OSTEOPOROSIS: A GROWING EPIDEMIC

SUMMARY The osteoporosis epidemic will continue unabated unless the issue of prevention of bone loss is seriously addressed. While a continuing programme of education for both the medical profession and the general public is necessary, positive action is required. Women lose bone at an accelerated rate following the menopause and this seems to be the optimal time for intervention. Those women who enter the menopause with the lowest bone density are at greatest risk of subsequent fracture. An individual's bone density can be accurately measured and those women who have the lowest bone density should have hormone replacement therapy (HRT) recommended, but it is important to discuss fully the possible benefits and risks. It is probable that non-hormonal agents for prevention of bone loss will be available in the near future, and cyclical diphosphonate therapy appears particularly promising. However, at the present time, long-term HRT is the mainstay for the prevention of bone loss.     

Osteoporosis treatment by gynecologist

Postmenopausal bone loss is accelerated since women experience menstrual irregularity. Postmenopausal women lose their bone mineral density by 20 to 25% during 10 years after menopause, therefore early detection of risks for postmenopausal osteoporosis is mandatory for prevention of the disease. Because estrogen deficiency is the primary cause of postmenopausal bone loss, hormone replacement therapy can be a reasonable choice for the first treatment of osteoporosis. However, to those who have contraindications against estrogen or who complain severe estrogen-related symptoms, other medication using SERM and bisphosphonate should be considered.     

A practical guide to the management of menopausal symptoms in breast cancer patients

Breast cancer is the most frequently diagnosed cancer in Canadian women. As a result of increased screening and improved treatment, more women are becoming long-term breast cancer survivors. However, due to either their treatment or prolonged survival, many of these women now have to face the consequences of premature menopause and prolonged estrogen deprivation. Hormone replacement therapy/estrogen replacement therapy (HRT/ERT) has, in the past, been recommended to healthy women at menopause not only for relief of short-term menopausal changes, particularly hot flashes, but also for its benefits on bone density, fracture reduction, and genitourinary symptoms. Recent studies have demonstrated that not only is HRT associated with an increased risk of developing breast cancer, but it also has been shown to increase the risk of recurrence in those with a breast cancer history. Until the safety of HRT/ERT in breast cancer patients can be more fully clarified, it would be wise to develop alternative strategies for the management of menopausal symptoms in these patients. This paper will discuss nonestrogen-based therapies for hot flashes, osteoporosis, and genitourinary symptoms, with emphasis on efficacy and safety in breast cancer survivors.     

Estrogen, SERM

Osteoporosis is uncommon before menopause and dramatically increases in prevalence thereafter. That is why estrogens provide protection against osteoporosis. Studies of women receiving estrogen replacement have demonstrated improvements in bone mineral density (BMD) as well as endothelial function. Recent randomized trials, however, have produced equivocal results and raised questions about whether combined hormonal replacement therapy (HRT) prevents later cardiovascular events. Investigations of alternatives to HRT have suggested that selective estrogen receptor modulators (SERMs) may confer cardiovascular and osteoporosis protection. Raloxifene is a second-generation SERM used for the prevention and treatment of postmenopausal osteoporosis. Raloxifene decreases the incidence of vertebral fractures by 30-50% in postmenopausal women with osteoporosis. We also studied its effect on postmenopausal elderly women with osteoporosis.     

Bone mineral density in postmenopausal breast cancer survivors

PURPOSE: The overall purpose of this longitudinal 18-month study was to test the feasibility and effectiveness of a multicomponent intervention for prevention and treatment of osteoporosis. The purpose of this article is to describe the baseline bone mineral density (BMD) findings for 30 postmenopausal women and to compare these BMD findings to time since menopause, body mass index, and tamoxifen use. DATA SOURCES: Baseline data of BMD findings for 30 postmenopausal women, who have had a variety of treatments including surgery, adjuvant chemotherapy and or tamoxifen, and are enrolled in the 18-month longitudinal study. A demographic questionnaire and a three day dietary record were used to collect baseline data. CONCLUSIONS: Eighty percent of the women with breast cancer history had abnormal BMDs at baseline (t-scores below -1.00 SD). Thinner women showed a greater risk for accelerated trabecular bone loss at the spine and hip. IMPLICATIONS FOR PRACTICE: These findings suggest the need for early BMD assessments and for aggressive health promotion intervention strategies that include a multifaceted protocol of drug therapy for bone remodeling, 1500 mg of daily calcium, 400 IU vitamin D and a strength weight training program that is implemented immediately following chemotherapy treatment and menopause in this high risk population of women.     

Efficacy of hormone replacement therapy on hyperlipidemia

In women, serum lipid levels and the incidence of myocardial ischemia increase after menopause. Deficiency of estrogen is believed to be the cause of these epidemiological phenomena. On the other hand, hormone replacement therapy(HRT), has prevailed in developed countries. Estrogen is replaced to ease climacteric disorders, and retard bone loss. Many clinical studies cleared the effect of HRT on lipids, in which total and LDL-C (cholesterol) decreased, and HDL-C increased. TG increased by conjugated equilin estrogen but not by transdermal estradiol. In our study, hepatic triglyceride lipase(HTGL) was suppressed by HRT, but lipoprotein lipase(LpL) was not suppressed. HRT decreases coronary artery diseases, but it is still controversial whether HRT is efficient in patients who already have heart disease.     

Hormone replacement therapy (HRT) for hyperlipidemia after menopause

Women are about 10 years older than men to suffer from ischemic heart disease(IHD) and they often experience a sudden rise in cholesterol after menopause. These phenomena are thought to be caused by the production of estrogen in women during normal menstruation cycle and its loss after menopause. Hormone replacement therapy(HRT) has been shown to reduce IHD by nearly 50 per cent. This is caused in part by effects of estrogen on lipid metabolism; it reduces LDL and Lp(a), and increases HDL. Although the first large prospective trial of HRT for secondary prevention of IHD failed to demonstrate estrogen's protective effects, HRT was effective in women with high Lp(a). Thus, selection of patients and HRT regimen seems important.     

THE LONG-TERM RISKS AND BENEFITS OF HORMONE REPLACEMENT THERAPY

There is increasing awareness that the long-term consequences of ovarian failure can be prevented or reduced with appropriate hormone replacement therapy (HRT). After the menopause, there is a rapid loss of trabecular bone resulting in a one in two lifetime risk of osteoporotic fracture. HRT prevents this bone loss and decreases the incidence of fracture. A minimum of 5 years treatment is recommended for significant benefit. Epidemiological evidence is accumulating that post-menopausal oestrogen therapy reduces the risk of cardiovascular disease and stroke by between 30 and 70% even in the presence of established risk factors. Given the prevalence of cardiovascular disease, this is likely to be one of the principle benefits of HRT in the next decade. Concerns about the long-term safety of HRT have focused on endometrial and breast cancer. The increase in risk of endometrial cancer associated with oestrogen only therapy is abolished with the sequential addition of a progestogen for 10-12 days each cycle. The possible effect of HRT on breast cancer risk has to be considered against the background of a one in 12 lifetime risk of developing this disease. The epidemiological studies investigating this relationship are reviewed in this paper. There is a broad consensus that 5-6 years duration of HRT does not increase breast cancer risk. Longer durations of therapy (10-15 years) have been reported to increase this risk although not all the data are in agreement. Other factors, such as family history and benign breast disease, may also influence the risk of breast cancer. The potential benefits of HRT on mortality and morbidity are enormous. Against this is a possible small increase in breast cancer risk with long-term usage. Greater awareness of the long term consequences of the menopause and the potential benefits of HRT should be encouraged so that women can make informed decisions about their need for HRT.     

Osteoporosis prevention, detection, and treatment. A mandate for primary care physicians

Prevention of bone loss through healthy lifestyle choices offers the greatest promise of minimizing fracture incidence. Safe, effective therapeutic options are available when drug therapy is prudent. Newer bisphosphonates, selective estrogen receptor modulators, and HRT delivery systems will soon be available to offer an even larger menu of choices for osteoporosis prevention and treatment. By implementing appropriate treatment, we can prevent bone loss, reduce fracture incidence, and improve function and quality of life, even in patients who have previously experienced fractures.     

Management of Menopausal Symptoms in Breast Cancer Patients

Menopause is associated with multiple clinical problems in women. These include significant problems with symptoms of hot flushes and vaginal dryness; and also long-term sequelae with an increased incidence of heart disease and with accelerated bone loss leading to osteopaenia. In general, these medical conditions are usefully ameliorated by giving oestrogen with or without progesterone (1-3). This treatment has thus become common practice in women who are going through menopause, even though some data suggest that hormone replacement therapy (HRT) does slightly increase the incidence of breast cancer, at least among current users (4).     

Design and baseline characteristics of the Soy Phytoestrogens As Replacement Estrogen (SPARE) study — A clinical trial of the effects of soy isoflavones in menopausal women

Following the results of the Women's Health Initiative, many women now decline estrogen replacement at the time of menopause and seek natural remedies that would treat menopausal symptoms and prevent bone loss and other long-term consequences of estrogen deficiency, but without adverse effects on the breast, uterus, and cardiovascular system. The results of most soy studies in this population have had limitations because of poor design, small sample size, or short duration. This report describes the study rationale, design, and procedures of the Soy Phytoestrogens As Replacement Estrogen (SPARE) study, which was designed to determine the efficacy of soy isoflavones in preventing spinal bone loss and menopausal symptoms in the initial years of menopause.Women ages 45 to 60 without osteoporosis and within 5 years from menopause were randomized to receive soy isoflavones 200 mg daily or placebo for 2 years. Participants have yearly measurements of spine and hip bone density, urinary phytoestrogens, and serum lipids, thyroid stimulating hormone, and estradiol. Menopausal symptoms, mood changes, depression, and quality of life are assessed annually.The SPARE study recruited 283 women, 66.1% were Hispanic white. With a large cohort, long duration, and large isoflavone dose, this trial will provide important, relevant, and currently unavailable information on the benefits of purified soy isoflavones in the prevention of bone loss and menopausal symptoms in the first 5 years of menopause. Given the high proportion of Hispanics participating in the study, the results of this trial will also be applicable to this minority group.     

Determinants of the first decade of bone loss after menopause at spine, hip and radius

This study documented bone loss at three different sites in the early postmenopausal period, and examined potential predictors. Forty-three women underwent repeated measurements of bone density at the lumbar spine, proximal femur and distal radius for up to 14 years. Individual rates of bone loss were calculated for the spine and hip; for radial trabecular bone, rates were calculated separately for two time periods, earlier and later after menopause. In the spine and radius, initially high rates of loss diminished with time after menopause. No positive correlations for bone loss were found between the three sites, suggesting that faster than average bone loss was specific to individual bones. High body mass index (BMI) was significantly protective against fast bone loss at the spine and radius; in the spine, each unit increase in BMI was associated with a approximately 5% reduction in the rate of bone loss. Of the other variables measured (maximum oxygen consumption, lean body mass, fat mass, mean psoas muscle area at the L3 level, hand grip strength as well as anthropometry) only bone densitometry was sufficiently predictive to help guidance on hormone replacement or other prophylactic therapy. The data suggest that the known relationship between excessive leanness and risk of osteoporosis and vertebral fracture after menopause might in part be due to fast post-menopausal bone loss. Because bulk of psoas muscle was associated with low spine loss rates, the data also support a role for applied muscular loading in local maintenance of bone density.     

Osteoporosis

Although powerful tools are available for the measurement of bone density, the diagnosis of osteoporosis is still made largely on clinical grounds. Bone density measurement is not recommended for routine screening, but it may be useful in deciding whether to treat high-risk patients and in following the effects of treatment. Estrogen therapy is used for the prevention of osteoporosis in women with early menopause and as treatment within five to seven years of menopause. Several agents currently being tested offer promise in restoring normal strength to osteoporotic bone.     

Prevention and treatment of osteoporosis in women with breast cancer

Women who have had breast cancer may be at higher risk for osteoporosis than other women. First, they are more likely to undergo early menopause, due to chemotherapy-induced ovarian failure or oopherectomy. In addition, chemotherapy may have a direct adverse effect on bone mineral density (BMD), and osteoclastic activity may increase from the breast cancer itself. While estrogen therapy is considered standard for the prevention and treatment of osteoporosis, use of estrogen in women with a history of breast cancer is usually contraindicated. The approach to osteoporosis in women with breast cancer is also affected by the use of tamoxifen in many, as this drug appears to have opposite effects on BMD in premenopausal and postmenopausal women. We have reviewed therapeutic alternatives for the prevention and treatment of osteoporosis, focusing on patients with a history of breast cancer. Alendronate and raloxifene are currently approved in the United States for the prevention of osteoporosis; alendronate, raloxifene, and calcitonin are approved for treatment. Alendronate has the greatest positive effect on BMD and reduces the incidence of vertebral and nonvertebral fractures. Raloxifene and calcitonin appear to reduce the incidence of vertebral fractures; their effects on the incidence of nonvertebral fractures are not yet proven. Although no published studies specifically address the use of these approved agents for osteoporosis in women with breast cancer, understanding their relative effects on BMD in postmenopausal women in general will facilitate therapy selection in this population. Postmenopausal women with a history of breast cancer should undergo bone mineral analysis. Normal results and absence of other risk factors ensure that calcium and vitamin D intake are adequate. If osteopenia or other risk factors are present, preventive therapy with alendronate or raloxifene should be considered. For osteoporosis, treatment with alendronate should be strongly considered. Raloxifene and calcitonin are alternatives when alendronate is contraindicated. Further studies are needed to evaluate the optimal timing of initial bone mineral analysis in premenopausal women after breast cancer diagnosis and to determine the value of preventive treatment in women scheduled to undergo chemotherapy.     

Menopause-associated metabolic manifestations and symptomatology in HIV infection: a brief review with research implications

Many women living with HIV in the United States have entered or will soon enter menopause. Clinical changes including increased visceral fat, reduced muscle mass, and changes in lipids and bone density are seen across the menopause transition among non-infected women. HIV and antiretroviral therapy use have been associated with similar manifestations, including reduced bone density, and changes in lipid metabolism and body composition. Menopause is also associated with changes in mood, quality of life, and vasomotor symptoms. Similar psychological indices are common among women with HIV, and may worsen during menopause transition. Research investigating the presence and acuity of metabolic, psychological, and vasomotor symptoms among perimenopausal women with HIV is limited. An important, yet unknown consideration for researchers and clinicians is how metabolic and psychological co-morbidities associated with HIV will influence changes associated with menopause in this population. Further research is needed to provide answers to these important questions.     

Osteoporosis: part I. Evaluation and assessment

Osteoporosis afflicts 75 million persons in the United States, Europe and Japan and results in more than 1.3 million fractures annually in the United States. Because osteoporosis is usually asymptomatic until a fracture occurs, family physicians must identify the appropriate timing and methods for screening those at risk. Prevention is the most important step, and women of all ages should be encouraged to take 1,000 to 1,500 mg of supplemental calcium daily, participate in regular weight-bearing exercise, avoid medications known to compromise bone density, institute hormone replacement therapy at menopause unless contraindicated and avoid tobacco and excessive alcohol intake. All postmenopausal women who present with fractures as well as younger women who have risk factors should be evaluated for the disease. Physicians should recommend bone mineral density testing to younger women at risk and postmenopausal women younger than 65 years who have risk factors for osteoporosis other than being postmenopausal. Bone mineral density testing should be recommended to all women 65 years and older regardless of additional risk factors. Bone mineral density screening should be used as an adjunct to clinical judgment only if the results would influence the choice of therapy or convince the patient to take appropriate preventive measures.     

Benefits of hormone replacement therapy in postmenopausal women

PURPOSE: To provide an overview of current research regarding hormone replacement therapy (HRT) and to assist healthcare providers to better educate patients about potential benefits of this therapy. DATA SOURCES: A systematic review of healthcare literature was conducted with 602 articles selected from CINAHL, Medscape, Pubmed, and Medline databases. Keywords directing the search included hormone replacement therapy, benefits of hormone replacement therapy and trends, hormone replacement therapy and osteoporosis, hormone replacement, and menopause symptoms. CONCLUSIONS: According to the literature, HRT can assist women with postmenopausal symptoms. In addition, research shows that HRT can help some postmenopausal women with selected comorbid conditions such as osteoporosis, type II diabetes, certain cardiovascular pathologies, and colorectal cancer. The decision as to who should use any form of HRT needs to be based on the individual woman's needs, quality of life, and potential risks versus benefits. IMPLICATIONS FOR PRACTICE: HRT has been a benefit to many women in the treatment of postmenopausal symptoms. Recent studies have shown that HRT, whether it is combined estrogen and progestin therapy, or estrogen-only therapy, can help postmenopausal women with osteoporosis and some selected comorbid conditions. Recent research indicates that some women are dying from comorbid conditions rather than breast cancer. Although the research regarding HRT in some areas may be limited, further research adds to existing knowledge and offers new ideas and possibilities in the treatment of postmenopausal symptoms and selected comorbid conditions. Certainly HRT can improve quality of life and possibly longevity for selected women. Ongoing research is needed to further validate such benefits, as well as to further explore the risks and benefits of long-term HRT. Increased knowledge about HRT will help healthcare providers better educate patients about the potential benefits of HRT, while providing documentation about who should take selected types of HRT or whether alternative treatment is preferred.     

Alternatives to hormone replacement therapy: a multi-method study of women's experiences

OBJECTIVE: To explore women's decision-making regarding use of complementary and alternative medicines (CAM) during menopause. METHODS: Qualitative interviews were conducted with 20 women who were currently or had previously used hormone replacement therapy (HRT), including questions about their experiences with alternatives to HRT. This was followed by a non-random questionnaire survey of 285 demographically representative Canadian women aged 45-65 who were current or former HRT users. RESULTS: Fifty-seven percent (57%, n = 162) of women reported either having used or considered a CAM approach for menopause. Women who had tried or considered CAM were significantly younger (mean age = 54.9 years versus 56.8 years; t(280) = 3.4, p < .05) and reported experiencing worse menopause-specific symptoms than those who had not, and these women also reported a worse experience of menopause overall. CONCLUSION: : A majority of menopausal women in the current study considered or tried CAM alternatives to HRT.