Gout on the legs: causes, symptoms, diagnosis and treatment

Gout in men: causes and treatment options

Gout is a fairly rare disease that is characterized by the accumulation of uric acid salts in the joints. Gout is much more common in men than in women. It manifests itself in very painful attacks, and they can occur in any joint of the human body.

Contributing to the development of gout are obesity, a sedentary lifestyle, a passion for alcoholic beverages, as well as heredity - if you have close relatives who once suffered from gout, the risk of this disease increases significantly.

Who gets sick more often

Some interesting facts:

According to statistics, 0.1% of the world's population suffers from this disease. An increase in the level of uric acid is detected much more often - in every 10-20th person (this does not mean at all that these people have gout, but it increases the likelihood of its development in the future).
The majority of patients are men (for every 1 woman there are 2 to 7 men suffering from gout).
Every year, about 1-3 cases of this disease are registered per 1000 men, and only 0.2 cases per the same number of women.
The peak incidence among men is 40-50 years old, among women - the postmenopausal period (usually 60 years and older). Women of reproductive age suffer from gout extremely rarely.
Gout is more common in developed, wealthy countries, where the population can afford to eat large amounts of foods rich in purines - meat and fish, in combination with alcohol. These data are confirmed by a significant decrease in morbidity during the Second World War, when people were forced to sharply limit their diet.

Who is most likely to get gout?

The incidence of gout, according to medical statistics, varies from 0.2 to 6%. Gout is considered to be a male disease. For every 10 men diagnosed with gout, there is one woman. Often, the first attack of the disease occurs in men aged 35 to 40 years. In women, the risk of morbidity after 50 years is very high. However, there are cases of earlier development of the disease. The risk group includes people who frequently consume meat and alcohol (especially beer). Gout is often diagnosed with concomitant diseases such as diabetes, obesity, and atherosclerosis.

Gout is considered a men's disease

Metabolism of uric acid in the body: the basics

Uric acid in the human body is formed by the decomposition of special substances - purines. Its reserves are about 1000 mg, and daily 650 mg are excreted from the body and the same amount enters.

Some purines enter the body with food, while others are synthesized in the body from other substances.

In the blood, uric acid is found in the form of free sodium urate. Normal values for its level are 0.3-0.42 mmol/l for men, and for women – 0.24-0.36 mmol/l. Concentrations of the substance above these numbers are regarded as hyperuricemia. In such patients, the risk of developing gout in the future is increased.

For many years, hyperuricemia can occur without any symptoms, without manifesting itself in any way, but sooner or later it will most likely develop into gout.

Gout in women

Signs of gout on the legs of women usually appear after 50 years, during menopause. The culprit is believed to be a change in the level of the female hormone estrogen. It prevents the development of the disease, but during menopause its content decreases significantly, so the risk of developing gout increases significantly.

Changes in the level of the female hormone estrogen are considered to be the culprit of the disease

Causes and mechanism of disease development

Eating large amounts of foods rich in purines can trigger a gout attack.
As mentioned above, the processes of secretion of uric acid and its entry into the body are normally balanced. Sometimes disturbances in these processes occur, which lead to increased levels of uric acid in the blood. In particular, these may be excessive formation (entering the body from the outside) and/or insufficient excretion of uric acid in the urine.

Depending on the mechanism of development, primary and secondary hyperuricemia are distinguished.

Primary hyperuricemia

This pathology is considered the cause of the development of primary gout. This is an inherited abnormality of purine metabolism. This fact is confirmed by the fact that gout often develops in relatives, and every 5th family member of a person with gout has an increased level of uric acid in the blood.

Risk factors for primary hyperuricemia are:

overeating, especially foods rich in purines, as well as fatty foods;
frequent consumption of large amounts of alcohol;
excess body weight;
high blood pressure;
increased levels of fats in the blood;
stress;
dehydration and others.

Secondary hyperuricemia

As a rule, this condition is caused by insufficiency of kidney function, which reduces the rate of excretion of uric acid salts from the body. Hyperuricemia can also be detected in the following diseases and conditions:

extensive psoriasis;
hypertension “with experience” (long-term);
hyperfunction of the parathyroid glands;
myxedema;
diabetes;
pregnancy complicated by toxicosis;
lead intoxication;
the use of certain medications (diuretics, small doses of salicylates and others).

Gout itself develops against the background of prolonged hyperuricemia. In response to high levels of uric acid in the blood, the body reacts by deposition of its salts (urates) in tissues and increased excretion of this substance in the urine.

Urates are deposited mainly in the area of cartilage, joints and structures that form them, in the skin and kidneys, disrupting their functions.

Their deposition in the structures of the kidney is especially dangerous - gouty nephropathy.

An acute attack of gout develops in people who have been suffering from hyperuricemia for a long time. Provoking factors contribute to this:

consumption of alcohol, fatty, purine-rich foods;
prolonged fasting;
injury;
heavy physical or mental stress;
infectious diseases;
use of certain medications.

These factors cause a sharp increase in the level of uric acid in the blood, the loss of small crystals of sodium urate into the joint cavity - this provokes the development of acute inflammation of the joint tissue.

What is gouty arthritis?

Gout is a serious metabolic disease in which there is an accumulation of sodium urates in the soft tissues of the joint, resulting in an inflammatory process. The disease often occurs in a chronic form. According to medical data, males are more likely to suffer from gout. In childhood, gout is not diagnosed, since children have a high metabolic rate, and urates are well excreted from the body. The pathological process can develop in any joints.

Most often the disease occurs in a chronic form

Characteristics of gout, clinical manifestations

The disease debuts with an attack of acute arthritis, affecting mainly the first metatarsophalangeal joint.
Manifestations of this pathology are:

attacks of acute gouty arthritis;
accumulation of urates in tissues – formation of tophi;
accumulation of uric acid crystals in the kidneys with the formation of stones - nephrolithiasis;
gouty (urate) nephropathy.

The course of gout is divided into 3 stages:

acute arthritis;
interictal gout;
chronic gout (tophus).

Let's look at each of them in more detail.

Acute gouty arthritis

It is characterized by a sudden onset, usually affecting only one joint. It contains all the signs of inflammation - redness of the skin, swelling, dysfunction and intense, rapidly increasing pain.

Arthritis develops under the influence of provoking factors (they are listed above), mainly at night or early in the morning, without treatment it lasts up to 10 days, then it goes away on its own (this is a characteristic feature of this pathology).

In the majority of patients (9 out of 10 cases), the first attack of gouty arthritis occurs with damage to the first metatarsophalangeal joint of the foot.

Without treatment, attacks gradually become more frequent, and each subsequent attack is more severe than the previous one, involving new joints.

Gouty arthritis in people of different ages and gender occurs with the following features:

in men, the pathological process primarily involves the toes, especially the big toe;
in women, even at the onset of the disease, 2 or more joints can be affected, in particular, the joints of the hands;
In elderly patients, polyarthritis with damage to the joints of the upper extremities is more often recorded, and tophi quickly appear.

Interictal gout

During the period between attacks of acute arthritis, patients with gout feel satisfactory and do not have any unpleasant symptoms. If during the first attack of gouty arthritis the patient did not receive treatment, it is very likely that he will develop a second attack within a year, and in almost all of these patients acute arthritis recurs within 2 years. With each subsequent attack, the period between them becomes shorter, and the arthritis itself becomes more and more severe.

Chronic tophi gout

As the name suggests, the disease at this stage is characterized by the deposition of tophi in the tissues, the development of a chronic form of arthritis, kidney stones and renal failure.

Tophi are found on the ears, in the area of the elbows and knee joints, under the skin or intradermally on the fingers, and less often in any other part of the body, including on the internal organs. Their sizes range from the head of a pin to a small apple. Tophi are painless. In some cases, ulceration of the skin over the tophi occurs and a white thick mass is released from them.

In some patients, tophi appear at the initial stage of the disease. So, this is typical for juvenile gout; it also occurs with blood cancer, renal failure and in elderly women taking diuretics.

Classification of gout

The pathological process happens:

Metabolic.
Renal.
Mixed.

The metabolic type manifests itself in the deposition of sodium urates in soft tissues, the renal type - in a decrease in the excretion of uric acid in urine.

Gout on the legs can be primary or secondary. In the first case, the cause of development is a hereditary factor and hypofunction of enzymes involved in metabolic processes. The secondary type is diagnosed as a complication of other diseases. Diseases of the kidneys, skin, blood, as well as taking certain medications can serve as an impetus for development.

In addition, gouty arthritis is classified into three stages:

Asymptomatic. Slight uricemia is observed in the blood. This stage does not manifest itself clinically and therefore often goes unnoticed.
Spicy. Gout attacks alternate with periods of calm.
Chronic. At this stage, the kidneys are affected.

Diseases of the kidneys, skin, and blood can become an impetus for the development of gout.
In medical practice, gout is divided into:

subacute;
infectious-allergic;
pseudophlegmonous;
rheumatoid;
periarthritic.

Diagnostic methods

During the interictal period, a blood test for the content of uric acid is of great diagnostic importance.
The patient is examined, as a rule, in a hospital, where he is hospitalized for suspected acute gouty arthritis. In order to confirm the diagnosis, he will be prescribed:

general blood test (during an attack, a high ESR (even up to 40 mm/h) and an increased number of leukocytes will be detected);
blood test for uric acid (it is worth considering that it is during the period of an acute attack of gout that the level of this substance may be within normal limits);
blood test for liver and kidney tests, cholesterol, triglycerides, and sugar;
general urinalysis (at a late stage of the disease, signs of kidney damage may be detected - decreased urine density, increased levels of leukocytes, albumin, and a small number of red blood cells);
examination of the synovial fluid of the affected joint (during the acute period, the level of leukocytes in it is sharply increased, urate crystals are detected);
examination of the subcutaneous tophi (it contains a thick white mass - sodium urate crystals; around there are signs of inflammation and cells of dense connective tissue);
radiography of the affected joint/joints (at the beginning of the disease, narrowing of the joint space and signs of destruction of the articular surface may be detected, and at a later stage - a symptom of a puncture (this is a tophi located in the thickness of the bone)).

Diagnostic criteria

Experts have developed criteria, the totality of which allows a patient to be diagnosed with gout.

A. Uric acid crystals were found in the joint fluid.

B. Tophi are determined to contain uric acid (which is confirmed by research).

B. At least 6 of the 12 signs listed below are present:

history of acute arthritis 2 times or more;
during an attack of acute arthritis, only 1 joint is affected;
the joint is maximally inflamed on the 1st day of the disease, then the inflammation gradually decreases;
the skin over the affected joint is red;
the tissues in the area of the first metatarsophalangeal joint are swollen, and the patient feels pain in it when moving;
the lesion is localized only on 1 foot;
there is a suspicion of the presence of tophi;
the level of uric acid in the blood is increased;
there is asymmetric swelling of the joints;
X-rays of the joints involved in the pathological process reveal cysts without erosion;
When inoculating synovial fluid, the growth of microbial or any other flora is not detected.

If a particular patient has points A, B and at least 6 of point C, the doctor diagnoses him with “gout”.

Differential diagnosis

Some diseases have a similar course to gout, in particular acute gouty arthritis. They should be distinguished from each other, since the treatment measures for each of them are usually different.

So, differential diagnosis should be carried out with the following diseases:

acute infectious arthritis;
septic arthritis;
reactive arthritis;
psoriatic arthritis;
pyrophosphate arthropathy;
rheumatoid arthritis;
osteoarthritis in the acute stage.

Prevention of problems

Most often, this problem occurs in those joints that were previously injured. To prevent attacks of pain, it is recommended to use loose shoes that fit comfortably on the foot. Frequent hypothermia of the extremities should not be allowed, so in frosty weather you should wear warm gloves and socks. For men whose professional activities involve constant exposure to the street in winter, it is important to take care of their own health by always carrying a special ointment to warm their feet and hands.

In case of frequent attacks of gouty pain, it is necessary to reconsider your lifestyle. Thus, frequent drinking of alcohol and smoking significantly interfere with the normal removal of uric acid, so they should be abandoned.

It is also necessary to limit the consumption of tea, coffee and other similar drinks, since the caffeine they contain helps bind uric acid, which slows down its elimination.

Men who are overweight or obese are much more likely to experience this condition. To prevent the development of the disease and the manifestation of its attacks, you should constantly adhere to your diet.

Thus, it is recommended to reduce the consumption of fish and meat dishes, tomatoes, fatty foods, and legumes to a minimum. It is also necessary to completely abandon the use of salt, or at least reduce its amount to a minimum. In this case, food preparation should take place completely without salt, adding a small amount of it to already prepared food. It is recommended to replace coffee and tea with herbal decoctions, preferably rose hips or mint. All this will ensure normalization of body weight in case of excess or obesity, and will also significantly reduce the likelihood of attacks of pain in the joints and the onset of gout.

Principles of treatment

The patient can receive treatment on an outpatient basis or in a rheumatology hospital. So, indications for hospitalization are:

a prolonged attack of gouty arthritis that cannot be controlled with non-steroidal anti-inflammatory drugs;
the need to select therapy aimed at reducing the level of uric acid in the blood.

Treatment measures are carried out with the aim of:

stopping an attack of acute arthritis in the shortest possible time with minimal harm to the patient;
preventing the development of new attacks of gouty arthritis (relapses);
preventing the development of complications associated with excess uric acid in the blood;
prevention and treatment of complications that arise during the treatment of gout itself.

The patient should be aware of the need to eliminate risk factors for hyperuricemia and repeated attacks of acute arthritis (he should lose weight, avoid intense physical activity, stop drinking alcohol, and so on). He also needs to be informed about the symptoms of relapse of the disease, the consequences of refusing treatment, the side effects of medications and the need to quickly eliminate the symptoms of an attack of acute arthritis.

In addition, the doctor recommends that the patient follow a diet. It involves excluding from the diet (or at least reducing consumption) foods high in purines (such as meat and offal, fatty fish, spices, legumes, cauliflower, strong tea and coffee, alcohol and others). The calorie intake and the amount of carbohydrates eaten are also reduced. Products containing polyunsaturated fatty acids are added to the diet.

Principles of treatment of acute gouty arthritis

Treatment should be started as early as possible, preferably in the first hours of arthritis development. For this purpose, non-steroidal anti-inflammatory drugs are used, and if they are ineffective, glucocorticoids are used locally or systemically. Previously, colchicine was used to relieve attacks of gouty arthritis, but in recent years this drug has become virtually unavailable due to the frequent development of side effects and the high risk of complications.

Nonsteroidal anti-inflammatory drugs (NSAIDs). Drugs of choice. Diclofenac, nimesulide, indomethacin, naproxen and others are used in full therapeutic doses until the signs of the inflammatory process completely disappear.
Colchicine. Previously used in cases of ineffectiveness or contraindications to the use of NSAIDs. The most powerful remedy that can suppress acute gouty arthritis. Often, during treatment with it, patients developed vomiting and diarrhea. Contraindicated in severe renal or heart failure, as well as in serious diseases of the digestive tract.
Glucocorticoids. They are prescribed to patients when NSAIDs are ineffective. If 1 or 2 joints are affected, drugs (often triamcinolone, methylprednisolone, betamethasone) are injected into the joint cavity. In case of multiple joint damage, glucocorticoids are prescribed for oral, intramuscular or intravenous administration (prednisolone, triamcinolone, methylprednisolone).

Therapy aimed at reducing serum uric acid levels

It is necessary because it prevents the development of repeated attacks of acute gouty arthritis and prevents the development of gout complications.

Indications for treatment are:

2 or more attacks of acute gouty arthritis within 12 months;
chronic tophi gout.

Antihyperuricemic therapy is prescribed to the patient for life. The target concentration of uric acid in the blood during treatment is 400 µmol/L or less. During an attack of arthritis, therapy is not started, but if an attack occurs during treatment, the antihyperuricemic drug is not discontinued.

Contraindications:

asymptomatic hyperuricemia (but not in persons suffering from cancer);
urolithiasis disease.

Against the background of properly administered antihyperuricemic treatment, the concentration of uric acid in the blood serum is normalized, attacks of acute arthritis occur less and less frequently, tophi decrease in size and gradually disappear, and urolithiasis does not progress. As a rule, significant improvement is observed in almost all patients after six months to a year of continuous use of the drug.

In the vast majority of cases, in order to reduce the level of uric acid in the blood, the patient is prescribed allopurinol.

Begin therapy with a low dose – 50 mg/day. Once every 2 weeks, the uric acid level is analyzed and, in the absence of positive dynamics, the dose of the drug is increased until normouricemia is achieved. The normal rate is considered to be a decrease in the concentration of uric acid in the blood serum by 10% from the initial level per month. The effective dose of the drug is individual for each patient and varies from 100 to 900 mg per day or even more.

Since allopurinol can have a damaging effect on the kidneys, treatment is carried out under the control of creatinine clearance. If the latter decreases to 30 ml/min or less, the dose of allopurinol is reduced.

If a patient stops taking allopurinol, the concentration of uric acid in his blood serum returns to initial values very quickly - within 3-5 days.

Allopurinol is a serious drug. Taking it is associated with the development of a number of side effects. However, for patients with gout it is simply necessary. That is why treatment should be carried out exclusively under the supervision of a doctor.

Allopurinol analogues are:

thiopurinol (it is not inferior in effectiveness to its counterpart and is much better tolerated by patients);
orotic acid (a less active drug, but at the same time enhances the excretion of uric acid by the kidneys; to be used in courses of 1 month with a break of 1-2 weeks);
hepatocatalase (injected intramuscularly 2-3 times a week).

Sometimes gout patients are prescribed medications that stimulate the excretion of uric acid in the urine. The most common drug in this regard is losartan. It is especially recommended to take it in patients whose hyperuricemia is caused by taking diuretics (hypothiazide and others). Uricosuric drugs also include anturan, ketazone, probenecid, acetylsalicylic acid and some others.

Patients receiving therapy with the above drugs are monitored at the dispensary, which means:

Once every 3-6 months – examination by a doctor;
Once every 2-4 weeks at the initial stages of treatment, then once every six months - determination of the concentration of uric acid in the blood serum;
biochemical blood test (liver, kidney tests) - once every 3 weeks, and subsequently - once every six months.

How to treat gout on the legs?

If gout on the legs is left unattended, the symptoms will intensify, and treatment in this case will be long and difficult. There is no single treatment regimen. The doctor develops a course of treatment based on the severity of the disease, the severity of symptoms, existing complications, as well as the characteristics of the body.

Medication therapy

Antigout drugs, depending on the principle of action, are divided into drugs taken during exacerbation and for the treatment of the chronic form. During an exacerbation, medications help relieve inflammation, pain and temperature. NSAIDs cope effectively with this task. They are prescribed for a short course because they have a number of side effects.

You can relieve the symptoms of gout on the legs in women and men with the help of:

"Diclofenac";
"Colchicine";
"Indomethacin".

Drugs for inflammation help relieve inflammation.
If NSAIDs do not cope with their task, then stronger drugs are prescribed - glucocorticoids. Available in the form of an injection solution. The medicine is injected directly into the joint cavity.

This group of medications includes:

"Methylprednisolone";
"Betamethasone."

In chronic cases, uricodepressive and uricosuric drugs are prescribed:

"Allopurinol";
"Hepatocatalase";
"Atophan";
"Ketasone".

These medications reduce uric acid levels and interfere with its synthesis.

Uricodepressive and uricosuric drugs are prescribed for chronic conditions

Surgery

If gout symptoms continue to progress in the legs of men or women, and drug therapy does not bring results, then doctors resort to radical treatment methods. Due to urate deposits, joint mobility is reduced; it can only be restored to its former functionality through surgery. Tophi are removed on an outpatient basis, under local anesthesia. Surgery does not solve all problems. Sometimes it can provoke a secondary infection or sepsis.

Which doctor should I contact?

If you suspect gout, especially in the case of inflammation of the big toe joint, you should consult a physician. After the initial diagnosis, the patient is referred to a rheumatologist. As the disease progresses and nephropathy develops, consultation with a nephrologist is necessary. Urolithiasis is a reason to be examined by a urologist or surgeon.

Specialists from the Kyiv Regional Clinical Hospital talk about the causes, symptoms and principles of treatment of gout (Russian - Ukrainian):

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What is gout

Gout is a pathological process with an ICD-10 code. It is associated with a malfunction of purine metabolism. Purines are chemical compounds responsible for the formation of DNA and RNA molecules. They are present in any living organism and therefore are found in any food.

When purines break down, uric acid is formed. This is a useful substance responsible for removing excess nitrogen from the body. But sometimes its concentration exceeds the permissible level. This can happen when the kidneys are unable to remove it from the body, or when a person eats too many foods rich in purines. In this case, uric acid salts (urates) are deposited at the joints of the bones. This process is called gout.

Pathogenesis

With gout, protein metabolism is disrupted, resulting in an increase in the level of uric acid salts in the body. Over time, they accumulate in connective and muscle tissue and cause reactive inflammation in the joints, which is manifested by local fever, swelling, redness and severe pain.

As the disease progresses, symptoms increase, joints lose their mobility and become deformed. The intensity of the pain decreases somewhat, but it becomes constant. Contractures and ankylosis are relatively rare. Uric acid diathesis can manifest itself in the form of damage to blood vessels, heart and kidneys. Exacerbation of gout directly depends on nutrition and the seasons.

Treatment during attacks

The first thing a person thinks about during an acute attack of illness is how to relieve pain. The first thing to do in this case is to ensure complete rest of the affected leg. At the same time, you should not cover your foot or put a sock on it - this also causes a severe attack of pain. If touching brings tolerable pain, then you should put an ice pack on the affected area. This brings relief to many.

During an attack of the disease, you should definitely drink as much fluid as possible - up to 3 liters per day. This can be water, mineral water, herbal infusions (yarrow, rose hips, mint). Relieving gout pain with painkillers does not have any effect. Neither aspirin, nor baralgin, nor tempalgin will help here. Many people who suffer from the disease begin to self-medicate, for example, dip their feet in herbal decoctions (which causes pain even more), or take one or another folk remedy that they heard from a neighbor or read in a magazine. Such treatment is unacceptable. But you just need to establish proper nutrition and you can say goodbye to attacks of illness for a long time.

Some bathhouse lovers like to visit it during an exacerbation of the disease. But in this case there can be no question of going to the bathhouse. And this is worth remembering. However, after the attack has passed, you can visit the bathhouse, but it is not recommended to stay in it for too long.

Many traditional healers talk about how to get rid of gout. But in fact, this disease cannot be cured; it is chronic, which means it is characterized by attacks and periods when a person feels just fine. The disease itself, or rather its symptoms, will disappear only when a person realizes that he needs to get rid of excess weight and establish proper nutrition, while almost completely he needs to give up meat and fats, and include as many vegetables and fermented milk as possible in his diet products.

Gout: symptoms

The most important symptom is gouty arthritis - inflammation of the joint on the foot or ankle, most often the big toe is affected by inflammation. As a rule, symptoms begin at night with severe and pressing pain in the joint area. The pain syndrome can last up to a week, the acute phase lasts 2-3 days, then the pain subsides. With secondary manifestations of gout, arthritis can affect other joints of the legs, gradually leading to arthrosis.

The main symptom of gout is the appearance of peculiar growths on the joints - tophi. If the growth is opened, whitish crystals of uric acid salts will be found in it. The formation of growths greatly harms normal life.

On the eve of pain attacks, one or more warning signs may appear:

Lack of appetite.
Temperature increase.
Mood swings.
Prostration.
Irritability.

Often during an attack, the heart rate increases, sweating increases, the temperature rises and chills appear. This is how the period of an acute attack proceeds.

In the chronic form of the disease, urate crystals combine into granules and the disease develops into gouty polyarthritis. Often there is a parallel development of kidney diseases.

Symptoms of chronic gout:

Crunching in joints (one or more).
Limitation of movements in the joint.
Joint pain.
Inflammation in the joint (redness of the skin around it).
Increased body temperature near inflammation or the whole body.

Gout pain

The occurrence of mild pain in the joint is the main symptom that characterizes the onset of gout. Swelling and heat on the skin of the affected joint are the main factors that accompany pain. Heat can be localized in patches in adjacent tissues. All symptoms accompanying pain occur within an hour. A regular pain reliever like aspirin will not help relieve the pain of these attacks.

With gout, an attack of pain appears in the damaged joint at night; by morning the pain subsides, but does not end the disease.

Gout on men's legs

Gout is characterized by a chronic form that cannot be cured until the disease is completely eliminated. In men, observation of the disease begins after 40 years, at first there are attacks of pain of very rare frequency, but over time the attacks occur more and more often. The first period may be characterized by a year of calm or more, but then the frequency of attacks may be less than a month.

During the course of the disease, joints can be destroyed, and the damaged areas will begin to fill with salts, which is precisely why growths appear.

Severe inflammation begins as a response of leukocytes to the appearance of a large amount of salts, which are perceived by the body as aggression and an aggressive body.

Gout in women

In women, gout begins to develop in adulthood and old age, after 55 years, which is caused by the end of menopause, when the body reduces the production of estrogens, female hormones. The manifestation of the disease is similar to that of men.