Postmenopausal Osteoporosis

Strategies for the prevention and treatment of osteoporosis during early postmenopause

Osteoporosis is a major cause of morbidity and death in older persons. For women who are 50 years of age, the estimated lifetime risk for osteoporotic fracture is 54%, and studies suggest that the ...

Background Systemic sclerosis (SSc) is a severe connective tissue disorder causing vascular, immune, and fibrotic changes in the skin and internal organs. Patients with SSc may have an increased risk of osteoporosis (OP) and fractures due to a chronic inflammatory state, latent malabsorption or malnutrition, immobilization, and use of corticosteroid therapy. Objectives: to determine the frequency of low mineral density, falls, low energy fractures and 10-year probability of new fracture in patients with SSc. Methods 191 patients with SSc were enrolled in the study: 160 women (mean age 51±13 yrs), among them 107 postmenopausal, and 31 men (mean age 53±14 yrs). Bone mineral density (BMD) was measured at lumbar spine (LS), femoral neck (FN) and total hip (TH) by dual energy X-ray absorptiometry (DXA, Hologic 4500A). BMD decreasing grade was determined in accordance to WHO criteria. All patients were interviewed on a special questionnaire and assessment of 10-year probability of new fracture by FRAX® was performed. Vitamin D level was measured in 104 patients. Results Low BMD was found in 68% women and 55% men: osteopenia in 30% and 32% and OP in 38% (21% in reproductive age and 50% in postmenopausal) and 23%, respectively. BMD in LS, FN and TH associated with body mass index (r=0,3, p=0,030; r=0,41, p=0,0027; r=0,49, p=0,0002, respectively) and duration of postmenopausal period in women (r=-0,56, p=0,023; r=-0,66, p=0,006; r=-0,63, p=0,009, respectively). BMD of LS and FN correlated with age (r=-0,22, p=0,045; r=-0,23, p=0,016, respectively), duration of SSc (r=-0,32, p=0,037; r=-0,31, p=0,046, respectively), glucocorticoid cumulative dose for LS only (r=-0,31, p=0,024). Mean 25(OH)D level was 19,83±11,06 ng/ml. Normal vitamin D level had 9% of SSc patients. No correlation between BMD and 25(OH)D level was found. 46 (24%) patients reported falls in the year prior to the interview, among them in 2 patients the fall led to fracture. A total of 48 (25%) patients had low energy fractures in the past, among them 8 (4%) of women had two or more fractures. Frequency of low energy fractures was 35%, 8% and 25% among postmenopausal women, women of reproductive age and men, respectively. The mean age at which the fracture occurred was 55±11 yrs. in postmenopausal women, 30±12 yrs. in young women and 60±12 yrs. in men. The most frequent were the fractures of distal forearm and vertebrae: 13 (7%) and 26 (14%) patients, respectively. Five patients each (3%) had ankle and humerus neck fractures and 7 – other localizations. Nobody reported the fracture of the proximal femur. Patients with abnormal BMD (OP or osteopenia) had a risk of falls and low energy fractures more than 2 times higher than patients with normal BMD (OR 2.93 [95% CI 1.11; 8.01], p=0,016 and OR 2.58 [95% CI 1.04; 6.6], p=0,025, respectively). 10-year probability of any major osteoporotic fracture was 18.4 ± 9.6% in women and 9.7 ± 8.6% in men and of hip fracture - 3.5 ± 3.7% and 1.5 ± 3.9%, respectively. Among all patients, 55% of women and 4% of men had a high risk of subsequent fractures using the FRAX® algorithm. Conclusion Low BMD was diagnosed in 68% of women and 55% of men with SSc. The correlations between BMD and age, body mass index, the duration of postmenopause were revealed. Additionally, we found associations with risk factors related to the disease itself: disease duration and glucocorticoid cumulative dose. Reduced BMD was associated with an increased risk of falls and fractures. 55% of women and 4% of men had a high risk of further fractures. Disclosure of Interests Olga Dobrovolskaya: None declared, Nikolay Demin: None declared, Oxana Desinova: None declared, Natalia Toroptsova Speakers bureau: Amgen, Lilly

Early diagnosis of osteoporosis and estimation of subjects that are at high risk for fracture, is neccesary for osteoporosis treatment. Dual-energy X-ray absorptometry (DXA) is a modern method for bone mineral density (BMD) evaluation. However, along BMD, clinical risk factors may significantly influence fracture development. Therefore, FRAX algorithm was designed for the assessment of a ten-year risk for serious osteoporotic fractures (SOF), as well as hip fractures. In the current study, we tried to evaluate the possible lumbal spine and hip BMD influence on ten year risk for SOF and hip fractures and potential role of FRAX in predicting the therapy in postmenopausal women with osteopenia. We performed the study on 385 postmenopausal women. According to the DXA measurements, at the lumbal (L) spine (L1–L4) and hip (femor neck), patients were then classified as normal, osteopenic, or osteoporotic. BMD evaluation included the L spine and the hip (subgroup 1), and only on the L spine (subgroup 2). By filling up the FRAX questionnaire, a ten-year risk for SOF fracture and hip fracture was calculated. BMD evaluation, in complete patient’s group and in subgroup 1, resulted in the highest number of osteoporosis (61.04%, 48.08%, retrospectively), while ospeopenia was a main finding in subgroup 2. In the subgroup 1, a high risk for SOF and hip fracture was detected in 16.45% and with high risk for hip fracture in 11.38% subjects. In subgroup 2, only high risk for hip fracture was observed in 3.16% subjects, indicating the active medicament treatment. Simultaneously, correlation of BMD results with FRAX values for SOF and hip fracture, showed significant negative correlation (p<0.001). Obtained results showed significant role of femur neck BMD evaluation in predicting the future factors, which may, together with FRAX analysis, improve the therapy approach in postmenopausal women with ospeopenia.

Overdiagnosis and Overtreatment of Osteoporosis: A Wolf in Sheep's Clothing.

Background:Thyroid hormones affect bone remodeling in patients with thyroid disease by acting directly or indirectly on bone cells. In view of limited information on correlation of thyroid function with bone mineral density (BMD) in euthyroid subjects, we undertook this study to evaluate the correlation between thyroid function with BMD in subjects with normal thyroid function and subclinical hypothyroidism.Material and Methods:A total of 1290 subjects included in this cross sectional study, were divided in Group-1 with normal thyroid function and Group-2 with subclinical hypothyroidism. Fasting blood samples were drawn for the estimation of serum 25(OH)D, intact parathyroid hormone, total and ionized calcium, inorganic phosphorus, and alkaline phosphatase. BMD at lumbar spine, femur, and forearm was measured.Results:BMD at all sites (radius, femur, and spine) were comparable in both groups. There was no difference in BMD when subjects were divided in tertiles of TSH in either group. In group-1, FT4 and TSH were positively associated with BMD at 33% radius whereas FT3 was negatively associated with BMD at femoral neck in multiple regression analysis after adjustment for age, sex, BMI, 25(OH)D and PTH levels. In group-2, there was no association observed between TSH and BMD at any site. Amongst all study subjects FT4 and FT3 were positively correlated with BMD at lumbar spine and radius respectively among all subjects.Conclusion:TSH does not affect BMD in euthyroid subjects and subjects with subclinical hypothyroidism. Thyroid hormones appear to have more pronounced positive effect on cortical than trabecular bone in euthyroid subjects.

To evaluate the occurrence of low bone mineral density (BMD) and its relationship with clinical and laboratorial characteristics in children and young adults with sickle cell anaemia living in Northeast-Brazil, and to assess the role of radiography in diagnosing low BMD. Bone mineral density of lumbar spine was measured by dual energy X-ray absorptiometry (DXA) in 27 patients with Sickle cell anaemia (SCA) aged 7-28years. Clinical history, calcium and calorie intake, laboratory measurements, anthropometrics and pubertal development were assessed, and X-rays were obtained. Z-scores and T-scores for weight, height, Body Mass Index (BMI) and BMD were calculated using age and gender matched reference data. Mean lumbar spine BMD Z-scores and T-scores were -1.81 SD in boys and -0.80 SD in girls. BMD Z-scores were below -2 SD in 33.3% of girls and in 46.7% of boys. Low BMD (<-2 SD) occurred significantly more in patients with low height-for-age (P=0.02), low weight-for-age (P=0.001) and low BMI-for-age (P=0.006). No significant relationships were found between BMD and other clinical and laboratory parameters. Radiography had a sensitivity of 75% and a specificity of 36% to detect low BMD, and was considered not useful in this context. Patients with low height and/or low weight-for-age seem to be at high risk for developing low BMD.

BackgroundRomosozumab, a monoclonal antibody against sclerostin, is a newly licensed dual-acting osteoporosis (OP) treatment for patients at very high fracture risk. Most patients included in the pivotal trials (ARCH[1] and...

The aim – to assess bone mineral density (BMD) and microarchitecture, as well as the risk of fractures in postmenopausal women with rheumatoid arthritis (RA). Materials and methods: 95 postmenopausal women (mean age 62.3±8.1 years) with a confirmed RA were included. All patients underwent a questionnaire, clinical and laboratory examination, dual-energy X-ray absorptiometry (DXA) of the lumbar spine (L1–L4), proximal femur, and trabecular bone score (TBS) assessment. The 10-year probability of osteoporotic fracture was calculated using the FRAX tool without including femoral neck (FN) BMD (BMD–), with FN BMD (BMD +) and additionally adjustment for TBS (BMD + TBS). Results. Osteoporosis (OP) was found in 41 (43.2%) patients: in L1–L4 – in 26,3%, in FN – in 22.1%, and in the total hip (TH) – in 11.6% persons. Degraded microarchitecture according to TBS was found in 38.9% of patients, partially degraded – in 25.3%, and normal – in 35.8% of women with RA. A high risk of fracture according to FRAX BMD– was detected in 49.5% of patients. TBS correlated with age (r=–0.30; p=0.003), duration of postmenopausal period (r=–0.26; p=0.014), cumulative dose of glucocorticoids (GCs) (r=–0.34; p=0.045), FRAX BMD– (r=–0.24; p&lt;0.05) and FRAX BMD+ (r=–0.21; p&lt;0.05); L1–L4 BMD (r=0.43; p&lt;0.001), FN BMD (r=0.21; p=0.038), TH BMD (r=0.23; p=0.02). Low TBS was significantly more often detected in people with a history of fractures compared to people without them (p&lt;0.05). Among RA patients with normal L1–L4 BMD 9.5% of persons had degraded microarchitecture of bone tissue according to TBS. The inclusion of TBS in FRAX increased the risk of fractures to high in 9.5% of patients and reduced it to low in 7.4% of women, due to which the total number of people with RA who had a high risk of fractures became 54.7%. Conclusion. OP was diagnosed in 43.2%, and degraded microarchitecture of bone tissue according to TBS – in 38.9% of postmenopausal women with RA. A high risk of fractures according to FRAX was found in 49.5%. TBS negatively correlated with age, duration of postmenopause, cumulative GCs dose, FRAX fracture risk, and positively correlated with BMD in all measurement sites. The FRAX adjustment by TBS redistributed patients in risk groups, as a result of which 54.7% of RA patients needed anti-osteoporotic treatment.

The aims of the study were to determine the mean trabecular bone score (TBS) of postmenopausal Taiwanese women and to analyze the value of TBS in predicting osteoporosis. A total of 1,915 postmenopausal women with lumbar spine and hip bone mineral density (BMD) and spine TBS were enrolled from a single medical center into this study. The women's BMD and TBS were measured using dual x-ray absorptiometry (Discovery Wi; Hologic, Bedford, Mass) and iNsight software (Med-Imaps SASU, Merignac, France), respectively. The women's demographic characteristics; lumbar spine, total hip, and femoral neck BMD; and lumbar spine TBS were recorded, and correlations among the parameters were identified using a 2-tailed Pearson test, in which a P value less than 0.05 was considered statistically significant. We developed simple linear regression models to represent changes related to TBS and performed an analysis of variance on the selected variables. The average age of the women was 62.5 ± 9.1 years (range, 25.7-93.7 years). The mean TBS was 1.300 ± 0.086 (range, 1.015-1.596). The TBS was weakly and negatively correlated with body mass index ( r = -0.078) and moderately and positively correlated with the lumbar spine BMD ( r = 0.619). The patients' lowest BMD values among those measured at multiple sites revealed a higher rate of osteoporosis (32.5%) than those measured at individual sites. Degraded TBS were noted in 21.2% of the participants, and a combination of BMD and TBS results predicted more individuals (7.8%) at a high risk of fracture than did the BMD result only. The rates of both osteoporosis and degraded TBS increased with age. Bone mineral density and TBS can be used in combination to predict osteoporosis in a greater number of postmenopausal Taiwanese women. Because the incidence of osteoporosis is the highest among older women, clinicians should pay careful attention to TBS degradation among older patients without low BMD.

Strengthening the bones in primary biliary cirrhosis

BACKGROUND AND OBJECTIVES:The effects of vitamin D on bone mass remain to be understood. This study was conducted with the objective of evaluating the influence of 25-hydroxyvitamin D (25OHD) levels on bone mineral density (BMD) among Saudi nationals.DESIGN AND SETTING:Cross-sectional study carried out at university hospital from 1 February 2008 to 31 May 2008.SUBJECTS AND METHODS:Healthy Saudi men and women in the peak bone mass (PBM) age group and those aged ≥50 years were recruited from the outpatient department of King Fahd University Hospital, Al Khobar, Saudi Arabia, between February 1, 2008, and May 31, 2008. Patient age and sex were documented, and body mass index was calculated. Hematological, biochemical, and serum 25OHD tests were performed. BMD was determined by dual-energy x-ray absorptiometry of the upper femur and lumbar spine. Patients were divided into three groups, based on their 25OHD level.RESULTS:Data from 400 patients were analyzed. Among individuals with a normal 25OHD level, 50% of women and 7% of men in the PBM age group and 26.4% of women and 49.2% of men aged ≥50 years had low bone mass. In patients with 25OHD insufficiency, 84.2% of women and 88.9% of men in the PBM age group and 83.3% of women and 80% of men aged ≥50 years had low bone mass. Results for patients with 25OHD deficiency revealed that none of the men and women in the PBM age group or ≥50 years old had normal BMD. Significant positive correlations between 25OHD level and BMD and significant negative correlations with parathyroid hormone were shown in most of the groups.CONCLUSIONS:This study showed that the vitamin D level significantly influences BMD reading among Saudi individuals. Evaluation and treatment of hypovitaminosis D should be considered during management of low bone mass.

Postmenopause and type 2 diabetes mellitus (T2DM) are associated with higher fracture risk. Sex hormones are important in maintaining woman skeleton health. The relationships of sex hormone(s) with bone mineral density (BMD) and fracture risk are still unclear in diabetic-postmenopausal women. This study aimed to investigate the relationships of sex hormones with BMDs and fracture risk in postmenopausal women with T2DM. Two hundred and fourteen postmenopausal women with T2DM were included. BMDs at lumbar spine (L2-4), femoral neck (FN) and total hip (TH) were measured by dual-energy X-ray absorptiometry (DXA). The 10-year probability of fractures was accessed by modified fracture risk algorithm (FRAX) tool. Serum concentrations of sex hormones were measured. Sex hormone binding globulin (SHBG) was a determinant of BMDs at L2-4 (β=-0.199, P<0.05), TH (β=-0.233, P<0.05), major osteoporotic fracture (MOF) (β=0.253, P<0.001) and hip fracture (HF) (β=0.262, P<0.001). Per SD increase in SHBG caused a 2% increase in the risk of osteoporosis/osteopenia. SHBG in quartile-4 was associated with 4.21 higher risk of osteoporosis/osteopenia compared with SHBG in quartile-1. In postmenopausal women with T2DM, higher serum SHBG tended to be associated with lower BMDs, and increased the risk of osteoporosis/osteopenia and the fracture risk.

Despite the fact that China amounts to one-fifth of the world's population, has a higher proportion of the elderly, and has a higher prevalence of osteoporosis and fracture, limited studies have investigated the association between dietary patterns and bone mineral density (BMD) as well as fracture risk among the elderly Chinese population. We aimed to investigate the association between different dietary patterns and BMD as well as the risk of fractures, and this association may vary between elderly women and men. Building upon the China Osteoporosis Prevalence Study, we included 17,489 subjects aged ≥40 years old randomly sampled across 44 counties/districts of 11 provinces or municipalities in China who completed a food frequency questionnaire. BMD was measured by dual x-ray absorptiometry. Vertebral fracture was defined based on lateral spine radiographs using the semi-quantitative technique of Genant. A diet rich in "carnivorous", "vegetarian", "dairy, fruit, and egg" was significantly associated with higher BMD at total hip (TH), femoral neck (FN), and lumbar spine 1-4 (L1-4). Yet, a diet rich in "beverage and fried food" was associated with a lower BMD at the FN and L1-4. High quartiles of the carnivorous diet were associated with 34%-39% reduced risk of clinical fracture in the past 5 years and vertebral fracture. Stronger associations were observed among women. Sensitivity analysis among postmenopausal women presented even stronger positive associations between carnivorous and vegetarian diets and high BMD, as well as between carnivorous diet and reduced risk of fractures. Our study suggested that a diet rich in meat, vegetables, and dairy, fruit, and eggs might be associated with greater BMD and a lower fracture risk, while beverage and fried foods may be associated with a lower BMD at L1-4, especially among elderly women. These findings are relevant to provide recommendations on dietary nutrition regarding the elderly population at high risk of osteoporosis and fractures, especially postmenopausal women.

The conclusions on the associations of serum follicle-stimulating hormone (FSH) and blood lead levels with bone mineral density (BMD) were controversial. Furthermore, little was known on the impacts of co-existence of serum FSH and blood lead levels on BMD and the risk of fractures in premenopausal and postmenopausal women. Therefore, the present study aimed to examine the associations of serum FSH and blood lead levels with BMD and the risk of fractures in premenopausal and postmenopausal women. Data were derived from the National Health and Nutrition Examination Survey. FSH is assayed using the Microparticle Enzyme Immunoassay technology. Blood lead levels were measured using atomic absorption spectrometry. BMD was measured using dual energy X-ray absorptiometry. Fractures were defined as subjects with fractures in any site of hip, wrist, and spine. This study included 3798 participants. Elevated blood lead levels were associated with increased serum FSH levels (β= 48.22, 95% CI: 40.21~ 56.22). Serum FSH levels were negatively associated with total femur BMD in pre- and postmenopausal women. However, elevated serum FSH levels were associated with a lower lumbar spine BMD and a higher risk of fractures only in postmenopausal women (β= -0.0010, 95% CI: -0.0015~ -0.0006; OR: 1.007, 95% CI: 1.000~1.014, respectively). Serum lead levels were associated with serum FSH levels. Serum FSH levels were associated with a lower BMD and a higher risk of fractures.