Awareness of risk of osteoporosis may cause uncertainty and worry in menopausal women

Does mandibular bone structure predict subsequent height loss? A longitudinal cohort study of women in Gothenburg, Sweden

BACKGROUND

Several risk factors for loss of height with increasing age have been identified.

OBJECTIVE

To investigate if mandibular bone structure predicts future height loss in middle-aged and elderly Swedish women.

DESIGN

Prospective cohort study with longitudinally measured heights, radiographical assessments of the cortical bone using Klemetti's Index (normal, moderate or severely eroded cortex) and classification of the trabecular bone using an index proposed by Lindh et al (sparse, mixed or dense trabeculation). No intervention was performed.

SETTING

Gothenburg, Sweden.

PARTICIPANTS

A population-based sample of 937 Swedish women born in 1914, 1922 and 1930 was recruited. At the baseline examination, the ages were 38, 46 and 54 years. All had undergone a dental examination with panoramic radiographs of the mandible, and a general examination including height measurements on at least two occasions.

MAIN OUTCOME MEASURE

Height loss was calculated over three periods 12-13 years (1968-1980, 1980-1992, 1992-2005).

MAIN RESULTS

Mean annual height loss measures were 0.075 cm/year, 0.08 cm/year and 0.18 cm/year over the three observation intervals, corresponding to absolute decreases of 0.9 cm, 1.0 cm and 2.4 cm. Cortical erosion in 1968, 1980 and 1992 significantly predicted height loss 12 years later. Sparse trabeculation in 1968, 1980 and 1992 also predicted significant shrinkage over 12 or 13 years. Multivariable regression analyses adjusting for baseline covariates such as height, birth year, physical activity, smoking, body mass index and education yielded consistent findings except for cortical erosion 1968-1980.

CONCLUSION

Mandibular bone structure characteristics such as severe cortical erosion and sparse trabeculation may serve as early risk factors for height loss. Since most individuals visit their dentist at least every 2 years and radiographs are taken, a collaboration between dentists and physicians may open opportunities for predicting future risk of height loss.

Patients' thoughts about assessment of fracture risk in a dental setting using FRAX-a qualitative interview study

FRAX is a tool based on questions that identifies persons at risk of fragility fractures. We interviewed patients about their thoughts on doing FRAX in a dental setting. They were generally positive but had some concerns that need to be considered before introducing FRAX in a dental setting.

PURPOSE

To investigate patients' thoughts about assessing the risk of fragility fractures using the FRAX tool in a dental setting. Sweden has a high incidence of fragility fractures, but many of these are preventable. The most common method for identifying persons with a high risk of sustaining fragility fractures is FRAX, a validated instrument for assessing the risk of suffering fragility fractures within 10 years. In the Nordic countries, most of the adult population has regular contact with their dentist, which could be useful in identifying high-risk individuals.

METHODS

A qualitative inductive approach to content analysis, with individual semi-structured interviews, was used. Seven women and three men, aged 65-75 years, were interviewed and assessed with FRAX.

RESULTS

An overarching theme was that patients considered a FRAX assessment in the dental setting a good service but doubted that the dentists would have the interest, time, and knowledge to do it. The patients had little knowledge and experience of osteoporosis and fragility fractures. They were positive towards assessing the fracture risk with the FRAX instrument. If they were found to have a high fracture risk, they expected the dentist to send a referral for further investigation and to collaborate in the risk assessment with their family physician. They thought risk assessment in a dental context would be a good service if the fee was the same as that in primary care.

CONCLUSION

Most participants were positive about having FRAX and other health assessments done in the dental clinic, but this study shows that patients have concerns that need to be addressed before introducing FRAX in this context.

Trabecular bone patterns as a fracture risk predictor: a systematic review

BACKGROUND

The aim of this systematic review was to evaluate the assessment of trabecular bone patterns in dental radiographs, for fracture risk prediction, compared with the current diagnostic methods.

METHODS

The PRISMA guidelines were followed. According to predefined inclusion criteria (PICO), literature searches were focussed on published studies with analyses of trabecular bone patterns on intraoral and/or in panoramic radiographs, compared with Dual X-ray Absorptiometry (DXA) and/or Fracture Risk Assessment Tool (FRAX), with the outcomes; fracture and/or sensitivity and specificity for osteoporosis prediction. The included studies were quality-assessed using the QUADAS-2 tool and the certainties of evidence was assessed using the GRADE approach.

RESULTS

The literature searches identified 2913 articles, whereas three were found to meet the inclusion criteria. Two longitudinal cohort studies evaluated the use of trabecular bone patterns to predict bone fractures. In one of the studies, the relative risk of fracture was significantly higher for women with sparse bone pattern, identified by visual assessment of dental radiographs, and in the other study by digital software assessment. Visual assessment in the second study did not show significant results. The cross-sectional study of digital analyses of trabecular bone patterns in relation to osteoporosis reported a sensitivity of 0.70 and a specificity of 0.69.

CONCLUSION

Based on low certainty of evidence, trabecular bone evaluation on dental radiographs may predict fractures in adults without a prior diagnosis of osteoporosis, and based on very low certainty of evidence, it is uncertain whether digital image analyses of trabecular bone can predict osteoporosis.

Mandibular cortical bone structure as risk indicator in fractured and non-fractured 80-year-old men and women

Objective

To investigate the association between mandibular cortex parameters and fracture in a group of 286 men and women, 79–80 years of age.

Study design

In a cross-sectional study, the mandibular cortex was evaluated with Klemetti’s index for cortical erosion. The cortical thickness was measured with a ruler adjusting for the magnification factor. The odds ratio (OR) for fracture when having a severely eroded cortex or a cortex thickness < 3 mm was calculated.

Results

A normal cortex was found in 65% of men, whereas only 7% had a severely eroded cortex. The OR for severely eroded cortex  as fracture risk predictor was significant (2.32; 95% CI 1.3–4.2), also when the female group was evaluated separately. A significant difference was found between the mean thickness for men (3.96 mm) and women (2.92 mm), respectively. The OR for cortical thickness < 3 mm was significant (2.00; 95% CI 1.1–3.6) in the total group, but not when men and women were evaluated separately.

Conclusions

Among old women, the cortical parameters were significantly associated with prevalent fracture. In old men, other circumstances may be more important.

The gap between women's needs when diagnosed with asymptomatic osteoporosis and what is provided by the healthcare system: A qualitative study

OBJECTIVES

Women diagnosed with asymptomatic osteoporosis need better support to understand the implications of the condition and how to practice self-management in their daily lives. In contrast, physicians report that asymptomatic osteoporosis is not a serious chronic condition and do not pay much attention to the condition compared to other chronic conditions. Therefore, the aim of this study was to investigate the gap between women's needs, when diagnosed with asymptomatic osteoporosis, and what is provided by the healthcare system.

METHODS

A secondary analysis of semi-structured interviews with 17 women newly diagnosed with asymptomatic osteoporosis was conducted and combined with semi-structured interviews with six physicians. Giorgi's descriptive phenomenological method was used in the analysis.

RESULTS

Two overall themes were identified: different perceptions of asymptomatic osteoporosis and discrepancies in the osteoporosis consultation. Habermas was used as a theoretical approach to discuss the findings.

DISCUSSION

We discuss that physicians pay too much attention to the objective world and highlight that there is a need for better inclusion of women's subjective and social worlds, to enable mutual understanding and communicative action in the osteoporosis consultation. This would lead to treatment decisions based on women's needs and support women in their self-management of osteoporosis.

Ambiguity hindering self-management and prevention of osteoporosis in post-menopausal women

As osteoporosis relies largely on self-managed prevention and adherence to long-term treatment regimens, it is imperative that those at risk understand the disease that they are attempting to prevent. Ambiguity regarding osteoporosis and reluctance to take anti-osteoporosis medication (AOM) as well as calcium was noted in Australian post-menopausal women. This may lead to underestimating women's own risk of osteoporosis and fracture.

INTRODUCTION

Fragility fractures caused by osteoporosis have been known to inflict significant personal and financial burden on individuals and society. As treatment of osteoporosis relies largely on self-managed prevention and adherence to long-term AOM regimens, it is imperative that women have a sound understanding of the disease that they are attempting to prevent. Much can also be gained from qualitatively exploring the level of osteoporosis knowledge particularly in post-menopausal women who are at greater risk of osteoporosis and fractures. This study thus aims to determine what post-menopausal Australian women know about osteoporosis and osteoporosis prevention.

METHOD

Six focus group sessions, using purposive sampling, were conducted with 23 female participants (mean age 68 years (range 62-83)). Women responded to a series of open-ended questions regarding their knowledge about osteoporosis. The audiotaped focus groups were transcribed verbatim and analysed using a thematic analysis framework.

RESULTS

Three key themes were identified: ambiguity about the nature of osteoporosis, ambiguity about osteoporosis prevention and reluctance to take AOM and calcium.

CONCLUSION

Ambiguity associated with risk and prevention may provide women with a false sense of security that they are adequately acting to prevent the disease. Underestimation of their risk of osteoporosis and fracture as well as reluctance associated with AOM may be barriers to osteoporotic fracture prevention.

Menopause uncertainty: the impact of two educational interventions among women during menopausal transition and beyond

Introduction

Menopause is a natural part of women's lives, which is associated with physical and mental changes and can lead to uncertainty and consequent undesirable effects in the lives of menopausal women. The present study was conducted to compare the impact of multimedia and booklet educational methods on the uncertainty about menopause during this transition period.

Materials and methods

In a cluster randomized trial 68 women aged 45-55 years were randomly allocated into two groups: multimedia and booklet. Data were collected using knowledge and uncertainty questionnaires about menopause in three stages, i.e. before intervention, immediately after intervention (two weeks later), and one month later. Repeated-measures analysis of variance (rANOVA) was used to compare knowledge and uncertainty scores between two groups for the duration of the study. Data were analysed using SPSS software and p values < 0.05 were considered as statistically significant.

Results

The results of the study indicated a high level of uncertainty in both groups before the implementation of the educational program. There was no significant difference between groups in terms of knowledge and uncertainty about menopause over time (p > 0.05). However, we found a significant increase in knowledge and a significant decrease in uncertainty scores in both groups (p < 0.001) after the interventions.

Conclusions

Although the findings of this study did not show a significant difference between the effect of multimedia and booklet educational methods in postmenopausal women, the high level of uncertainty of women before intervention and its significant reduction after the implementation of the educational programs indicated the importance of education throughout this period.

Direct and indirect healthcare costs of lung cancer CT screening in Denmark: a registry study

INTRODUCTION

A study based on the Danish Randomised Controlled Lung Cancer Screening Trial (DLCST) calculated the healthcare costs of lung cancer screening by comparing costs in an intervention group with a control group. Participants in both groups, however, experienced significantly increased negative psychosocial consequences after randomisation. Substantial participation bias has also been documented: The DLCST participants reported fewer negative psychosocial aspects and experienced better living conditions compared with the random sample.

OBJECTIVE

To comprehensively analyse the costs of lung cancer CT screening and to determine whether invitations to mass screening alter the utilisation of the healthcare system resulting in indirect costs. Healthcare utilisation and costs are analysed in the primary care sector (general practitioner psychologists, physiotherapists, other specialists, drugs) and the secondary care sector (emergency room contacts, outpatient visits, hospitalisation days, surgical procedures and non-surgical procedures).

DESIGN

To account for bias in the original trial, the costs and utilisation of healthcare by participants in DLCST were compared with a new reference group, selected in the period from randomisation (2004-2006) until 2014.

SETTING

Four Danish national registers.

PARTICIPANTS

DLCST included 4104 current or former heavy smokers, randomly assigned to the CT group or the control group. The new reference group comprised a random sample of 535 current or former heavy smokers in the general Danish population who were never invited to participate in a cancer screening test.

MAIN OUTCOME MEASURES

Total healthcare costs including costs and utilisation of healthcare in both the primary and the secondary care sector.

RESULTS

Compared with the reference group, the participants in both the CT group (offered annual CT screening, lung function test and smoking counselling) and the control group (offered annual lung function test and smoking counselling) had significantly increased total healthcare costs, calculated at 60% and 48% respectively. The increase in costs was caused by increased use of healthcare in both the primary and the secondary sectors.

CONCLUSION

CT screening leads to 60% increased total healthcare costs. Such increase would raise the expected annual healthcare cost per participant from EUR 2348 to EUR 3756. Cost analysis that only includes costs directly related to the CT scan and follow-up procedures most likely underestimates total costs. Our data show that the increased costs are not limited to the secondary sector.

TRIAL REGISTRATION NUMBER

NCT00496977.

Knowledge, beliefs, and concerns about bone health from a systematic review and metasynthesis of qualitative studies

Background

Patients with low bone density or osteoporosis need information for effective prevention or disease management, respectively. However, patients may not be getting enough information from their primary care providers or other sources. Inadequate disease information leaves patients ill-informed and creates misconceptions and unnecessary concerns about the disease.

Objective

We systematically reviewed and synthesized the available literature to determine patient knowledge, beliefs, and concerns about osteoporosis and identify potential gaps in knowledge.

Methods

A systematic search was conducted for full-text qualitative studies addressing understanding, literacy, and/or perceptions about osteoporosis and its management, using Medline, EMBASE, Web of Science, Cochrane Library, CINAHL, ERIC, PsychINFO, Psyc Behav Sci Collec, and PubMed, from inception through September 2016. Studies were selected by two reviewers, assessed for quality, and themes extracted using the Joanna Briggs Institute data extraction tool. Thematic analysis was used to identify themes and subthemes.

Results

Twenty-five studies with a total of 757 participants (including 105 men) were selected for analysis out of 1031 unique citations. Selected studies were from Australia, Canada, Denmark, Norway, the United Kingdom, and the United States. Four main themes emerged: inadequate knowledge, beliefs and misconceptions, concerns about osteoporosis, and lack of information from health care providers. Participants had inadequate knowledge about osteoporosis and were particularly uninformed about risk factors, causes, treatment, and prevention. Areas of concern for participants included diagnosis, medication side effects, and inadequate information from primary care providers.

Conclusion

Although there was general awareness of osteoporosis, many misconceptions and concerns were evident. Education on bone health needs to reinforce areas of knowledge and address deficits, misconceptions, and concerns.

Screening for Underlying Osteoporosis in Fragility Fracture Patients: The Patients Perspective

Background:

Early detection and treatment of osteoporosis are essential in preventing fractures and fracture-related morbidity and mortality. Fractures beget fractures and it is relevant and well-documented beneficial to target osteoporosis screening in patients already suffering a fracture. The associated increased number of patients being confronted with a potential diagnosis of osteoporosis makes it worth considering how this affects patients.

Objective:

The aim of this study was to explore fracture patients’ experiences when confronted with the option of being screened for osteoporosis as the underlying reason of their fracture.

Methods:

In a phenomenological hermeneutic framework, semi-structured interviews were performed in 15 fragiligty fracture patients being offered screening for osteoporosis. Analysis inspired by Ricoeur consisting of naive reading, structural analysis, and critical analysis and discussion was applied.

Results:

Fracture patients were condemned to make a choice when confronted with the possibility of the early detection of osteoporosis. Many questions regarding prevention of new fractures and prospects in the case of a positive test result were raised. The major themes were related to the consequences of knowing what might be hidden in the bones, and the responsibility to prevent illness.

Conclusion:

The confrontation with the potential risk of osteoporosis provokes fear and worry in patients about lived daily life and anxiety about being treated as a sick person, but in return, it motivates patients to adopt a bone-healthy lifestyle. In general, patients prefer to be given knowledge of their bone health status over not knowing, and being able to seek further information on the condition facing them.

Left in limbo - Experiences and needs among postmenopausal women newly diagnosed with osteoporosis without preceding osteoporotic fractures: A qualitative study

Introduction Despite the fact that the first osteoporotic fracture is preventable, osteoporosis is still a major health challenge. The disease is highly prevalent among postmenopausal women. However little is known about how to meet and support women, when they are diagnosed with osteoporosis without preceding fractures. Therefore this study aims at gaining a deeper understanding of how women experience being diagnosed. Furthermore to describe and identify their needs, which should be met in future healthcare services. Methods We conducted a phenomenological qualitative study. We included 17 women aged 52-65 and collected data through semi-structured interviews. We analysed data following Giorgi's methodology. Findings Needs among the women were classified into three main themes: (1) needs of targeted and tailored information about osteoporosis, (2) needs of being prepared for GP visit to participate in treatment decision-making and (3) needs of being able to take care of bone health. Conclusion and implications In general the women experienced as been left 'in limbo', and they requested targeted and tailored information about osteoporosis. In particular, they want information about dual-energy X-ray absorptiometry (DXA) scan results and treatment options in advance of the GP visit. This will help them in being prepared and able to participate in treatment decisions. They ask for support in self-management of the disease with less focus on disease and risk of fracture. Instead, they demand more attention on the benefits of detecting early stage osteoporosis. The study highlights the call for new approaches to postmenopausal women newly diagnosed with osteoporosis without preceding fractures.

Qualitative Insights from the Osteoporosis Research: A Narrative Review of the Literature

Purpose. Much of the research on osteoporosis has been generated quantitatively. However, the qualitative osteoporosis literature provides valuable information on patient and clinician experiences and perspectives, informing the design and implementation of health research and healthcare services. To identify knowledge gaps and inform the design of future qualitative research, a narrative review was conducted to consolidate and synthesize the existing insights available within the qualitative osteoporosis research. Methods. Search terms reflecting the domains of osteoporosis and qualitative research were entered into the Scopus database to generate a comprehensive survey of qualitative research in the area of osteoporosis. Articles were thematically analysed and the results are presented in the form of a narrative review. Results. Forty-four articles were included in the narrative review. Qualitative research in the field of osteoporosis research can be summarized by 3 thematic areas: the meaning of osteoporosis for patients and the public, the lived experience of an osteoporosis diagnosis, and the programmatic approach to osteoporosis prevention and treatment. Conclusions. Qualitative studies provide clinically valuable insights in how osteoporosis is conceptualized and managed and programmatic aspects of osteoporosis treatment. The findings of this narrative review suggest the need for balance between presenting osteoporosis as a serious health condition and producing unwarranted anxiety and inactivity so as to ensure the best possible outcomes for individuals with osteoporosis.

From resistance to rescue--patients' shifting attitudes to antihypertensives: a qualitative study

OBJECTIVE

The objective of this study was to gain a deeper knowledge and understanding of experiences of antihypertensive drug treatment.

DESIGN

Interview study.

SETTING

A primary health care centre in western Sweden.

METHOD

Qualitative interviews and analyses through systematic text condensation described by Malterud.

SUBJECTS

Ten informants in pharmacological treatment for high blood pressure (six men and four women).

MAIN OUTCOME MEASURE

Experiences of hypertension drug treatment.

RESULTS

The findings revealed a process starting with resistance to drug treatment related to lack of control, side effects, and unwanted awareness of impaired health. These negative feelings then changed into a positive desire for lifestyle changes caused by a fear of cardiovascular disease which in turn changed the attitude towards drugs into seeing them as a rescue remedy and something normal and this then evoked health care trust.

CONCLUSION

Despite initial resistance to treatment, the experience of antihypertensive drug treatment became more positive with time. Confidence in the health care system is important for adherence to treatment. General practitioners have a key role in this regard.

Women's experiences of their osteoporosis diagnosis at the time of diagnosis and 6 months later: a phenomenological hermeneutic study

This paper describes a phenomenological hermeneutic study of experiences of women who were recently diagnosed with osteoporosis. The research objective was to investigate women's experiences of living with osteoporosis during the first 6 months after diagnosis when treatment was first prescribed. Fifteen women were included in the study. The inclusion criteria were a DXA scan at one of the two hospitals showing a T-score below −2.5 (lower back or hip), age 65 years or older; no previous known osteoporotic fracture; at least one of the known risk factors for osteoporosis; and prescription of anti-osteoporotic treatment. Exclusion criteria were previous diagnosis of osteoporosis or previous treatment with anti-osteoporotic medication. Data were collected through in-depth interviews shortly after diagnosis and 6 months later. The performed analyses were inspired by Paul Ricoeur's theory of interpretation of texts comprising three levels: naïve reading, structural analysis, and critical interpretation and discussion. Three key themes emerged: 1) being diagnosed, 2) being prescribed medical treatment, and 3) being on the path of learning to live with osteoporosis. The findings suggest a need for improved support for the patients to gain understanding of their diagnosis and the risk of osteoporotic fracture as well as to learn to live with osteoporosis. The study highlights new health promotion areas for targeting interventions at newly diagnosed patients, helping them accept and interpret the diagnosis, and the medical treatment.

Presenting the improved possibility for staying well might be better than talking about change in risk: use of the non-occurrence probability increase (NOPI)

OBJECTIVE

Talking about risk with patients is problematic since the individual's risk is not addressed and is usually very low. This study aimed to see how fact presentation influenced the decision-making process for general practitioners concerning treatment for the prevention of cardiovascular disease. Rather than looking at the risk of becoming ill, often presented as high figures of relative risk reduction (RRR), it could be useful to present the probability of staying well, i.e. from the concept of non-occurrence probability (NOP) and non-occurrence probability increase (NOPI)--simply a single measure of change in NOP.

DESIGN

General practitioners (GPs) had personal response keypads to answer two questions, presented differently, concerning whether they would allow themselves to be treated or not be treated for the risk of cardiovascular death.

SETTING AND SUBJECTS

Five audiences consisting of general practitioners attending lectures.

RESULTS

When the question was presented as RRR, 68% and 86%, respectively, of the physicians responded that they would take the decision to treat. When presented as the concept of NOPI the figures were reduced to 18% and 16%, respectively (p < 10-6).

IMPLICATIONS

Developing tools to explain treatment effect is crucial to enhancing health care quality. Since NOPI is one potential way of presenting prevention of risk we encourage future research to evaluate the NOPI concept compared with RRR and absolute risk reduction (ARR).

Handling knowledge on osteoporosis--a qualitative study

The aim of this qualitative study was to increase understanding of the importance of osteoporosis information and knowledge for patients' ways of handling osteoporosis in their everyday lives. Interviews were performed with 14 patients recruited from two English university hospitals and 12 patients from a Danish university hospital. Critical psychology was used as a theoretical framework for the data analysis, which aimed at shedding light on patients' ways of conducting everyday life with osteoporosis. The themes that emerged from the analysis showed that life conditions influenced the way in which risk, pain and osteoporosis were handled. Everyday life was also influenced by patients' attitude to treatment. The patients who were experiencing emotional difficulties in handling osteoporosis were not those suffering from severe osteoporosis and fractures. Approaches to living with knowledge of future fracture risk varied according to the individual patient's resourcefulness and experiences.

Breast cancer screening: ''reassuring'' the worried well?

BACKGROUND

One of the suggested benefits of cancer screening is the peace of mind and reassurance experienced by those women who are given negative results. The aim of the present study was to investigate whether there was a difference in the expression of psychosocial aspects in a population of women offered screening compared to a population of women not offered screening for breast cancer.

METHODS

One thousand women, aged 50-69 years, were randomly drawn from the Danish Civil Registration System to receive part I of the questionnaire Consequences of Screening in Breast Cancer (COS-BC1): the sample consisted of 500 women living in a geographical area where screening mammography had been offered for more than 10 years and 500 women living in an area where the public health authorities had never invited women to breast cancer screening.

RESULTS

A total of 759 women returned the questionnaire. Those living in areas where screening was not offered reported more negative psychosocial aspects compared to women living in areas where screening was offered.

CONCLUSIONS

The results indicate that women tend to perceive breast cancer screening as a reassuring preventive initiative. Alternatively, the results indicate that the lack of invitation to breast cancer screening may have a negative psychosocial impact.

Critiques of the risk concept--valid or not?

The increasing use of the risk concept in healthcare has caused concern among medical doctors, especially general practitioners (GPs). Critics have claimed that risk identification and intervention create unfounded anxiety, that the concept of risk is not useful at the individual patient level, that patients' risk concept is different from an epidemiological one, that resources are better spent elsewhere, or that commercial interests take advantage of risk information to promote sales. In this paper the authors discuss the concept of risk and address the critique. There is evidence that commercial interests promote risk interventions, that patients may misunderstand risk information, and that risk information can cause unnecessary anxiety. The authors have found no empirical data on the amount of time primary healthcare providers spend on risk interventions, and have not identified any valid arguments that risk information is not useful for the individual patient. Decision-making under uncertainty is a core element of medical practice, and GPs need to be suitably trained to inform patients such that they make good decisions when they are faced with uncertainty. The concept of risk is therefore useful for GPs, and in fact a key issue. It is concluded that risk critique should be based on sound theory and empirical data. Critics may do well in making clear distinctions between facts and value judgements.

Discourses on menopause — Part I: Menopause described in texts addressed to Danish women 1996—2004

To understand Danish women's very different ways of interpreting menopausal experiences and the way they construct meaning relating to menopause, it is necessary to include the context in which meaning is constructed as well as the background of cultural attitudes to menopause existing in the Danish society. Using documentary material, the aim of this article was to describe different discourses on menopause in Denmark that present themselves to menopausal women, and to discuss how these discourses may affect women's identity and constitute their scope of action. One hundred and thirty-two pieces of text under the heading or subject of `menopause' or `becoming a middle-aged woman', published from 1996 to 2004, were included. All material was addressed to Danish women, and consisted of booklets and informational material, articles from newspapers and magazines and popular science books. Seven different discourses on menopause were identified: the biomedical discourse; the `eternal youth' discourse; the health-promotion discourse; the consumer discourse; the alternative discourse; the feminist/ critical discourse; and the existential discourse. The biomedical discourse on menopause was found to be dominant, but was expanded or challenged by other discourses by offering different scopes of action and/or resting on different fundamental values. The discourses constructed and positioned individual women differently; thus, the women's position varied noticeably from one discourse to another. Depending on the discourse drawn upon, the woman's position could be that of a passive patient or that of an empowered woman, capable of making her own choices in relation to her health.

Perceived risk of osteoporosis: restricted physical activities? Qualitative interview study with women in their sixties

OBJECTIVE

To explore elderly women's physical activity in relation to their perception of the risk of osteoporosis.

DESIGN

Qualitative study using in-depth interviews.

SETTING

Informants were purposely selected from a Danish population-based, age-specific cohort study conducted in the county of Copenhagen with people born in 1936.

SUBJECTS

Women in their sixties.

RESULTS

Women who perceived a current risk of osteoporosis tended to reduce their physical activity in an attempt to reduce the risk of bone damage. This behaviour was related to the imagined fragility of the bones (the risk inside the body), and the actual situations (the risk outside the body), including places and activities. Knowledge of a reduced bone mass reinforced the women's uncertainty about what their bones could endure. Experiences managing physical activity without injury resulted in reinterpretations of their risk of bone fractures and increased physical activity.

CONCLUSIONS

Perceived risk of osteoporosis may lead to decreased physical activity and hence actually increase the risk. When informing individuals about health risk people's images and imaginations of the actual risk have to be acknowledged. When a bone scan is being considered, explicit advice encouraging physical activity - especially the weight-bearing kind - should be stressed.

Intermittent exposure to ethanol vapor affects osteoblast behaviour more severely than estrogen deficiency does in vitro study on rat osteoblasts

With rising rates of alcohol consumption acute and chronic damage from alcohol is expected to increase all over the world. Habitual excessive alcohol consumption is associated with pathological effects on bone. The aim of the present in vitro study was to investigate comparatively the proliferation and synthetic activity of osteoblasts (OB) isolated from the trabecular bone of rats previously exposed to 7-week intermittent exposure to ethanol vapor, sham-aged rats and long-term estrogen deficient rats. Cell proliferation (WST1) and synthesis of alkaline phosphatase (ALP), osteocalcin (OC), collagen I (CICP), transforming growth factor beta1 (TGF-beta1), interleukin-6 (IL-6), tumor necrosis factor alfa (TNFalpha) were measured at 3, 7 and 14 days of culture. Osteoblast proliferation rate and TGF-beta1, IL-6 and TNFalpha syntheses were significantly affected by alcohol exposure. Estrogen deficiency and alcohol consumption share many common pathophysiological mechanisms of damage to bone, but alcohol affects OB proliferation and TNFalpha synthesis significantly more than menopause does. Therefore, these in vitro data suggest that alcohol has even more deleterious effects on bone than estrogen deficiency does.

Menopausal women's positive experience of growing older

OBJECTIVE

This paper aims to describe menopausal women's positive experience of growing older and becoming middle-aged.

METHODS

Qualitative interviews with 24 menopausal women, selected on the basis of a questionnaire, covering a broad spectrum of Danish women in terms of experience of menopausal symptoms, treatment, contact with the health care system, and social background.

RESULTS

The women expressed varied and many-facetted views on ageing and clearly connected the fact that they were menopausal to the ageing process. All, except one, mentioned positive aspects of growing older: 1. they had become more experienced and competent; 2. they had gained more freedom; 3. they perceived possibilities of personal development that made them able to hold on to their own opinions and better speak their minds. The described positive effects were the result of having lived a long life, of good and evil, not of the menopause itself. The women also mentioned negative aspects: 1. negative expectations; 2. negative experiences. Positive aspects, often of psychological or existential nature, seemed to outweigh the negative experiences which were mostly related to bodily changes or losses.

CONCLUSION

This paper discusses the importance of avoiding unnecessary negative expectations of ageing and menopause and of focusing, instead, on the positive aspects of growing older. Health professionals should reconsider the necessity to talk about future risks with healthy women, and instead support the women's agenda when they try to cope with real-life problems.

Making the invisible body visible. Bone scans, osteoporosis and women's bodily experiences

The imaging technology of bone scans allows visualization of the bone structure, and determination of a numerical value. Both these are subjected to professional interpretation according to medical (epidemiological) evidence to estimate the individual's risk of fractures. But when bodily experience is challenged by a visual diagnosis, what effect does this have on an individual? The aim of this study was to explore women's bodily experiences after a bone scan and to analyse how the scan affects women's self-awareness, sense of bodily identity and integrity. We interviewed 16 Danish women (aged 61-63) who had had a bone scan for osteoporosis. The analysis was based on Merleau-Ponty's perspective of perception as an embodied experience in which bodily experience is understood to be the existential ground of culture and self. Women appeared to take the scan literally and planned their lives accordingly. They appeared to believe that the 'pictures' revealed some truth in themselves. The information supplied by the scan fostered a new body image. The women interpreted the scan result (a mark on a curve) to mean bodily fragility which they incorporated into their bodily perception. The embodiment of this new body image produced new symptom interpretations and preventive actions, including caution. The result of the bone scan and its cultural interpretation triggered a reconstruction of the body self as weak with reduced capacity. Women's interpretation of the bone scan reorganized their lived space and time, and their relations with others and themselves. Technological information about osteoporosis appeared to leave most affected women more uncertain and restricted rather than empowered. The findings raise some fundamental questions concerning the use of medical technology for the prevention of asymptomatic disorders.