Bone resorption and fracture across the menopausal transition: the Study of Women's Health Across the Nation

Update on the role of bone turnover markers in the diagnosis and management of osteoporosis: a consensus paper from The European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO), International Osteoporosis Foundation (IOF), and International Federation of Clinical Chemistry and Laboratory Medicine (IFCC)

PURPOSE

The International Osteoporosis Foundation (IOF) and the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) have proposed procollagen type I N propeptide (PINP) and β isomerized C-terminal telopeptide of type I collagen (β-CTX-I) as reference bone turnover markers (BTMs) for osteoporosis. This report examines the published literature since the 2011 IOF-IFCC position paper in order to determine the clinical potential of the reference BTMs and newer markers for the prediction of fracture risk and monitoring the treatment of osteoporosis.

METHODS

Evidence for the relationship between BTMs and subsequent fractures was gathered from prospective studies through literature review of the Medline database from years 2011 to May 2024. The impact of treatment on BTMs was also studied by examining publications in that period. Studies of the accuracy of BTMs in the assessment of bone turnover in the setting of advanced chronic kidney disease were also examined.

RESULTS

Increased BTM concentrations are associated with higher fracture risk in postmenopausal women. PINP and β-CTX-I measured in blood are associated with fracture risk but their interaction with other risk factors has not been sufficiently studied limiting their incorporation into fracture risk algorithms. Treatment-induced changes in PINP and β-CTX-I account for a substantial proportion of fracture risk reduction and are useful for improving adherence; they are recommended for inclusion in studies to examine adherence in individual patients. However, total PINP (tPINP) and β-CTX-I may be elevated in CKD due to renal retention. Bone alkaline phosphatase (BALP), intact PINP (iPINP), and tartrate resistant acid phosphatase 5b (TRACP5b) show the most promise in discriminating high and low turnover bone diseases in patients with advanced CKD and for predicting fracture risk, monitoring treatment response, and assessing the risk of treatment-related complications.

CONCLUSION

We re-affirm the use of serum/plasma tPINP and plasma β-CTX-I as reference BTMs with appropriate patient preparation and sample handling and measurement by standardized/harmonized assays in clinical studies to accumulate further data, and for monitoring treatment of osteoporosis in the setting of normal renal function in clinical practice. BALP and TRACP5b, measured by standardized assays, are recommended as reference BTMs for CKD-associated osteoporosis and should be included in observational and intervention studies to ascertain their utility for risk-evaluation, treatment initiation, and assessment of treatment response in CKD-associated osteoporosis.

Association between Body Composition Characteristics and Bone Mineral Density across Menopausal Transition Stages

OBJECTIVES

This cross-sectional study assessed the association between body composition characteristics and bone mineral density (BMD) across different menopausal transition stages.

METHODS

In total, 320 rural women aged 45-60 years were recruited. Body composition and BMD at different skeletal sites were evaluated by dual energy X-ray absorptiometry.

RESULTS

The BMD and bone mineral content of the entire hip, lumbar region, and left arm significantly decreased across most of the menopausal transition stages, which was confirmed by Tukey post hoc analysis. Multiple linear regression analysis revealed that BMD at the hip, lumbar region, and left arm were strongly and positively associated with weight. However, BMD was negatively associated with % total body fat (TBF) across all the four menopausal stages except for lumbar BMD at the late postmenopausal stage (Model 1). Lean mass was positively and significantly associated with BMD at all the skeletal sites evaluated except for some fluctuations in lumbar BMD (Model 2). Furthermore, waist circumference was significantly associated with BMD in the late postmenopausal stage (Model 3) .

CONCLUSIONS

Weight and lean mass are significant predictors of BMD during the menopausal transition and beyond. Furthermore, %TBF may be a negative indicator of BMD.

ED-71 Improves Bone Mass in Ovariectomized Rats by Inhibiting Osteoclastogenesis Through EphrinB2-EphB4-RANKL/OPG Axis

Purpose

Estrogen deficiency is the main reason of postmenopausal osteoporosis. Eldecalcitol (ED-71) is a new active vitamin D analogue clinically used in the treatment of postmenopausal osteoporosis. We aimed to investigate whether EphrinB2-EphB4 and RANKL/RANK/OPG signaling cooperate in mediating the process of osteoporosis by ED-71.

Methods

In vivo, the ovariectomized (OVX) rats were administered orally with 30 ng/kg ED-71 once a day for 8 weeks. HE staining, Masson staining and Immunofluorescence staining were used to evaluate bone mass, bone formation, osteoclastogenesis associated factors and the expression of EphrinB2, EphB4, RANKL and OPG. In vitro, H2O2 stimulation was used to simulate the cell environment in osteoporosis. Immunofluorescence, quantitative real time PCR (qRT-PCR), enzyme-linked immunosorbent assay (ELISA) and Western Blot were applied to detect the expression of EphrinB2, EphB4, RANKL and OPG. In osteoblasts, EphB4 was knocked down by EphB4 small-interfering RNA (siRNA) transfection. LY294002 (PI3K inhibitor) or ARQ092 (AKT inhibitor) was used to block PI3K/AKT pathway. An indirect co-culture system of osteoblasts and osteoclasts was established. The mRNA and protein expression of osteoclastogenes is associated factors were tested by qRT-PCR and Western Blot.

Results

ED-71 increased bone mass and decreased the number of osteoclasts in OVX rats. Moreover, ED-71 promoted the expression of EphrinB2, EphB4, and decreased the RANKL/OPG ratio in osteoblasts. Osteoclastogenesis was restrained when osteoclasts were indirectly co-cultured with ED-71-treated osteoblasts. After silencing of EphB4 expression in osteoblasts, ED-71 inhibited the expression of P-PI3K and P-AKT and increased the ratio of RANKL/OPG. This reversed the inhibitory effect of ED-71 on osteoclastogenes. Therefore, in ED-71-inhibited osteoclastogenes, EphB4 is a key factor affecting the secretion of RANKL and OPG by osteoblasts. EphB4 suppressed the RANKL/OPG ratio through activating PI3K/AKT signaling in osteoblasts.

Conclusion

ED-71 inhibits osteoclastogenesis through EphrinB2-EphB4-RANKL/OPG axis, improving bone mass in ovariectomized rats. PI3K/AKT pathway is involved this process.

Menopausal status, age at menopause and risk of all-cause mortality among Chinese women: findings from a 10-year prospective study

Introduction

Menopause characteristics (menopausal status and age at menopause) have been implicated in future health consequences. However, evidence of the impact on menopause on total mortality has been inconsistent. The present study aimed to investigate the associations of menopausal status and age at menopause with the risk of all-cause mortality in Chinese women.

Methods

We used prospective data from the China Kadoorie Biobank cohort study that recruited over 300 000 women aged 30-79 years from 10 regions across China between 2004 and 2008. All participants were prospectively followed up, with a median follow-up of 10.20 years. Cox proportional hazard regression was used to examine HRs with 95% CIs for all-cause mortality associated with menopausal status and age at menopause.

Results

Compared with premenopausal women, postmenopausal women were at higher risk of all-cause mortality with adjusted HR of 1.11 (95% CI 1.03 to 1.20). Among postmenopausal women, the HRs of total mortality were 1.25 (95% CI 1.14 to 1.36), 1.09 (95% CI 1.03 to 1.15), 0.98 (95% CI 0.94 to 1.02) and 0.97 (95% CI 0.91 to 1.04) for menopause at ages less than 40, 40-44, 50-53 and 54 years or older, respectively, relative to 45-49 years. In addition, for each 1-year increase in age at menopause was associated with a 1% decreased risk of death from all causes (95% CI 0.98 to 0.99).

Conclusions

Women with postmenopausal status had a higher risk of all-cause mortality than premenopausal women, particularly for ages at menopause younger than 45 years.

[Status Quo and Prospects of Research on Precision Nursing of Life-Cycle Health and Disease]

With the changing lifestyle and spectrum of diseases among Chinese people, the life-cycle approach to health has been given national strategic importance. Over the past decade, global nursing researchers have gradually started to pay more attention to the research related to precision nursing at different stages of the life cycle. Researchers have applied multi-omics to explore the pathogenesis and novel biomarkers of relevant symptoms in tumor patients or patients with chronic diseases in order to manage symptoms with better precision. However, systematic theories of precision nursing of life-cycle health and disease have not yet been developed, and the research field and its implications still need to be continuously expanded and innovated. In the nursing discipline, the advantages of interdisciplinary integration should be given full play and the precise and effective resolution of life-cycle health problems should be taken as its goal. Through accurately defining key quantitative objective indicators of nursing care, the nursing discipline will be able to achieve early identification of life-cycle health problems, clarify the occurrence and patterns of change in life-cycle health problems, and gain a better understanding of the regulatory mechanisms. Precise and effective nursing-related technologies and products of non-medication and non-surgery nature should be developed to achieve better precision in nursing interventions, thereby effectively promoting recovery from diseases and improving the overall health of the people.

The role of menopausal hormone therapy in the prevention and treatment of low bone density in perimenopausal and postmenopausal women

PURPOSE OF REVIEW

The purpose of this review is to summarize the evidence on the benefits of menopausal hormone therapy (MHT) for the maintenance of skeletal health, prevention of osteoporosis and related fractures in peri and postmenopausal women.

RECENT FINDINGS

We will review the impact of estrogen on skeletal health as well as the physiology of bone loss during the perimenopause and postmenopause. We will then elucidate the data that include estrogen alone and combination of MHT to demonstrate that in the absence of contraindication, MHT should be considered as an option for the maintenance of skeletal health both when concomitant menopausal symptoms are present and when not.

SUMMARY

It has been well established that estrogens maintain bone mineral density (BMD) and reduce fracture risk at all sites. However, the most extensively studied form of estrogen with established fracture prevention is oral doses of synthetic estrogens. Due to the reduced risk profile, lower doses of bioidentical oral or transdermal estrogens are often preferred in clinical practice. We will highlight the current data on improvement in BMD and fracture risk reduction, including differences in formulation, dose, and route of delivery, to support a provider in the clinical decision-making process.

Probiotics and Prebiotics: Any Role in Menopause-Related Diseases?

PURPOSE OF REVIEW

The aim of this review is to provide an overview of the menopause-related changes in microbiota and their role in the pathogenesis of menopause-related diseases. In addition, evidence on probiotic supplementation as a therapeutic strategy is discussed.

RECENT FINDINGS

The human microbiota is a complex community that lives in a mutualism relationship with the host. Menopause is associated with dysbiosis, and these changes in the composition of microbiota in different sites (gut, vaginal, and oral microbiota) might play a role in the pathogenesis of menopause-related diseases (i.e., osteoporosis, breast cancer, endometrial hyperplasia, periodontitis, and cardiometabolic diseases). The present review highlights the pivotal role of microbiota in postmenopausal women health, in particular it (a) may increase intestinal calcium absorption thus preventing osteoporosis, (b) is associated with reduced risk of breast cancer and type 1 endometrial hyperplasia, (c) reduces gingival inflammation and menopausal periodontitis, and (d) beneficially affects multiple cardiometabolic risk factors (i.e., obesity, inflammation, and blood glucose and lipid metabolism). However, whether oral probiotic supplementation might be used for the treatment of menopause-related dysbiosis requires further clarification.

The correlation of the fecal microbiome with the biochemical profile during menopause: a Brazilian cohort study

BACKGROUND

Hormonal, biochemical, and metabolic changes after menopause may alter the quality of life of women, leading to vasomotor, psychological, and genitourinary symptoms, and changes in their gut microbiota, which regulates estrogen levels through the estroboloma. Fecal samples were used to investigate the changes in the gut microbiota during aging and hormonal changes in women. A balanced gut microbiota has been associated with health or disease conditions and remains poorly understood after menopause. This study identified the fecal microbiota, and their association with biochemical and hormonal parameters of a cohort of women in the climacteric in the city of Ouro Preto-MG, Brazil.

METHODS

A total of 102 women aged 40 to 65 years old were recruited and distributed into three groups according to the STRAW criteria for reproductive stage: reproductive (n = 18), premenopausal (n = 26), and postmenopausal (n = 58). Blood samples were collected to measure their serum biochemical and hormone levels, and the participants answered a questionnaire. The gut microbiota was analyzed from fecal samples by qPCR using the genera Bifidobacterium, Bacteroides, Lactobacillus, and Clostridium.

RESULTS

The following parameters showed differences among the groups: total cholesterol, triglycerides, VLDL, ApoB, urea, calcium, uric acid, and alkaline phosphatase (p < 0.05). qPCR revealed the genus Clostridium to be the most abundant in all three groups. In the reproductive age group, the significant correlations were: Bacteroides with glucose (r = -0.573 p = 0.0129), and SDHEA (r = -0.583 p = 0.0111). For the premenopausal group, they were: Bifidobacteria with total cholesterol (r = 0.396 p = 0.0451), LDL (r = 0.393 p = 0.0468), ApoB (r = 0.411 p = 0.0368); Lactobacillus and calcium (r = 0.443 p = 0.0232), ALP (r = 0.543 p = 0.0041), LPa (r =-0.442 p = 0.02336); and Bacteroides and urea (r =-0.461 p = 0.0176). In the postmenopausal group, they were Bifidobacterium and ALP (r =-0.315 p = 0.0159), Lactobacillus and urea (r =-0.276 p = 0.0356), and Clostridium and beta estradiol (r =-0.355 p = 0.0062).

CONCLUSION

In conclusion, the hormonal and metabolic changes during menopause in the population studied were accompanied by a significant change in the fecal microbiota, especially of the genus Clostridium.

The Abundance of Trace Elements in Human Bone Relative to Bone Type and Bone Pathology

As the global population ages and the proportion of individuals afflicted with musculoskeletal disease spirals upward, there is an increasing interest in understanding and preventing bone-related diseases. Bone diseases, such as osteoporosis and osteoarthritis, are known to be influenced by a variety of factors including age, gender, nutrition, and genetics, but are also inherently linked to the human body's ability to produce biominerals of suitable quality. Because the crystal lattice structure and mineralogy of bone hydroxyapatite is surprisingly analogous to geological hydroxyapatite, trace element levels and exposure have long been proposed to influence the structure of biominerals as they do geological minerals (e.g., strontium substitution changes the crystal lattice of bone minerals, while toxic lead disrupt bone cellular processes leading to bone disease). Here, we explore the distribution of trace elements in human bones to evaluate the distribution of these elements with respect to bone type (cortical vs. trabecular) and bone disease (osteoarthritis vs. osteoporosis). We find higher concentrations of many metabolically active transition metals, as well as lead, in cortical bone compared to trabecular bone. When compared to patients who have osteoarthritis, and thus presumably normal bone minerals, osteoporosis patients have higher concentrations of scandium and chromium (Cr) in trabecular bone, and Cr and lead in cortical bone. Lower concentrations of barium and titanium are associated with osteoporotic trabecular bone. This survey is an exploratory cross-sectional geochemical examination of several trace element concentrations previously understudied in human bone minerals.

Effects of Combination Oral Contraceptives on Bone Mineral Density and Metabolism in Perimenopausal Korean Women

Objectives

Methods

Results

Conclusions

Fracture risk assessment in diabetes mellitus

Growing evidence suggests that diabetes mellitus is associated with an increased risk of fracture. Bone intrinsic factors (such as accumulation of glycation end products, low bone turnover, and bone microstructural changes) and extrinsic factors (such as hypoglycemia caused by treatment, diabetes peripheral neuropathy, muscle weakness, visual impairment, and some hypoglycemic agents affecting bone metabolism) probably contribute to damage of bone strength and the increased risk of fragility fracture. Traditionally, bone mineral density (BMD) measured by dual x-ray absorptiometry (DXA) is considered to be the gold standard for assessing osteoporosis. However, it cannot fully capture the changes in bone strength and often underestimates the risk of fracture in diabetes. The fracture risk assessment tool is easy to operate, giving it a certain edge in assessing fracture risk in diabetes. However, some parameters need to be regulated or replaced to improve the sensitivity of the tool. Trabecular bone score, a noninvasive tool, indirectly evaluates bone microstructure by analyzing the texture sparsity of trabecular bone, which is based on the pixel gray level of DXA. Trabecular bone score combined with BMD can effectively improve the prediction ability of fracture risk. Quantitative computed tomography is another noninvasive examination of bone microstructure. High-resolution peripheral quantitative computed tomography can measure volume bone mineral density. Quantitative computed tomography combined with microstructure finite element analysis can evaluate the mechanical properties of bones. Considering the invasive nature, the use of microindentation and histomorphometry is limited in clinical settings. Some studies found that the changes in bone turnover markers in diabetes might be associated with fracture risk, but further studies are needed to confirm this. This review focused on summarizing the current development of these assessment tools in diabetes so as to provide references for clinical practice. Moreover, these tools can reduce the occurrence of fragility fractures in diabetes through early detection and intervention.

Menopausal hormone therapy for the management of osteoporosis

Postmenopausal osteoporosis is a frequent clinical condition which affects nearly 1 in 3 women. Estrogen deficiency leads to rapid bone loss which is maximal within the first 2-3 years after the menopause transition and can be prevented by menopause hormone therapy (MHT). Not only, MHT prevents bone loss and the degradation of the bone microarchitecture but it significantly reduces the risk of fracture at all bone sites by 20-40%. It is the only anti-osteoporotic therapy that has a proven efficacy regardless of basal level of risk, even in low-risk women for fracture. Following the publication of the WHI results, use of MHT has considerably declined due to safety concerns which raise the question as to whether it might still be used in the prevention of osteoporosis. Over the last years, subsequent re-analyses of the WHI and further trials have challenged the initial conclusions of the WHI. It is now clearer that the individual benefit-risk balance of MHT is dependent on the individual risk profile in each woman as well as whether estrogen is opposed or unopposed, the type of estrogens and progestogens or doses and routes of administration. It must be also reminded that to date osteoporosis is a chronic disease that cannot be cured. The choice of the 1st treatment option should thus always be made in the context of a more comprehensive long-term strategy. This is particular true in early postmenopausal women found to be at low/moderate risk of fragility fracture over the first 10 years after menopause but who may have a much greater lifetime risk. In the absence of contraindication, use of MHT should be considered as a 1st option for the maintenance of bone health in those women where specific bone active medications are not warranted. Subsequent reassessment of the individual benefit-risk balance of MHT is thereafter recommended, with the possibility of switching to another osteoporosis treatment if the balance is not considered as favourable as at the beginning of the menopause for women still at high risk of fracture.

Findings from a feasibility study of estradiol for hypogonadal women with cystic fibrosis-related bone disease

Background

Advancements in therapies for patients with cystic fibrosis (CF) have decreased mortality, leading to increased prevalence of chronic complications including bone disease. CF-related bone disease (CFBD) is characterized by low bone mineral density (BMD) and fragility fractures. Estrogen deficiency increases bone resorption, resulting in decreased BMD that can be restored with estrogen replacement. Current CF guidelines recommend treating female hypogonadal patients with CFBD with estrogen replacement, but no prospective study has investigated the effects of estrogen supplementation on CFBD. Estrogen is known to modulate inflammatory markers and autoimmune diseases.

We proposed to test the hypothesis that estrogen status plays a critical role in optimizing bone health, modulating inflammation, preserving lung function, and maximizing quality of life in premenopausal women with CF.

Methods

We planned a randomized, placebo-controlled, investigator- and patient-blinded, pilot trial with two parallel arms. Eligible subjects were women with CF 18–50 years old with hypogonadism and low BMD who were not taking systemic glucocorticoids, had not had a prior transplant, and did not have contraindications to oral estradiol. Subjects would be block randomized to receive oral estradiol or placebo for 6 months. The primary outcome was feasibility metrics. Secondary outcomes included relative changes in estradiol, bone turnover markers, lung function, inflammatory markers, and quality of life metrics. The study was funded through departmental funds.

Results

Of 233 subjects screened, 86 subjects were women with CF 18–50 years old and none were eligible for participation. Most subjects were excluded due to absent DXA report (24%), normal BMD (22%), or use of systemic estrogen (16%). Due to difficulty recruiting the planned 52 subjects, the trial was closed for recruitment and no subjects were randomized.

Conclusion

This study was designed to investigate the feasibility of a safety and efficacy trial of estrogen therapy for women with CF. Unfortunately, due to eligibility criteria, the study was unable to recruit subjects. This feasibility study highlights the need for improved BMD screening in young women with CF. Future study designs may require the incorporation of a screening DXA as part of subject recruitment.

Trial registration

The study was registered on ClinicalTrials.gov (NCT03724955).

Faster Lumbar Spine Bone Loss in Midlife Predicts Subsequent Fracture Independent of Starting Bone Mineral Density

CONTEXT

Bone mineral density (BMD) decreases rapidly during menopause transition (MT), and continues to decline in postmenopause.

OBJECTIVE

This work aims to examine whether faster BMD loss during the combined MT and early postmenopause is associated with incident fracture, independent of starting BMD, before the MT.

METHODS

The Study of Women's Health Across the Nation, a longitudinal cohort study, included 451 women, initially premenopausal or early perimenopausal, and those transitioned to postmenopause. Main outcome measures included time to first fracture after early postmenopause.

RESULTS

In Cox proportional hazards regression, adjusted for age, body mass index, race/ethnicity, study site, use of vitamin D and calcium supplements, and use of bone-detrimental or -beneficial medications, each SD decrement in lumbar spine (LS) BMD before MT was associated with a 78% increment in fracture hazard (P = .007). Each 1% per year faster decline in LS BMD was related to a 56% greater fracture hazard (P = .04). Rate of LS BMD decline predicted future fracture, independent of starting BMD. Women with a starting LS BMD below the sample median, and an LS BMD decline rate faster than the sample median had a 2.7-fold greater fracture hazard (P = .03). At the femoral neck, neither starting BMD nor rate of BMD decline was associated with fracture.

CONCLUSION

At the LS, starting BMD before the MT and rate of decline during the combined MT and early postmenopause are independent risk factors for fracture. Women with a below-median starting LS BMD and a faster-than-median LS BMD decline have the greatest fracture risk.

[Menopause, menopause hormone therapy and osteoporosis. Postmenopausal women management: CNGOF and GEMVi clinical practice guidelines]

Postmenopausal osteoporosis is a frequent clinical condition, which affects nearly 1 in 3 women. Estrogen deficiency leads to rapid bone loss, which is maximal within the first years after the menopause transition and can be prevented by menopause hormone therapy (MHT). Assessment of the individual risk of osteoporosis is primarily based on the measurement of bone mineral density (BMD) at the spine and femur by DXA. Clinical risk factors (CRFs) for fractures taken either alone or in combination in the FRAX score were shown not to reliably predict fractures and/or osteoporosis (as defined by a T-score<-2.5) in early postmenopausal women. If DXA measurement is indicated in all women with CRFs for fractures, it can be proposed on a case-by-case basis, when knowledge of BMD is likely to condition the management of women at the beginning of menopause, particularly the benefit-risk balance of MHT. MHT prevents both bone loss and degradation of the bone microarchitecture in early menopause. It significantly reduces the risk of fracture at all bone sites by 20 to 40% regardless of basal level of risk with an estrogen-dependent dose-effect. Given the inter-individual variability in bone response, individual monitoring of the bone effect of MHT is warranted when prescribed for the prevention of osteoporosis. This monitoring is based on repeated measurement of lumbar and femoral BMD (on the same DXA measurement system) after 2years of MHT, the response criterion being no significant bone loss. Discontinuation of treatment is associated with a resumption of transient bone loss although there is a large variability in the rate of bone loss among women. Basically, there is a return to the level of fracture risk comparable to that of in untreated woman of the same age within 2 to 5years. Therefore, when MHT is prescribed for the prevention of osteoporosis in women with an increased risk at the beginning of menopause, measurement of BMD is recommended when MHT is stopped in order to consider further management of the risk of fracture whenever necessary (with possibly another anti-osteoporotic treatment).

Critical Role of Estrogens on Bone Homeostasis in Both Male and Female: From Physiology to Medical Implications

Bone is a multi-skilled tissue, protecting major organs, regulating calcium phosphate balance and producing hormones. Its development during childhood determines height and stature as well as resistance against fracture in advanced age. Estrogens are key regulators of bone turnover in both females and males. These hormones play a major role in longitudinal and width growth throughout puberty as well as in the regulation of bone turnover. In women, estrogen deficiency is one of the major causes of postmenopausal osteoporosis. In this review, we will summarize the main clinical and experimental studies reporting the effects of estrogens not only in females but also in males, during different life stages. Effects of estrogens on bone involve either Estrogen Receptor (ER)α or ERβ depending on the type of bone (femur, vertebrae, tibia, mandible), the compartment (trabecular or cortical), cell types involved (osteoclasts, osteoblasts and osteocytes) and sex. Finally, we will discuss new ongoing strategies to increase the benefit/risk ratio of the hormonal treatment of menopause.

Age of Natural Menopause Among Jordanian Women and Factors Related to Premature and Early Menopause

OBJECTIVE

The aim of this study was to assess factors related to the onset of premature/early natural menopause among Jordanian women.

METHODS

A cross-sectional study was conducted in early 2016. Subjects were enrolled based on random drop-off technique to the Obstetrics and Gynecology clinics at the Jordan University Hospital. Women 18 years of age and above were initially eligible to enroll, and women who had surgically induced menopause or specific disease were excluded from the analysis. Relevant data were collected using a questionnaire that included 30 questions. The following variables were collected: socio-demographic, body mass index, chronic conditions, diseases, reproductive characteristics, and health status. Hormone indicators of menopause were tested by measuring estrogen (E2) and follicle-stimulating hormone (FSH) levels. Age at natural menopause (ANM) was self-reported retrospectively and considered an independent variable against BMI, smoking, hormone therapy, and concomitant diseases. Association analysis and multinomial logistic regression were used to examine the associated factors of ANM with adjusted odds ratios (ORs), and their 95% confidence intervals (CIs) were reported.

RESULTS

A total of 409 women were included in the analysis, aged between 20-75 years. The mean ANM in our sample was 48.5±5.0, with 2.7% of the women experienced premature menopause (ANM <40) and 7.8% early menopause (ANM 40-44). Within the menopause women (n=242), the percentage of women who had premature menopause was 4.5%, 13.6% with early menopause, and 21.1% with late menopause (ANM >52). Smoking was the major risk factor for premature/early menopausal age among Jordanian women with an OR of 2.46 (95% CI: 1.08-5.59, p<0.05). On the other hand, women with occasional arthritis symptoms and diseases such as hypertension, diabetes, dyslipidemia, and their combination were associated with average (45-52 years) or late menopause (>52 years).

CONCLUSION

Smoking is the main contributor of premature/early menopause in Jordanian women. Increased awareness and public health policy about the adverse effects of smoking on women's reproductive health are needed.

Premenopausal and early postmenopausal trabecular bone score (TBS) and fracture risk: Study of Women's Health Across the Nation (SWAN)

BACKGROUND

Evidence that trabecular bone score (TBS), an index of bone microstructure, is a risk factor for future fracture comes mainly from studies of late postmenopausal women.

OBJECTIVE

To discern whether premenopausal TBS or early postmenopausal TBS predict fracture.

DESIGN

A 22-year, prospective analysis from the Study of Women's Health Across Nation.

SETTING

Community-based cohort.

PARTICIPANTS

272 Black, 174 Japanese, and 364 White women.

MAIN OUTCOME MEASURES

Incident fractures: 292 in premenopausal sample and 141 in early postmenopausal sample.

RESULTS

Separate Cox proportional hazard regressions modeled time to incident fracture as a function of TBS measured during premenopause or early postmenopause. Models were initially adjusted for age, race/ethnicity, SWAN clinical site, body mass index, use of calcium, vitamin D, bone beneficial or bone adverse medication. Next, we added lumbar spine (LS) or femoral neck (FN) bone mineral density (BMD) and, finally, history of prior fracture, to the models. For each standard deviation decrement in premenopausal TBS, fracture hazard was elevated by 17% (relative hazard [RH] 1.17 [95% CI, 1.02-1.35]); after adjusting for LS or FN BMD, the relation between premenopausal TBS and fracture was no longer statistically significant. There was a similar-magnitude, marginally statistically significant, association between early postmenopausal TBS and fracture, unadjusted for BMD (RH 1.15 [0.95-1.39]).

CONCLUSIONS

Variation in premenopausal TBS is related to fracture risk, but this association is not independent of BMD.

The challenge of long-term adherence: The role of bone turnover markers in monitoring bisphosphonate treatment of osteoporosis

Oral Bisphosphonates (BPs) are the mainstay of osteoporotic treatment, however long-term adherence remains a challenge, primarily owing to the chronic character of the disease and the regimen complexity. Poor compliance has been shown to have a clear link to fracture risk. The role of bone turnover markers (BTMs) as a tool to ascertain adherence and response to therapy is supported by their rapid response to treatment; a decrease in values is witnessed within days or weeks of commencing treatment. A greater reduction of serum CTX and NTX is evidenced with alendronate and ibandronate compared to risedronate. A change in bone formation BTMs appears to be related to vertebral fracture risk reduction, whereas no significant relationship is evident for hip and non-vertebral fractures. The utility of BTMs as an adjunct for monitoring withdrawal of treatment with oral BP has also been suggested. Finally, studies evaluating BTMs as an intervention, failed to demonstrate any effect on adherence. This review explores the challenge of long-term adherence with bisphosphonates and provides an analytic framework with respect to the role of BTMs in monitoring bisphosphonate treatment, adherence and the offset of treatment effect.

The Association between Fast Increase in Bone Turnover During the Menopause Transition and Subsequent Fracture

CONTEXT

Bone turnover increases rapidly during the menopause transition (MT) and plateaus above premenopausal levels in early postmenopause. It is uncertain whether higher bone turnover is associated with fracture in midlife women with near-normal bone mineral density (BMD).

OBJECTIVE

Examine whether faster increases in bone turnover during the MT (2 years before to 2 years after the final menstrual period [FMP]), and greater bone turnover during early postmenopause (≥2 years after the FMP) are risk factors for subsequent fracture, accounting for BMD.

DESIGN AND SETTING

The Study of Women's Health Across the Nation, a longitudinal cohort study of the MT.

PARTICIPANTS

A total of 484 women (initially pre- or early perimenopausal, who transitioned to postmenopause) with bone turnover (urine collagen type I N-telopeptide), BMD, and fracture data.

MAIN OUTCOME MEASURE

Incident fracture after the MT.

RESULTS

Adjusting for age, race/ethnicity, fracture before the MT, cigarette use, body mass index, and study site in Cox proportional hazards regression, each SD increment in the rate of increase in bone turnover during the MT was associated with 24% greater hazard of incident fracture in postmenopause (P = .008). Accounting for the same covariates, each SD increment in bone turnover during early postmenopause was associated with a 27% greater hazard of fracture (P = .01). Associations remained significant after controlling for MT rate of change and early postmenopausal level of BMD.

CONCLUSION

Faster increases in bone turnover during the MT and greater bone turnover in early postmenopause forecast future fractures.

A bone resorption marker as predictor of rate of change in femoral neck size and strength during the menopause transition

We assessed whether a bone resorption marker, measured early in the menopause transition (MT), is associated with change in femoral neck size and strength during the MT. Higher levels of bone resorption were associated with slower increases in femoral neck size and faster decreases in femoral neck strength.

PURPOSE

Composite indices of the femoral neck's ability to withstand compressive (compression strength index, CSI) and impact (impact strength index, ISI) forces integrate DXA-derived femoral neck width (FNW), bone mineral density (BMD), and body size. During the menopause transition (MT), FNW increases, and CSI and ISI decrease. This proof-of-concept study assessed whether a bone resorption marker, measured early in the MT, is associated with rates of change in FNW, CSI and ISI during the MT.

METHODS

We used previously collected bone resorption marker (urine collagen type I N-telopeptide [U-NTX]) and femoral neck strength data from 696 participants from the Study of Women's Health Across the Nation (SWAN), a longitudinal study of the MT in a multi-ethnic cohort of community-dwelling women.

RESULTS

Adjusted for MT stage (pre- vs. early perimenopause), age, body mass index (BMI), bone resorption marker collection time, and study site in multivariable linear regression, bone resorption in pre- and early perimenopause was not associated with transmenopausal decline rate in femoral neck BMD. However, each standard deviation (SD) increase in bone resorption level was associated with 0.2% per year slower increase in FNW (p = 0.03), and 0.3% per year faster declines in CSI (p = 0.02) and ISI (p = 0.01). When restricted to women in early perimenopause, the associations of bone resorption with change in FNW, CSI, and ISI were similar to those in the full sample.

CONCLUSIONS

Measuring a bone resorption marker in pre- and early perimenopause may identify women who will experience the greatest loss in bone strength during the MT.

Trabecular bone score and bone remodelling markers identify perimenopausal women at high risk of bone loss

CONTEXT

Bone loss is accelerated in the late perimenopause and early menopause. The date of the final menstrual period cannot be stated until 1 year after it has ended, and at that time, most of the rapid bone loss phase will have elapsed. Therefore, early detection of bone loss is crucial.

OBJECTIVES

To evaluate the utility of bone turnover markers (BTM) to identify the women who are more likely to lose more bone mass during the transition to menopause and quantify the loss of bone quality measured by trabecular bone score (TBS).

DESIGN, PATIENTS AND SETTING

Sixty-four healthy premenopausal women, mean age between 44 and 57 years old, were enrolled and followed up for 5 years. Clinical features, lifestyle, bone densitometry, TBS and BTM (CTX, P1NP and osteocalcin) were measured at baseline and follow-up.

RESULTS

All women had densitometrically normal bone at the time of enrolment. After 5 years, 48.4% had normal bone mineral density, 45.8% low bone mass and 6.3% osteoporosis. Women with osteopenia/osteoporosis at follow-up had higher CTX and P1NP at enrolment compared with women with densitometrically normal bone. The areas under the curve for the prediction of low bone mass or osteoporosis were 0.69 (P = 0.011) for P1NP, 0.69 for CTX (P = 0.013) and 0.77 (P 0.001) for OC. A significant correlation was found between P1NP increase after 5 years and the decrease in lumbar bone density (r = -0.383, P = 0.002). At baseline, 7 (10.9%) women had deteriorated microarchitecture (TBS < 1.3). Three of these women developed osteoporosis and four osteopenia at follow-up.

CONCLUSIONS

Women with higher P1NP and CTX and lower TBS at baseline had lower BMD in the transition to menopause suggesting these novel tools could have potential use in identifying women at high risk of rapidly decreasing bone mass.

Bone Health During the Menopause Transition and Beyond

The menopause transition is a critical period for bone health, with rapid losses in bone mass and strength occurring in a 3-year window bracketing the date of the final menstrual period. Declines in bone mass are accompanied by deleterious changes in bone macrostructure and microarchitecture, which may be captured by changes in composite strength indices and indices of trabecular thickness and connectivity. The onset of the rapid bone loss phase is preceded by changes in sex steroid hormones and increases in markers of bone resorption, measurements of which may be clinically useful in predicting the onset of the rapid loss phase and in identifying the women who will lose the most bone strength over the menopause transition.

Weight loss and bone mineral density in obese adults: a longitudinal analysis of the influence of very low energy diets

Background

The long-term effect of weight reduction on skeletal health is not well understood. The purpose of this study was to examine the impact of an intensive medical weight loss intervention using very low energy diet (VLED) (~ 800 cal/day) that result in significant changes in body weight, on total body bone mineral density (BMD) over 2 years.

Methods

We examined the impact of VLED-induced weight loss on BMD and FFM (Fat-free Mass) after 3–6 months and again while in weight maintenance at 2 years in 49 subjects. The effects of absolute and relative rate of weight reduction assessed by change in weight in kilograms were assessed using general linear modeling, with baseline BMD (or FFM) as a covariate, and age, sex and changes in body weight as primary model predictors.

Results

At the end of 2 years, the average weight loss was greater for men (weight: 23.51 ± 12.5 kg) than women (weight: 16.8 ± 19.2 kg) and BMD loss was greater among women (0.03 ± 0.04 g/cm² vs 0.01 ± 0.04 g/cm²) (all p < 0.05). After adjusting for baseline BMD, age, and sex, there was a small but significant association between total weight loss and 2-year BMD (β = − 0.001 g/cm²; p = 0.01). Similarly, there was a significant independent association between total weight loss and 2-year FFM (β = − 116.5 g; p < 0.01).

Conclusions

Despite significant weight loss with VLED, there was only a small loss is BMD.

Bone turnover markers after the menopause: T-score approach

Bone turnover increases at the menopause and is associated with accelerated bone loss. However, it is not known to what extent there is an imbalance between the processes of bone resorption and bone formation, nor whether it is the rate of bone turnover or the bone balance that is most closely associated with the rate of bone loss. We studied 657 healthy women ages 20 to 79 from five European cities (the OPUS Study) and divided them into two premenopausal age groups, 20 to 29 (n=129), 30 to 39years (n=183), and three postmenopausal groups 1 to 10years (n=91), 11 to 20years (n=131) and 21+ years since menopause (n=123). We measured collagen type I C-telopeptide (CTX, a marker of bone resorption) and procollagen I N-propeptide (PINP, a marker of bone formation). We used these two markers to calculate the overall bone turnover and the difference between bone formation and resorption (bone balance) using the results from the women ages 30 to 39years to calculate a standardised score (T-score). We found that the CTX and PINP levels were higher in the women ages 20 to 29 and in the women in the three menopausal groups as compared to women ages 30 to 39years (p<0.001). For example, the CTX and PINP levels were 80 and 33% higher in women 1 to 10years since menopause as compared to women ages 30 to 39years. In this group of postmenopausal women, the bone turnover expressed as a T-score was 0.72 (0.57 to 0.88, 95%CI) and the bone balance was -0.37 (-0.59 to -0.16). There was greater rate of bone loss from the total hip in all the groups of women after the menopause compared to women before the menopause. We conclude that the bone loss after the menopause is associated with both an increase in bone turnover and a negative bone balance and that bone loss was most clearly associated with overall bone turnover.

Age at natural menopause and associated factors in adult women: Findings from the China Kadoorie Biobank study in Zhejiang rural area

Objectives

To investigate the factors associated with age at natural menopause in a large population of Chinese adult women.

Methods

This cross-sectional study was part of the baseline survey of China Kadoorie Biobank in Zhejiang Province. A total of 17,076 postmenopausal women were included in the present study. Relevant data of socio-demographic, lifestyle, dietary and reproductive characteristics were collected. Multinomial logistic regression models were used to examine the associated factors of age at natural menopause with adjusted odds ratios (ORs) and their 95% confidence intervals (CIs) were reported.

Results

The mean age at natural menopause was 48.94 years, with 3.40% of the women experienced premature menopause and 6.75% early menopause. Younger age, higher education, consumption of meat (1–3 days per week) and increased parity were associated with late menopause. Current smoking, underweight, higher physical activity, consumption of sea food (1–3 days per week), fresh eggs (≥4 days per week), fresh fruits (≥1 day per week), taking vitamins, experiencing severe food shortage, earlier age at menarche and older age at first birth were associated with earlier age at natural menopause.

Conclusions

These results suggest that certain factors involved with socio-demographic, lifestyle, dietary and reproductive characteristics are related to the age at natural menopause in Chinese women.

Association of Urinary Citrate With Acid-Base Status, Bone Resorption, and Calcium Excretion in Older Men and Women

CONTEXT

Elevated urine net acid excretion (NAE), indicative of subclinical metabolic acidosis, has been associated with higher bone turnover. Urine citrate, which is a common clinical measure, changes in response to acid-base status but its association with bone turnover is uncertain.

OBJECTIVE

We evaluated the association between change in urine citrate and change in bone turnover and calcium excretion.

DESIGN, INTERVENTION, AND PARTICIPANTS

A total of 233 healthy men and women ≥60 years old were randomly assigned to 1.0 mmol/kg/d potassium bicarbonate (KHCO3), 1.5 mmol/kg/d KHCO3, or placebo for 84 days.

OUTCOME MEASURES

Urine citrate, NAE, N-telopeptide of collagen type-I (NTX), calcium excretion, and serum amino-terminal propeptide of type 1 procollagen (P1NP) were measured before and after intervention.

RESULTS

Urine citrate increased dose dependently after KHCO3 supplementation (P trend < 0.001). The urine citrate change was significantly inversely associated with P1NP change (P = 0.021) but not with change in NTX (P = 0.051) or calcium excretion (P = 0.652). The NAE change was positively associated with change in NTX and calcium excretion (P ≤ 0.003) but not with change in P1NP (P = 0.051). When the urine citrate change and NAE change were included in the same model, the urine citrate change was not associated with change in NTX, calcium excretion, or serum P1NP (P ≥ 0.086), whereas change in NAE remained associated with change in NTX and calcium excretion (P ≤ 0.003).

CONCLUSION

Urine citrate may not be a suitable alternative to NAE when assessing acid-base status in relation to bone turnover in older adults.

Age at natural menopause and risk of diabetes in adult women: Findings from the China Kadoorie Biobank study in the Zhejiang area

Aims/Introduction

There has been considerable professional debate on the association between age at menopause and diabetes risk, while the findings are controversial. The present study explored the association between late menopause and the prevalence of diabetes in the Chinese population.

Material and Methods

The data were part of the baseline survey of China Kadoorie Biobank from Zhejiang Province. A total of 17,076 postmenopausal women were included in the present study. Logistic regression models were used to calculate the adjusted odds ratios and their 95% confidence intervals.

Results

Of the participating women, 1,288 (7.54%) had type 2 diabetes. In comparison with those with menopause at 46–52 years, women with menopause at a later age (≥53 years) were 1.21‐fold (95% confidence interval 1.03–1.43) more likely to have diabetes.

Conclusions

The present findings suggested that later age at menopause was associated with an increased prevalence of diabetes.

Bone Turnover Markers: Use in Fracture Prediction

Bone turnover markers (BTMs) provide us with a noninvasive approach to studying bone turnover and they can be measured easily and with good precision, especially using automated analyzers. BTMs increase at menopause, and these higher levels are associated with more rapid bone loss. In some but not all studies, they are also associated with greater risk of fracture. However, the evidence base for use as predictors of fracture is not robust, and so BTMs have not been included in fracture prediction models. Further research is needed, and this might include (1) use of reference analytes such as C-telopeptide of type I collagen and procollagen I N-propeptide, measured using automated analyzers in subjects in the fasting state on more than 1 occasion; (2) careful collection of vertebral fractures, which would be the primary endpoint; and (3) common approach to statistical analyses with results expressed as hazard ratio per standard deviation of increase in BTM. We believe that by improving our approach to studying the relationship between BTMs and fracture risk, any association will become clearer and that in the future we might then be able to include BTMs in our fracture prediction models.

Preliminary investigation of urine N-telopeptide concentration as a biomarker of bone resorption in dogs receiving glucocorticoids

OBJECTIVES

The influence of glucocorticoid therapy on bone resorption in dogs using a urine N-telopeptide assay was investigated.

MATERIALS AND METHODS

Thirty-one dogs receiving oral glucocorticoids and 31 age-matched healthy control dogs were enrolled. Urine N-telopeptide concentration was measured using a commercially available immunoassay and results were expressed as a ratio against urinary creatinine concentration. Dogs receiving glucocorticoids were divided into three subgroups based on daily glucocorticoid dose and three subgroups based on treatment duration. Urine N-telopeptide concentration was then compared between groups.

RESULTS

Urine N-telopeptide concentration was significantly higher in dogs receiving glucocorticoids compared to the control group.

CLINICAL SIGNIFICANCE

This preliminary study demonstrates significant increase in urine N-telopeptide concentration in dogs receiving glucocorticoid therapy compared to control dogs. Further studies are needed to assess whether this increase in urine N-telopeptide concentration correlates with decreases in bone mineral density as has been identified in humans.

The association between bone turnover markers and kyphosis in community-dwelling older adults

PURPOSE

Hyperkyphosis, accentuated curvature of the thoracic spine, is often attributed to osteoporosis, yet its underlying pathophysiology is not well understood. Bone turnover markers (BTM) reflect the dynamic process of bone formation and resorption. This study examined the association between serum BTM levels and kyphosis in community-dwelling older adults.

METHODS

Between 2003 and 2006, 760 men and women in the Rancho Bernardo Study age 60 and older had blood drawn and kyphosis measured. Fasting serum was assayed for N-telopeptide (NTX) and procollagen type 1 n-terminal propeptide (P1NP), markers of bone resorption and formation, respectively. Participants requiring two or more 1.7 cm blocks under their head to achieve a neutral supine position were classified as having accentuated kyphosis. Analyses were stratified by sex and use of estrogen therapy (ET). Odds of accentuated kyphosis were calculated for each standard deviation increase in log-transformed BTM.

RESULTS

Mean age was 75 years. Overall, 51% of 341 non-ET using women, 41% of 111 ET-using women, and 75% of 308 men had accentuated kyphosis. In adjusted models, higher P1NP and NTX were associated with decreased odds of accentuated kyphosis in non-ET using women (P1NP: OR = 0.78 [95% CI, 0.58-0.92]; NTX: OR = 0.68 [95% CI, 0.54-0.86]), but not in men or ET-using women (p > 0.05).

CONCLUSIONS

The selective association of higher bone turnover with reduced odds of accentuated kyphosis in non-ET using women suggests that elevated BTM were associated with a lower likelihood of hyperkyphosis only in the low estrogen/high BTM environment characteristic of postmenopausal women who are not using ET.

Urinary N-telopeptide and Rate of Bone Loss Over the Menopause Transition and Early Postmenopause

The purpose of this study was to assess the ability of urinary N-telopeptide (U-NTX) to gauge rate of bone loss across and after the menopause transition (MT). U-NTX measurement was measured in early postmenopause in 604 participants from the Study of Women's Health Across the Nation (SWAN). We examined the association between U-NTX and annualized rates of decline in lumbar spine and femoral neck bone mineral density (BMD) across the MT (1 year before the final menstrual period [FMP] to time of U-NTX measurement), after the MT (from time of U-NTX measurement to 2 to 4 years later), and over the combined period (from 1 year before FMP to 2 to 4 years after U-NTX measurement). Adjusted for covariates in multivariable linear regression, every standard deviation (SD) increase in U-NTX was associated with 0.6% and 0.4% per year faster declines in lumbar spine and femoral neck BMD across the MT; and 0.3% (lumbar spine) and 0.2% (femoral neck) per year faster declines over the combined period (across and after the MT) (all p < 0.01). Each SD increase in U-NTX was also associated with 44% and 50% greater risk of fast bone loss in the lumbar spine (defined as BMD decline in the fastest 16% of the distribution) across the MT (p < 0.001, c-statistic = 0.80) and over the combined period (across and after the MT) (p = 0.001, c-statistic = 0.80), respectively. U-NTX measured in early postmenopause is most strongly associated with rates of bone loss across the MT, and may aid early identification of women who have experienced fast bone loss during this critical period. © 2016 American Society for Bone and Mineral Research.

Prevalent and Incident Vertebral Deformities in Midlife Women: Results from the Study of Women's Health Across the Nation (SWAN)

BACKGROUND

Vertebral fractures are the most common type of osteoporotic fracture among women, but estimates of their prevalence and incidence during middle-age are limited. The development of vertebral morphometry (VM) using dual energy X-ray absorptiometry (DXA) makes it more feasible to measure VM in large, longitudinal, observational studies. We conducted this study to: 1) contribute to the scant knowledge of the prevalence, incidence and risk factors for vertebral deformities in middle-aged women; and 2) to evaluate the performance of DXA-based VM measurement in a large, community based sample.

METHODS

The sample is derived from the Study of Women's Health Across the Nation (SWAN), a multi-site, community-based, longitudinal cohort study of the MT. Using Hologic QDR 4500A instruments, we acquired initial VM measurements in 1446 women during calendar years 2004-2007; in 2012-2013, a follow-up VM was obtained in 1108. Annually, lumbar spine (LS) and femoral neck (FN) bone mineral density (BMD) were measured and participant characteristics were assessed with standardized instruments. Multivariable logistic regression models examined the relations between prevalent deformity and relevant characteristics. Analyses of characteristics associated with prevalent deformity were restricted to 824 women who had not taken bone active medications since SWAN baseline. We calculated incident deformity per person year (PY) of observation, standardized to 1000 person-years.

RESULTS

The cranial portion of the VM image yielded the lowest proportions of readable vertebrae: from T4 through T6, between 43% and 63% of vertebral bodies were evaluable. Greater BMI was associated with fewer readable levels (B = -0.088, p<0.0001). In the baseline sample of 1446 women, the prevalence of vertebral deformity was 3.2% (95% CI: 2.3, 4.1). The relative odds of deformity increased by 61% per SD decrement in baseline LS BMD (p = 0.02) and were 67% greater per SD decrement in baseline FN BMD (p = 0.04). Odds of prevalent deformity increased by 21% per year increment in age (p = 0.02). On average, 1108 women were followed for 6.8 years (SD 0.5 years, range 5.1-8.3 years) and we observed an incidence of 1.98 vertebral deformities per 1000 PY. In the longitudinal sample, 628 participants had never used bone active medications; their vertebral deformity incidence was 2.8 per 1000 PY.

CONCLUSION

Prevalence of vertebral deformity in SWAN participants aged 50-60 years was low and lower bone density at the LS and FN was strongly related to greater risk of prevalent deformity. Only about half of the vertebral levels between T4-T6 could be adequately imaged by DXA. Greater BMI is associated with fewer readable vertebral levels.

Daily Intake of Milk Enriched with n-3 Fatty Acids, Oleic Acid, and Calcium Improves Metabolic and Bone Biomarkers in Postmenopausal Women

OBJECTIVE

Nutritional strategies can be effective for the prevention of menopause-related diseases, such as osteoporosis and cardiovascular disease. Our aim was to evaluate the effects of a dairy product enriched in polyunsaturated fatty acids, calcium, oleic acid, and vitamins on cardiovascular markers and bone metabolism in postmenopausal women with moderate cardiovascular risk.

METHODS

One hundred seventeen healthy postmenopausal women (aged 45 ± 7.7 years) were allocated to 2 groups: the intervention group (IG; n = 63), who consumed 0.5 L/day of a low-lactose skimmed milk enriched with 40 mg/100 mL of eicosapentaenoic acid (EPA) + docosahexaenoic acid (DHA), 0.54 g/100 mL oleic acid, and vitamins, and the control group (CG; n = 54), who consumed 0.5 L/day of semiskimmed milk 0.5 L/day enriched with vitamins A and D.

RESULTS

After 12 months, in the IG there was an improvement in lipid profile: a -5.78% decrease in total cholesterol (p = 0.010), -9.79% (p = 0.004) in low-density lipoprotein (LDL) cholesterol, -9.56% (p < 0.001) in total cholesterol (TC)/high-density lipoprotein (HDL) ratio, and -3.38% in LDL/HDL ratio (p < 0.001). No changes were observed in the CG. In the IG we observed a decrease of -28.20% in high-sensitivity C-reactive protein (hs-CRP; p = 0.012). There was no effect on bone turnover markers or serum osteoprotegerin (OPG) in either of the study groups. In the IG, receptor activator of nuclear factor κB ligand (RANKL) was reduced -17.64% (p = 0.003), with no effect in the CG.

CONCLUSION

In postmenopausal women with moderate cardiovascular risk, dietary supplementation with a dairy drink enriched with fatty acids (EPA+DHA), oleic acid, minerals, and vitamins induces a positive effect on cardiovascular risk and parameters of bone metabolism. Its regular consumption may be a useful nutritional support for postmenopausal women.

Bone health after menopause

PURPOSE OF REVIEW

This article reviews recent publications (January 2014-June 2015) on bone health and menopause.

RECENT FINDINGS

Recent articles suggest that simple instruments, such as the osteoporosis self-assessment tool based on age and weight may identify women age 50-64 for bone mineral density (BMD) testing. Rescreening of women age 50-64 is not recommended because their overall risk of fracture is quite low. A novel risk factor for hip fracture among non-Caucasian women is socioeconomic status. Midlife women with low serum 25-hydroxyvitamin D (<20 ng/ml) have an increased risk of fracture over the menopausal transition and vitamin D supplementation is warranted. Wrist fractures are the most common fracture in women age 50-64. Women who experience a wrist fracture have an increased risk of subsequent fracture and should have a BMD scan. Results of studies using composite measures of femoral neck strength relative to load emphasize the need for osteoporotic research to move beyond BMD.

SUMMARY

This recent research has provided new and important findings improving our understanding of osteoporosis during the menopausal transition.

Menopause prediction and potential implications

Reproductive ageing in women is characterized by a decline in both the quantity and quality of oocytes. Menopause is reached upon exhaustion of the resting primordial follicle pool, occurring on average at 51 years of age (range 40-60 years). The mean global age at natural menopause (ANM) appears robust, suggesting a distinct genetic control. Accordingly, a strong correlation in ANM is observed between mothers and daughters. Few specific genetic determinants of ANM have been identified. Substantial efforts have been made to predict ANM by using anti-Müllerian hormone (AMH) levels. AMH serum concentrations at reproductive age predict ANM, but precision is currently limited. Early ANM is associated with early preceding fertility loss, whereas late menopause is associated with reduced morbidity and mortality later in life. Menopause affects various women's health aspects, including bone density, breast, the cardiovascular system, mood/cognitive function and sexual well-being. If the current trend of increasing human life expectancy persists, women will soon spend half their life postmenopause. Unfortunately, increased longevity does not coincide with an equal increase in years spend in good health. Future research should focus on determinants of long term health effects of ANM, and efforts to improve women's postmenopausal health and quality of life.

Parity, lactation, bone strength, and 16-year fracture risk in adult women: findings from the Study of Women's Health Across the Nation (SWAN)

Our objective was to examine the associations of lifetime parity and accumulated length of lactation with bone strength in women prior to the menopause transition and fracture risk during and after the transition. Participants were 2239 pre- or early peri-menopausal women from the Study of Women's Health Across the Nation (SWAN), ages 42-53 years at baseline, who had no childbirths after age 42. Bone mineral density (BMD) was measured in the femoral neck and the lumbar spine at the baseline SWAN visit using dual-energy x-ray absorptiometry, and the composite indices of femoral neck strength relative to load (in three failure modes: compression, bending, and impact) were calculated from femoral neck BMD, femoral neck size, and body size. Data on fractures after age 42 were collected for a median follow-up of 15.7 years (interquartile range, 11.4-18.5 years). In multiple linear regressions adjusted for covariates, lifetime parity was associated positively with femoral neck strength relative to load (0.024 standard deviation (SD) increment in impact strength index per childbirth, p=0.049), but accumulated length of lactation was associated negatively with lumbar spine BMD (0.018 SD decrement per every additional 6 months of lactation, p=0.040). In Cox proportional hazards regressions adjusted for covariates, neither parity nor lactation was associated with fracture hazard after age 42. In conclusion, parity and lactation have little impact on peak bone strength prior to menopause, and do not affect fracture risk after age 42 over 16-year follow-up.

HIV and Menopause: A Systematic Review of the Effects of HIV Infection on Age at Menopause and the Effects of Menopause on Response to Antiretroviral Therapy

More than half of persons living with HIV infection in the United States (U.S.) will be ≥50 years of age by 2020, including postmenopausal women. We conducted a systematic literature review about the effects of (1) HIV infection on age at menopause and (2) menopause on antiretroviral therapy (ART) response, in order to inform optimal treatment strategies for menopausal women living with HIV infection. We used the Ovid Medline database from 1980 to 2012. We included studies that focused on HIV-infected persons, included postmenopausal women, and reported outcome data for either age at menopause or response to ART across menopause. We identified six original research articles for age at menopause and five for response to ART across menopause. Our review revealed that current data were conflicting and inconclusive; more rigorous studies are needed. Disentangling the effects of menopause requires well-designed studies with adequate numbers of HIV-infected and HIV-uninfected women, especially disproportionately affected women of color. Future studies should follow women from premenopause through menopause, use both surveys and laboratory measurements for menopause diagnoses, and control for confounders related to normal aging processes, in order to inform optimal clinical management for menopausal women living with HIV.

2013 Up-date of the consensus statement of the Spanish Menopause Society on postmenopausal osteoporosis

Postmenopausal osteoporosis is a major female health problem that increases morbidity, mortality and healthcare system costs. Considering that gynecologists are the primary health practitioners involved in the treatment of women with osteoporosis in our country, a panel of experts from the Spanish Menopause Society met to establish a set of criteria and procedures for the diagnosis and treatment of this disease based on the best available evidence and according to the model proposed by the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system to elaborate clinical practice guidelines and to classify the quality of the evidence and the strength of the recommendations. These recommendations should be a reference to gynecologist and other health professionals involved in the treatment of postmenopausal women.

Changes in bone resorption across the menopause transition: effects of reproductive hormones, body size, and ethnicity

OBJECTIVE

Our objective was to characterize changes in bone resorption in relation to the final menstrual period (FMP), reproductive hormones, body mass index (BMI), and ethnicity.

METHODS

Urinary type I collagen N-telopeptide (NTX), estradiol, and FSH levels were measured annually for up to 8 years spanning the menopause transition in 918 African American, Chinese, Japanese, or Caucasian women.

RESULTS

Urinary NTX began to increase sharply about 2 years before the FMP, reaching its peak level about 1 to 1.5 years after the FMP. NTX levels declined modestly from 2 to 6 years after the FMP but remained about 20% higher than before the menopause transition. The sharp rise in FSH occurred in conjunction with a sharp decline in estradiol and shortly after FSH levels began increasing rapidly. The mean increase in urinary NTX across the menopause transition was greatest in women with BMI <25 kg/m² and smallest in women with BMI >30 kg/m². Increases in NTX were greatest in Japanese women and smallest in African Americans. These differences were attenuated, but not eliminated, when analyses were adjusted for covariates, particularly BMI.

SUMMARY

During the menopause transition, a decline in ovarian function beginning about 2 years before the FMP is followed by an increase in bone resorption and subsequently by bone loss. The magnitude of the increase in bone resorption is inversely associated with BMI. Ethnic differences in changes in bone resorption are attenuated, but not eliminated, by adjustment for BMI. Ethnic differences in BMI, and corresponding ethnic differences in bone resorption, appear to account for much of the ethnic variation in perimenopausal bone loss.

Predicting the timeline to the final menstrual period: the study of women's health across the nation

CONTEXT

Predicting the final menstrual period (FMP) would help women know when their menopause transition will be completed. Additionally, biological changes, such as accelerated bone loss, precede the FMP by at least 1 year.

OBJECTIVE

Our objective was to assess whether FSH, estradiol, or urinary N-telopeptide predict where an individual is on her timeline to FMP.

METHODS

The sample was 554 women from the Study of Women's Health Across the Nation. We modeled the probability of having crossed specified landmarks: 2 years before, 1 year before, and the FMP. We also modeled the probability of being in narrower intervals: 2 to1 year before FMP, 2 years before FMP and FMP, or 1 year before FMP and FMP. We determined the candidate markers that best predicted having crossed each landmark, with the optimum defined as the greatest area under the receiver-operator curve; created formulas for the probability of having crossed each landmark; and calculated sensitivity and specificity.

RESULTS

Final models included current estradiol and FSH (each as a fraction of 1 previous reference measure), age, menopause transition stage, race/ethnicity, and whether serum was collected during the early follicular phase. Areas under the receiver-operator curves of final models that predicted the probability of a woman having crossed 2 years before, 1 year before, and the FMP itself were 0.902, 0.926, and 0.945, respectively. If we classified women as having crossed the 2 years before the FMP landmark when predicted probability exceeded 0.3, sensitivity was 85% and specificity 77%.

CONCLUSION

This model could help patients and researchers estimate the time to FMP.