Bone density issues in the adolescent gynecology patient

Primary Ovarian Insufficiency, Bone Health, and Other Outcomes in Adolescents

Adolescents with primary ovarian insufficiency (POI) frequently present with arrested pubertal development or amenorrhea. Early evaluation of menstrual irregularities can avoid a delayed diagnosis. There are various genetic, autoimmune, and iatrogenic causes of POI, although most of the cases will not have an identified cause. Prompt initiation of hormone replacement therapy will restore developmentally appropriate pubertal progression, establishment of menses, and optimization of bone and cardiovascular health. The diagnosis of POI is often unexpected and life-altering for an adolescent and has broad health and psychosocial implications that are best approached with empathy, educational resources, and engagement of multidisciplinary specialists.

Effect of Education on Preventive Behaviors of Osteoporosis in Adolescents: A Systematic Review and Meta-Analysis

BACKGROUND

Osteoporosis is one of the diseases that can be prevented by correcting health behaviors during adolescence.

OBJECTIVE

This study was conducted to evaluate the effect of education on preventive behaviors of osteoporosis including physical activity, calcium intake and practice (primary outcomes) and knowledge and attitude related to osteoporosis (secondary outcomes) in adolescents.

METHOD

A search was done in Cochrane Library, PubMed, Embase, Web of Sciences, Scopus, Google Scholar, SID and Magiran regardless of the time limit. To evaluate the quality of selected controlled trials, Cochrane collaboration' instrument was used for assessing the risk of bias. RevMan software was used to analysis and report the data.

RESULTS

Of 2159 articles retrieved, 20 of them were reviewed and 18 of them entered the mete-analysis. The meta-analysis showed significant differences between the education and control groups in terms of calcium intake (SMD = 0.78, 95%CI = 0.55 to 1.02, P < 0.00001), practice (SMD = 0.54, 95%CI = 0.41 to 0.68, P < 0.0001), knowledge (SMD = 1.76, 95%CI = 1.10 to 2.42, P < 0.00001) and attitude (SMD = 0.96, 95%CI = 0.53 to 1.40, P < 0.0001) mean score in adolescents but education is not effective on average minute/week of physical activity per week (MD = 31.94, 95%CI = -6.53 to 70.40, P = 0.10), mean score of physical activity (MD = 2.66, 95%CI = -0.55 to 5.88, P = 0.10) and percent of students participated in the physical activity (OR = 1.45, 95%CI = 0.30 to 6.91, P = 0.64).

CONCLUSION

Education is effective in improving their knowledge and attitudes toward osteoporosis. It can also improve some health-related behaviors for bone health such as sufficient dairy calcium intake but it has not been effective in establishing a regular exercise program.

Skeletal status and body composition in young women with functional hypothalamic amenorrhea

CONTEXT

Functional hypothalamic amenorrhea (FHA) related to hypoestrogenism and hormonal status may influence skeletal homeostasis and body composition. The study aimed to evaluate hormones concentrations, body composition and bone strength in FHA cases.

PATIENTS AND METHODS

Total body scans using DXA method (DPX-L, GE Lunar) were performed in a group of 27 women aged 21.8 years ± 3.9 with FHA related to weight loss. References of healthy control subjects were used to calculate Z-scores (age and gender matched), SD-scores (height and gender matched), and SDs-scores (weight and gender matched). Whole skeleton bone mineral content (TBBMC, g) and density (TBBMD, g/cm(2)), lumbar spine (L2-L4) bone mineral density (SBMD; g/cm(2)), lean body mass (LBM, g) and fat mass (FM, g) were investigated. Relative bone strength index was calculated as the TBBMC/LBM ratio. Serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol, testosterone, and prolactin (PRL) concentrations were assayed to characterize hormonal profile of FHA cases.

RESULTS

Hormonal evaluation in patients with FHA revealed significantly decreased serum concentrations of gonadotropins and estradiol. Serum LH concentrations were 1.47 ± 0.89 mIU/ml, FSH 4.44 ± 1.94 mIU/ml. Estradiol concentrations in serum were 27.08 ± 13.10 pg/ml. As evidenced by Z-scores, FHA cases had decreased SBMD, TBBMD and TBBMC Z-scores of -1.23 ± 0.90 (p < 0.0001), -0.72 ± 0.86 (p < 0.001), and -0.90 ± 1.40 (p < 0.01), respectively. Reduced FM, LBM and FM/LBM ratio Z-scores of -1.80 ± 2.28 (p < 0.001), -0.59 ± 1.49 (p < 0.05) and -0.74 ± 1.55 (p < 0.05), but not TBBMC/LBM Z-score of -0.54 ± 2.14 (ns) were noted in FHA cases compared with healthy control cases. TBBMC, TBBMD, TBBMC/LBM when BH- or BW-matched were normal as evidenced by SD-scores and SDs-scores. SBMD remained reduced when BH-matched (SD-score = -0.40 ± 0.86; p < 0.05) whereas FM and FM/LBM were lower than expected in healthy, both compared to BH- and BW-dependent references. The length of amenorrhea in months negatively correlated with SBMD Z-score (R = -0.39, p < 0.05), and SD-scores for SBMD (R = -0.48), TBBMD (R = -0.43), TBBMC (R = -0.46) (all p < 0.05) and positively with SDs-scores for FM (R = 0.44, p < 0.05).

CONCLUSION

Patients with FHA were characterized by lower concentrations of serum FSH, LH and estradiol concentrations. Moreover, FHA cases had decreased FM and an imbalanced relationship between BW, FM, and LBM. Despite reduced BMD and BMC, bone strength was not significantly affected by FHA.

[Clinical practice guidelines for evaluation and treatment of osteoporosis associated to endocrine and nutritional conditions. Bone Metabolism Working Group of the Spanish Society of Endocrinology]

OBJECTIVE

To provide practical recommendations for evaluation and treatment of osteoporosis associated to endocrine diseases and nutritional conditions.

PARTICIPANTS

Members of the Bone Metabolism Working Group of the Spanish Society of Endocrinology, a methodologist, and a documentalist.

METHODS

Recommendations were formulated according to the GRADE system (Grading of Recommendations, Assessment, Development, and Evaluation) to describe both the strength of recommendations and the quality of evidence. A systematic search was made in MEDLINE (Pubmed), using the following terms associated to the name of each condition: AND "osteoporosis", "fractures", "bone mineral density", and "treatment". Papers in English with publication date before 18 October 2011 were included. Current evidence for each disease was reviewed by two group members, and doubts related to the review process or development of recommendations were resolved by the methodologist. Finally, recommendations were discussed in a meeting of the Working Group.

CONCLUSIONS

The document provides evidence-based practical recommendations for evaluation and management of endocrine and nutritional diseases associated to low bone mass or an increased risk of fracture. For each disease, the associated risk of low bone mass and fragility fractures is given, recommendations for bone mass assessment are provided, and treatment options that have shown to be effective for increasing bone mass and/or to decreasing fragility fractures are listed.

Hypoestrogenism in young women and its influence on bone mass density

One of the most important hormonal factors responsible for bone health is estradiol. Genetic factors, adequacy of hormonal functioning, nutrition and physical activity may be the markers of bone status and development in young women. During adolescence, women reach peak bone acquisition and develop a skeletal mass. This process is largely regulated by endocrine factors mainly such as adequate levels of gonadal, adrenal and pituitary hormones. The crucial role played by estradiol and its impact on bones are very multiple. Estradiol induces growth factors' activation, receptor activator of nuclear factor kappa B ligand (RANKL) production inhibition and is mainly referred to antiresorptive activity. Clinical situations leading to hypoestrogenism has been linked to decreased bone mineral density leading to osteopenia and osteoporosis. This status both in fertile and perimenopausal women can increase the risk of pathological fractures. Such conditions as hypothalamic-pituitary insufficiency (functional hypothalamic amenorrhea, anorexia nervosa, Kallmann syndrome, hyperprolactinemia), ovarian failure (gonadal dysgenesis, premature ovarian failure) and iatrogenic treatment (surgery, chemotherapy, radiotherapy) can cause hypoestrogenism. The treatment of osteopenia and osteoporosis caused by hypoestrogenism is very essential and multidirectional. The crucial role of the therapy is the achievement of proper serum estradiol concentration and eliminate the causes of hypoestrogenism.

Characteristics of the female athlete triad in collegiate cross-country runners

The Female Athlete Triad is a life-threatening syndrome defined by disordered eating, amenorrhea, and osteoporosis.

OBJECTIVE AND PARTICIPANTS

The author's purpose in this study was to examine female cross-country runners' (N=300) calcium consumption, along with the prevalence of 2 components of the triad: disordered eating and menstrual dysfunction.

METHODS

The author used measures including the Orientation to Exercise Questionnaire, Calcium Rapid Assessment Method, and questions related to height, weight, exercise time, perceptions of eating disorders, and menstrual status. Previous or current eating disorders were reported by 19.4% of the women, 23.0% had irregular menstrual cycles, and 29.1% had inadequate calcium intake.

RESULTS

Those athletes perceiving a previous/current eating disorder scored higher on the Orientation to Exercise questionnaire than did those who did not perceive such.

CONCLUSION

The author recommends educational efforts for the prevention of components of the Female Athlete Triad.

Relationship between adolescent amenorrhea and climacteric osteoporosis

OBJECTIVES

The relationship between climacteric osteoporosis and disturbances in menstrual cycle during adolescence was examined.

METHODS

Seven hundred and seventy-one questionnaires were shared out among women visiting the outpatient department for climacteric complaints for the first time between 2001 and 2004. Questions revealed the age, age at menarche and menopause, the regularity or irregularity of menstrual cycle during adolescence and adult ages. The bone mineral density was examined using the Dual Energy X-ray Absorptiometry (DEXA) method on the lumbar spine.

RESULTS

Six hundred and thirty-five of the 771 questionnaires were suitable for analysis. Osteoporosis was observed in 30.1% of the cases. Age, age at the menarche or at the menopause did not alter in the subgroups with or without osteoporosis. The incidence and severity of osteoporosis were significantly higher in patients reporting secondary amenorrhea during adolescent ages (42.1%; average BMD of the lumbar spine 71.6+/-3.9), as compared to the patients with normal cycle (30.4%; average BMD of the lumbar spine 84.8+/-7.8). No correlation between the occurrence of osteoporosis and the frequency of menstrual cycle during adulthood was observed.

CONCLUSIONS

Secondary amenorrhea during the years of adolescence might play a role in the development of more severe osteoporosis in menopause.

Ovarian Dysfunction, Stress, and Disease: A Primate Continuum

Menopause is recognized as a period of increased risk for coronary heart disease (CHD) and osteoporosis. Vulnerability to these conditions is often attributed to the naturally occurring estrogen deficiency characteristic of this part of the life cycle. Premenopausal reductions in endogenous estrogen occasioned by functional ovarian abnormalities or failure are hypothesized to be similarly pathogenic and to accelerate development of CHD and osteoporosis prematurely, thereby increasing the health burden of older women. These functional abnormalities, which occur along a continuum from mild, luteal phase progesterone deficiency to amenorrhea, are relatively common and are often attributed to psychogenic factors (stress, anxiety, depression, or other emotional disturbance), exercise, or energy imbalance. Although numerous investigators have commented on these functional deficits, the abnormalities can be difficult to diagnose and are generally unappreciated for the contribution they may make to postmenopausal disease. Studies in nonhuman primates confirm that these deficits are easily induced by psychological stress and exercise, and that they accelerate the development of cardiovascular disease and perhaps bone loss in the presence of a typical North American diet. However, functional reproductive deficits are also reversible and are thus potentially amenable to environmental or behavioral intervention. Data from both women and nonhuman primates support the hypothesis that functional reproductive deficits are adaptive when triggered appropriately but are detrimental when activated in an environment (e.g., sedentary lifestyle, high-fat diet) permissive to the development of chronic disease.

Association between vegetarian diet and menstrual problems in young women: a case presentation and brief review

In the last twenty years, several studies have suggested the existence of an association between vegan diets and adolescent menstrual disorders. We share our experience with this problem and a review of the literature on the subject. We conclude that despite the existence of some evidence to the possible association between vegetarian diet and menstrual disorders, it is still not clear if this association is due solely to the vegetarian diet or due to the overall inadequate nutrition with decreased proportions of fat and protein in the diet. We believe that more prospective, well controlled studies are needed to truly explain this association.

Eating disorders

Anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified remain a significant cause of morbidity and mortality in girls and young women. Management of eating disorders typically requires a multidisciplinary team approach, often spear-headed by the clinician initially detecting the illness. This article addresses the definitions and prevalence of eating disorders, tips on recognition and management of medical complications, and reproductive health concerns for these young women. Issues surrounding care of the patient with the female athlete triad, or amenorrhea, osteopenia, and eating disorders, are also discussed.