Best Laboratory Screening in Diagnosing Secondary Osteoporosis and Fracture Risk Assessment Tool and the National Osteoporosis Guideline Group Performance in Determining Clinical Risk: A Cross-Sectional Evaluation of the Bone Health in Postmenopausal Brazilian Women

BACKGROUND

Identifying postmenopausal women with a high risk of having osteoporosis and fractures is a current challenge. This study aimed to assess the diagnostic performance of biochemical tests in identifying secondary osteoporosis and the fracture risk assessment tool (FRAX) in identifying fracture risk.

METHODS

Data from biochemical tests and bone densitometry of postmenopausal women were analyzed. Additionally, the FRAX result was obtained and the patients were classified according to the National Osteoporosis Guideline Group (NOGG).

RESULTS

A total of 646 women were evaluated, of whom 201 (31.1%) had osteoporosis or a previous frailty fracture. These women had statistically different parathyroid hormone (PTH) and alkaline phosphatase serum levels (p<0.01 and p=0.02, respectively) than those without osteoporosis or fracture. However, those at high risk had a higher prevalence of hypovitaminosis D (46% vs. 36%) and hypocalciuria (17% vs. 9%). The FRAX showed an area under the curve of 0.757 (p<0.01) and 0.788 (p<0.01) for identifying women at risk for "major fractures" and "hip," respectively. The NOGG categorization had a sensitivity of 19% to identify high-risk women, a specificity of 91.3% for low-risk women, with a positive predictive value of 57.4% and a negative predictive value of 64.6%.

CONCLUSIONS

The evaluation of PTH, 25-hydroxy-vitamin D, serum calcium, and 24-hr urinary calcium proved adequate for initial osteoporosis screening. The FRAX tool has a regular ability to screen women at risk for fracture, and the NOGG method has high specificity to identify those at low risk.

Abstract P4-10-05: Safety and efficacy of low dose topical testosterone for sexual function improvement in women with breast cancer under treatment with ovarian suppression and aromatase inhibitor

Background: Premenopausal, high-risk, hormone receptor-positive breast cancer patients areoften treated with ovarian suppression in combination with aromatase inhibitors (AI). Thiscombination results in important adverse effects, particularly in sexual function, such as vaginaldryness and loss of libido. Vaginal estrogen is effective but may elevate serum estradiol levelsand, theoretically, may increase recurrence risk. Vaginal testosterone is also commonlyprescribed to ameliorate symptoms, though its safety remains uncertain, with limited availabledata. In our study, we aimed to determine the safety and efficacy, particularly regarding sexualfunction, of a low-dose, topical testosterone gel administration.Methods: This is a pilot, single-center study, designed to evaluate the efficacy of topicaltestosterone gel (3 mg/ml/per day) in improving sexual function in 30 premenopausal patientson ovarian suppression in combination with an AI. The primary safety endpoint was todetermine serum estradiol, measured by liquid chromatography mass spectrometry (E2) on amonthly a basis for 3 consecutive months. The primary efficacy endpoint was assessed by meansof the Female Sexual Function Index (FSFI) questionnaire, that include various domains of sexualfunction such as libido, sexual satisfaction and vaginal lubrication. The score can range from 2to 36, being 2 the lowest and 36 the highest sexual satisfaction. Patients had to have a baselineE2 of less than 2.7 pg/ml prior to study entry.Results: Herein, we report the preliminary results on the first 20 patients. The mean age was39.3 years, 85% had early or locally advanced disease and 15% had metastatic disease. Tenpatients completed the 3-month treatment, while five are still on therapy. Four of the 20discontinued treatment, mainly due to logistical difficulties during the follow-up visits. Onepatient had a localized allergic reaction and, also, discontinued treatment. A total of 15 patientsmaintained the value of E2 of less than 2,7 pg/ml during the 3-month treatment in all 3measurements. We observed an improvement in FSFI measures over the visits, with an increasefrom a mean of 10.2 at baseline to 19.4 at the third month (P<0.001), with the greatestimprovement observed between the second and third months.Conclusion: Our preliminary findings suggest that topical testosterone appears safe andeffective in improving sexual function in patients on ovarian suppression and aromataseinhibitor. Further studies are clearly warranted.

Citation Format: Patrícia Taranto, Diogo de Brito Sales, Luciano de Melo Pompei, Alessandro Leal, Gustavo Schvartsman, Antonio Carlos Buzaid. Safety and efficacy of low dose topical testosterone for sexual function improvement in women with breast cancer under treatment with ovarian suppression and aromatase inhibitor [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P4-10-05.

Performance of the Fracture Risk Assessment Tool Associated with Muscle Mass Measurements and Handgrip to Screen for the Risk of Osteoporosis in Young Postmenopausal Women

OBJECTIVE

 To evaluate the improvement in screening accuracy of the Fracture Risk Assessment Tool (FRAX) for the risk of developing osteoporosis among young postmenopausal women by associating with it clinical muscle mass measures.

METHODS

 A sample of postmenopausal women was submitted to calcaneal quantitative ultrasound (QUS), application of the FRAX questionnaire, and screening for the risk of developing sarcopenia at a health fair held in the city of São Bernardo do Campo in 2019. The sample also underwent anthropometric measurements, muscle mass, walking speed and handgrip tests. A major osteoporotic fracture (MOF) risk ≥ 8.5% on the FRAX, a classification of medium risk on the clinical guideline of the National Osteoporosis Guideline Group (NOGG), and a QUS T-score ≤ -1.8 sd were considered risks of having low bone mass, and QUS T-score ≤ -2.5sd, risk of having fractures.

RESULTS

 In total, 198 women were evaluated, with a median age of 64 ±  7.7 years, median body mass index (BMI) of 27.3 ±  5.3 kg/m² and median QUS T-score of -1.3 ±  1.3 sd. The accuracy of the FRAX with a MOF risk ≥ 8.5% to identify women with T-scores ≤ -1.8 sd was poor, with an area under the curve (AUC) of 0.604 (95% confidence interval [95%CI]: 0.509-0.694) for women under 65 years of age, and of 0.642 (95%CI: 0.571-0.709) when age was not considered. Including data on muscle mass in the statistical analysis led to a significant improvement for the group of women under 65 years of age, with an AUC of 0,705 (95%CI: 0.612-0.786). The ability of the high-risk NOGG tool to identify T-scores ≤ -1.8 sd was limited.

CONCLUSION

 Clinical muscle mass measurements increased the accuracy of the FRAX to screen for osteoporosis in women aged under 65 years.

White, brown, and bone marrow adipose tissue behavior in DHEA-induced PCOS mice

METHODS

Thirty-one female C57BL/6J mice were divided into four groups: two were treated with subcutaneous dehydroepiandrosterone (DHEA) implants and divided into normal and hypercaloric diet (HFD). Two were control and divided into normal and HFD. Presence of insulin resistance, growth, and adipocyte markers expression of white and brown adipose tissues and growth and inflammatory cytokines expression of bone marrow adipose tissue were evaluated.

RESULTS

Hypercaloric diet groups presented higher total weight gain and huge growth in all fat sites, except bone marrow. They also demonstrated greater expression of adipocyte markers in sites of white adipose tissue. DHEA + HFD group showed more insulin intolerance than all other groups. DHEA shows to abrogate AdipoQ expression in all fatty tissues.

CONCLUSIONS

DHEA alone does not influence adipose tissue growth, but contributes to increased insulin resistance and influences the expression of adipokines. Proximal MAT showed different behavior from the other fat depot.

Bleeding Pattern and Management of Unexpected Bleeding/Spotting with an Extended Regimen of a Combination of Ethinylestradiol 20 mcg and Drospirenone 3 mg

Objective

To compare the bleeding pattern in women using ethinylestradiol 20 mcg/drospirenone 3 mg (EE 20 mcg/DRSP 3 mg) in a 24/4-day cyclic regimen with an extended regimen. Unexpected bleeding/spotting in the extended regimen group was managed by allowing a 4-day hormone-free interval (HFI).

Methods

This was a randomized, prospective, open-label, multicenter study. Participants (N = 348) were randomized to receive EE 20 mcg/DRSP 3 mg in either an extended regimen (EE/DRSP_es group) or a 24/4-day cyclic regimen (EE/DRSP_24/4 group) and followed for 168 days. In the EE/DRSP_es group, a 4-day HFI was allowed whenever unexpected bleeding/spotting persisted for ≥7 consecutive days. The participants assessed their bleeding daily as “no bleeding,” “spotting,” or “light,” “moderate,” or “heavy” bleeding according to a predefined scale.

Results

EE/DRSP_es group experienced fewer days of bleeding than those using a 24/4 cyclic regimen (P < 0.001). After 168 days, 57.5% of women in the EE/DRSP_es group achieved complete amenorrhea (i.e., neither bleeding nor spotting) and 73.9% achieved “no bleeding” (i.e., no bleeding with or without spotting) during the final 28-day interval of the study period. Women in the extended group who instituted the 4-day HFI experienced a 94.1% rate of successful management of unexpected bleeding/spotting.

Conclusion

The use of EE 20 mcg/DRSP 3 mg in an extended regimen resulted in high rates of amenorrhea and “no bleeding”. Unexpected bleeding/spotting in the EE/DRSP_es group could be managed effectively with a 4-day HFI.

Clinical Trial Registration

International Standard Randomised Controlled Trial Number (ISRCTN57661673): http://www.controlled-trials.com/isrctn/pf/57661673.

The Effect of Testosterone Replacement on Intramedullary, Inguinal and Visceral Fat in Ovariectomized Rats

OBJECTIVE

 The present article aims to evaluate the impact of testosterone treatment on the expansion of visceral, subcutaneous and intramedullary adipose tissue of ovariectomized rats and the visceral and subcutaneous fat expression of peroxisome proliferator-activated receptors (PPARs) gamma. METHODS:  In total 48 female Wistar rats were castrated and randomly divided into 6 treatment groups: group E2 was submitted to estradiol 5 μg/day; group T, to testosterone 5 μg/day; group E2 + T, to estradiol 5 μg/day + testosterone 5 μg/day; group TT, to testosterone 30 μg/day; group E2 + TT, to estradiol 5 μg/day + testosterone 30 μg/day; and placebo was administered to group P. After 5 weeks, the rats were euthanized, the inguinal and visceral adipose tissues were harvested, weighted, and had their PPAR gamma expression evaluated by reverse transcription quantitative polymerase chain reaction (RT-qPCR). The right femurs were harvested and histologically prepared to perform the number count of the intramedullary adipocytes.

RESULTS

 The expansion of visceral fat tissue was much higher in the TT group when compared with other treated groups (p < 0.001). The TT group also showed a higher expansion of inguinal fat (p < 0.01), and groups E2 + T and E2 + TT presented lower growth compared to the P group (p < 0.01). The number of femur intramedullary adipocytes only showed significant differences between groups TT and E2 + TT (p < 0.05). The expression of PPAR gamma showed no differences among the groups.

CONCLUSION

 The use of testosterone in high doses leads to an important expansion in both visceral and inguinal adipose tissues. Association with estradiol exerts an expansion-repressive effect on the visceral and inguinal adipose tissues.

Is the Expression of the Components of the Carotid Matrix of Rats Influenced by Estrogen, Progestin and Tibolone?

OBJECTIVE

 To analyze the effects of estrogen alone or in combination with progestogens and tibolone (TIB) on the expression of the extracellular matrix metalloproteinases 2 and 9 (MMP-2 and MMP-9), of perlecan, and of heparanase (HPSE) of the vascular walls of the carotid arteries.

METHODS

 A total of 30 250-day-old ovariectomized Wistar rats were orally treated for 5 weeks with: a) 1 mg/kg of estradiol benzoate (EB); b) EB + 0.2 mg/kg of medroxyprogesterone acetate (MPA); c) EB + 0.2mg/kg of norethisterone acetate (NETA); d) EB + 2 mg/kg of dydrogesterone (DI); e) 1 mg/kg of TIB; f) placebo (CTR). Following treatment, the expression of mRNA for MMP-2, MMP-9, and HPSE was analyzed by real-time polymerase chain-reaction (PCR), and the expression of MMP-2, of MMP-9, of tissue inhibitor of metalloproteinase 2 (TIMP-2), and of perlecan was quantified by immunohistochemistry in the carotid arteries.

RESULTS

 The groups showed significant differences on mRNA HPSE expression (p = 0.048), which was higher in the EB, EB + MPA, and TIB groups. There was no statistically significant difference in mRNA MMP-2 or MMP-9 expression. The immunohistochemical expression of MMP-2, of TIMP-2, of MMP-9, of HPSE, and of perlecan showed no differences between groups.

CONCLUSION

 Estradiol alone or associated with MPA and TIB treatment can increase mRNA HSPE expression of the walls of the carotid arteries in ovariectomized rats.

Brazilian guidelines for the diagnosis and treatment of postmenopausal osteoporosis

Osteoporosis is the leading cause of fractures in the population older than 50 years. This silent disease affects primarily postmenopausal women and the elderly, and the morbidity and mortality rates are high. The main goal of treating osteoporosis is the prevention of fractures. The identification of populations at risk through early diagnosis and treatment is essential. The last Brazilian guideline for the treatment of postmenopausal osteoporosis was elaborated in 2002. Since then, new strategies for diagnosis and risk stratification have been developed, and drugs with novel action mechanisms have been added to the therapeutic arsenal. The Osteoporosis and Osteometabolic Diseases Committee of the Brazilian Society of Rheumatology, in conjunction with the Brazilian Medical Association and other Societies, has developed this update of the guidelines for the treatment of postmenopausal osteoporosis according to the best scientific evidence available. This update is intended for professionals in many medical and health specialties involved in the treatment of osteoporosis, for physicians in general and for health-related organizations.

Differential Diagnosis between Bartholin Cyst and Vulvar Leiomyoma: Case Report

Genital leiomyomas are rare tumors that can often be misdiagnosed as Bartholin cyst. We report a case of a 32-year-old patient who had a cystic nodulation in the left labium majus that was suggestive of Bartholin cyst. A resection surgery was performed, and the definitive histopathology diagnosis was vulvar leiomyoma. The macroscopic features of cystic lesions difficult the differential diagnosis between leiomyoma and Bartholin cyst; therefore, a histopathologic examination is often recommended.

Drospirenone/Ethinylestradiol: A Review on Efficacy and Noncontraceptive Benefits

Considerable advances have been made in the field of combined oral contraceptives since their introduction 50 years ago. This ongoing evolution has been focused on reducing the estrogen dose and synthesizing new progestogens. A recently launched combination of ethinylestradiol 20 μg and drospirenone 3 mg demonstrates the advantages of a lower estrogen dose with the antimineralocorticoid activity of drospirenone that is responsible for the drug's significant antiandrogenic and antimineralocorticoid effects, reflected clinically in lower rates of adverse events including less fluid retention. In addition to the drug's contraceptive efficacy, its effects on the skin and other classic noncontraceptive benefits, the ethinylestradiol 20 μg and drospirenone 3 mg combination has demonstrated highly satisfactory results in women with premenstrual dysphoric syndrome.

[Assessment of pain sensitivity and factors involved in the quality of the sample fluid cytologic papillary: preliminary results from the use of automated collection]

PURPOSE

to evaluate painful sensitivity and factors involved in producing papillary fluid suitable for cytological analysis by means of automated collection.

METHODS

we selected 50 asymptomatic women without a personal or family history of breast cancer, outside the pregnancy and childbirth cycle in order to collect papillary fluid by the automated system. We recorded and related to the production of papillary fluid patient age, smoking habit, previous breast surgery, parity, breastfeeding, menopausal status and age at menarche. All material collected was fixed in appropriate place, and sent separately for cytological analysis. The painful sensitivity of the collection procedure was assessed using the Borg Category-Ratio Scale (CR10 Scale).

RESULTS

patient age ranged from 22 to 59 years, mean 41.6 ± 8.6 years. Of the 50 patients, 20 (40%) showed no papillary fluid suitable for analysis in the breasts. In those patients from whom appropriate fluid was obtained for analysis of papillary cytology, parity was inversely related to the ability to obtain suitable cell samples with a level of statistical significance of p=0.035, OR=0.0032 (95%CI=0.0001-0.1388). Regarding soreness, the exam was well tolerated.

CONCLUSIONS

the automated method of fluid collection for analysis of papillary cytology was well tolerated by the women; thus producing analyzable material in 60% of cases, a rate was inversely related to parity.

Application of Osteorisk to postmenopausal patients with osteoporosis

CONTEXT AND OBJECTIVE

Identification of women at risk of bone fracture is becoming less dependent on evaluating bone mineral density through placing greater value on clinical risk factors. The aim of this study was to evaluate the sensitivity of the Osteorisk clinical tool for identifying Brazilian postmenopausal women with osteoporosis, compared with bone densitometry.

DESIGN AND SETTING

Cross-sectional observational study at Faculdade de Medicina do ABC.

METHOD

Information on 812 postmenopausal osteoporotic women was retrospectively evaluated from medical records. The women were divided into the age groups 50-59, 60-69, 70-79 and over 80 years. The results from the Osteorisk clinical tool, which uses only age and weight, were compared with bone densitometry T-scores.

RESULTS

There were significant correlations between the results from the Osteorisk clinical tool and from bone densitometry, in relation to the lumbar spine (P = 0.027) and hip (P < 0.001), thus showing a non-arbitrary relationship. The overall sensitivity of Osteorisk for identifying women with "high risk of osteoporosis" was 86.5%, and it was higher for hip osteoporosis alone (97.2%) than for lumbar spine osteoporosis (85.8%). The sensitivity was better among older women.

CONCLUSION

Osteorisk seems to present good sensitivity for identifying postmenopausal women at risk of osteoporosis. It should be used when bone densitometry is not easily available or as a means of selecting individuals for referral for bone densitometry.