Reduced bone mineral density in postmenopausal women self-reporting premenopausal wrist fractures

Osteoporosis in premenopausal women

The development of osteoporosis and fractures in young premenopausal women is infrequent and is usually associated with secondary causes of osteoporosis. Therefore, it is recommendable to perform a clinical evaluation and a thorough laboratory study searching for possible causes of bone loss in these patients. Treatment depends on the cause of osteoporosis and the associated processes as well as the future gestational desire of the patient, all of which should be taken into account when evaluating the most adequate diagnostic and the therapeutic approach in these patients.

Sports participation and fracture in older Australian men

Older men who participated in a sporting activity were less likely to sustain any fracture or major osteoporotic fracture over a 6-year follow-up period.

PURPOSE

Regular weight-bearing physical activity can reduce fracture risk through an increase in bone strength, as well as reducing falls risk by improving muscle strength and balance. In this study, we aimed to determine whether a specific type of physical activity, sports participation, reduces fracture risk in older Australian men.

METHODS

Participation in sporting activities was documented for men aged 60 years and over enrolled in the Geelong Osteoporosis Study situated in south-eastern Australia. Fractures at any skeletal site (excluding skull, face, fingers and toes) and major osteoporotic fracture sites (MOF; wrist, proximal humerus, spine and hip) were ascertained through examination of radiological reports (median follow-up 6.63 years, IQR 5.58-7.29). Multivariable logistic regression was used to investigate the association between sports participation (either binary or continuous) and any fracture or MOF. Other clinical measures and lifestyle variables (such as comorbidity, falls and mobility) were included as potential confounders.

RESULTS

During follow-up, 82 of 656 men (12.5%) sustained at least one fracture at any site and 58 sustained at least one MOF (8.8%). Of those who did and did not fracture (any site), 17 (20.7%) and 204 (35.5%) participated in at least one sporting activity. For MOF, the values were 11 (19.0%) and 210 (35.1%), respectively. Participation in any sporting activity was associated with a reduction in the likelihood of any fracture during follow-up (unadjusted: OR 0.47, 95%CI 0.27-0.83), which persisted after adjusting for other factors (adjusted: OR 0.52, 95%CI 0.29-0.91). The results for MOF were similar (unadjusted: OR 0.43, 0.22-0.85; adjusted 0.48, 0.24-0.95). When considering sports participation as a continuous variable, a trend was observed (adjusted: p = 0.051 and p = 0.059 for any and MOF, respectively). A sensitivity analysis showed similar results when excluding men who reported using a walking aid.

CONCLUSIONS

In this group of older men, participation in sporting activity was associated with a reduced risk of fracture during the subsequent follow-up period.

Prior fracture as a risk factor for future fracture in an Australian cohort

SUMMARY

This study investigated the influence of prior fracture on the risk of subsequent fracture. There was a higher risk of subsequent fracture in both young and older adult age groups when Australian males or females had already sustained a prior fracture. Fracture prevention is important throughout life for both sexes.

INTRODUCTION

The purpose of this study was to determine the impact of prior fracture on the risk of subsequent fracture across the adult age range in Australian males and females.

METHODS

All-cause fractures were grouped into age categories for males and females enrolled in the Geelong Osteoporosis Study (Australia) using retrospective self-report data and prospective radiology-confirmed data. For all age categories, the relative risk (RR and 95% confidence interval (CI)) of subsequent fracture in a later age category was compared between those with prior fracture and those without.

RESULTS

For both sexes, childhood fracture increased the risk of subsequent fracture in adolescence (males: RR 21.7; 95% CI 16.0, 27.4; females: RR 8.1; 3.5, 12.8). Males with adolescent fracture had increased risk of subsequent fracture in early adulthood (RR 11.5; 5.7, 17.3) and mid-adulthood (RR 13.0; 6.3, 19.7). Additionally, males with young adulthood or mid-adulthood fracture had increased risk of subsequent fracture in the following age group (RR 11.2; 4.4, 17.9, and RR 6.2; 0.8, 11.7, respectively). Mid-adult fractures increased the risk of subsequent fracture in older adulthood (RR 6.2; 0.8, 11.7). Females with childhood or adolescent fracture had an increased risk of fracture in young adulthood (RR 4.3; 0.7, 7.9, and RR 10.5; 4.4, 16.6), and prior fracture in older adult life increased the risk of subsequent fracture in old age (RR 14.9; 6.4. 23.3).

CONCLUSIONS

Fracture prevention strategies may be more effective if attention is directed towards individuals with prior fracture at any age as they have a higher likelihood of sustaining a subsequent fracture later in life.

Age- and sex-related patterns of first fracture and fracture prevalence

There are few data documenting the pattern of prevalent fracture across the entire adult age range, so we aimed to address this gap by investigating the prevalence of fractures in an Australian cohort. All-cause (ever) fractures were identified for males and females enrolled in the Geelong Osteoporosis Study (Australia) using a combination of radiology-confirmed and self-reported data. First fractures were used to generate age-related frequencies of individuals who had ever sustained a fracture. Of 1,538 males and 1,731 females, 927 males and 856 females had sustained at least one fracture since birth. The proportion of all prevalent fractures in the 0-10 year age group was similar for both sexes (~10%). In males, the proportion with prevalent fracture increased to 34.1% for age 11-20 year. Smaller increases were observed into mid-life, reaching a plateau at ~50% from mid to late life. The age-related prevalence of fracture for females showed a more gradual increase until mid-life. For adulthood prevalent fractures, approximately 20% of males had sustained a first adulthood fracture in the 20-30 year age group, with a gradual increase up to the oldest age group (49.1%), while females showed an exponential pattern of increase from the 20-30 year age group (6.8%) to the oldest age group (60.4%). In both sexes, those who had not sustained a fracture in childhood or early adulthood generally appeared to remain fracture-free until at least the sixth decade. When considering the prevalence of adulthood fractures across the age groups, males showed a gradual increase while females showed an exponential increase.

Medical management following an osteoporotic fracture

Osteoporotic fractures are common and account for an important medical impact and high induced health-related costs. The most common fracture sites are the vertebra, wrist, proximal humerus and proximal femur. Osteoporosis must benefit from a medical treatment after a fragility fracture. This management is currently insufficient in France, although diagnostic tools (DEXA scan), effective treatments and guidelines are available and have been widely disseminated. Orthopaedic and trauma surgeons must emphasize to patients with a fracture that they need to consult their general practitioner or rheumatologist to decide how their osteoporosis will be diagnosed and treated.

Premenopausal osteoporosis: how to treat?

There is no agreement in defining osteoporosis in premenopausal women and diagnosis must be done carefully and not based on densitometric parameters. One must take into account the presence of other risk factors and history of fragility fractures, diseases or drugs that cause bone loss. Over 50% of premenopausal women with osteoporosis will have a secondary cause, with the remainder diagnosed with idiopathic osteoporosis. Therapeutic considerations are limited by a few studies in this group of patients, especially in regard to the risk of fractures. On the other hand, the FRAX index cannot be applied to premenopausal women. This article will review the measures to apply depending on the type of premenopausal osteoporosis, based on current scientific evidence.

Bone changes in spouses having shared lifestyle for 40 years

OBJECTIVES

Spousal concordance has already been observed for several other diseases but it has not yet been studied for bone loss. Our aim was to determine whether or not bone changes were the same within spouses who have shared the same environment for many decades.

METHODS

We conducted a prospective study on an average of 5±3 years in a single center. We evaluated in the 104 spouses who came at least twice and had more than 1 year of follow-up the changes in bone mineral density (BMD) at femoral neck adjusted on weight and height, and on hormone replacement therapy use and duration for women. Lifestyle characteristics and biological parameters were evaluated at baseline.

RESULTS

The mean (±SD) baseline age of wives was 63±5 years and that of their husbands was 66±5 years. They had been living together for 40±8 years. Most of the environmental baseline factors were correlated within partners: BMI (r=0.26, P<0.01), 25-OHD(3) (r=0.32, P<0.01), daily calories (r=0.52, P<0.001) and calcium intake (r=0.31, P<0.01), physical activity (r=0.43, P<0.0001). Bone loss was observed in wives (-0.0023 g/cm(2)/yr, P<0.01) but not in their husbands (0.0016 g/cm(2)/yr, P=0.10). Changes of BMD were not correlated within spouses (r=0.0004, P=0.99). In women, 25-OHD(3) and interactions of tobacco with 25-OHD(3) and calories intake explained 37% of the bone loss variance (P<0.01).

CONCLUSION

Environmental factors do not appear to influence changes in bone density in the same manner in subjects of different genders.

Escitalopram versus ethinyl estradiol and norethindrone acetate for symptomatic peri- and postmenopausal women: impact on depression, vasomotor symptoms, sleep, and quality of life

OBJECTIVE

To examine the efficacy and tolerability of escitalopram (ESCIT) compared to estrogen and progestogen therapy (EPT) for the treatment of symptomatic peri- and postmenopausal women.

DESIGN

Forty women (aged 40-60 years) with depressive disorders and menopause-related symptoms were randomly assigned to an 8-week open trial with ESCIT (flexible dose, 10-20 mg/day; fixed dose, 10 mg/day for the first 4 weeks) or estrogen plus progestogen therapy (ethinyl estradiol 5 microg/day plus norethindrone acetate 1 mg/day). Primary outcome measures included Montgomery-Asberg Depression Rating Scale and the Greene Climacteric Scale at week 8. Secondary outcome measures included the Clinical Global Impressions as well as sleep and quality of life assessments.

RESULTS

Thirty-two women (16 on EPT, 16 on ESCIT) were included in the analyses. Full remission of depression (score of <10 on the Montgomery-Asberg Depression Rating Scale) was observed in 75% (12/16) of subjects treated with ESCIT, compared to 25% (4/16) treated with EPT (P = 0.01, Fisher's exact tests). Remission of menopause-related symptoms (>50% decrease in Greene Climacteric Scale scores) was noted in 56% (9/16) of women treated with ESCIT compared to 31.2% (5/16) on EPT (P = 0.03, Pearson's chi2 tests). Improvement in sleep, hot flashes, and quality of life was observed with both treatments.

CONCLUSIONS

ESCIT is more efficacious than EPT for the treatment of depression and has a positive impact on other menopause-related symptoms. ESCIT may constitute a treatment option for symptomatic menopausal women who are unable or unwilling to use hormone therapy.

Sleep disorders in women: clinical evidence and treatment strategies

Sleep disorders are more prevalent in women than in men. Sex hormones modulate sleep-wake behaviors and mood and may contribute to heightened risk across the life cycle of women. Sleep disorders may have a unique expression in women, emerging throughout their reproductive life cycle. These conditions require careful treatment strategy to manage medical, hormonal, and behavioral contributing factors to poor sleep efficiency and impaired quality of life. This review focuses on clinical evidence for sleep disorders in women and discusses existing evidence of risk factors and treatment options for insomnia and sleep-disordered breathing in women.

Osteoporosis in otherwise healthy perimenopausal and early postmenopausal women: physical and biochemical characteristics

Population studies have shown that about 3-5% of perimenopausal women already have osteoporosis according to the WHO definition of osteoporosis for postmenopausal women ( t -score<or=-2.5). In general, this bone loss arises from well-characterized diseases or conditions that affect acquisition of peak bone mass and/or the rate of bone loss after peak bone mass has been attained. However, there often remains a subset of these women, with no identifiable cause of bone loss. This group has so far been little studied. We prospectively evaluated a group of 60 perimenopausal and early postmenopausal women (mean age 52.2+/-2.5 years) who were found to have apparently unexplained low bone mass, and we compared them to 120 controls matched for age and menopausal status. These women were extensively investigated, including by detailed questionnaire and laboratory testing. Of the 60 women with osteoporosis, only three were found to have previously undiagnosed disorders (two with subclinical hyperthyroidism and one with elevated serum PTH levels) that might have contributed to their low bone mass. On the other hand, osteoporotic patients were characterized by a significantly lower body weight, higher prevalence of personal and parental histories of fractures and a higher level of bone turnover as assessed by increased serum osteocalcin and bone alkaline phosphatase levels and urinary type I collagen C-telopeptide (CTX) excretion, as compared to controls. These findings support theories of a genetic contribution to osteoporosis and underline the predictive value of a previous history of personal and familial fracture in the identification of osteoporosis in early postmenopausal women.

Treatment of low bone mass in premenopausal women: when may it be appropriate?

The diagnosis and treatment of osteoporosis in postmenopausal women has been well defined. Criteria for making a diagnosis using bone density testing has been established and widely disseminated. However, the definition established by the World Health Organization for osteoporosis cannot be used for other populations such as premenopausal women without further study. Measuring bone mass in premenopausal women should be done infrequently and only if specific and significant risk factors are present. Premenopausal women have a low risk for fracturing but women with low bone mass are at a greater risk for developing fractures before and after menopause. The major reason for low bone mass is the failure to reach peak bone mass because of genetic influences, although some environ-mental factors may also play a role. Hormonal therapy for hypogonadism, treatment of diseases such as hyperpara-thyroidism, and keeping medications with detrimental effects on bone to a minimum are important components of treatment. Pharmacologic treatment of low bone mass in premenopausal women has not been well studied although on rare occasions it may be appropriate in women with low bone mass, defined as a Z score of -2 or less, and the presence of other diseases or risk factors. Caution is urged because of the unknown effects of treatment in this population. Further study of the implications of low bone mass and the effects of treatment in this group of women is needed.

Premenopausal bone health assessment

The World Health Organization criteria for classification of bone mineral density (BMD) cannot be applied to premenopausal women because the relationship between BMD and fracture risk is not the same as in postmenopausal women. Approximately 2.5% of premenopausal women have BMD that is more than 2.0 standard deviations below the mean BMD of an age-, gender-, and ethnicity-matched reference population. Most premenopausal women with low BMD have low peak bone mass and low 5- to 10-year probability of fracture. The management of these patients involves nonpharmacologic lifestyle measures and reassurances that fracture risk is low. A minority of premenopausal women with low BMD have significant elevation of fracture risk, usually a result of contributing diseases, conditions, or medications that may be identified and treated. Premenopausal women with fractures are at increased risk for postmenopausal osteoporosis and fractures later in life.

Low bone mineral density in premenopausal women

With the proliferation of bone densitometers, an increasing number of premenopausal women are having their bone density tested. Approximately 15% of premenopausal women have bone mineral density that is more than 1 standard deviation less than the young-adult mean, and approximately 0.6% are more than 2.5 standard deviation below young-adult mean bone density. Most premenopausal women with low bone density have low peak bone mass, stable bone density, and low short-term absolute risk of fracture. The management of these patients involves nonpharmacologic lifestyle measures and reassurances that fracture risk is low. A minority of premenopausal women with low bone density have increased short-term absolute fracture risk with contributing diseases, conditions, or medications that should be identified and treated. Premenopausal women with fractures are at increased risk for fractures later in life. Methods for evaluating these patients and selecting those who require additional care are reviewed.