Postmenopausal osteoporosis

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

[1], [2], [3], [4], [5], [6], [7]

Epidemiology

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

[8], [9], [10], [11], [12], [13],

Risk factors

Survey on the presence of postmenopausal osteoporosis is necessary for patients who have risk factors for the development of osteoporosis when collecting an anamnesis:

• fractures of bones in the anamnesis;
• The presence of osteoporosis in close relatives;
• elderly age;
• low body weight (body mass index less than 20);
• later menarche (after 15 years);
• early menopause (up to 45 years);
• bilateral oophorectomy (especially at a young age);
• long (more than 1 year) amenorrhea or periods of amenorrhea and / or oligomenorrhoea;
• more than 3 births in reproductive age;
• prolonged lactation (more than 6 months);
• vitamin D deficiency;
• decreased calcium intake;
• alcohol abuse, coffee, smoking;
• excessive physical exertion;
• sedentary lifestyle.

[14], [15], [16], [17], [18], [19],

Symptoms of the postmenopausal osteoporosis

The symptoms of osteoporosis are rather meager. The disease is characterized by pain in the spine, pelvic region 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 is increased, posture is altered (kyphosis of the thoracic spine is formed), movements in the lumbar spine are limited, and growth is reduced.

Forms

There are primary and secondary osteoporosis. Primary osteoporosis develops in the climacteric period. 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 decreases;
• prolonged immobilization;
• malnutrition (vitamin D deficiency, reduced calcium intake);
• excessive consumption of alcohol, coffee, smoking;
• prolonged use of corticosteroids, heparin, anticonvulsants.

[20]

Diagnostics of the postmenopausal osteoporosis

• To confirm the diagnosis of osteoporosis or osteopenia, it is necessary to determine bone mineral density (BMD) using bone densitometry. Gold standard among the methods of bone densitometry is dual-energy x-ray densitometry.
• There are also single-photon densitometers for measuring BMD bristles, distal forearm and shin bones. However, it should be borne in mind that the BMD of the distal bone in most women in the menopausal period differs little from those in the norm and does not always reflect the age-related metabolic changes.
• Ultrasonic densitometry of the calcaneus is also used to diagnose osteoporosis.
• X-ray diagnosis is informative only if more than 30% of bone mass is lost.
• Biochemical markers of bone resorption in urine:
  • ionizing calcium / creatinine;
  • hydroxyproline / creatinine;
  • structural components of type I collagen (pyridoline and deoxypyrininoline);
  • bone alkaline phosphatase.
• Whey osteocalcin.

[21], [22]

Differential diagnosis

Differential diagnosis is carried out if:

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

[23], [24], [25], [26]

Treatment of the postmenopausal osteoporosis

The goal of treatment of postmenopausal osteoporosis is the blockade of bone resorption processes and the activation of bone remodeling processes.

Non-pharmacological treatment of postmenopausal osteoporosis

When osteoporosis is recommended to lead an active, healthy lifestyle with moderate physical exertion. Especially it is necessary to avoid sudden movements, falls and lifting of weights.

In the diet should include foods high in calcium (fish, seafood, milk), as well as exclude alcohol, coffee and quit smoking.

Drug therapy for postmenopausal osteoporosis

In postmenopausal osteoporosis, pathogenetic systemic hormone replacement therapy is performed. Also used drugs of other groups.

• Calcitonin 50 IU subcutaneously or intramuscularly after 1 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 severe osteoporosis and vertebral fractures, it is recommended to increase the dosage to 100 IU per day subcutaneously or intramuscularly once a day for 1 week, then 50 IU daily or every other day for 2-3 weeks.
• Bisphosphonates (etidronic acid) at 5-7 mg / kg body weight for 2 weeks every 3 months.
• Alendronic acid 1 capsule 1 time per week.
• Calcium carbonate (1000 mg) in combination with colcalciferol (800 IU). The drug is indicated both for prevention of osteoporosis and fractures, and for complex therapy of osteoporosis in combination with calcitonin ylm bisphosphonate. The intake of 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 effect, but they have an estrogen-like effect on the bone tissue, which increases the BMD.

[27], [28], [29], [30], [31],

Surgical treatment of postmenopausal osteoporosis

Do not use for this disease.

Student training

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

Further management of the patient

The therapy of postmenopausal osteoporosis is long. It is necessary to monitor BMD with bone densitometry once a year.

To assess the effectiveness of treatment dynamically, it is recommended to determine the markers of bone tissue formation:

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

Prevention

For the prevention of osteoporosis recommend a full-fledged diet with sufficient calcium content, the rejection of bad habits. With insufficient intake of calcium from food, an additional intake of calcium preparations in combination with vitamin D3 is recommended.

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

[32], [33], [34], [35], [36], [37], [38], [39], [40], [41],

Forecast

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

[42], [43], [44], [45]