears to be greater for
therapy to symptomatic women for relief of menopausal symptoms
perimenopausal symptomatic women than for postmenopausal
(1A) but should inform their patients that despite the fact that such
women. (IA)
therapy has demonstrated a beneficial effect in osteoporosis
3. Estrogen therapy is not currently recommended for reducing the
prevention (1A), no data are yet available on reduction of fracture
risk of dementia developing in postmenopausal women or for
retarding the progression of diagnosed Alzheimer’s disease,
although limited data suggest that early use of HT in the
menopause may be associated with diminished risk of later
9. Treatment with alendronate, risedronate, or zoledronic acid should
dementia. (IB)
be considered to decrease the risk of vertebral, nonvertebral, and
hip fractures. (1A)
Chapter 7: Bone Health
10. Etidronate is a weak antiresorptive agent and may be effective in
1. The goals of osteoporosis management include assessment of
decreasing the risk of vertebral fracture in those at high risk. (1B)
fracture risk and prevention of fracture and height loss. (1B)
Selective estrogen receptor modulators
2. A stable or increasing BMD reflects a response to therapy in the
11. Treatment with raloxifene should be considered to decrease the
absence of low trauma fracture or height loss. Progressive
risk of vertebral fractures. (1A)
decreases in BMD, with the magnitude of bone loss being greater
than the precision error of the bone densitometer, indicate a lack of
response to current therapy. Management should be reviewed and
modified appropriately. (1A)
12. Treatment with calcitonin can be considered to decrease the risk
of vertebral fractures and to reduce pain associated with acute
3. Physicians should identify the absolute fracture risk in
vertebral fractures. (1B)
postmenopausal women by integrating the key risk factors for
fracture; namely, age, BMD, prior fracture, and glucocorticoid
Parathyroid hormone
use. (1B)
13. Treatment with teriparatide should be considered to decrease the
4. Physicians should be aware that a prevalent vertebral or
risk of vertebral and nonvertebral fractures in postmenopausal
nonvertebral fragility fracture markedly increases the risk of a
women with severe osteoporosis. (1A)

Menopause is a critical phase in the lives of women. It choicesandmedicaloptionsandtomakerecommendations
evokes discussion, controversy, and concern among
that will maintain or improve her quality of life. This oppor-
women and their health care providers about how best to
tunity requires that health care providers avail themselves of
deal with acute symptoms and what changes or interven-
the available scientific information on aging and familiarize
tions are best for optimization of long-term health. In 2009,
themselves with the emerging information.
as the largest demographic from the “baby-boomer” gener-
The appropriateness of offering HT as an option to meno-
ation reaches age 50 years, we will begin a period of historic
pausal women has come under the spotlight with conflict-
demand for menopausal counselling.
ing reports of benefits and risks and confusion about how
Women entering menopause are highly motivated to make
these compare. This document will provide the reader with
changes to optimize their health. Thus, health care provid-
an update about the controversies surrounding HT for
ers have a unique opportunity to review a woman’s lifestyle
menopausal women and will try to bring balance and per-
spective to the risks and benefits to facilitate informed dis-
cussion about this option.
Abbreviations Used in This Guideline
In 2006, the SOGC published a detailed update from the
bone mineral density
Canadian Consensus Conference on Menopause that high-
body mass index
lighted recommendations for counselling and care of
coronary artery disease
menopausal women.1 Few of these recommendations have
conjugated equine estrogens
changed, although new data have allowed some additional
confidence interval
insights, which are reflected in the recommendations of the
C-reactive protein
current report.
cardiovascular disease
The current consensus document was developed after a
hormonal replacement therapy after breast cancer—
detailed review of publications pertaining to menopause,
Is it safe?
osteoporosis, and postmenopausal HT. Published literature
Heart and Estrogen/progestin Replacement Study
was identified through searching PubMed (up until
hazard ratio
February 7, 2008) and the databases of the Cochrane
hormone therapy
Library (issue 1, 2008), with the use of a combination of
controlled vocabulary (e.g., Hormone Replacement Ther-
intima–media thickness
apy, Cardiovascular Diseases, Mental Health) and key
Multiple Outcomes of Raloxifene Evaluation
words (e.g., hormone replacement therapy, coronary heart
medroxyprogesterone acetate
disease, mental well-being). Research-design filters for sys-
odds ratio
tematic reviews, randomized and controlled clinical trials,
randomized controlled trial
and observational studies were applied to all PubMed
relative risk
searches. Results were limited to publication years 2002 to
selective estrogen-receptor modulator
2008; there were no language restrictions. Additional infor-
mation was sought in BMJ Clinical Evidence, in guidelines col-
serotonin–norepinephrine reuptake inhibitor
lections, and from the Websites of major obstetric and
selective serotonin reuptake inhibitor
gynaecologic associations world wide.
Study of Tamoxifen and Raloxifene
Women’s Health Initiative
Women’s Health Initiative Memory Study
1. Bélisle S, Blake J, Basson R, Desindes S, Graves G, Grigoriadis S, et al.
Canadian Consensus Conference on Menopause, 2006 update. J Obstet
WISDOM Women’s International Study of long Duration
Gynaecol Can 2006;28(2 Suppl 1):S1-S112.
Oestrogen after Menopause

Chapter 1
Towards a Healthier Lifestyle
In 2009, as the largest demographic from the menopause,andcertainsegmentsofthepopulation,suchas
“baby-boomer” generation reaches age 50 years, a period
African-Americans, are more likely to manifest these risk
of historic demand for menopausal counselling will begin,
factors. HT appears to slightly increase the risk of ischemic
along with an unprecedented opportunity to influence pat-
stroke, and caution should be taken to manage hyperten-
terns of disability and death in the later decades of life. As
sion and other risk factors in women seeking treatment for
outlined in the following chapters of this update to the
distressing vasomotor symptoms.5 Clearly, risk factors for
stroke should be addressed in all menopausal women and
Canadian Consensus Conference on Menopause1 and the
particularly in those seeking HT.
Canadian Consensus Conference on Osteoporosis,2 many
of the risk factors for the conditions prevalent among older
The mainstay for CVD prevention will remain a lifelong
women are modifiable through changes in lifestyle.
pattern of healthy living incorporating a balanced,
heart-healthy diet, moderate exercise, maintenance of a
healthy body weight, avoidance of smoking, limited con-
sumption of alcohol, and attention to treatment of known
Women entering menopause today have had the advantages
risk factors, such as hypertension, hypercholesterolemia,
of growing up with access to better nutrition, a greater focus
and diabetes mellitus.
by society and by health care professionals on preventive
health care, and much improved access to information
about healthy living. Over the past 25 years, the risk of heart
disease has progressively fallen.3 Still, CVD remains the
The benefits of a healthy lifestyle extend well beyond opti-
leading cause of death and an important contributor to ill-
mizing cardiovascular health. For best preservation of
memory and cognition, women should be advised about the
postmenopausal women will have CVD, and a third will die
importance of good overall health, including good cardio-
from it. The risk of CVD rises with age and increases signif-
vascular health, exercise,6 avoidance of excessive alcohol
icantly after menopause.
consumption, and measures to reduce the risk of diabetes
and hypertension, as well as maintenance of an active mind.
The INTERHEART study, an RCT examining modifiable
risk factors across many populations, determined that the
The risk of breast cancer associated with postmenopausal
main risks for CVD are modifiable and that for women
HT is the health risk of greatest concern to women and to
94% of CVD risk could be attributed to modifiable factors.4
their physicians. Singletary7 tried to place various breast
Factors identified in that study as contributing substantially
cancer risk factors into perspective, noting that HT, as a
to increased CVD risk included diabetes mellitus, hyperten-
risk, rates about the same as early menarche, late meno-
sion, abdominal obesity, current smoking, and psychosocial
pause, and a variety of lifestyle-associated risks, such as
stress. Each of these risks can be reduced through appropri-
excessive alcohol consumption and failure to exercise.
ate choices, interventions, or both. Available evidence dem-
Attention should be directed to modifiable risk factors,
onstrates that initiation of HT should be done with caution
such as smoking, sedentary lifestyle, excessive intake of
in women with distressing vasomotor symptoms who are
alcohol, and postmenopausal weight gain.8 Reduction of
more than a decade after menopause because of the associa-
dietary fat intake was not associated with any reduction in
tion with an increased risk of adverse cardiac events. Atten-
breast cancer risk in the WHI9 but may help prevent cardio-
tion to correction of underlying cardiovascular risk factors
vascular diseases and possibly ovarian cancer.10
before initiation of HT would be important in these isolated
Adequate calcium and vitamin D intake is necessary to
attain and maintain normal bone quantity and quality and
Stroke is also a leading cause of disability and death among
thus achieve optimal bone strength. But an exercise pro-
women, especially postmenopausal women. Risk factors for
gram is also essential to the prevention and treatment of
stroke (obesity, hypertension, smoking, and diabetes) are
osteoporosis. A comprehensive calculation of the 10-year
common among North American women as they enter
absolute fracture risk, available from the World Health

Menopause and Osteoporosis Update 2009
Organization,11 includes current tobacco smoking and alco-
available in 13 languages, and a version has been specially
hol intake of 3 or more units daily among the risk factors
tailored for First Nations, Inuit, and Métis people.
now added to the traditional risk factors of age, low BMD,
The guide encourages Canadians to focus on vegetables,
prior fracture, and glucocorticoid use. Younger individuals
fruit, and whole grains, to include milk, meat, and their
at a low risk of fracture are appropriately managed with life-
alternatives, and to limit foods that are high in calories, fat
style changes and strategies designed to prevent bone loss,
(especially trans fats), sugar, and salt. The enhanced, inter-
with an emphasis on regular exercise and reduced con-
active Web component, “My Food Guide,” helps users per-
sumption of alcohol (to less than 2 drinks/d) and coffee (to
sonalize the information according to age, sex, and food
less than 4 cups/d). Smoking cessation should also be
preferences; it includes more culturally relevant foods from
strongly advised.
a variety of ethnic cuisines. To build a customized plan for
Some of the risk factors for urinary incontinence are modi-
healthy choices in both nutrition and physical activity after
fiable with lifestyle changes. Those identified include obe-
menopause, a woman can start by choosing “Female” and
sity, amount and type of fluid intake, and smoking. For
age “51 to 70.” She learns that she should be consuming
obese women (mean baseline BMI, 38.3 kg/m2), even a
each day 7 servings of vegetables and fruits, 6 of grain prod-
reduction in BMI of as little as 5% can result in significant
ucts, 3 of milk and alternatives, and 2 of meat and alterna-
subjective improvement in urine loss.12 The effect of BMI
tives. Within each food group, she is invited to choose 1 to 6
and weight gain was assessed in 30 000 women with
examples. For the first group, vegetables and fruits, the
new-onset urinary incontinence in the Nurses’ Health Study
long, colourfully illustrated list (with serving sizes and notes
II.13 Increasingly higher BMI was related to increasing odds
about acceptable alternatives) is headed by 3 general recom-
of incontinence developing (P for trend < 0.001). The
mendations: eat at least 1 dark green and 1 orange vegetable
increases were similar for all incontinence types. The odds
a day, prepare vegetables and fruits with little or no added
of incontinence also increased with increasing adult weight
fat, sugar, and salt, and have vegetables and fruits more
gain (P for trend < 0.001): the OR for at least weekly incon-
often than juice. The vegetables and fruits are grouped in 2
tinence developing was 1.44 (95% CI, 1.05 to 1.97) among
lists, 1 of dark green and orange choices and the other of
women who had gained 5.1 to 10 kg since early adulthood
additional choices. After making selections and clicking on
and 4.04 (95% CI, 2.93 to 5.56) among women who had
“Next,” the woman is presented with the other categories
gained more than 30 kg compared with women who had
of food in turn and then categories of physical activity. At
maintained their weight within 2 kg. In the same popula-
the end a colourful PDF of “My Food Guide” is produced;
tion, physical activity was associated with a significant
it can be printed or saved on one’s computer. This summary
reduction in the risk of urinary incontinence developing.
reiterates the tips for each food category and the portion
The results appeared to be somewhat stronger for stress uri-
size for each choice, notes that “age 50 or over, include a
nary incontinence than for urge urinary incontinence.14
vitamin D supplement of 10 mg (400 IU), and recommends
“Build 30 to 60 minutes of physical activity into your day
every day.”
Also on the guide’s website is “My Food Guide Servings
Canada’s Food Guide
Tracker”. This tool helps users keep track of the amount
and type of food eaten each day and to make comparisons
Since 1942, Canada’s Food Guide has provided advice on
with the recommendations. Tips about food and physical
food selection and nutritional health. With the February
activity are reiterated on the sheet that is printed out. A
2007 launch of the latest version, Eating Well with Canada’s
recent RCT has shown that people trying to lose weight
Food Guide,15 come 2 major changes: the guide now offers
who use a dietary log will lose twice as much weight as those
information on the amount and types of food recom-
who do not keep track of their food intake.16 Those studied,
mended according to age and sex, and it emphasizes the
at an average age of 55 years, were overweight or obese. All
importance of combining regular physical activity with
participants were asked to revise their diets to include less
healthy eating. With the growing concern about the rates of
fat, more vegetables, fruits, and whole grains, to increase
overweight and obesity among Canadians, providing advice
their exercise, and to attend meetings that encouraged calo-
on portion size and the quality of food choices was a key
rie restriction, moderate-intensity physical activity, and
consideration in this revision of the guide. The new guide
dietary approaches to reduce hypertension.
was developed through widespread consultation with
approximately 7000 stakeholders, including dietitians, sci-
Linked to the Food Guide website is the site for EATracker
entists, physicians, and public health personnel with an
(Eating and Activity Tracker),17 a tool developed by the
interest in health and chronic disease prevention. It is
Dietitians of Canada to provide even more detailed

CHAPTER 1: Towards a Healthier Lifestyle
Selected resources
Organization and details
Breast cancer risk
US National Cancer Institute: Breast Cancer Risk
Assessment Tool
Disease risk and
Siteman Cancer Center, Washington University School of
Medicine: Your Disease Risk (health tool, originally developed
at the Harvard Center for Cancer Prevention, which covers
cancer, diabetes, heart disease, osteoporosis, and stroke)
Public Health Agency of Canada: Physical Activity Guide
Heart disease and
Heart and Stroke Foundation of Canada: information on heart
disease, stroke, nutrition, physical activity, smoking cessation,
and stress reduction
Society of Obstetricians and Gynaecologists of Canada: clini-
cal practice guidelines, consensus conference reports, and
educational material for consumers
Health Canada: Eating Well with Canada’s Food Guide
Dietitians of Canada: EATracker (Eating and Activity Tracker)
Osteoporosis Canada: information on diagnosis, prevention,
and treatment
Sexual health
Society of Obstetricians and Gynaecologists of Canada: news
and information on sexual-health issues, including a section
for women over 50 years of age
Weight control
US National Heart, Lung, and Blood Institute: Aim for a Healthy
Weight (Obesity Education Initiative: information for patients
and the public and for health professionals)
*Last accessed September 1, 2008.
nutritional information and guidance as one progresses
day to get the fat that is needed; this amount includes oil
through an attempt to make healthy changes in both eating
used for cooking, salad dressings, margarine, and mayon-
and physical activity.
naise. Having 2 servings of fish a week is also
As Dr David Butler-Jones, Chief Public Health Officer for
Canada, said at the launch of the new food guide, “By
increasing their levels of physical activity, improving eating
Other dietary strategies to reduce the CVD risk include
habits, and achieving healthy weights, Canadians can help
increasing the intake of flavonoids22,23 (found in vegetables,
ensure good health and prevent many chronic diseases,
fruits, and tea), dietary folate24 (found in vegetables, fruits,
including some cancers, type 2 diabetes, cardiovascular
and grains), and soy products25 (sources of isoflavones).
disease and stroke.”
Diet and Bone Health
Diet and Heart Disease
Minimizing the rate of bone loss with age requires adequate
Observational studies show a relationship between serum
nutrition and, in particular, adequate intake of calcium and
cholesterol levels and CVD.18 Dietary measures to lower
vitamin D. If dietary intake is reduced in order to lower
those levels are an important part of the prevention of
dietary fat content, calcium intake may need to be supple-
CVD.19 Evidence from the Nurses’ Health Study suggests
mented. Diet alone is not sufficient to prevent bone loss in
that replacing dietary saturated fat and trans fatty acids with
women with early menopause. 26 Supplementation of both
nonhydrogenated, monounsaturated, and polyunsaturated
calcium and vitamin D may be necessary, especially in those
fats may be more effective in reducing the CVD risk than
with low intake of dairy products.
reducing overall fat intake in women.20 The intake of
omega-3 fatty acids is linked to a reduced risk of CVD;21
For postmenopausal women the SOGC recommends a
potential dietary sources of these fats include cold water
total intake of 1500 mg of elemental calcium from dietary
fish (salmon, tuna, and halibut), flax seeds, and flax seed oil.
and supplemental sources and, to ensure optimal calcium
Canada’s Food Guide recommends limiting the amount of
absorption, supplementation with 800 IU/d of vitamin D
saturated fat and trans fatty acids used each day and includ-
(twice as much vitamin D as recommended in Canada’s Food
ing 30 to 45 mL (2 to 3 tablespoons) of unsaturated fat each
Guide) for women 50 years of age or older.

Menopause and Osteoporosis Update 2009
Diet and Cancer
6. Pines A, Berry EM. Exercise in the menopause—an update. Climacteric 2007;10(Suppl
It has been estimated that 30% to 40% of all cancer could
be prevented with a healthy diet, regular physical activity,
7. Singletary SE. Rating the risk factors for breast cancer. Ann Surg 2003;4:474–82.
and maintenance of an appropriate body weight.27 Possible
8. Reeves GK, Pirie K, Beral V, Green J, Spencer E, Bull D. Million Women Study
Collaboration. Cancer incidence and mortality in relation to body mass index in the
associations between aspects of diet and breast cancer have
Million Women Study: cohort study. BMJ 2007;335:1134. Epub 2007 Nov 6.
come under scrutiny, with emphasis on intake of fat and
9. Prentice RL, Caan B, Chlebowski RT, Patterson R, Kuller LH, Ockene JK, et al.
isoflavones. Reduction of dietary fat intake in the WHI was
Low-fat dietary pattern and risk of invasive breast cancer: the Women’s Health
not associated with any reduction in breast cancer risk,9
Initiative Randomized Controlled Dietary Modification Trial.JAMA 2006;295:629–42.
although it may have a benefit in preventing ovarian cancer.10
10. Prentice RL, Thomson CA, Caan B, Hubbell FA, Anderson GL, Beresford SA, et al.
Low-fat dietary pattern and cancer incidence in the Women’s Health Initiative Dietary
Modification Randomized Controlled Trial. J Natl Cancer Inst 2007;99:1534–43.
11. FRAX: WHO fracture assessment tool [Web site]. Sheffield, England: World Health
In addition to protecting against CVD, diabetes, and breast
Organization Collaborating Centre for Metabolic Bone Diseases. Available