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The silent killer: why we ignore Osteoporosis

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Dr Aruna Caldera , Consultant Rheumatologist

Silent yet destructive, Osteoporosis often advances without warning until a simple fall results in a life altering fracture. In this interview Dr. Anura Caldera, Consultant Rheumatologist sheds light on a condition long misunderstood as an inevitable part of ageing. He explains why Osteoporosis is preventable, detectable, and treatable when addressed early and awareness especially among women and the elderly can mean the difference between independence and disability. Drawing from years of frontline experience, Dr. Caldera unpacks the myths, risks and lifesaving interventions surrounding one of the world’s most under diagnosed bone diseases.

Dr. Caldera is a product of Royal College with advanced foreign training that has shaped his professional expertise. This blend of strong local education and global training has been central to the perspective and standards he brings to his work today.

All of us may have seen the elderly woman in the neighbourhood who broke her hip, disappeared from the community, and passed away a few months later. We may also have seen another woman who gradually stoops forward and ends up needing a walking stick in no time. But many of us may never have realized that these are complications of a disease that could have been prevented.

What is Osteoporosis?

Osteoporosis is a systemic bone disease that reduces bone mineral density, making bones extremely weak and fragile. This reduction in bone density makes bones highly prone to fractures, often involving the hip, spine, forearm just above the wrist and upper arm, even following minor falls.

What happens in Osteoporosis?

Bones are dynamic structures, meaning they are constantly being built up and broken down within the body. Two main cell types are responsible for this process: osteoblasts, which form bone, and osteoclasts, which break down bone.

When we are young and healthy, these cells work in perfect harmony, maintaining strong and healthy bones. Ideally, we should not fracture a bone even if we fall from our own height.

In Osteoporosis, this balance is tipped towards bone breakdown. Over time, bone mineral density gradually decreases to dangerous levels. At this stage, even minor trauma—such as slipping while trying to sit on a chair and falling to the ground—can result in a fracture, particularly of the hip.

Why aren’t patients aware of it?

The major problem with Osteoporosis is that it has no symptoms until it causes a fracture. When you have diabetes, you may urinate frequently, feel excessive thirst, and lose weight. When your heart arteries are blocked, you may feel breathless climbing a few stairs. When your kidneys are failing, your feet may swell. But with Osteoporosis, you feel nothing.

By the time symptoms appear, the disease has already manifested its complications—fractures. Most patients in Sri Lanka discover they have Osteoporosis only after breaking a bone.

Some patients gradually lose height over time due to silent fractures of the spine, known as vertebral wedge fractures. Sometimes the pain is so minimal that the patient is unaware a fracture has occurred. Degeneration of spinal discs can also contribute to height loss. A stooped posture may develop for the same reasons. Lower back pain usually appears only once fractures have occurred.

What treatment options are available?

The mainstay of treatment is anti-resorptive therapy, which is available in tablet, injection, and infusion forms. The most commonly used medication is alendronate 70 mg, taken once weekly on an empty stomach with 200 ml of water. Patients must remain upright and avoid eating for at least 30 minutes after taking the tablet.

There are also monthly tablet formulations. If oral medications are poorly tolerated, treatment can be switched to an annual infusion such as zoledronic acid or six-monthly denosumab subcutaneous injections. Other treatment options are also available.

In addition, patients require calcium and vitamin D supplementation. The minimum recommended intake is 700 mg of calcium and 800 IU of vitamin D, obtained through a combination of diet and supplements. Combination tablets containing calcium and vitamin D in these ranges are generally safe.

How long should patients be treated?

The duration of treatment depends on the individual patient. A common misconception is that five years of treatment is sufficient for everyone. This is incorrect.

Decisions regarding treatment duration and drug holidays must be made carefully, based on multiple factors. Patients require regular DXA and FRAX assessments to monitor treatment response and identify new risk factors. If the response is inadequate, the physician may need to change the antiresorptive medication—for example, from oral therapy to infusion. Osteoporosis cannot be effectively managed by prescribing a single medication and assuming five years of treatment will resolve the condition.

Why is Osteoporosis called a “silent killer”?

Osteoporosis-related hip fractures significantly increase the risk of death within the following year, with up to 30% of patients dying within 12 months of a hip fracture. Death often results from complications such as pneumonia or blood clots due to prolonged immobility.

A significant number of survivors also lose their independent mobility after a hip fracture. Therefore, it is far better to be safe than sorry—get tested and treated when necessary. One of the greatest assets in old age is independent mobility, which allows a person to remain self-sufficient and maintain quality of life.

As a result, patients tend to attribute their pain to this condition. However, the real cause may be that one of the weakened vertebrae has already fractured and collapsed, and the next bone at risk of fracture could be the hip.

Which patients are most affected?

Peak bone mass is achieved in the early 30s, after which bone mineral density gradually declines. This loss is usually minimal and does not significantly increase fracture risk.

However, once women reach menopause, the lack of estrogen accelerates bone loss to a level where bone mineral density may reach Osteoporotic levels.

A study conducted in Sri Lanka in 2004 by Prof. Sisira Siribaddana and Prof. Sarath Lekamwasam revealed that 42.3% of women aged 50-59, 67.5% of women aged 6069, and 81.6% of women over 70 had Osteoporosis. According to similar studies, 94% of Sri Lankan patients with Osteoporosis are female. These figures are notably higher than those seen in many developed countries, where the prevalence is lower.

How can we diagnose this condition?

Any woman over the age of 50 should undergo a “fracture risk assessment”. Those with an intermediate or higher risk should then have a bone mineral density assessment using a DXA scan. This scan measures bone density in the spine, hip, and, in selected cases, the wrist.

The T-score is used to guide treatment decisions in most patients. However, a FRAX score—calculated using an online tool—is particularly useful for patients with borderline bone density (Osteopenia), as the DXA scan alone cannot reliably predict hip or major Osteoporotic fracture risk in all individuals.

There is one situation where treatment is initiated even without a DXA scan: when a patient has already suffered a fracture believed to be due to Osteoporosis. In such cases, treatment is started even if the DXA scan (Dual Energy Xray Absorptiometry scan) does not show established Osteoporosis.

Additional blood tests may be required, though not all are necessary for every patient. These commonly include serum calcium, vitamin D levels, parathyroid hormone levels (in selected patients), and routine kidney and liver function tests. Further investigations may be arranged on a patient-by-patient basis.

Are there other high-risk groups apart from post-menopausal women?

Yes. Other risk factors include advancing age, low Body Mass Index (BMI), previous fragility fractures, a parental history of hip fractures, long-term steroid therapy (more than three months), smoking, alcohol consumption exceeding three units per day, rheumatoid arthritis, type 1 diabetes, chronic liver disease, chronic kidney disease, sex hormone deficiency, and concurrent malignancy.

FRAX score is a fracture risk assessment tool that is particularly valuable for patients who do not meet treatment thresholds based on DXA results alone.



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Rediscovery of Strobilanthes pentandra after 48 years

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Strobilanthes pentandra, one of Sri Lanka’s most elusive endemic flowering plants

A Flower Returns From Silence:

Nearly half a century after it slipped into botanical silence, a ghost flower of Sri Lanka’s misty highlands has returned—quietly, improbably, and beautifully—from the folds of the Knuckles mountain range.

In a discovery that blends patience, intuition and sheer field grit, Strobilanthes pentandra, one of Sri Lanka’s most elusive endemic flowering plants, has been rediscovered after 48 years with no confirmed records of its existence in the wild. For decades, it lived only as a name, a drawing, and a herbarium sheet. Until now.

This rare nelu species was first introduced to science in 1995 by renowned botanist J. R. I. Wood, based solely on a specimen collected in 1978 by Kostermans from the Lebnon Estate area. Remarkably, Wood himself had never seen the plant alive. The scientific illustration that accompanied its description was drawn entirely from dried herbarium material—an act of scholarly faith in a plant already vanishing from memory.

Renuka

From then on, Strobilanthes pentandra faded into obscurity. For 47 long years, there were no sightings, no photographs, no field notes. By the time Sri Lanka’s 2020 National Red List was compiled, the species had been classified as Critically Endangered, feared by many to be lost, if not extinct.

The turning point came not from a planned expedition, but from curiosity.

In October 2025, Induwara Sachinthana, a fourth-year medical student at the University of Peradeniya with a sharp eye for plants, stumbled upon an unfamiliar flowering shrub while trekking in the Knuckles region.

Sensing its importance, he photographed the plant and sent the images for verification, asking a simple but crucial question: Could this be the recently described Strobilanthes sripadensis, discovered from the Sri Pada sanctuary in 2022?

At first glance, the resemblance was striking. But something didn’t quite add up.

Based on the location, morphology, and subtle floral traits, the initial response was cautious: it was neither S. sripadensis nor S. pentandra—or perhaps something entirely new. Yet, as the pieces slowly aligned, and as the habitat details became clearer, the possibility grew stronger: this long-lost species had quietly persisted in the rugged heart of Knuckles.

Strobilanthes pentandra

The confirmation followed through collaborative expertise. Leading Strobilanthes specialist Dr. Renuka Nilanthi Rajapakse, together with Dr. Himesh Dilruwan Jayasinghe and other researchers, carefully examined the evidence. After detailed comparison with historical descriptions and herbarium material, the verdict was clear and electrifying: this was indeed Strobilanthes pentandra.

What followed was not easy.

A challenging hike through unforgiving terrain led to the first live confirmation of the species in nearly five decades. Fresh specimens were documented and collected, breathing life into what had long been a botanical myth.

Adding further weight to the rediscovery, naturalist Aruna Wijenayaka and others subsequently recorded the same species from several additional locations within the Knuckles landscape.

The full scientific credit for this rediscovery rightfully belongs to Induwara Sachinthana, whose curiosity set the chain in motion, and to the dedicated field teams that followed through with persistence and precision.

Interestingly, the journey also resolved an important taxonomic question. Strobilanthes pentandra bears a strong resemblance to Strobilanthes sripadensis, raising early doubts about whether the Sri Pada species might have been misidentified.

Detailed analysis now confirms they are distinct species, each possessing unique diagnostic characters that separate them from each other—and from all other known nelu species in Sri Lanka. That said, as with all living systems, future taxonomic revisions remain possible. Nature, after all, is never finished telling her story.

Although the research paper is yet to be formally published, the team decided to share the news sooner than planned. With many hikers and locals already encountering the plant in Knuckles, its existence was no longer a secret. Transparency, in this case, serves conservation better than silence.

This rediscovery is more than a scientific milestone. It is a reminder of how much remains unseen in Sri Lanka’s biodiversity hotspots—and how easily such treasures can vanish without notice. It also highlights the power of collaboration across generations, disciplines and institutions.

Researchers thanked the Department of Wildlife Conservation and the Forest Department for granting research permissions, and to the many individuals who supported fieldwork in visible and invisible ways.

After 48 years in the shadows, Strobilanthes pentandra has stepped back into the light—fragile, rare, and reminding us that extinction is not always the final chapter.

Sometimes, nature waits.

By Ifham Nizam ✍️

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Desire to connection. understanding sexual health in modern relationships

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Desire to connection. understanding sexual health in modern relationships

A conversation about intimacy, belonging and relationships with Dr Yasuni Manikkage

In an age where relationships are shaped as much by emotional awareness as by digital connection, conversations about sexual health are finally stepping out of the shadows.

As Dr. Yasuni Manikkage explains, sexual health is not just a medical issue but a lived experience woven through communication, consent, mental wellbeing and self-respect. Many couples share a home, a bed, even children, yet still feel like “Roommates with responsibilities” rather than lovers, which often signal a lack of emotional safety rather than a lack of physical contact. When desire shifts, they may panic, blame themselves or fear the relationship is dying, instead of recognising that changes in desire are common, understandable, and often transformable with knowledge, honest dialogue, and small daily acts of connection.

Q: Why did you decide to talk about sexual desire and connection now?

A: Because so many couples quietly suffer here. They love each other, share a home, raise children, but feel like “roommates with responsibilities” rather than lovers. They rarely talk about sex openly, so when desire changes, they panic, blame themselves, or assume the relationship is dying. I want people to know shifts in desire are common, understandable, and often treatable with knowledge, communication, and small daily changes.

Q: You say there is an “education gap” in sexual health. What do you mean by that?

A: Most women have never been properly taught about their own sexual anatomy, especially where and how they feel pleasure. Many men, on the other hand, have been left to “figure it out” from pornography, jokes, and guesswork. That’s a terrible training manual for real bodies and real emotions. This gap affects how easily women reach orgasm, how safe they feel in bed, and how satisfied both partners feel in the relationship.

Q: We hear about the “orgasm gap.” Is it really not biological?

A: There are biological factors, yes, but the main gap we see between men’s and women’s orgasm rates in heterosexual relationships comes from communication, knowledge, and what I call “pleasure equity.” In many bedrooms, the script is focused on penetration, speed, and the man’s climax. Women’s pleasure is often treated as optional or “extra.” When couples learn anatomy, slow down, focus on both bodies, and talk about what feels good, that gap narrows dramatically.

Q: Most people think desire should be spontaneous. Is that a myth?

A: It’s one of the biggest myths. Movies show desire as a spark that appears out of nowhere: one glance across the room and suddenly you’re tearing each other’s clothes off. That kind of spontaneous desire does happen, especially early in a relationship. But for many people, especially women, desire is often “responsive”. That means they start feeling desire after some warmth, touch, emotional closeness, or stimulation, not before.

So, if you’re waiting to “feel like it” before you touch or connect, you may wait a very long time. For many, desire comes “after” they start, not before.

Q: How would you scientifically describe sexual desire?

A: Desire is not just a physical urge. It’s a blend of attraction to your partner’s body and personality, emotional connection and feeling cared for, a sense of self-expansion or growth, learning, feeling alive with them, trust and safety, both emotionally and physically. It’s contextual: it changes with stress, health, life stages, and relationship quality. It’s relational: it lives between two nervous systems, not just in one body. And for many, it’s responsive: you get in the mood “after” a hug, a joke, a shower together, not randomly at 3 p.m. on a Tuesday.

Q: You mentioned an “updated sexual response cycle.” What does that look like in real life?

A: Older models suggested a straight line: desire, arousal, orgasm and resolution. That’s tidy, but human beings are messy and complex. Modern understanding is more like a circle or loop. You can enter the cycle at different points: maybe you start with touch, or a feeling of closeness, or even just a decision to connect. Desire doesn’t always come first; sometimes it shows up halfway through.

For example, you may feel tired and not “in the mood,” but you agree to cuddle and share some gentle touch. As you relax and feel appreciated, arousal builds, and then desire appears. That’s normal, not fake.

Q: Are there real gender differences in how desire works?

A: There are common patterns, though individuals vary a lot. Many women tend to enter through emotional intimacy: feeling heard, understood, and safe. Physical touch then wakes up arousal, and desire follows.

Many men more often start with physical attraction or arousal. They may feel desire quickly in response to visual or physical cues, and emotional intimacy can deepen later.

Both patterns are healthy and normal. The problem starts when each partner assumes the other should work exactly like them, and if they don’t, they must be “cold” “needy” or “broken.” Understanding these differences turns conflict into curiosity.

Q: How does desire change as a relationship ages?

A: Think of three broad stages.

stage 1 – Early Attraction (0-6 months): High novelty, strong chemistry, lots of dopamine. You’re discovering each other; desire often feels effortless. stage 2 – Deepening Intimacy (6 months-2 years): You know each other better. The high settles. Desire becomes more linked to emotional closeness. Frequency may drop, and that is “normal”.

stage 3 – Maintenance and Maturity (2-10+ years): Life arrives -work, kids, money, health. Desire usually doesn’t feel automatic. It needs conscious attention, novelty, and emotional safety.

A common mistake is comparing stage 3 desire to Stage 1 and assuming, “we’ve failed.” Actually, you’ve just moved into a different phase that requires new skills.

Q: What are some main things that influence desire?

A:We can think in three layers.

Biological: hormones (testosterone, estrogen), brain chemicals (dopamine, serotonin), medical conditions like diabetes, heart disease, cancer, chronic pain, sleep problems, menopause, and genital issues such as vaginal dryness or pelvic floor pain.

Psychological: negative early sexual experiences, trauma or abuse, body image concerns, low self-esteem, anxiety, depression, and certain mental health conditions.

Relational and social: how safe and respected you feel, attachment style, quality of communication, power imbalances, work and financial stress, caregiving burdens, privacy, and cultural messages that centre on penetration over pleasure. Desire is never “just in your head” or “just in your hormones” – it’s all three interacting.

Q: What tends to kill desire in long-term relationships?

A: Several patterns show up again and again:

Resentment and unresolved conflict – small hurts that never get repaired.

Lack of emotional safety – fear of being judged, rejected, or punished for being vulnerable.

Poor communication – avoiding difficult topics, sarcasm instead of honesty.

Body image shame – feeling unattractive, “too old,” “too fat,” or “not enough.”

Power imbalance -one partner controlling decisions, money, or sex.

Sexual guilt or religious shame messages that sex is dirty, selfish, or only for reproduction.

Stress, burnout, depression -when your nervous system is in survival mode, it doesn’t prioritise pleasure.

You can’t expect desire to flourish in an environment that feels unsafe, unfair, or constantly tense.

Q: And what actually builds desire?

A: Desire thrives in a combination of safety and aliveness.

Emotional intimacy: feeling seen, heard, and valued.

Nervous system calm: your body is relaxed enough to feel pleasure, not just guard against danger.

Open communication: you can talk about wants, limits, and fantasies without mocking or shutting each other down.

Continued growth: doing new things together, seeing new sides of each other, evolving as a team.

I often say: stagnation is desire’s enemy; growth is its ally. Even small adventures -trying a new cafe, dancing in the living room, travelling a different route-can reawaken curiosity.

Q: Can you give couples a simple framework to reconnect?

A: Yes, I often share a six-step framework that’s practical and gentle.

1. Check in: Ask, “How connected do we feel lately?” Not just “How often are we having sex?”

2. Non-sexual touch: Hugs, stroking hair, holding hands – without expecting sex at the end.

3. Novelty: Try something new together: a class, a walk in a different place, a game, a shared hobby.

4. Appreciation: Tell your partner what you notice and value about them, including non-sexual qualities.

5. vulnerability: Share one fear, one hope, or one truth you usually hide.

6. Initiation: Don’t wait for desire to fall from the sky. Gently invite connection; sometimes the mood follows the movement.

You don’t need to do all of this perfectly. Even one or two steps, done consistently, can shift the energy between you.

Q: How can someone tell if their desire problem needs more attention or professional help?

A: some warning signs include:

You feel emotionally distant, even though you still love each other.

Desire has dropped sharply and is tied to stress, shame, or unspoken conflict.

You feel unable to talk about sex without fighting or shutting down.

sex is used to avoid real intimacy, or to keep the peace, rather than to connect.

You feel afraid or ashamed to say what you truly want-or what you don’t want. In these situations, talking to a doctor, a sexual medicine specialist, or a therapist can be very helpful. You are not “broken” for needing support.

Q: Many couples say, “We love each other but there’s no spark.” What do you tell them?

A: I often say, “Let’s first normalise where you are.” If you’ve been together for years, maybe raising children and navigating financial pressures, it’s normal that your desire doesn’t look like the early days. That doesn’t mean your relationship is dying.

usually, you’re in the maintenance phase. Desire is quieter but can be reawakened with intentional effort: scheduling time for each other, bringing in novelty, and rebuilding emotional safety. It’s less about chasing fireworks and more about tending a fire so it doesn’t go out.

Q: what about couples with mismatched desires – one wants sex often, the other rarely?

A: This is extremely common. The mistake is to frame it as “the pursuer is demanding” and “the less-desiring partner is rejecting.” underneath, there are often two different nervous systems trying to feel safe.

one partner might use physical closeness to feel secure and loved. The other might need emotional safety first before their body can relax into physical intimacy. When couples understand this, they stop seeing each other as enemies and start cooperating: “How can we meet ‘both’ our needs, instead of arguing about who is right?”

Q: Many people, especially women, say sex feels like an obligation. What does that signal to you as a doctor?

A: It’s a red flag – not that the person is broken, but that something important is missing. sex should be about connection, pleasure, and mutual choice. when it becomes a duty, I look for:

Emotional disconnection or resentment.

Fear of conflict or abandonment if they say no.

Lack of felt safety or freedom to express preferences.

The solution is not to “force yourself more.” It is to rebuild emotional safety, renegotiate consent and expectations, and often to have very honest conversations about what feels missing or painful.

Q: If you could leave couples with a few key messages about desire and connection, what would they be?

A: I’d highlight four truths:

Desire and emotional intimacy are deeply connected. When you feel safe, loved, and seen, desire has space to grow.

Desire changes across life and relationship stages. That’s normal, not evidence of failure.

Safety is the foundation. without trust and a calm nervous system, no technique or position will fix desire.

You have agency. Through communication, intentional connection, and sometimes professional help, it is possible to revive and reshape your sexual relationship. If you are reading this and thinking, “This sounds like us,” my invitation is simple: start with one honest conversation. Ask your partner, “Where do you naturally enter the cycle -through emotions, touch, or arousal? What helps you feel desire? What do you need from me to feel safe and wanted?”

Those questions, asked with kindness and curiosity, can quietly change the entire trajectory of a relationship.

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Ramazan spirit comes alive at ‘Marhaba’

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The committee driving excellence

At Muslim Ladies College

The spirit of Ramadan came alive at the Muslim Ladies as the much-awaited pre-Ramadan sale “Marabha” organised by MLC PPA unfolded at SLEC the event drew students, parents and old girls to a colourful celebration filled with the aromas of traditional delicacies and the buzz of excitement from the buzzling stalls

Behind the seamless flow and refined presentation were Feroza Muzzamil and Zamani Nazeem. Whose dedication and eye for detail elevated the entire occasion. Their work reflected not only efficiency but a deep understanding of the institution’s values. It was an event, reflected teamwork, vision and a shared commitment to doing things so beautifully. The shoppers were treated to an exquisite selection of Abayas, hijabs and modern fashion essentials, carefully curated to blend contemporary trends with classic elegance. Each stall offered unique piece from intricately embroidered dresses to chic modern designs. The event also highlighted local entrepreneurs a chance to support homegrown talent. Traditional Ramazan goods and refreshment added a delighted touch, making it as much a cultural celebration as a shopping experience.

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