Vitamin D- How Low Can You Go?

by Lauren Streicher, MD

Vitamin D: It’s the magical supplement pill you can purchase at your local pharmacy that prevents cancer, and reduces the risk of autoimmune diseases, chronic inflammation, multiple sclerosis, osteoporosis, heart disease, and even the flu. Or is it?

A quick Internet search would seem to confirm the many health benefits of vitamin D. But before you go out and purchase a lifetime supply, there are two things that you should know about this much-touted vitamin.

The first is that scientific research shows only one absolutely proven medical reason to take vitamin D: to facilitate the absorption of calcium that can decrease bone loss and reduce your risk of breaking a bone. Even if vitamin D doesn’t prevent cancer and chronic disease, prevention of osteoporosis is reason enough to want to maintain an adequate vitamin D level.

Which leads me to the second thing you should know about vitamin D: Experts are still debating the optimal vitamin D level to assure bone health, but also for other possible health benefits. Recommendations have ranged from the Institute of Medicine’s suggested 20 nanograms per milliliter (ng/mL), to the National Osteoporosis Foundation‘s 30 ng/mL, to the Vitamin D Council‘s 40-80 ng/mL.

Why You May Need That Vitamin D Supplement

It’s no surprise that a significant portion of the adult population has low, and sometimes really low, vitamin D levels. The winter months pretty much guarantee a deficit in many adults, since vitamin D is synthesized in the skin after exposure to sunlight.  Even if you live on the beach, getting plenty of sunshine — and therefore vitamin D — puts you at risk for melanoma, wrinkles, and sunspots. Skin problems like these make basking in the sun without a hat, sunglasses, and a high SPF sunscreen a forbidden treat. And there is not much vitamin D found naturally in food, so you can’t always improve your levels through diet.

There are other reasons that you may have low vitamin D levels. Decreased absorption of vitamin D due to gastrointestinal illness, surgery, and normal aging also can contribute to levels that are too low in your body to effectively protect your bones.

Researchers have also theorized about the connection between vitamin D levels and inflammation. But, as a July 2014 Inflammation Research review  states, “Evidence that vitamin D supplementation cures or prevents chronic disease is inconsistent.” What appears to be likely is that chronic inflammation is what leads to low vitamin D levels in the body.

Why You May Need Less Vitamin D Than You Think

The debate over vitamin D  is no small issue, since almost half of all women break a bone after menopause, and millions of women over the age of 50 are advised by their doctors to take a vitamin D supplement to get their levels up to “normal.”

A study published in the August 2015 issue of the Journal of the American Medical Association looked specifically at the serum (or  blood) levels of vitamin D needed to absorb calcium. In this randomized, double-blind clinical trial,  researchers at the University of Wisconsin at Madison gave230 postmenopausal women under the age of 75 one of the following:

  • Dailyand monthly doses of placebo pills
  • Daily 800 international units (IU) vitamin D3 with monthly placebo pills (low dose)
  • Daily placebo pills with twice monthly doses of50,000 IU vitamin D3 (high dose)

This trial lasted for four years, and the results revealed a couple of things:

First, calcium absorption increased 1 percent in the high-dose group, but decreased 2 percent and 1.3 percent  in the low-dose and placebo groups, respectively. So while supplementing with high levels of D increased calcium absorption, it wasn’t enough to deliver bone and muscle health benefits.

Second, the researchers found that the most-commonly cited recommendation, to maintain a level of at least 30 ng/mL, is not necessary for bone health.

This is a major paradigm shift, since most doctors (myself included) have routinely measured serum vitamin D levels and recommended a supplement to patients whose levels are lower than 30.

As the authors of the Wisconsin study concluded, “Study results do not justify the common and frequently touted practice of administering high- dose cholecalciferol (vitamin D3) to older adults to maintain serum [vitamin D] levels of 30 ng/mL or greater.” They suggest instead that a lower minimum level, 20 ng/mL, is adequate.

While the jury is still out on this one, it is something to consider. No, I haven’t stopped my daily vitamin D supplement (I live in cold, cloudy Chicago). But I’m certainly thinking about it.

Originally published 8/15/15

Incontinence: Can It Kill You?

By Lauren Streicher, MD 


Involuntary loss of urine is embarrassing, inconvenient and distressing, but the one thing I have always assured my patients is that it is not a life-threatening condition. Recently, my perspective on that has changed.

One of my patients mentioned to me that she had just recovered from a hip fracture that required a lengthy hospitalization and surgery. I asked her how she broke her hip and she replied, “I fell down at home.” That’s not unusual. In fact, most hip fractures occur from falls at home. She then said, “Actually, I never told anyone else, but I will admit to you that I was rushing to get to the bathroom and didn’t quite make it. I slipped on my urine and fell.”

I wondered how many other home falls were due to incontinence and did a little digging.

I found a number of studies that confirmed the association between urinary urgency, incontinence and falls that result in fracture including a 2013 article in the Journal of Clinical Nursing that showed that these often occur in elderly women living at home. It’s impossible to know exactly how many women fracture their hip running to get to the bathroom. Just as my patient didn’t report the reason for her fall, many women probably don’t report the reason for their fall to medical providers. Millions of women, especially older women, live with urinary incontinence. While we can’t know for sure how many falls every year result from rushing to the bathroom, the numbers are likely very high.

This is no small issue. There are 54 million people with osteoporosis in the United States. About one in three people who fracture their hip will die within a year of the fracture. In spite of the prevalence of the problem, most women do not report their incontinence. The reasons vary from embarrassment to assuming that a leaky bladder is a “normal consequence of aging.” Unfortunately, about half of women that do report leakage to a health-care provider are inadequately treated. Pads and diapers are commonly recommended, but they should be thought of as a means to manage–not treat–incontinence.

Know that there are many options available for treating your incontinence. You can have relief now, whether it’s with surgery, medication, pelvic-floor physical therapy, or an electrical stimulation biofeedback device, without waiting until you are older to do so. If your primary-care doctor or gynecologist does not offer options, consider seeing a urogynecologist.

While it is important to prevent and treat bone loss, preventing falls is equally important. If you are one of those women that gets that sudden “gotta go” feeling and then dashes, make sure there is a clear path between the bed and the bathroom. And then make an appointment to see your doctor.

Origianlly published 11/14 2014

A Risky Side Effect of Hot-Flash Treatment: Bone Loss June 30, 2015 June 30, 2015

In spite of the reassurances of menopause experts like me, many women choose not to take estrogen or have been advised by their doctors to steer clear. In fact, fewer than 10 percent of women with hot flashes ultimately accept a prescription for estrogen, and many never fill it. For the 90 percent who prefer not to take estrogen, or have been told they should not, most quickly find that doing yoga, wearing layers, and avoiding red wine are not real solutions.

For years, my go-to alternative to estrogen therapy has been to prescribe a selective serotonin reuptake inhibitor (SSRI) such as Paxil (paroxetine) or a serotonin and norepinephrine reuptake inhibitor (SNRI) such as venlafaxine. It has been known for some time that these non-hormonal drugs developed to treat depression also significantly reduce hot flashes in menopausal women.

The problem, other than that women really don’t want to be prescribed an antidepressant for hot flashes when their problem is not depression, is that many women experience the known side effects of SSRIs – namely, loss of libido and weight gain. The last thing a menopausal woman needs is a drug that might sabotage her diet or an already waning sex drive!

Now there is an additional concern. A new study published in the BMJ journal Injury Prevention suggests that hot-flashing women who take an SSRI at the standard doses used to treat depression may accelerate bone loss and increase their fracture risk. This is actually not new information: Prior epidemiological studies on bone fracture risk following exposure to SSRIs have reported an association (as opposed to a cause-and-effect relationship) between SSRI treatment and fractures.

The real question: Is the same issue seen in low-dose paroxetine? Specifically, does Brisdelle (the only FDA-approved nonhormonal option for hot flash relief), with 7.5 milligrams of paroxetine, have the same side effects seen in doses of 10, 20, 30, and 40 mg of paroxetine?

In clinical trials, Brisdelle, unlike the higher doses of paroxetine used to treat depression, was not associated with a decrease in libido or an increase in weight.

At this point, it is impossible to say with certainty that 7.5 mg of paroxetine does not accelerate bone loss since this dose was not studied in the BMJ/Injury Prevention group. However, it stands to reason that 7.5 mg of paroxetine used to treat hot flashes is less likely to cause bone loss than higher doses intended to treat depression.

So, the bottom line: SSRIs are an excellent option to alleviate hot flashes if estrogen is not an option. But make sure you are bone savvy. Take your calcium, get in that weight-bearing exercise, check your vitamin D levels, and have your bone density checked according to National Osteoporosis Foundation guidelines. Know that if you are losing bone, your SSRI might be part of the problem. As with every drug with potential side effects, it makes good sense to take the lowest dose needed to treat the problem. While it’s tempting to take a less expensive higher-dose generic to alleviate your hot flashes, know it might kill your libido, put on the pounds, and possibly deplete your bones.