Vitamin K
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Vitamin K Looks Great

Vitamin K has three forms K(1), K(2), and K(3).  K(2) or menaquinone is absorbed 90% more easily than K(1) or phylloquinone.  K(2) is the form used in Japanese studies.  However, the cost of K(1) is much less and appears to work just as well. 

Vitamin K until recently has been a relatively neglected vitamin.  It is unavailable in most pharmacies except in small amounts as part of multivitamin formulations.  Eight double-blind studies in just the last several years have shown that vitamin K is very important in the treatment of osteoporosis.  Seven studies is a lot.  It takes just two DB studies for the FDA to approve a patented medication for the treatment of human illness.  Vitamin K helps build the collagen matrix for bone formation as well as other actions.  When combined with vitamin D, calcium, magnesium, and the avoidance of salt, it appears very unlikely that the expensive medications are necessary.  Perhaps, bisphosphonates (risedronate (Actonel), ibandronate (Boniva) and alendronate (Fosamax) should be reserved for osteoporosis patients failing on the above inexpensive and far healthier supplement and diet program.  However, alendronate did best in a head-to-head study, although vitamins D and K were not combined and other diet strategies were not encouraged.  Three double-blind studies have shown vitamin K helps cancer of the liver patients live somewhat longer.

Single human studies find evidence that vitamin K might preserve arterial elasticity, and prevent cancer of the liver.  The prevention study is really exciting since treating liver cancer already developed has much less impact.  Human studies also show some benefit in the treatment of leukemia, liver, and lung cancers.  Epidemiologic research suggests vitamin K might help prevent heart disease, and osteoarthritis.  It is important for newborn children and is routinely given by injection at birth.

Animal and lab research suggests that vitamin K might help the brain including behavioral problems, the retina of the eye, and several other cancers.  

The large majority of people get too little vitamin K.  The majority of adults in studies in Ireland and in Norway did not get the American recommended dietary intake and research from Tufts University suggests that even the recommended levels are too low, at least for senior citizens.  I recommend that all thin women over the age of 35 take vitamin K(1) 500-1000 mcg once a day.  However, people on blood thinners should avoid vitamin K supplements, since blood thinners work by blocking vitamin K.  Taking a vitamin K supplement won't thicken your blood, but it would neutralize the effects of some blood thinners. 

Two 500 mcg pills daily would cost as little as $22 per year (www.iherb.com).  When combined with vitamin D 1000 IU, magnesium 250-500 mg/day, and calcium 1000 mg/day (women only for the calcium), the total cost for treating osteoporosis would be as little as $47 per year vs. $1000 for bisphosphonates.  While bisphosphonates have many side-effects and no other health benefits, my recommended supplements are very likely better for osteoporosis and have numerous additional health benefits.

The standard Daily Value for vitamin K is 80 mcg.  This appears too low in many situations.  Diet might contribute 20-120 mcg.  Commonly available pill sizes are 100 mcg, 500 mcg, and a combination of 9 mg K(1) and 1 mg of vitamin K(2).  Studies suggest that the 100 mcg dose may be too small for many conditions.  The 9 mg pill with 1 mg. of K(2) is six times more expensive but at least 20 times stronger than the 500 mcg pill and costs $7/month.  Many studies have been done with 45 mg of vitamin K(2), a very potent size apparently not yet available in the U.S.  Research suggests that 500-1000 mcg of K(1) is probably enough for osteoporosis, although I would recommend the 9 mg pill for those infected with hepatitis B or C.

Lab studies have suggested that vitamin K might have an anti-cancer effect against a variety of cancers including ovarian and liver, leukemia and lung cancers (Int J Oncol. 2003 Sep;23(3):627-32). The FDA now requires 150 mcg per day of vitamin K in intravenous feeding (JPEN J Parenter Enteral Nutr. 2003 May-Jun;27(3):220-4). 

Few Irish Adults Get Enough Vitamin K: Dietary vitamin K1 (phylloquinone) intake in a nationally representative sample of 1,379 Irish adults found the daily intake of phylloquinone from food sources was 79 microg. Vegetables contributed 48%, particularly green vegetables (26%). Potatoes (including chipped and fried potatoes), dairy products and fat spreads contributed 10 % each and meat contributed 8%. Only 17% of men and 27% of women met the U.S. adequate intakes of 120 and 90 microg/d, respectively. Phylloquinone (vitamin K1) intakes and food sources in 18-64-year-old Irish adults. Duggan P, Cashman KD, et al. University College Cork, Ireland. Br J Nutr. 2004 Jul;92(1):151-8. 

Vitamin K Intake Inadequate in Norway: Data from 1997 nation-wide Norwegian dietary study NORKOST II found intake of vitamin K is less than 50% of the recommended. Stores of vitamin K are small and the T/2 in the body is approximately 1-1.5 day. Vitamin K executes its effects by carboxylation of proteins and as ligand (vitamin K2) for a nuclear transcription factor. Biological effects beyond coagulation include bone formation, neural functioning and blood vessel calcification. Anticoagulation with warfarin inhibits vitamin K-dependent reactions and may have detrimental effects on bone formation. Biological effects of vitamin K and concentration of vitamin K in Norwegian food. Drevon CA, Henriksen HB, et al. University of Oslo. Tidsskr Nor Laegeforen. 2004 Jun 17;124(12):1650-4. 

Most Americans Inadequate Intake: In a study using 14-day food intake diaries of a nationwide sample of about 2,000 households, only half the females age 13 and over and less than half the males got the RDA. Also, the current RDA may not be sufficient for maximizing vitamin K's function in bones. The vitamin adds chemical entities called carboxyl groups to osteocalcin and other proteins that build and maintain bone. Phylloquinone is found in some oils, especially soybean oil, and in dark-green vegetables such as spinach and broccoli. For instance, one serving of spinach or two servings of broccoli provide four to five times the RDA of phylloquinone. However, the vitamin K in oil might be less active.  Sarah Booth, Tufts.

Vitamin K Recommended Intake Inadequate for Older Adults: In an 84-day study of 21 older women fed a K(1)-restricted diet (18 micro g/d) for 28 days, followed stepwise by 86, 200 and 450 micro g/d of phylloquinone, gamma-carboxylation of prothrombin was restored to normal levels in response to K(1) supplementation at 200 micro g/d. In contrast, all other biochemical markers of vitamin K status remained below normal levels after short-term supplementation of up to 450 micro g/d of phylloquinone. The findings suggest that the current recommended vitamin K (90 micro g/d) in women do not support maximal osteocalcin gamma-carboxylation in older women. Dietary phylloquinone depletion and repletion in older women. Booth SL, Martini L, et al. Tufts University. J Nutr. 2003 Aug;133(8):2565-9.

Low Vitamin K Associated with Low Bone Mineral Density: In a study of vitamin K status and BMD at the hip and spine in 741 men and 863 women ages 32-86 who participated in the Framingham Heart Study (1996-2000), among men, low plasma K(1) was associated with low BMD at the femoral neck (P = 0.009). Among postmenopausal women not using estrogen replacements, low plasma K(1), phylloquinone, was associated with low spine BMD (P = 0.007). There were no significant associations between biochemical measures of vitamin K and BMD in either premenopausal women or postmenopausal women using estrogen replacements. Associations between Vitamin K Biochemical Measures and Bone Mineral Density in Men and Women. Booth SL, Broe KE, et al. Tufts University. J Clin Endocrinol Metab. 2004 Oct;89(10):4904-9.  

No Link in Vitamin K Intake and Bone Mineral Content in Girls: In a 4-year study of 245 healthy girls ages 3-16 (median vitamin K intake 45 mcg/day), vitamin K status were not consistently associated with current or gain in bone mineral content.  Better vitamin K status was associated with decreased bone turnover in healthy girls consuming a typical US diet. Randomized phylloquinone supplementation trials are needed to further understand the potential benefits of phylloquinone on bone acquisition in growing children. Vitamin K, bone turnover, and bone mass in girls. Kalkwarf HJ, Khoury JC, Children's Hospital Medical Center, Cincinnati, Am J Clin Nutr. 2004 Oct;80(4):1075-80

High Vitamin K-1 Intake Linked to Healthy Diet Overall: In 2,941 adults mean age 54 participating in the Framingham Heart Study, those in the highest fifth in vitamin K-1 intake consumed more fruit, vegetables, fish, dietary fiber, and dietary supplements ( P <.001), and consumed less meat and less saturated fat ( P <.001). Higher phylloquinone intakes were also associated with lower triglyceride concentrations ( P <.001). A high phylloquinone intake may be a marker for an overall heart-healthy dietary pattern. Dietary phylloquinone intake as a potential marker for a heart-healthy dietary pattern in the Framingham Offspring cohort. Braam L, McKeown N, et al, University of Maastricht, The Netherlands. J Am Diet Assoc. 2004 Sep;104(9):1410-4 

Mode of Action: Vitamin K is as a cofactor for the carboxylation of Vitamin-K dependent (VDK) proteins which renders them active. VKD proteins are present in every tissue and are important to bone mineralization, arterial calcification, apoptosis, phagocytosis, growth control, chemotaxis, and signal transduction. The physiology of vitamin K nutriture and vitamin K-dependent protein function in atherosclerosis. Berkner KL, Runge KW. Case Western Reserve University, Cleveland. J Thromb Haemost. 2004 Dec;2(12):2118-32 

Alcoholism Risk May be Lowered by Vitamin K at Birth: Taking advantage of a serendipitous event in the history of treating newborns, two thirds of the original 330 subjects in this study were high-risk sons of alcoholic fathers. Of 238 completing the 30-year follow-up, 44 received vitamin K supplementation at birth; 161 were considered high risk, and 66 were categorized as having lower birth weight (<6 lbs). Vitamin K treatment, inherited risk and low birth weight each independently predicted alcohol dependence and problem drinking. Vitamin K treatment was associated with significantly lower rates of alcohol dependence and fewer symptoms of problem drinking. Vitamin K might reduce early postnatal hemorrhage and oxidative brain damage, and thus lower the risk of alcoholism. Neonatal vitamin K might reduce vulnerability to alcohol dependence in Danish men. Manzarda AM, et al. University of Kansas. . J Stud Alcohol 2005 Sep;66(5):586-92. Vitamins K and D are recommended at birth.

Alzheimer's: MMSE Higher with Higher Vitamin K and D: In a study of 200 women with AD (mean age 80) and 100 age-matched community dwelling controls, BMI was significantly lower in women with more severe AD (MMSE<16). Metacarpal BMD ( P <.02) and serum concentrations of vitamin K 1 (P <.03) and 25(OH)D 3 (P <.001) were lower in severe AD than in mild AD (MMSE>15). Serum levels of intact PTH and Glu OC in severely demented patients were higher than those with mild dementia ( P <.001). Serum PTH concentration correlated negatively with serum 25(OH)D 3 level (P =.016). Serum concentration of vitamin K 1 correlated positively with that of 25(OH)D 3 (P <.001) and MMSE score (P <.001), and negatively with Glu OC (P <.001). Vitamin K deficiency and osteopenia in elderly women with Alzheimer's disease. Sato Y, Honda Y, et al. Arch Phys Med Rehabil. 2005 Mar;86(3):576-81.

Arterial Elasticity: Vitamin K Helps Protect in Older Women: Matrix-Gla Protein (MGP) is a strong inhibitor of vascular calcification, the expression of which is vitamin D dependent. MGP contains five gamma-carboxyglutamic acid (Gla)-residues which are formed in a vitamin K-dependent carboxylation step and which are essential for its function. Vitamin K-deficiency results in undercarboxylated, inactive MGP. In a 3-year DB PC study of 181 postmenopausal women, the elastic properties of the common carotid artery in those with minerals, vitamin D and vitamin K (MDK) remained unchanged, but decreased in the MD- and placebo-groups. Beneficial effects of vitamins D and K on the elastic properties of the vessel wall in postmenopausal women: a follow-up study. Braam LA, Hoeks AP, Brouns F, Hamulyak K, Gerichhausen MJ, Vermeer C. University of Maastricht, Netherlands. Thromb Haemost. 2004 Feb;91(2):373-80.  

Arthritis: Vitamin K May Reduce Osteoarthritis: Poor intake of vitamin K is common. Insufficient vitamin K can result in abnormal cartilage and bone mineralization. In 672 participants (mean age 66) in the Framingham Offspring Study, a population-based prospective observational cohort, the prevalence of osteoarthritis, osteophytes, and joint space narrowing and adjusted mean number of joints with all 3 features in the hand decreased significantly with increasing plasma phylloquinone levels (P < 0.03 for all), e.g. a 30% decrease in osteoarthritis of the hands and 40% for the knee (P = 0.01). Low vitamin K status is associated with osteoarthritis in the hand and knee. Neogi T, et al. Boston University. Arthritis Rheum 2006 Mar 29;54(4):1255-1261.

Body Mass and Egg Laying in Love Birds Helped: Best body mass (BM) development and egg laying activity could be observed in lovebirds of group V2 with the highest vitamin K(3) supplementation. Wolf P, et al. Hannover, Germany. J Anim Physiol Anim Nutr (Berl). 2005 Apr;89(3-6):222-8. 

Brain: Vitamin K Might Be Important: Studies with animals support a role for vitamin K (VK) in the biosynthesis of sphingolipids, a class of complex lipids present in high concentrations in the brain. In mice and rats, VK deficiency decreases levels of brain sulfatides and causes behavioral alterations. Researchers measured the two main K vitamins, phylloquinone (K1) and menaquinone-4 (MK-4), in nine distinct brain regions. Both regional K1 and MK-4 increased with K1 intake (P<0.05). Sphingolipid distribution varied across brain regions (P<0.001) but was not affected by K1 intake. In the Low and Adequate intake groups but not the High group, brain MK-4 concentration was positively correlated with the concentrations of sulfatides (L, r=0.518; A, r=0.479) and sphingomyelin (L, r=0.515; A, r=0.426), and negatively correlated with ganglioside concentration (L, r=-0.398); A, r=-0.353). Sphingolipids are involved in major cellular events such as cell proliferation, differentiation and survival. The strong associations reported here between brain MK-4 and sphingomyelin, sulfatides and gangliosides suggest that this vitamin may play an important role in the brain. Menaquinone-4 concentration is correlated with sphingolipid concentrations in rat brain. Carrie I, Portoukalian J, et al. Universite de Montreal. J Nutr. 2004 Jan;134(1):167-72.

Contact Dermatitis Reported Due to Topical Cosmetic use of vitamin K. Contact Dermatitis. 2005 Feb;52(2):113-4.

Child Fractures Low Bone Density: Previous reports have indicated a variety of potential contributors to fracture risk including low bone mineral content and density, milk avoidance, lack of exercise, asthma, obesity, and a high consumption of carbonated beverages. In a study of 150 children aged 4-16 years, children who had sustained one or more fractures had a significantly lower BMC and aBMD at all sites than controls after conversion to size adjusted z scores (L2-4 BMC P=0.0002; L2-4 aBMD P<0.0001; TB BMC P<0.0001; TB aBMD P<0.0001); estimates for TB excluded fracture sites. There was, however, no difference in adjusted bone mass between children with one and those with recurrent fractures. Children with recurrent fractures had a significantly lower milk intake, lower levels of physical activity, a higher BMI, and a higher consumption of carbonated beverages than controls. The prevalence of risk factors was not, however, significantly higher than controls in children with a single fracture.

Treatment of Disease

Cancer: Leukemia Helped by Vitamin K: A multi-center pilot study of 47 patients in Japan of myelodysplastic syndrome (MDS) and post-MDS acute myeloid leukemia treatment with K2 found that K2 was effective in reducing blast cell numbers in bone marrow and/or peripheral blood in 71%. Of patients with refractory anemia with excess of blast in transformation, and those with post-MDS AML who used oral vitamin K2 without other medications, 44% had improvement. K2 ranged from 20-135 mg/day orally or 10-50 mg/day intravenously, with 83% receiving an oral dose of 45 mg/day. Miyazawa K, Nishimaki J, et al. Vitamin K2 therapy for myelodysplastic syndromes and post-MDS acute myeloid leukemia: information through a questionnaire survey of multi-center pilot studies in Japan. Leukemia 2000;14:1156-1157. 

Cancer of the Liver: Vitamin K Prevented Liver Cancer in Viral Hepatitis: In a DB PC study of 40 women with an average age of 60 and with viral liver cirrhosis (mostly Hepatitis C), only 2 of 19 women on 45 mg/d of vitamin K2 vs. 9 of the 19 women on placebos. On multivariate analysis with adjustment for age, alanine aminotransferase activity, serum albumin, total bilirubin, platelet count, alpha-fetoprotein, and history of treatment with interferon alfa, the risk ratio for the development of hepatocellular carcinoma in patients given vitamin K2 was 0.13 (P =.05). Role of vitamin K2 in the development of hepatocellular carcinoma in women with viral cirrhosis of the liver. Habu D, Shiomi S, et al. Osaka City University. JAMA. 2004 Jul 21;292(3):358-61.  Ed: This study was undertaken to determine the value of vitamin K in preventing osteoporosis in older women with liver problems.  The 90% decrease in liver cancer was an unexpected finding, according to Shiomi.  Oddly, the evidence that vitamin K is active against liver cancer dates from lab studies from the University of Pittsburgh published in May, 1998 in The Journal of Biological Chemistry. Brian Carr, MD, director of the Liver Cancer Center at the University of Pittsburgh Cancer Institute said then, "We now know that the vitamin K compounds not only can kill liver cancers, but also can destroy other types of cancer in tissue cultures, including breast cancer and melanoma. It appears to stop cancer cell growth without producing toxicity. We now are testing this compound against cancers in rats, and given positive results, we hope to begin clinical trials of this agent within two years." Liver cancer is thought to be one of the three most common cancers worldwide. The disease caused about 15,000 U.S. deaths in 1997. Major causes of this cancer include infection with either hepatitis B or C or chronic alcohol consumption. 

Cancer: Liver: Vitamin K Appeared to Help Liver Cancer: In a study of 40 hepatocellular carcinoma patients receiving oral K1 (40 mg/day), all patients evaluated had a 20% tumor response rate, with five patients living greater than one year on treatment. Hepatology 1996;348A. The same research team reported a phase I/II trial of K1 with hepatoma patients which resulted in decreased cancer growth. Cart BI. University of Pittsburgh. A phase I/phase II study of high dose vitamin K to patients with advanced inoperable hepatocellular carcinoma: interim analysis. Hepatology 1994;20:278A.

Cancer: Liver Cancer Studied: In a study of 14 hepatocellular carcinoma patients given vitamin K1 20 mg twice daily until disease progressed, four of the nine able to be evaluated were reported to have stable disease, while five progressed. No toxicity was found in any of the participants. Zaniboni A, Biasi L, et al. Phase II study of high-dose vitamin K1 in hepatocellular carcinoma: a GISCAD study. ASCO 1998:17:1182.

Cancer: Liver Cancer Patients Live Longer: In a DB PC study of 42 patients with advanced hepatocellular carcinoma with portal vein thrombosis, high dose vitamin K3 IV 50 mg/day with daily increase of dose by 50 mg for 6 days, followed by 20 mg i.m. twice daily for 2 weeks. Of the 23 patients treated with vitamin K, one (4.3%) achieved complete response and three (13%) partial response, for a total of four (17.4%) objective responders overall. The overall mean survival was 8.9 vs. 6.8 months for the placebo (P = 0.552)(30% longer). High dose vitamin K3 infusion in advanced hepatocellular carcinoma. Sarin SK, et al. New Delhi, India. J Gastroenterol Hepatol 2006 Sep;21(9):1478-82.

Cancer: Liver Cancer Slowed by Vitamin K: In a Japanese trial of 121 patients with hepatocellular cancer undergoing conventional therapy (percutaneous tumor ablation and/or transcatheter arterial embolization), patients were given 45 mg/day oral vitamin K2. Portal vein invasion after 12 months was 2% with K2 vs. 23% for controls. At two years, 23% of K2 patients vs. 47% of controls were found to have invasion into the portal vein. Jancin B. Vitamin K cuts hepatocellular CA mortality. Fam Pract News 2002;32:16. In one case on an 85 year old, all values normalized after 3 months with vitamin K as the sole treatment. World J Gastroenterol 2005 Nov 14;11(42):6722-4.

Cancer: Liver: Vitamin K Deficiency Protein Big Risk Factor: Des-gamma-carboxyprothrombin (DCP), also known as a protein induced by vitamin K absence or antagonist II, is an abnormal prothrombin. The level of serum DCP is used in clinical diagnosis and prognosis of patients with hepatocellular carcinoma (HCC). A retrospective study was performed of 132 patients each with a single primary HCC nodule. Expression of DCP in tissues was evaluated with immunohistochemical staining using anti-DCP antibody (MU-3). DCP expression, even if it was observed only in non-cancer tissues, was related to poorer prognosis. The combined evaluation of tissue DCP expression and serum DCP levels showed that prognosis was poorest for patients showing positive tissue DCP expression and high levels of serum DCP. Des-gamma-carboxyprothrombin expression in cancer and/or non-cancer liver tissues: association with survival of patients with resectable hepatocellular carcinoma. Tang W, Kokudo N, et al. University of Tokyo. Oncol Rep. 2005 Jan;13(1):25-30 

Cancer: Liver: Vitamin K Deficiency Protein Marker For Invasiveness: In hepatocellular carcinoma (HCC), a protein induced by vitamin K absence or antagonist-II (PIVKA-II) is high in specificity of HCC and means a higher risk of future portal venous invasion by the cancer. Alpha-fetoprotein (AFP) is low in specificity and is not correlated with PIVKA-II. Lens culinaris agglutinin-reactive fraction of alpha-fetoprotein (AFP-L 3) is high in HCC specificity, and after treatment it is used for malignancy when AFP-L3 is positive. Tumor markers of hepatocellular carcinoma. Kubo S, Matsukawa M. Showa University, Tokyo. Gan To Kagaku Ryoho. 2004 Dec;31(13):2203-6; Similar: Best Pract Res Clin Gastroenterol. 2005 Feb;19(1):91-9.

Cancer: Liver: Vitamin K with ACE Inhibitor Help Prevent: Combination of vitamin K(2) and the angiotensin-converting enzyme inhibitor, perindopril, attenuates the liver enzyme-altered preneoplastic lesions in rats via angiogenesis suppression. Yoshiji H, et al. Nara Medical University, Japan.

Cancer: Lung Cancer Helped a Little by Vitamin K: The most common form of vitamin K in animals is menaquinone 4 or vitamin K2, produced by intestinal bacteria from exogenous naphthoquinones. Menadione (K3) is a synthetic analogue that acts as a provitamin. K3 cannot exert all the functions of natural vitamin K. Menadione (150-200 mg/day IV) increased survival time (5.42 months with menadione and radiation versus 3.77 months with radiation alone) in inoperable bronchial carcinoma patients. Mitchell JS, Brinkley D, Haybittle JL. Clinical trial of radiosensitizers, including synkavit and oxygen inhaled at atmospheric pressure. Acta Radiol Ther Phys Biol 1965;3:329-341. 

Cancer: May Help Multiple Myeloma: Hemaetologia 2006 May;91(5):613-9.

Cancer: Newborn Vitamin K Injection Doesn’t Prevent Cancer: In a national case-control study of childhood cancer, 2530 children diagnosed with cancer before 15 years of age, 1174 of whom had leukemia and 4487 control children without cancer, there was no association between the administration of i.m. vitamin K at birth and either leukemia or other cancers later in childhood. Vitamin K and childhood cancer: a report from the United Kingdom Childhood Cancer Study. Fear NT, Roman E, Ansell P, Simpson J, Day N, Eden OB; United Kingdom Childhood Cancer Study. University of Leeds, UK. Br J Cancer. 2003 Oct 6;89(7):1228-31. Ed: Vitamin K is often given to newborns to prevent a rare bleeding condition due to inadequate vitamin K levels causing the blood not to coagulate. Vitamin K prevents a variety of cancer cells from growing in vitro, but it is unclear whether it has similar effects in real life. 

Glucocorticoid-Induced Osteoporosis (GIOP) is recommended treated with bisphosphonates. However, bisphosphonates have gastrointestinal side effects, and a potential risk for pregnant women and children. An analog of vitamin K(2) reduced the fracture risk independent from the bone mineral densities in GIOP. Since GIOP induced bone fracture even in the high bone mass, the vitamin K(2) analog should be an effective therapeutic agent for GIOP through increasing bone strength without an increase in bone mineral density. Vitamin K(2) as a potential therapeutic agent for glucocorticoid-induced osteoporosis. Tanana I, et al. Fujita Health University. Clin Calcium 2006 Nov;16(11):1851-7. Ed: Research suggests that vitamin K should be used whenever steroids are given for over 3 months.

Cystic Fibrosis Children May Benefit: In a study of 20 CF children already on vitamin D supplements, adding vitamin K for 1 year made a variety of beneficial changes in bone health. Authors state that vitamin K supplementation may have a beneficial role in bone health in CF children. Eur J Ped 2006 Apr 19.

Crohn's Disease Patients Need Vitamin K: There is a high prevalence of osteopenia among patients with Crohn's disease (CD). In a study of 44 CD patients and 44 controls, vitamin K(1) intake in CD patients tended to be lower (117 vs. 148 mug/d; p= 0.059). Glu and NTx concentrations in CD patients were higher (mean, 5.1 vs. 3.9 ng/ml; p= 0.03 for Glu; and 49 vs. 26 nM BCE/mM creatinine; p= 0.001 for NTx). In CD patients, Glu was significantly correlated with NTx (r= 0.488; p < 0.001), even after controlling for age, gender, vitamin D status, calcium intake, and corticosteroid use. The rate of bone resorption in the CD inversely correlated with vitamin K status, suggesting that it is an etiological factor for CD-related osteopenia. Vitamin K status in patients with Crohn's disease and relationship to bone turnover. Duggan P, O'Brien M, et al. University College, Cork, Ireland. Am J Gastroenterol. 2004 Nov;99(11):2178-85

Dysmenorrhea: Vitamin K Used in China: This unscientific report claims benefit for primary dysmenorrhea in women ages 14-25. MedGenMed. 2004 Dec 27;6(4):45.

Fractures: Vitamin K Great for Reducing Osteoporosis and Fractures: In authors reviewed 13 double-blind studies on bone loss, and 7 reported fracture data. All but 1 showed an advantage of phytonadione and menaquinone in reducing bone loss. The odds ratio (OR) favoring menaquinone was 0.40 for vertebral fractures, 0.23 for hip fractures, and  0.19 for all nonvertebral fractures. Vitamin K and the Prevention of Fractures: Systematic Review and Meta-analysis of Randomized Controlled Trials. Cockayne S, et al. University of York, England. Arch Int Med 2006 Jun 26;166(12):1256-61. Ed: Vitamin K via the internet, depending on the dose, costs only $2-$6 per month vs. $100 for Fosamax. No prescription is needed and I have not seen any reported side-effects. 

Heart: Not Associated with Decreased Heart or Stroke Death: Phylloquinone (vitamin K(1)) intake, derived mainly from green vegetables, had no benefit on the risk of cardiovascular diseases [total and fatal coronary heart disease (CHD), non-fatal myocardial infarction, total and ischemic stroke] in a study of 40,087 men in the Health Professionals' Follow-up Study. After adjustment for lifestyle factors, the relative risks of total CHD events in increasing quintile categories of phylloquinone intake were 1 (reference), 0.84, 0.87, 0.82 and 0.84, respectively (P = 0.05). However, the risk of CHD events and strokes did not remain significantly associated with phylloquinone intake after adjustment for lifestyle and other dietary factors. Phylloquinone intake and risk of cardiovascular diseases in men. Erkkila AT, et al. Tufts University, Nutr Metab Cardiovasc Dis 2006 Aug 21.

Heart: Vitamin K Associated with Fewer Heart Deaths: Vitamin K-dependent proteins, including matrix Gla-protein, have been shown to inhibit vascular calcification. Activation of these proteins via carboxylation depends on the availability of vitamin K. In 4,807 adults with no history of heart attacks followed for 10 years, after adjustment for age, gender, BMI, smoking, diabetes, education, and dietary factors, the relative risk (RR) of coronary heart disease mortality was reduced in the mid and upper thirds of dietary vitamin K-2 compared to the lower third [RR = 0.73 and 0.43]. Intake of menaquinone was also inversely related to all-cause mortality [RR = 0.91 and 0.74] and severe aortic calcification [odds ratio of 0.71 and 0.48]. Phylloquinone intake was not related to any of the outcomes. Dietary intake of menaquinone is associated with a reduced risk of coronary heart disease: the Rotterdam study. Geleijnse JM, Vermeer C, et al., Erasmus Medical Center, Rotterdam, The Netherlands; J Nutr. 2004 Nov;134(11):3100-5. Ed: K(1) intake is small as is K(2). A 500 mcg K(1) supplement is 6 times with normal K(1) intake and, by biological conversion, will increase K(2). It is very likely that increase will place the individual in the upper third. 

Heart: No Association Found Between Low Intake and Calcified Arteries: In animals, low intake of total vitamin K has been shown to accelerate vascular calcification via the MGP mechanism. In this study of 807 active-duty US Army personnel, ages 39-45, without known coronary heart disease, researchers found no significant correlation between coronary artery calcification and vitamin K1 intake (r=0.132, P=0.106). Vitamin K1 intake and coronary calcification. Villines TC, Hatzigeorgiou C, et al. Walter Reed. Bethesda, Maryland, USA. Coron Artery Dis. 2005 May;16(3):199-203.

Infants: Oral Vitamin K OK to Prevent Bleeding: Of 507,850 Danish babies, 78% and 22% received oral and intra-muscular prophylaxis. Weekly oral prophylaxis of K(2) 2mg at birth and 1 mg once a week was recommended for breastfed infants. No cases of vitamin K deficiency bleeding (VKDB) were reported. Weekly oral vitamin K prophylaxis in Denmark. Hansen KN, Minousis M, et al, Denmark. Acta Paediatr. 2003 Jul;92(7):802-5. 

Infants: Routine Vitamin K for Newborns Saves Lives and Disability: The estimated incidence of late onset vitamin K deficiency bleeding into the brain in infants who received no prophylaxis was unexpectedly high in a 5-year Vietnam study (116 per 100,000 births) with 142 and 81 per 100,000 births in rural and urban areas respectively. Mortality was 9%. Of the surviving infants, 42% were neurologically abnormal at the time of hospital discharge. Routine vitamin K prophylaxis at birth would significantly reduce infant morbidity and mortality at only $ 87 per disability adjusted life year saved. Intracranial haemorrhage due to late onset vitamin K deficiency bleeding in Hanoi province, Vietnam. Danielsson N, Hoa DP, et al, Stockholm, Sweden. Arch Dis Child Fetal Neonatal Ed. 2004 Nov;89(6):F546-50 

Infants: Give Mothers Who Will Deliver Early Vitamin K: Infants less than 35 weeks' gestation age are susceptible to periventricular-intraventricular hemorrhage. In a randomized study of 90 pregnant women in preterm labor at less than 35 weeks, antenatal vitamin K1 10 mg per day injection intramuscularly or intravenously for 2-7 days resulted in less infant brain hemmorrhage: vitamin K 32% vs. controls 52% (P = 0.036), and a lower frequency of severe PIVH was 5% vs. 20% (P = 0.038). Liu J, et al. Beijing Obstetrics and Gynecology Hospital. . J Perinat Med 2006;34(2):173-6. Ed: Since vitamin K has a wide safety margin, it would seem sensible to give in to all pregnant women late in pregnancy.  However, I haven't seen this recommendation yet.

Multiple Sclerosis: Vitamin K Helped Prevent Animal Model of MS: In experimental autoimmune encephalomyelitis (EAE), an animal model of multiple sclerosis (MS), VK2 helped although it was not effective when given after the onset. Inflammatory cellular infiltration and the expression of both MHC class II and inducible nitric oxide synthase (iNOS) were reduced in the spinal cords of VK2-treated rats with EAE. The inhibitory effect of VK2 on the iNOS expression in glial cells was also observed in vitro. Considering the long use of VK2  is without noticeable untoward effects, it may be applicable to the patients with MS. Vitamin K(2) ameliorates experimental autoimmune encephalomyelitis in Lewis rats. Moriya M, et al. Osaka University, Japan. J Neuroimmunol. 2005 Sep 5

Osteoporosis: Vitamin K Did Very Well at Preventing Vertebral Fractures: In a 2-year DB study, 396 postmenopausal women ages 50 to 75 were divided into six equal groups: hormone replacement therapy, etidronate, calcitonin, alfacalcidol, vitamin K-2, or no treatment. The 2-year mean changes in bone mineral density were 2.0% for hormone replacement therapy, -0.5% for etidronate, 1.6% for calcitonin, -3.6% for alfacalcidol, -1.9% for vitamin K, and -3.3% for control. Vertebral fractures occurred in 26% of control patients. Compared with controls, the relative risks of vertebral fracture were 0.35 for hormone replacement therapy, 0.40 for etidronate, 0.41  for calcitonin, 0.56  for alfacalcidol, and 0.44 for vitamin K. Comparative efficacy of hormone replacement therapy, etidronate, calcitonin, alfacalcidol, and vitamin K in postmenopausal women with osteoporosis: The Yamaguchi Osteoporosis Prevention Study. Ishida Y, Kawai S., Yamaguchi University, Japan. Am J Med. 2004 Oct 15;117(8):549-55.   

Osteoporosis: Vitamin K and D and Calcium Reduced Fractures by 86% in Alzheimer’s: Deficiency of vitamins D and K1 causes reduced bone mineral density (BMD) in female AD patients. In a DB PC 2-year study of 200 AD patients, those who received 45 mg menatetrenone (K-2), 1000 IU ergocalciferol (vitamin D) and 600 mg calcium daily for 2 years had BMD in the second metacarpals increased by 2.3% in the treated group and decreased by 5.2% in the untreated group (P < 0.0001). Serum levels of vitamin K2 and 25-hydroxyvitamin D increased by 284.9% and 147.9%, respectively, in the treated group. Twenty-two patients in the untreated group sustained nonvertebral fractures (15 with hip fractures, two fractures each at the distal forearm and the proximal femur, each one fracture at the proximal humerus, ribs, and pelvis), and three fractures (2 with hip fractures, one fracture at the proximal femur) occurred among the treated patients (P = 0.0003; odds ratio = 7.5). Menatetrenone and vitamin D2 with calcium supplements prevent nonvertebral fracture in elderly women with Alzheimer's disease. Sato Y, Kanoko T, et al. Japan. Bone. 2005 Jan;36(1):61-8.

Osteoporosis: Vitamin K Alone No Benefit for Female Athletes’ Bones: Low bone mass leading to stress fractures is a problem among female athletes. In a prospective cohort study, 115 female endurance athletes in amenorrheic, eumenorrheic, or estrogen-supplemented groups were randomized to either placebo or vitamin K(1). After 2 years, bone mineral density in the lumbar spine remained constant, but bone density in the femoral neck had decreased significantly in all three subgroups. The decrease was higher in amenorrheic (-6.5%) than in eumenorrheic (-3.2%) and estrogen-supplemented athletes (-3.9%). Supplementation with vitamin K did not affect the rate of bone loss. Factors affecting bone loss in female endurance athletes: a two-year follow-up study. Braam LA, Knapen MH, et al. University of Maastricht. Am J Sports Med. 2003 Nov-Dec;31(6):889-95.

Osteoporosis: Vitamin K Increased Benefit of Calcium-Magnesium-Vitamin D: In a 3-year DB PC study, 155 postmenopausal women received either placebo, or calcium, magnesium, zinc, and vitamin D (800 IU/day) (MD group), or the same formulation with additional 1 mg/day vitamin K1 (MDK group). The group receiving the supplement containing additional vitamin K1 showed reduced bone loss of the femoral neck: after 3 years the difference between the MDK and the placebo group was 1.7% and that between the MDK and MD group was 1.3. No significant differences were observed among the three groups at the site of the lumbar spine. Vitamin K1 supplementation retards bone loss in postmenopausal women between 50 and 60 years of age. Braam LA, Knapen MH, et al. University of Maastricht. Calcif Tissue Int. 2003 Jul;73(1):21-6

Osteoporosis: Vitamin K Reduced Fractures 90% in Small Study of Parkinson’s Woman: Significant reduction in bone mineral density (BMD) occurs in Parkinson's disease (PD), correlating with immobilization and with vitamin D deficiency, and increasing the risk of hip fracture, especially in women. As a biological indicator of compromised vitamin K status, an increased serum concentration of undercarboxylated osteocalcin (Oc) has been associated with reduced BMD in the hip and an increased risk of fracture in otherwise healthy elderly women. In a DB PC study of 120 PD patients, half received 45 mg of MK-4 daily for 12 months. At baseline, both groups showed vitamin D and K(1) deficiencies, high serum levels of ionized calcium, and glutaminic residue (Glu Oc), and low levels of parathyroid hormone (PTH) and 1,25-dihydroxyvitamin D [1,25-(OH)(2)D], indicating that immobilization-induced hypercalcemia inhibits renal synthesis of 1,25-(OH)(2)D and compensatory PTH secretion. BMD in the second metacarpals increased by 0.9% in the treated group and decreased by 4.3% in the untreated group (p < 0.0001). Vitamin K(2) level increased by 260% in the treated group. Correspondingly, significant decreases in Glu Oc and calcium were observed in the treated group, in association with an increase in both PTH and 1,25-(OH)(2)D. Ten patients sustained fractures (eight at the hip and two at other sites) in the untreated group, and one hip fracture occurred among treated patients (p = 0.0082; odds ratio = 11.5). The treatment with MK-4 can increase the BMD of vitamin D- and K-deficient bone by increasing vitamin K concentration, and it can also decrease calcium levels through inhibition of bone resorption, resulting in an increase in 1,25-(OH)(2)D concentration. Amelioration of osteoporosis by menatetrenone in elderly female Parkinson's disease patients with vitamin D deficiency. Sato Y, Honda Y, et al. Hirosaki University. Bone. 2002 Jul;31(1):114-8 

Osteoporosis: Bone Loss in Liver Disease Helped by Vitamin K: Bone loss frequently appears in the natural history of liver disease. In a 2-year DB PC study, 50 women with viral hepatitis cirrhosis received either placebo or vitamin K2 (menatetrenone). The percentages of change from the initial BMD was -0.5% for the vitamin K2-treated group -4.6% for the control group. (p = 0.002). In the vitamin K2-treated group, the ratio of osteocalcin to undercarboxylated osteocalcin in those patients with increases in BMD after 1 yr of treatment was significantly lower than that in patients showing decreases in BMD (p = 0.017). No adverse effects of vitamin K2 were noted. Vitamin K2 (menatetrenone) for bone loss in patients with cirrhosis of the liver. Shiomi S, Nishiguchi S, et al. Osaka City University. Am J Gastroenterol. 2002 Apr;97(4):978-81

Osteoporosis: Combined Vitamins K and D Excellent for Osteoporosis: In a 2-year DB PC study of 172 women with osteopenia and osteoporosis, patients received either vitamin K(2), vitamin D(3), vitamin K(2) and D(3) combined, or dietary therapy alone. Combined therapy with vitamin K(2) and D(3) markedly increased bone mineral density (4.92%), while vitamin K(2) alone increased it only 0.135%. The bone markers measured, revealed stimulation of both bone formation and resorption activity. We observed an increase in coagulation and fibrinolytic activity that was within the normal range. Effect of continuous combined therapy with vitamin K(2) and vitamin D(3) on bone mineral density and coagulofibrinolysis function in postmenopausal women. Ushiroyama T, Ikeda A, Ueki M. Osaka Medical College. Maturitas. 2002 Mar 25;41(3):211-21

Osteoporosis: Prevents Bone Less and Maintains Bone Strength: Vitamin K mediates the synthesis of proteins regulating bone metabolism. Results in a 3-year DB PC study of 325 postmenopausal women showed that K(2) 45 mg/day improved BMC and femoral neck width, but not DXA-BMD. Hence high vitamin K(2) intake may contribute to preventing postmenopausal bone loss. Vitamin K(2) supplementation improves hip bone geometry and bone strength indices in postmenopausal women. Knapen MH, et al. University of Maastricht, The Netherlands. Osteoporosis Int 2007 Feb 8.

Osteoporosis: Alendronate Better than Either D or K: In a 3-year study of 776 elderly osteoporotic patients treated with alendronate, etidronate, alfacalcidol, and vitamin K2 or a control group, the increase in lumbar bone mineral density after the treatment was highest in ALN treated group (8%) followed by EHDP (6%). VD3 (1-0%) and K2 (-2%). ALN group exhibited more powerful inhibition of fracture rate (Odds ratio 0.305 versus the control, p < 0.01) than the other groups (Odds ratios 0.604-0.668 versus the control p < 0.05). ALN treatment has achieved a wide range effectiveness regardless of fracture risk. EHDP showed significant inhibition of fracture in low risk osteoporosis. VD3 or K2 treated groups did not inhibit new fracture occurrence in low risk osteoporosis but did so in high risk osteoporosis. A head-to-head comparative study for evaluation of effectiveness among drugs for osteoporosis. Shiraki M. Research Institute and Practice for Involutional Diseases. Nippon Ronen Igakkai Zasshi 2006 Jan;43(1):45-7. Ed: Combining vitamin D and K with calcium, magnesium, and reducing sodium would likely be a powerful natural treatment.

Osteoporosis: High Dietary Vitamin K Not Enough: In the Danish Osteoporosis Prevention Study, a population-based cohort of 2,016 perimenopausal women, vitamin K(1) intake and BMD were assessed at baseline and after 5- and 10-years of follow-up. Dietary vitamin K(1) intake (60 mug/day) was close to the daily intake recommended by the Food and Agriculture Organization (FAO). Cross-sectional and longitudinal analyses showed no associations between intake of vitamin K(1) and BMD of the femoral neck or lumbar spine. Neither did BMD differ between those 5% that had the highest vitamin K(1) intake and those 5% that had the lowest. No effect of vitamin K(1) intake on bone mineral density and fracture risk in perimenopausal women. Rejnmark L, et al. Aarhus University Hospital, Denmark, . Osteoporosis Int 2006 May 9.

Osteoporosis: Vitamin K Alone Did Almost as Well as Bisphosphonate: In a 2-year DB PC study of 72 osteoporotic women, 53-78 years of age, patients received either intermittent cyclical etidronate (200 mg/day, 14 days per 3 months) or menatetrenone (Vitamin K-2) (45 mg/day); or calcium lactate (2 g/day). There was a significant decrease in forearm BMD in the calcium group (P < 0.0001), a significant increase in BMD with vitamin K compared with to calcium (P < 0.0001), and a significant increase in BMD etidronate compared with that in the calcium and vitamin K groups (P < 0.0001 and P < 0.01, respectively). The indices of new vertebral fractures/1000 patient-years with etidronate or vitamin K were significantly higher than for calcium (chi(2) = 47.7; P < 0.0001 and chi(2) = 42.4; P < 0.0001, respectively), and did not differ significantly between each other. Effect of menatetrenone on bone mineral density and incidence of vertebral fractures in postmenopausal women with osteoporosis: a comparison with the effect of etidronate. Iwamoto J, Takeda T, Ichimura S. Keio University. J Orthop Sci. 2001;6(6):487-92

Osteoporosis: Hip Fractures Prevented by Vitamin K: In a 3-year DB PC study of 181 women given placebo or calcium-zinc-magnesium and vitamin D or same + vitamin K, vitamin K had a substantial beneficial effect with 1.7% more femoral neck bone than placebo and 1.3% than with combo without K. Vitamin K1 Supplementation Retards Bone Loss in Postmenopausal Women Between 50 and 60 Years of Age. Calcif Tissue Int 2003 Apr 3; Calcif Tissue Int. 2003 Jul;73(1):21-6.

Osteoporosis: Not Much Benefit From Low 200 mcg Dose in Normal Women: In a 2-year study of 244 healthy, nonosteoporotic women randomized to receive either (1) placebo, (2) 200 mug/day vitamin K(1), (3) 10 mug (400 IU) vitamin D(3) plus 1000 mg calcium/day, or (4) combined vitamins K(1) and D(3) plus calcium, significant bone mineral loss was seen only at the mid-distal radius but with no significant difference between groups. Women who took combined vitamin K and vitamin D plus calcium showed a significant and sustained increase in both BMD and BMC at the site of the ultradistal radius. Two-year randomized controlled trial of vitamin k(1) (phylloquinone) and vitamin d(3) plus calcium on the bone health of older women. Bolton-Smith C, et al. J Bone Miner Res 2007 Apr;22(4):509-19.

Retina: Vitamin K Protects Retina of Rats: Rats were given low, adequate or high levels K(1) diets. No association of diet and retina thickness was detected among young (6 month) animals. The sparing effect of vitamin K in the retina was most evident in the inner plexiform layer and in the photoreceptor inner and outer segments of older rats. No effect occurred on the age-dependent loss of photoreceptor cells, interneurons or ganglion cells. Vitamin K maintains the aging retina and suggest that the sparing effect does not reflect the survival-promoting (anti-apoptotic) activities of vitamin K-dependent proteins. Effects of long-term vitamin K (phylloquinone) intake on retina aging. Carrie I, Ferland G, Obin MS. Universite de Montreal. Nutr Neurosci. 2003 Dec;6(6):351-9

Warfarin Coagulopathy: Vitamin K Works Well: Lancet 11/4/00

In Japan, vitamin K(2) is used in drug therapy against atherosclerosis, or calcification in diabetes mellitus or dialysis, due to its promotion of the carboxylation of the matrix Gla protein. Atherosclerosis and matrix dystrophy. Seyama Y, Wachi H. Hoshi University, Tokyo. J Atheroscler Thromb. 2004;11(5):236-45

Cancer: Hepatocellular Liver Carcinoma Helped by Vitamin K and ACE Inhibitor in Rats: Treatment with both VK and Perindopril markedly inhibited the development of preneoplastic lesions in association with suppression of neovascularization in the liver. The combination treatment with VK and PE exerted a more potent inhibitory effect as compared with the single agent treatments. Yoshiji H, et al. Nara, Japan. J Hepatol. 2005 May;42(5):687-93.

Protein C, a vitamin K-dependent serine protease zymogen that circulates in plasma, is converted by limited proteolysis to activated protein C (APC) by the thrombin-thrombomodulin complex. APC exerts anticoagulant, antiinflammatory, cytoprotective, and antiapoptotic activities. Recombinant APC therapy reduces mortality in severe sepsis patients.

My Published Letter on Vitamin K

Dr. Radecki's British Medical Journal Response: Published in the BMJ: Calcium and vitamin D in preventing fractures: Vitamin K supplementation has powerful effect. British Med J 2005;331:108:

"The study by Porthouse et al (BMJ 4/30/05) appears well done with an excellent review of the vitamin D and calcium research. Obviously, vitamin D and calcium are not enough.

What I was disappointed with is that there is absolutely no mention of the extensive research coming out of Japan and the Netherlands showing that vitamin K supplementation has a powerful effect in decreasing osteoporosis and osteoporosis related fractures. And combining vitamin K, vitamin D, and calcium appears ideal.

Researchers from Osaka Medical College showed that vitamin K and vitamin D together increased bone density much better than vitamin K alone (Ushiroyama, 2002).

When comparing calcium and vitamin D alone vs. placebo, University of Maastricht researchers found little benefit on bone loss. But those randomized to take vitamin K in addition to calcium and vitamin D had significantly less femoral neck bone loss after three years (Braam, 2003).

The Yamaguchi Osteoporosis Prevention Study showed that vitamin K alone reduced vertebral fractures by 56% compared to placebo, comparable to the benefit found from etidronate (Ishida, 2004).  

Researchers at Hirosaki University in Japan showed that vitamin K lowered bone fractures in elderly female Parkinson's patients by 90% (Sato, 2002). The same research team showed an 86% decrease in fractures in elderly Alzheimer's patients treated with a combination of vitamin K, vitamin D, and calcium vs. placebo (Sato, 2005).

I just can't believe how the medical establishment blocks out the vitamin K research. Trashing vitamin D and calcium helps certain international drug giants who control most academic centers in the U.S. and around the world. If the medical standard became to first use vitamins D and K with calcium before using bisphosphonates and SERMs, billions of dollars per year would be saved by the public.

Braam LA, Knapen MH, Geusens P, Brouns F, Hamulyak K, Gerichhausen MJ, Vermeer C. University of Maastricht. Vitamin K1 supplementation retards bone loss in postmenopausal women between 50 and 60 years of age. Calcif Tissue Int. 2003 Jul;73(1):21-6

Ishida Y, Kawai S., Yamaguchi University, Japan. Comparative efficacy of hormone replacement therapy, etidronate, calcitonin, alfacalcidol, and vitamin K in postmenopausal women with osteoporosis: The Yamaguchi Osteoporosis Prevention Study. Am J Med. 2004 Oct 15;117(8):549-55. 

Sato Y, Honda Y, Kaji M, Asoh T, Hosokawa K, Kondo I, Satoh K. Hirosaki University. Amelioration of osteoporosis by menatetrenone in elderly female Parkinson's disease patients with vitamin D deficiency. Bone. 2002 Jul;31(1):114-8 

Sato Y, Kanoko T, et al. Japan. Menatetrenone and vitamin D2 with calcium supplements prevent nonvertebral fracture in elderly women with Alzheimer's disease. Bone. 2005 Jan;36(1):61-8.

Ushiroyama T, Ikeda A, Ueki M. Osaka Medical College. Effect of continuous combined therapy with vitamin K(2) and vitamin D(3) on bone mineral density and coagulofibrinolysis function in postmenopausal women. Maturitas. 2002 Mar 25;41(3):211-21"


Thomas E. Radecki, M.D., J.D.

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