Postmenopausal osteoporosis

Postmenopausal osteoporosis is a multifactorial systemic skeletal disease characterized by a decrease in bone mass and disruption of the microarchitecture of bone tissue, which leads to increased bone fragility, and develops after natural or surgical menopause.

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Epidemiology

Osteoporosis ranks 4th after cardiovascular, oncological and respiratory diseases. The incidence of postmenopausal osteoporosis in developed countries is 25–40%, with a predominance among white women. The incidence of osteoporosis in women over 50 is 23.6%.

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Risk factors

Patients whose medical history reveals risk factors for osteoporosis should be examined for postmenopausal osteoporosis:

• history of bone fractures;
• presence of osteoporosis in close relatives;
• old age;
• low body weight (body mass index less than 20);
• late menarche (after 15 years);
• early menopause (before 45 years);
• bilateral oophorectomy (especially at a young age);
• prolonged (more than 1 year) amenorrhea or periods of amenorrhea and/or oligomenorrhea;
• more than 3 births during reproductive age;
• long-term lactation (more than 6 months);
• vitamin D deficiency;
• reduced calcium intake;
• abuse of alcohol, coffee, smoking;
• excessive physical activity;
• sedentary lifestyle.

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Symptoms postmenopausal osteoporosis

Symptoms of osteoporosis are quite meager. The disease is characterized by pain in the spine, in the pelvic area and tibia, fractures of spongy bones (compression fractures of the vertebrae, fractures of the distal radius, ankles, femoral neck). As osteoporosis progresses, deformation of the vertebral bodies occurs, muscle weakness increases, posture changes (kyphosis of the thoracic spine is formed), movement in the lumbar spine is limited, and height decreases.

Forms

A distinction is made between primary and secondary osteoporosis. Primary osteoporosis develops during menopause. Secondary osteoporosis occurs against the background of the following conditions:

• endocrine diseases (hyperthyroidism, hypoparathyroidism, hypercorticism, diabetes, hypogonadism);
• chronic renal failure;
• diseases of the gastrointestinal tract, in which the absorption of calcium in the intestine is reduced;
• prolonged immobilization;
• nutritional deficiencies (vitamin D deficiency, decreased calcium intake);
• excessive consumption of alcohol, coffee, smoking;
• long-term use of corticosteroids, heparin, anticonvulsants.

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Diagnostics postmenopausal osteoporosis

• To confirm the diagnosis of osteoporosis or osteopenia, bone mineral density (BMD) must be determined using bone densitometry. The gold standard among bone densitometry methods is dual-energy X-ray densitometry.
• There are also single-photon densitometers for measuring BMD of the hand, distal forearm and shin bones. However, it should be taken into account that BMD indicators of the distal bone sections in most women in the climacteric period differ little from those in the norm and do not always reflect age-related metabolic changes.
• Ultrasound densitometry of the calcaneus is also used to diagnose osteoporosis.
• X-ray diagnostics are informative only when there is a loss of more than 30% of bone mass.
• Biochemical markers of bone resorption in urine:
  • ionizing calcium/creatinine;
  • hydroxyproline/creatinine;
  • structural components of type I collagen (pyridoline and deoxypyrininoline);
  • bone alkaline phosphatase.
• Serum osteocalcin.

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Differential diagnosis

Differential diagnostics are carried out in the presence of:

• endocrine diseases (hyperthyroidism, hypoparathyroidism, hypercorticism, diabetes, hypogonadism);
• chronic renal failure;
• diseases of the gastrointestinal tract, in which the absorption of calcium in the intestine is reduced;
• prolonged immobilization;
• nutritional deficiencies (vitamin D deficiency, decreased calcium intake);
• excessive consumption of alcohol, coffee, smoking;
• long-term use of corticosteroids, heparin, anticonvulsants.

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Treatment postmenopausal osteoporosis

The goal of treatment of postmenopausal osteoporosis is to block bone resorption processes and activate bone remodeling (formation) processes.

Non-drug treatment of postmenopausal osteoporosis

With osteoporosis, it is recommended to lead an active, healthy lifestyle with moderate physical activity. It is especially necessary to avoid sudden movements, falls and lifting heavy objects.

The diet should include foods high in calcium (fish, seafood, milk), and also exclude alcohol, coffee, and quit smoking.

Drug therapy for postmenopausal osteoporosis

In postmenopausal osteoporosis, pathogenetic systemic hormone replacement therapy is performed. Drugs from other groups are also used.

• Calcitonin 50 IU subcutaneously or intramuscularly every other day or 50 IU intranasally 2 times a day, course from 3 weeks to 3 months with minimal symptoms of osteoporosis or as maintenance therapy. In case of severe osteoporosis and vertebral fractures, it is recommended to increase the dosage to 100 IU per day subcutaneously or intramuscularly 1 time per day for 1 week, then 50 IU daily or every other day for 2-3 weeks.
• Bisphosphonates (etidronic acid) 5–7 mg/kg body weight for 2 weeks every 3 months.
• Alendronic acid 1 capsule once a week.
• Calcium carbonate (1000 mg) in combination with cholecalciferol (800 IU). The drug is indicated both for the prevention of osteoporosis and fractures, and for the complex therapy of osteoporosis in combination with calcitonin or bisphosphonate. Taking calcium carbonate with cholecalciferol is indicated for life.
• Tamoxifen or raloxifene, 1 tablet once a day for no more than 5 years, is usually prescribed for breast cancer and osteoporosis. The drugs do not have an antiestrogenic property, but have an estrogen-like effect on bone tissue, resulting in an increase in BMD.

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Surgical treatment of postmenopausal osteoporosis

Do not use for this disease.

Patient education

It is necessary to explain to the patient that it is more difficult to restore bone tissue than to preserve it. Maximum bone mass is achieved at the age of 20-30 years, and 3 main protective factors: physical activity, adequate nutrition and normal levels of sex hormones - are a necessary condition for its preservation.

Further management of the patient

Therapy for postmenopausal osteoporosis is long-term. It is necessary to monitor BMD using bone densitometry once a year.

For dynamic assessment of treatment effectiveness, it is recommended to determine markers of bone tissue formation:

• serum osteocalcin;
• alkaline phosphatase isoenzyme;
• procollagen peptides.

Prevention

To prevent osteoporosis, it is recommended to eat a balanced diet with sufficient calcium content and give up bad habits. If calcium intake with food is insufficient, additional intake of calcium preparations in combination with vitamin D3 is recommended.

Early administration of hormone replacement therapy in perimenopause or after total oophorectomy prevents postmenopausal osteoporosis, since bone remodeling depends on the level of sex steroids (estrogens, progesterone, testosterone, androstenedione, dehydroepiandrosterone sulfate) in the female body.

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Forecast

Doubtful, since it is more difficult to restore bone tissue than to preserve it. Maintaining a sufficient level of sex hormones in women during menopause and adequate therapy significantly reduce the risk of progression of postmenopausal osteoporosis.

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