Longitudinal changes in hip geometry in relation to the final menstrual period: Study of Women's Health Across the Nation (SWAN)

Using a Composite Summary of Daily Sex Hormones to Gauge Time Until Menopause: A Focus on Pregnanediol Glucuronide (PDG)

CONTEXT

The timing of a woman's final menstrual period (FMP) in relation to her age is considered a valuable indicator of overall health, being associated with cardiovascular, bone health, reproductive, and general mortality outcomes.

OBJECTIVE

This work aimed to evaluate the relationship between hormones and the "time to FMP" when daily hormone trajectories are characterized by their 1) entropy, and 2) deviation from premenopausal/stable cycle patterns (representing a textbook "gold standard"; GS).

METHODS

As part of the Study of Women's Health Across the Nation, urinary luteinizing hormone (LH), follicle-stimulating hormone (FSH), estrogen conjugates (E1C), and pregnanediol glucuronide (PDG) were measured daily from a multiracial sample of 549 mid-life women for the duration of one menstrual cycle. Hormone trajectories were mapped onto a plane with axes representing Fuzzy entropy (FuzzEn) and the normalized dynamic time warping distance (DTW) from the GS.

RESULTS

Viewing FSH, E1C, PDG, and LH through this lens reveals that, contrary to existing wisdom, PDG stands out as a powerful predictor/descriptor of "time to FMP." Using cluster analyses to discretize PDG on the DTW/FuzzEn plane yields statistically different survival curves, and Cox proportional hazards analyses confirm that this separation persists in the presence of known covariates of FSH, antimüllerian hormone, age, body mass index, financial hardship, smoking status, and cycle length.

CONCLUSION

Since PDG is generally not considered a predictor/descriptor of ovarian aging, this work validates the DTW/FuzzEn analytical framework and introduces another metric/hormone to be used in FMP-related preventive care.

Calcium plus vitamin D supplementation during pregnancy has no impact on postpartum transient longitudinal changes in hip geometry in adolescent mothers: a secondary analysis of a randomised controlled trial

We have previously demonstrated that calcium plus vitamin D supplementation during adolescent pregnancy reduces the magnitude of transient postpartum bone mass loss. In the present post hoc analysis, we further investigated the effect of calcium plus vitamin D supplementation during pregnancy in hip geometry throughout one year postpartum in Brazilian adolescents with low daily calcium intake (∼600 mg/d). Pregnant adolescents (14-19 years) were randomly assigned to receive calcium (600 mg/d) plus vitamin D3 (200 μg/d) or a placebo from 26 weeks of gestation until parturition. Dual-energy X-ray absorptiometry images were obtained at 5 (n 30 and 26 for calcium plus vitamin D and placebo, respectively), 20 (n 26 and 21) and 56 (n 18 and 12) weeks postpartum, and hip geometry parameters were analysed by Advanced Hip Assessment software. The effects of the intervention, time point and their interaction were assessed using repeated-measures mixed-effects models. No significant intervention effects or intervention × time interactions were observed on hip geometry parameters (P > 0·05). Time effects were observed in cross-sectional area, cross-sectional moment of inertia and section modulus parameters with decreases from the 5th to the 20th week postpartum followed by recovery from the 20th to the 56th week (P < 0·05). Our findings indicate that the postpartum period is associated with transient changes in the hip geometry of lactating adolescent mothers, regardless of the low calcium intake and the supplementation offered during pregnancy, suggesting that a physiological adaptation of these adolescents to low calcium intake is at play.

Age-related Differences in Volumetric Bone Mineral Density, Structure, and Bone Strength of Surgical Neck of Humerus in Postmenopausal Women

OBJECTIVE

Postmenopausal changes in bone mass and structure compromise the mechanical properties of proximal humerus, predisposing it to low-energy fractures with complex morphology. The aim of the study is to investigate associations of bone quality and estimated bone strength of the surgical neck with age after menopause.

METHODS

A total of 122 healthy postmenopausal women were recruited from December 2016 to December 2022 and assigned to three groups: the 50-59 years group, the 60-69 years group, and the older than 70 years group. Bone properties of the surgical neck, including volumetric bone mineral density (vBMD), cortical thickness (CTh), the periosteal and medullary size, and estimated indices of bone strength were evaluated by quantitative computed tomography.

RESULTS

Compared to the 50-59 years group, postmenopausal women aged over 70 years were characterized by lower cortical thickness (13.9%) and vBMD (6.65%), as well as reduced strength indices including the minimum and maximum section modulus (Zmin 18.11%, Zmax 21.71%), polar section modulus (Zpol 20.21%), and the minimum and maximum second moments of area (Imax 21.01%, Imin 21.43%). Meanwhile, the difference in periosteal diameter and perimeter, total area in three groups did not reach statistical significance. Both cortical thickness and vBMD value were inversely associated with age, showing 10.56% and 23.92% decline. Imax showed the greatest age-related decrease between age of 54 and 86 years (39.08%), followed by Zmax (-35.77%), Imin (-35.73%), Zpol (-34.90%) and Imin (-23.92%).The strength indices had stronger correlations with cortical thickness than with bone size or density.

CONCLUSION

In postmenopausal women, aging is associated with a significant decline in cortical bone thickness and mechanical strength of the proximal humerus, especially over the age of 70 years.

Changes in bone density and structure of proximal humerus with aging in Chinese women

AIMS

This study aimed to investigate age- and menopause-related differences in bone mineral density (BMD), bone structure and estimated bone strength at surgical neck of humerus in Chinese female sample.

METHODS

We conducted a cross-sectional cohort study of 171 Chinese women. Bone mass, indices of geometric properties and estimated mechanical strength of the surgical neck were evaluated by quantitative computed tomography (QCT). Comparisons were performed across menstrual status categories. Age-related changes in QCT-derived bone parameters were calculated.

RESULTS

The age-related difference of BMD and cortical thickness was 40.25 % and 32.86 % between the age of 20 and 86 years. Progressive periosteal and endosteal expansion was associated linearly with age. Estimated mechanical strength indexes showed significant quadratic associations with age, with their peak occurred at the age of 46-55 years. The quartile of women with the greatest medullary diameter also had the lowest valve of BMD and cortical thickness and the greatest in skeletal width. Compared to premenopausal individuals, perimenopausal women were distinguished by lower cortical thickness (18.63 %) and BMD (20.05 %). The continued decrease in cortical thickness and BMD was noted after menopause. The medullary and periosteal diameter increased by 17.98 % and 9.34 % respectively in perimenopausal period, but not after menopause. The accelerated loss of the maximum and polar section modulus was observed in late postmenopausal women.

CONCLUSIONS

The increase in bone size only occurred during the menopause transition. Obvious loss of resistance to bending was in late postmenopausal period.

Twelve-month resistance and impact exercise program or risedronate provides a relative benefit to hip bone structure in postmenopausal women: results from a randomized controlled trial

Bone strength estimates are important for fracture prevention. This study compared bone strength changes in postmenopausal women with low bone mass who were assigned to 12 months of exercise, a bone medication, or control. Exercise and bone medications benefited structure at the hip. Structure should be considered in fracture prevention research.

PURPOSE

Exercise and bisphosphonates reduce fracture risk, but their impact on estimates of bone strength remains uncertain. This study compared changes in tibial bone strength using peripheral quantitative computed tomography (pQCT) and hip structure analysis (HSA) outcomes from dual-energy X-ray absorptiometry (DXA) scans in postmenopausal women with low bone mass assigned to 12 months of exercise, risedronate, or control.

METHODS

In this RCT, 276 postmenopausal women within 6 years of menopause were randomly assigned to three groups: exercise (92), risedronate (91), or control (93). Exercise included weighted jogging and progressive resistance exercises; risedronate treatment was 150 mg monthly; all groups received calcium and vitamin D. pQCT and DXA images were obtained at baseline and 6 and 12 months and compared between groups over time.

RESULTS

Participants had a mean (± SD) age of 54.5 (± 3.2) years with an average of 36.7 (± 40.7) months postmenopause. No significant differences were found between groups for the change in pQCT outcomes (volumetric bone mineral density, area, and strength estimates). At 12 months, mean percent differences (95% CI) in HSA measures between exercise and controls were as follows: intertrochanteric, cross-sectional area 2.25% (0.28, 4.12) (p = .03), cross-sectional moment of inertia (CSMI) 5.67% (1.47, 9.87) (p < .01), and section modulus (SM) 4.38% (1.02, 7.74) (p = .01), and narrow neck, average cortical thickness 2.37% (-0.08, 4.83) (p = .031). Mean percent differences (95% CI) in HSA measures between risedronate and control were as follows: intertrochanteric, CSMI 4.28% (-0.24, 8.81) (p = .03) and SM 3.35% (-0.21, 6.91) (p = .03), and shaft, subperiosteal width 0.82% (0.05, 1.58) (p = .047), CSMI 2.53% (0.88, 4.18) (p = .004), and SM 1.57% (0.34, 2.8) (p = .008). Exercise maintained neck-shaft angle compared to both control 1.27% (0.13, 2.41) (p = .04) and risedronate 1.31% (0.23, 2.39) (p = .03). All other differences for changes in HSA outcomes over time were not significantly different between the exercise and risedronate groups.

CONCLUSION

Exercise and bisphosphonates may influence structural and strength estimates at the hip, but not at peripheral sites (tibia). Neither exercise nor bisphosphonates were found to be superior in improving estimates of hip bone strength.

Femora of women with premature ovarian insufficiency exhibit reduced strength and misalignment with the transmitted vertical forces from the upper body

BACKGROUND

Women with premature ovarian insufficiency (POI) lack oestrogen, which is a key determinant of bone growth, epiphyseal closure, and bone tissue organisation. Although dual-energy X-ray absorptiometry (DXA)-derived areal bone mineral density (BMD) remains the gold standard for fracture risk evaluation, it does not fully characterise the skeletal abnormalities present in these women. Hence, we aimed to assess hip/femur anatomy, strength, and geometry and femoral alignment using advanced hip analysis (AHA).

METHODS

We conducted a cross-sectional, case-control study including 89 women with spontaneous normal karyotype POI (s-POI) or iatrogenic POI (i-POI), aged 20-50 years compared with 89 age- and body mass index (BMI)-matched population-based female controls. Hip anatomy, strength, geometrical parameters, and femur alignment were measured using hip DXA images and Lunar AHA software. Femoral orientation angle (FOA) was quantified as the overall orientation of the femur with respect to the axis of the forces transmitted from the upper body.

RESULTS

The median age of POI diagnosis was 35 (18-40) years; the mean POI duration at the time of DXA was 2.07 (range 0-13) years, and 84% of POI women received oestrogen therapy. Areal BMD at all sites was significantly lower in the POI group (all P < .05). Indices of compressive and bending strength were lower in women with POI compared with controls, specifically the cross-sectional area (CSA, mm2) and section modulus (SM, mm3) (139.30 ± 29.08 vs 157.29 ± 22.26, P < .001 and 665.21 ± 129.54 vs 575.53 ± 150.88, P < .001, respectively). The FOA was smaller (124.99 ± 3.18) in women with POI as compared with controls (128.04 ± 3.80; P < .001) at baseline and after adjusting for height and femoral neck BMD.

CONCLUSION

Alongside lower BMD at multiple sites, the femora of women with POI demonstrate reduced strength and a misalignment with forces transmitted from the upper body. Further research is needed to establish the role of these newly identified features and their role in fracture risk prediction in this population.

Osteoporosis and Fracture Risk among Older US Asian Adults

PURPOSE OF REVIEW

This review summarizes the current knowledge regarding osteoporosis and fracture among older US Asian adults.

RECENT FINDINGS

Asian adults have lower (areal) bone density than non-Hispanic White adults and thus are more likely to be diagnosed and treated for osteoporosis, despite their lower risk of hip fracture. The latter may relate to favorable characteristics in hip geometry, volumetric bone density, and bone microarchitecture; lower risk of falls; and other clinical factors. The fracture risk calculator FRAX accounts for the lower risk of hip fracture among US Asian adults. However, data on major osteoporotic fracture risk remain limited. Fracture rates also vary by Asian subgroup, which may have implications for fracture risk assessment. Furthermore, among women receiving bisphosphonate drugs, Asian race is a risk factor for atypical femur fracture, an uncommon complication associated with treatment duration. Recent clinical trial efficacy data pertaining to lower bisphosphonate doses and longer dosing intervals may be relevant for Asian adults. More research is needed to inform osteoporosis care of US Asian adults, including risk-benefit considerations and the optimal duration of bisphosphonate treatment. Greater evidence-based guidance for primary fracture prevention among US Asian adults will ensure health equity in the prevention of osteoporotic fractures.

Menopause-related cortical loss of the humeral head region mainly occurred in the greater tuberosity

AIMS

Proximal humerus fractures are commonly observed in postmenopausal women. The goal of this study was to investigate menopause-related changes in cortical structure of the humeral head.

MATERIALS AND METHODS

Clinical computed tomography (CT) scans of 75 healthy women spanning a wide range of ages (20-72 years) were analyzed. For each subject, cortical bone mapping (CBM) was applied to create a color three-dimensional (3D) thickness map for the proximal humerus. Nine regions of interest (ROIs) were defined in three walls of the humeral head. Cortical parameters, including the cortical thickness (CTh), cortical mass surface density (CM), and the endocortical trabecular density (ECTD), were measured.

RESULTS

Compared to premenopausal women, postmenopausal women were characterized by a significantly lower CTh and CM value in the lateral part of the greater tuberosity. Similar changes were only found in ROI 4, but not in ROIs 5-6 in the lesser tuberosity. Linear regression analysis revealed that the CTh and CM value of ROIs 1, 3, and 4 were negatively associated with age. These results showed that menopause-related loss in CTh and CM was mainly in the greater tuberosity besides the proximal part of the lesser tuberosity. Trabecular bone variable measured as ECTD showed a notably lower value in ROIs 1-9 in postmenopausal vs. premenopausal group. Inverse linear associations for ECTD and age were found in ROIs 2, 3, 5, 6, 7, and 9, indicating no site-specific differences of endocortical trabecular bone loss between the greater and lesser tuberosity.

CONCLUSIONS

Menopause-related cortical loss of the humeral head mainly occurred in the lateral part of the greater tuberosity. The increased rate of humeral bone loss in the greater tuberosity may contribute materially to complex proximal humerus fractures.

Dairy intake is not associated with improvements in bone mineral density or risk of fractures across the menopause transition: data from the Study of Women's Health Across the Nation

Objective:

Menopause represents a period in which bone deterioration is accelerated; thus, primary prevention strategies to address age-related bone loss are crucial. Dairy products contain more than a dozen essential nutrients, including calcium, phosphorus, vitamin D, and high-quality protein, as well as bioactive compounds that may promote bone mineralization. However, the relationship between dairy consumption and bone health across the menopause transition remains largely unknown. The purpose of this analysis was to estimate the change in lumbar spine and femoral neck bone mineral density and the risk of bone fracture by the frequency of dairy intakes among women across the menopausal transition using the publicly available data from the Study of Women's Health Across the Nation.

Methods:

We analyzed total dairy foods in four categories of <0.5, 0.5 to <1.5, 1.5 to <2.5, and ≥2.5 servings/d or <1.5 and ≥1.5 servings/d. A general linear model was used to estimate the association of dairy intake with the 10-year bone mineral density loss rate and a linear mixed model was used to estimate the annualized bone mineral density loss rate of the femoral neck and lumbar spine. A Cox proportional hazard model was applied to calculate hazard ratios and 95% confidence intervals of the nontraumatic fractures. Poisson regression was used to determine the relative risks and 95% confidence intervals of the nontraumatic fractures. The models were controlled for race/ethnicity, age, height, weight, smoking status, physical activity, alcohol consumption, calcium use, menopausal status, and total caloric intake.

Results:

No significant differences in bone mineral density change were observed, regardless of baseline menopausal status. No significant differences in the risk of nontraumatic fracture were observed.

Conclusions:

In this group of US women undergoing the menopausal transition, dairy food intake was neither associated with femoral and spine bone mineral density loss nor the risk of fractures.

Hormones and bone loss across the menopause transition

The menopause transition is a critical period for bone health in women, with rapid losses in bone mass and strength occurring over an approximately 3-year window bracketing the date of the final menstrual period. The onset of the rapid bone loss phase is preceded by large changes in sex steroid hormones, measurements of which may be clinically useful in predicting the onset of the rapid loss phase and identifying the women who will lose the most bone mass during this rapid bone loss phase. Here we summarize recent and new findings related to the ability of sex hormone levels to (1) determine if a woman in her 5th decade of life is about to enter or has already entered the rapid phase of bone loss, and (2) if she will lose more than the average amount of bone mass over the menopause transition.

Evaluation of Hip Geometry Parameters in Patients With a Distal Radius Fracture

BACKGROUND

Patients with a distal radius fracture (DRF) have an increased risk of subsequent fractures including hip fractures. The purpose of this study was to evaluate whether women with a DRF have certain hip geometry parameters known to indicate susceptibility to hip fractures.

METHODS

We compared bone mineral density (BMD) and hip geometry parameters (hip axis length, neck shaft angle, mean cortical thickness, femur neck width, cross-sectional area [CSA], cross-sectional moment of inertia, section modulus, and buckling ratio) in 181 women with a DRF (DRF group) and 362 propensity score-matched women without a fracture (control group). We evaluated the associations between DRF and hip geometry parameters using logistic regression analysis.

RESULTS

The DRF group had lower hip BMD; lower cortical thickness, CSA, and section modulus; and higher buckling ratio than the control group (all p < 0.05). The occurrence of a DRF was significantly associated with decreases in neck shaft angle (odds ratio [OR], 1.047; 95% confidence interval [CI], 1.008-1.088) and CSA (OR, 3.114; 95% CI, 1.820-5.326) after adjusting for age, BMI, and total hip BMD.

CONCLUSIONS

In this study, women with a DRF were more likely than women without a DRF to have hip geometry parameters known to indicate susceptibility to hip fractures. Our results suggest that not only low hip BMD but also a decreased CSA could account for the increased risk of subsequent hip fracture in patients with a DRF.

Factors of mineral homeostasis impairment and bone mineral density loss in women with central hypogonadism

OBJECTIVE

The aims of the study were to estimate markers of mineral turnover and bone mineral density (BMD) in young women with central hypogonadism (CH) in comparison with healthy young and postmenopausal women, and to reveal the possible impact of different factors on BMD.

METHOD

We examined 73 patients with CH (mean age 25 [21.2; 30.5] years, mean duration of amenorrhea 5 [2.3; 10.1] years), 47 young healthy women (mean age 24 [23.1; 28.0] years) and 50 healthy women in natural postmenopause (mean age 56 [53; 58] years, mean duration of 6 [2; 10] years since last menstrual period). Women with CH were examined before and after 12 months of treatment with 17β-estradiol 2 mg and dydrogesterone 10 mg in continuous sequential fashion.

RESULTS

Levels of calcium, alkaline phosphatase, and C-terminal telopeptide of type I collagen were statistically higher in women with CH without treatment than in young healthy women but did not differ from those in postmenopausal women. Prevalence of T-score ≤-2.5 standard deviations was higher in CH than in postmenopause both in lumbar vertebrae and total femur. Factors that were responsible for lower BMD in young women with CH included the duration of hypoestrogenism, primary amenorrhea, and hypoandrogenism.

CONCLUSION

Central hypogonadism at a young age poses a higher risk of bone metabolism impairment than physiological menopause.

Trabecular Bone Score Declines During the Menopause Transition: The Study of Women's Health Across the Nation (SWAN)

CONTEXT

Rapid bone density loss starts during the menopause transition (MT). Whether other components of bone strength deteriorate before the final menstrual period (FMP) remains uncertain.

OBJECTIVE

To discern whether trabecular bone score (TBS) declines during the MT.

DESIGN

An 18-year longitudinal analysis from the Study of Women's Health Across Nation.

SETTING

Community-based cohort.

PARTICIPANTS

A total of 243 black, 164 Japanese, and 298 white, initially pre- or early perimenopausal women, who experienced their FMP.

MAIN OUTCOME MEASURES

TBS, an indicator of bone strength.

RESULTS

Multivariable mixed effects regressions fitted piecewise linear models to repeated measures of TBS as a function of time before or after the FMP; covariates were age at FMP, race/ethnicity, and body mass index. Prior to 1.5 years before the FMP, in the referent individual (a white woman with age at FMP of 52.2 years and body mass index of 28.0 kg/m2), TBS evidenced no change (slope 0.12% per year, P = 0.2991). TBS loss began 1.5 years before the FMP, declining by 1.16% annually (P < 0.0001). Starting 2 years after the FMP, annual rate of TBS loss lessened to 0.89% (P < 0.0001). In the 5 years before through the 5 years after the FMP, in the referent individual, total TBS decline was 6.3% (P < 0.0001), but black participants' total TBS loss was 4.90% (P = 0.0008, difference in black and white 10-year change). Results for Japanese did not differ from those of white women.

CONCLUSIONS

The occurrence of an MT-related decline in TBS supports the thesis that this period is particularly damaging to skeletal integrity.