Osteoporosis

Of all the discomforts and inconvenience, both big and small, you may experience during menopause, one of the most important is osteoporosis.

What is osteoporosis?

Osteoporosis is a condition in which there is less normal bone than expected for a woman’s age, with an associated increase in the risk of fractures. Essentially, the bones develop lots of holes in them which makes them weaker even though they still look normal on the outside.

What causes osteoporosis?

Bone tissue is being destroyed and reformed continuously in your body. A balance has to be maintained between the osteoclasts (which break down bone) and the osteoblasts (which make new bone). Estrogen plays an important part in the production of new bone. In the absence of estrogen bone is broken down and not replaced. Calcium is the substance that gives bone its strength. Estrogen helps in transporting calcium from the blood and keeps it in the bone. In the absence of estrogen, calcium moves from the bone back ito the blood. The end result- weak bones that are full of holes!

What increases your risk of getting osteoporosis?

1. Low bone density – From the moment you are born, new bone is being deposited in your body. This continues until you are about 35 years old when laying down of bone stops. At this stage, you have achieved your peak bone density. If it is low, then you have a greater risk of developing osteoporosis.
2. Premature menopause If you experience menopause before the age of 35 years your bone loss will start earlier than in a woman who has menopause at 45.
3. Removal of the ovaries and uterus  If you have had your ovaries removed for any reason, within a few years, you may develop osteoporosis. Even if your uterus is removed without the ovaries, you still have an increased risk of developing osteoporosis compared to a woman who has both uterus and ovaries intact.
4. Smoking  Apart from the many health hazards associated with smoking, it does not allow the body to taken in as much oxygen as it needs, which makes bones weak. Also, if you’re a heavy smoker, you run the risk of reaching menopause up to 5 years before a non-smoker.
5. Drugs  Medication used for some health conditions such as asthma, can lead to osteoporosis if taken in large quantities for a long time.

What are the features that suggest you might have osteoporosis?

Fractures
If you fracture your hip, wrist or spine after a minor fall e.g. tripping over something in the house, you may have osteoporosis, especially if you are over 40. It is usually not suspected or diagnosed in the early stages. By the time you have a fracture, you may have lost 1/3 of your bone mass.

Backache
If you have constant severe backache this may be due to a spinal fracture. Many tiny fractures of the bone cause them to collapse. This causes pressure on the nerves and leads to pain. This is also the cause of “Dowager’s hump” which is common in post-menopausal women. Collapse of the bones of the spine causes the curvature of the upper spine which gives the appearance of hunching over and causes loss of height.

Tests used to detect Osteoporosis

1. bone density test – This is a simple test similar to an x-ray that can be carried out in a hospital x-ray department or a clinic and assessed by a radiologist. It measures the thickness and strength of the bones. Usually the spine and femur (thigh bone) are measured. This test can be used:
   • to detect osteoporosis for the first time and
   • to measure if the condition is worsening or improving, especially if you are receiving treatment.
   Bone density scans should be done around the time of menopause to help predict the likelihood of developing osteoporosis. This is important because up to 1/3 of your bone may have been lost by the time you develop symptoms. Bone loss is fastest immediately after menopause and gradually slows sown over the years, by which time the bones have undergone a lot of damage.
2. ultrasound – Ultrasound of the heel can give an idea of the health of other bones in the body.

Osteoporosis Treatment

Hormone replacement therapy (HRT)
This is the most potent medical treatment to stop bone loss and encourage new bone deposits. Estrogen with progesterone acts to slow calcium loss from the bones and increase it’s absorption from the intestines. In low doses, estrogen slows down bone loss but at higher doses can actually help increase bone mass.

Selective estrogen receptor modulators
These have the same benefits as estrogen by slowing down bone loss.

Complementary therapies
These include acupuncture and TENS ( transcutaneous electrical nerve stimulation).

Pain management

1. Physiotherapy in the form of exercises to increase muscle strength and tone also help to relieve pain. Exercising in a water pool is very helpful as it allows an increased range of bodymovement because the water supports your body and bears your weight. Physiotherapy may also involve the use of ultrasound and electrotherapy.
2. Medication used for pain relief ranges from paracetamol and codeine to the more potent morphine. It is recommended that you take the lowest dose of the least potent painkiller that gives you relief from pain. Paracetamol is safe at recommended doses and non-addictive (unlike codeine and morphine).

Preventing osteoporosis

Osteoporosis prevention starts well before the menopausal years, during your late teens, 20s and early 30s, when preventing osteoporosis is the last thing on your mind.

Peak bone mass

Peak bone mass (PBM) is the amount of tissue in your bones when they are at their most dense. The higher your peak bone mass, the less likely you are to develop osteoporosis.

What affects your peak bone mass?

• If you spend much of your 20s and 30s being a couch potato, you are more likely to develop osteoporosis. Exercise (especially the weight-bearing type like walking and climbing stairs), increases PBM.
• Early onset of menstruation and late menopause are associated with increased PBM.
• Having several pregnancies increases PBM.
• If you use oral contraceptives for a long time your PBM will be increased.
• Healthy diet – you need lots of vitamin D and calcium for strong healthy bones.

Measures for osteoporosis prevention and reduction

Diet

You need a diet high in calcium and Vitamin D which helps the calcium to be absorbed into the body. If you aren’t getting enough calcium in your diet, you may need supplements.

Exercise

At least 30 minutes of weight-bearing exercise e.g. walking up stairs 3 times a week markedly reduces your osteoporosis risk. Walking is good general exercise because it helps posture which helps to maintain balance. This is important to prevent falls which may lead to fractures.

Do you need HRT?

HRT is probably the most effective way or preventing osteoporosis by maintaining bone mass.
However, it is not efective in some women. You may be wary of taking HRT because of the much-publicized side effects. Some women abandon HRT after only a few months.

It is important to discuss all the options available to you with your doctor. Often, adjusting the dose or the way the hormones are taken can significantly improve the side-effects without canceling out the advantages.

As menopause approaches, many women begin to worry about osteoporosis and how to prevent it.
This is something to be concerned about because the drop in estrogen production which occur after menopause causes an increase in bone loss leading to fragile bones.

Factors which increase the risk of developing osteoporosis include:

1. low bone density (thickness of your bones) at the time of menopause
2. smoking
3. premature menopause
4. removal of the ovaries and uterus
5. drugs (e.g. some asthma medications)

After menopause, bone loss is almost inevitable, so at this point, you’re trying to reduce the rate at which it is lost, and if possible reverse the loss.
The WHI (Women’s Health Initiative) trials on the effects of hormone replacement therapy also included a trial on the effects of Calcium and Vitamin D supplementation on:

1. the risks of suffering hip fractures and other fractures which are strongly associated with osteoporosis,
2. bone density and
3. the risk of getting colorectal cancer.

The 36,252 women who chose to take part in the Calcium/Vitamin D (CaD) trial were randomly assigned to two groups:

• one group taking a pill containing 500mg of Calcium and 200IU (IU =international units) of Vitamin D twice a day (a total of 1000mg of Calcium and 400IU of Vitamin D daily)
• the other group receiving an inactive placebo.

Overall:

1. women taking CaD had 12% fewer hip fractures
2. they had slightly fewer fractures overall but the difference was not significant
3. women who took their pills regularly had 29% fewer fractures than the placebo group
4. women 60 years and over had a 21% decreased risk of hip fracture compared to women over 60 in the placebo group
5. women on CaD had slightly increased bone density
6. they also 17% more kidney stones
7. there was no difference in the occurrence of colorectal cancer between the two groups

It is important to note that many of the women enrolled in the CaD trial already had a lower risk of developing hip fractures than women in the general population because:

1. most were on hormone replacement therapy which reduces the risk of developing osteoporosis
2. many already had a high personal intake of Calcium and Vitamin D
3. most had higher than average weight which also tends to reduce risk

These observations may explain the fact that there wasn’t much difference overall between the two groups. It is possible that differences may be greater in women who are not on hormone replacement therapy.

What does this mean for women worried about osteoporosis

1. Women over 50 should take a total of 1000 – 1200mg of Calcium and 400 – 600IU of Vitamin D a day.
2. Calcium and vitamin D are more effective when they are taken regularly.
3. Lifestyle changes that can help include :
   • eating a low fat, high fibre diet
   • carrying out weight-bearing exercise (e.g. walking and climbing stairs). The benefits of exercise aren’t limited to helping to reduce bone loss. Women who exercise have better posture and balance and are less likely to fall in the first place and so tend to have fewer fractures.