{"paper_id":"e43d23e0-1c98-4281-bd99-c12d76d46374","body_text":"189\nfeatured paper\nDOI: https://doi.org/10.5114/pm.2016.65682\nMenopause Rev 2016; 15(4): 189-192\nCorresponding author:\nMarian Szamatowicz, Department of Reproduction and Gynecological Endocrinology, Medical University \nof Bialystok, Bialystok, Poland, e-mail: mszamatowicz@pwsip.edu.pl\nSubmitted: 8.12.2016\nAccepted: 21.12.2016\nAbstract\nOsteoporosis is a very common disease among women. It is frequently called a silent epidemic and, due \nto its impact on osteoporotic fractures with high morbidity and mortality, also a silent killer. There are a num-\nber of significant risk factors for osteoporosis, some of them very strongly related to the functioning of the \nreproductive system. These include menstrual irregularities, premature ovarian failure, early natural or surgical \nmenopause, a high number of pregnancies, and long-term breast-feeding. Hence, there is every reason to in-\nclude gynaecologists in the multidisciplinary team striving to cope with this dreadful disease. Calculation of the \n10-year fracture risk, done by means of the FRAX calculator, and classification of women according to the level \nof risk could prove to be an effective method of limiting the negative effects of osteoporosis.\nKey words: osteoporosis, risk factors, FRAX calculator, gynaecologists.\nIntroduction\nThe dramatic increase in average life expectancy is \nwidely regarded as one of the greatest achievements \nof the 20 th century. Until fairly recently, people could \nhardly exceed the age of 50 years. Nowadays in Japan, \nthe current leader, people live to be on average over 83 \nyears old, and in several other countries up to at least \n81 years [1]. While the population is getting older, the  \nsilent killer, the silent thief, or the silent epidemic, as os-\nteoporosis is frequently called, has become one of the \nmajor public health problems [2]. The disease used to be \ncharacterised by low bone mass and microarchitectur -\nal deterioration of the bone tissue, leading to enhanced \nbone fragility and, consequently, to an increase in frac-\nture risk. This description has been recently modified, \nhowever, and osteoporosis is now portrayed as a skeletal \ndisorder characterised by compromised bone strength, \npredisposing a  person to an increased risk of fracture \n[3]. There is abundant evidence showing that the prev-\nalence of osteoporosis increases with age and that the \nage-related bone loss is greater in women than in men. \nHormonal disturbances during the reproductive age \nand changes occurring at menopause constitute some \nof the major factors leading to osteoporosis in women. \nOvarian ageing results in a  rapid and considerable de-\ncrease in 17β-estradiol secretion and, consequently, an \nincreased secretion of cytokines, which activate osteo-\nclasts. RANKL, interleukin-1β, interleukin-6, and tumour \nnecrosis factor are molecules that cause an increase in \nHow can gynaecologists cope with the silent killer – osteoporosis?\nMarian Szamatowicz\nMedical Institute, Łomża State University of Applied Sciences, Łomża, Poland \nDepartment of Reproduction and Gynaecological Endocrinology, Medical University of Bialystok, Poland\nbone resorption, which leads to bone loss and microar-\nchitectural deterioration, as previously mentioned [5-7]. \nThe changes in bones constitute a serious public health \nproblem through their close connection with age-related \nfractures. Lifetime risk of any fracture is very high and, \naccording to the data presented in the report from the \nyear 2015 in Poland, it is estimated to stand at 40% for \nwomen and 13% for men. In the year 2010 in Poland, \nthere were 2,247,000 osteoporotic fractures in wom-\nen and 463,000 in men. Several osteoporotic fractures, \nespecially hip fracture, have a very high morbidity and \nmortality [8]. The same report reveals that the cost of \ntreatment of osteoporosis and osteoporotic fractures is \nvery high, amounting to nearly 3 billion PLN. Therefore, it \nis of great significance to recognise both the risk factors \nand prophylactic methods to stop the disease. \nRisk factors for osteoporosis\nThere are many factors that can contribute to \na greater likelihood of the development of osteoporo-\nsis, including age, sex, race, lifestyle, as well as certain \nmedical conditions and treatments. Some of these are \nunfortunately out of our control, including:\n•\tsex: women are much more likely to develop osteopo-\nrosis than men,\n•\tage: the risk of osteoporosis is higher in older subjects,\n•\trace: white women are at the greatest risk of osteo-\nporosis,\n\nMenopause Review/Przegląd Menopauzalny 15(4) 2016\n190\n•\tfamily history: parents or siblings with osteoporosis \nincrease one’s risk of developing the disease,\n•\tbody frame size: people with small body frames tend \nto have a higher risk of osteoporosis.\nAlso the choice of lifestyle can influence the risk of \nosteoporosis. The most prevalent risk factors in this re-\nspect are as follows:\n•\texcessive alcohol consumption: regular consumption \nof more than two drinks a day,\n•\ttobacco use: smoking has been shown to diminish \nbone endurance.\nAlso of great importance are some endocrine fac-\ntors in people who have increased or diminished levels \nof certain hormones in their bodies:\n•\toestrogen levels: they are considered to be some of \nthe strongest risk factors for osteoporosis in women \nat menopause and those treated for breast cancer,\n•\tthyroid diseases: the risk is greater in subjects with \nhigh concentrations of thyroid gland hormones,\n•\tother glands: overactive parathyroid and adrenal \nglands increase the risk of osteoporosis.\nOther risk factors, which must not be overlooked, in-\nclude dietary factors, such as low calcium intake, eating \ndisorders or gastrointestinal surgeries, administration \nof steroids (prevalently corticosteroids) and other med-\nications, as well as numerous medical conditions, such \nas celiac disease, inflammatory bowel disease, kidney \nor liver disease, cancer, lupus, multiple myeloma, and \nrheumatoid arthritis [9, 10].\nIn clinical practice, the prevention of osteoporosis \nought to consist of eliminating or limiting the specific \nrecognised risk factors.\nDiagnosis of osteoporosis\nThe proper diagnosis of osteoporosis should be con-\nsidered an essential step as it offers guidance for the \nprevention of bone loss and fragility fractures. It should \ncomprise both instrumental evaluation and biochemical \ntests. The instrumental evaluation of bone mineral mea-\nsurements must provide reliable data, and for this pur-\npose dual energy X-ray absorptiometry (DEXA) has be-\ncome the most widely used technique. It facilitates the \nassessment of BMD (the amount of bone mass g/cm\n2) \nof the whole skeleton or its specific sites. DEXA is usual-\nly performed at the level of lumbar spine and proximal \nfemur [11, 12]. The BMD test measures bone mineral \ndensity and compares it to that of an established norm \nor standard to give a score. T -score is the result of the \ncomparison of the BMD test with an ideal or peak bone \nmineral density of a healthy 30-year-old adult. A T-score \nof 0 means that the investigated BMD is equal to the \nnorm for a healthy young adult. Differences between the \ninvestigated BMD and that of the healthy young adult \nnorm are presented in units called standard deviations \n(SDs). The more SDs below 0, the lower the investigated \nBMD and the higher the risk of fracture. A  T-score be-\ntween +1 and –1 is considered normal, between –1 and \n–2.5 as indicative of low bone mass diagnosed as osteo-\npaenia, whereas of –2.5 or lower is indicative of osteopo-\nrosis. The greater the negative number of the T-score, the \nmore severe the osteoporosis. The measurement of bone \nmineral density (BMD) in the assessment of osteoporosis \nis the most widely used parameter, but bone strength \nis also influenced by bone quality and tissue properties, \nand these are currently evaluated by means of some oth-\ner available radiological techniques [13]. Nevertheless, \nDEXA is still a more frequently selected technique than \nquantitative computerised tomography (QCT) thanks to \nthe lower cost of its use, lower radiation dose, as well as \nhigher accuracy and shorter image acquisition time [12].\nThe International Osteoporosis Foundation recom-\nmends the use of a marker of bone formation (serum \nprocollagen type I N propeptide, s-PINP) and a marker \nof bone resorption (serum c-terminal telopeptide of \ntype I collagen, s-CTX) in clinical practice as markers of \nbone turnover for the prediction of fracture risk [14, 15].\nThe assessment of fracture risk\nCalculation of the 10-year major osteoporotic frac-\nture risk and a  subsequent analysis of cost-effective \ntreatment options allow clinicians to identify individu-\nals who really need specific medication and to screen \nout those who do not. It has been recently shown that \n55-70% of fractures occur in people who do not fulfil \nthe densitometric criteria of osteoporosis. Results of \nnumerous observations have been taken into account \nin order to specify clinical risk factors that can be used \nwith or without BMD to identify people with the risk of \nfracture. A group of WHO experts has published a re-\nport distinguishing the following risk factors: previous \nfracture, parent fractured hip, smoking, glucocorticoids, \nrheumatoid arthritis, secondary osteoporosis, alcohol \nconsumption exceeding three units per day, and a fem-\noral neck BMD T score of –2.5 or less. Finally, they have \nestablished an algorithm to function as a FRAX calcu-\nlator (WHO Fracture Risk Assessment Tool), combining \nthe influence of clinical risk factors of fractures with \nand without BMD [16, 17]; it is available on-line at \nwww.shef.ac.uk/FRAX. Unfortunately, there is no model \ndesigned specifically for Poland, and thus the results al-\nways refer to the English population. However, bearing \nin mind the reality of Polish medical care and the fact \nthat the use of the online FRAX calculator is time-con-\nsuming, a team from Cracow has invented a modifica-\ntion of it called the hand-held FRAX calculator [18]. This \ndevice calculates the 10-year fracture risk and helps to \nassign patients to one of three groups: group 1 – pa-\ntients with a high risk of fracture, who need immedi-\nate treatment; group 2 – intermediate group – patients \nwho need densitometric evaluation if FRAX score was \n\nMenopause Review/Przegląd Menopauzalny 15(4) 2016\n191\ncalculated on the basis of BMI; and group 3 – low-risk \ngroup of patients who need neither treatment nor fur -\nther diagnostics. The FRAX calculator is definitely not \nthe best tool for evaluation of the fracture risk, but its \nsimplicity makes it currently the most popular option \n[19]. The hand-held FRAX calculator might be a  very \nvaluable tool in the hands of medical practitioners for \nprotecting women against osteoporosis [20, 21]. In Po-\nland, it is now commercially available at a low cost.\nWhat can gynaecologists do in the fight \nagainst osteoporosis?\nFor many women it is not an easy task to find a doc-\ntor who specialises in osteoporosis because there is no \nphysician speciality dedicated solely to osteoporosis. As \na result, women who suffer from the disease are treat-\ned by a range of medical specialists, such as endocrinol-\nogists, who treat the endocrine system, which controls \nthe body’s metabolic activity, rheumatologists, who \ntreat and diagnose the diseases of bones, joints, mus-\ncles, and tendons, orthopaedic surgeons, who deal with \nthe consequences of osteoporosis, geriatricians, trained \non the ageing process and the conditions that often af-\nfect the elderly, family doctors, knowledgeable in many \nmedical disciplines, internists trained in general internal \nmedicine, and finally gynaecologists, who diagnose and \ntreat conditions of the female reproductive system as-\nsociated with osteoporosis.\nThe role of sex hormones in bone breakdown is very \nwell-documented. They control the development and \nactivity of both osteoclasts (bone breakers) and osteo-\nblasts (bone builders). Women experience a rapid de-\ncline in bone density after menopause, when the ova-\nries stop producing oestrogens, especially oestradiol, \nthe most potent form of oestrogen. The hormonal sit-\nuation in perimenopausal women has been frequently \ndescribed, and there is no point in repeating it here. On \nthe other hand, there are many events in the reproduc-\ntive life of women that definitely have to be recognised \nas risk factors of osteoporosis. This is where gynaecol-\nogists ought to do their best to limit the progression of \nthe silent killer [22].\nIrregular periods in young women may be a warn-\ning sign of hormonal disturbances that could lead to \nosteoporosis. Loss of menstrual regularity, secondary \namenorrhoea or oligomenorrhoea constitute evidence \nof ovarian insufficiency and, consequently, oestrogen \ndeficiency, which is a  known risk factor for osteopo-\nrosis. The evaluation and treatment of ovarian insuffi-\nciency is a task for gynaecologists if the development of \nosteoporosis is to be limited in later years [23].\nPrimary ovarian insufficiency is not frequent but \nis an important cause of ovarian hormone deficiency \nassociated with multiple health risks, including de-\ncreased bone density, and an increased risk of fractures. \nTailored hormonal replacement therapy to ameliorate \nbothersome menopausal symptoms can also diminish \nother health risks [24].\nNumber of pregnancies and the relationship be-\ntween parity and bone mineral density. There are data \nthat suggest that the number of pregnancies has a neg-\native effect on BMD values and that this situation may \nlead to osteoporosis and fractures in the future [25].\nProlonged breast-feeding affects bone metabolism \nand calcium homeostasis. It can also influence the de-\nvelopment of postmenopausal osteoporosis in highly \nsusceptible populations [26].\nHormone replacement therapy, especially with oes-\ntrogens, has an essential impact on female bone health \nas it promotes the activity of osteoblasts, cells that pro-\nduce bone. When considering the effect of HRT on other \nimportant disease outcomes in the global model (data \nof Women’s Health Initiative, WHI), this kind of therapy \nwas not recommended even in cases of high fracture \nrisk [27]. At present, the recommendations are differ -\nent. After ten years, scientists found answers to many \nquestions and confirmed hormonal therapy (HT) (cur -\nrently suggested name – menopausal hormone thera-\npy) to be safe and effective for most newly menopausal \nwomen [28]. Recent data support the initiation of MHT \naround the time of menopause to treat menopause-re-\nlated symptoms and to prevent osteoporosis in wom-\nen at high risk of fracture [29, 30]. Moreover, reports \non some new aspects of postmenopausal osteoporosis \ntreatment through the application of transcutaneous \noestrogens supplemented with intravaginal lutein have \nbeen recently published [31].\nHormonal contraception presents different strat-\negies. Preparations containing oestrogens have a pos-\nitive effect on bones. Long-term premenopausal oral \ncontraceptive users enter menopause with a bone den-\nsity that is 2-3% higher than in non-users. Preparations \ncontaining progestogen alone have an adverse effect \non BMD, causing significant bone loss [32, 33].\nIn the prevention of osteoporosis there are three \nvery important areas that require special attention, i.e. \nto provide sufficient calcium and vitamin D support, \nto advise patients to quit smoking and reduce alcohol \nconsumption, and to do regular exercise.\nThe above-mentioned risk factors for osteoporosis, \na disease which very frequently does not manifest it-\nself until pain appears or a fracture occurs, should be \nseriously kept in mind by gynaecological practitioners. \nThe simplest recommended solution is to calculate the \n10-year fracture risk by means of the FRAX calculator \nand to assign women to one of the three groups de-\nscribed in the section the assessment of fracture risk.\nDisclosure\nAuthor reports no conflict of interest.\n\nMenopause Review/Przegląd Menopauzalny 15(4) 2016\n192\nReferences\n1. 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